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Joint mobilization after lumbar or cervical fusion
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Joint mobilization after lumbar or cervical fusion - August 9, 2007 1:48:43 AM
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Kaden
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Hey folks,
I was wondering what thoughts are out there with regards to mobilizing joint above and below a fusion site. How do folks do this and minimize stress to the fusion site.
Thanks in advance for any help.
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RE: Joint mobilization after lumbar or cervical fusion - August 9, 2007 9:40:16 AM
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FLAOrthoPT
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considering the joints above and below will become pivot points and will probably need stabilzation way more than mobilization, wondering WHY you want to mobilize these joints?
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RE: Joint mobilization after lumbar or cervical fusion - August 9, 2007 11:43:21 AM
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jddufault
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I agree with FLA. The areas above and below the spinal fusion (over a period of time) tend to become hypermobile in an effort to compensate for lack of mobility at the fused level. I would not chose mobilizations but rather an increased focus on lumbar stabilization through TA control and hip disassociaton. More details about your patient maybe helpful for us to understand your thoughts for mobilization.
J
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RE: Joint mobilization after lumbar or cervical fusion - August 9, 2007 12:10:29 PM
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jlharris
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Neuromuscular stabilization and intervetebral joint hypomobility are two different animals. I find many of my lumbar fusion pt's have significant intervetebral hypomobility (which often responds nicely to gentle mobilization) and neuromuscular trunk instability.
To be honest, though, I tend to try Lumbar AROM solely initially to treat the hypomobility but wouldn't hesitate to mobilize adjacent joints to improve intervetebral mobility.
< Message edited by jlharris -- August 9, 2007 12:14:12 PM >
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RE: Joint mobilization after lumbar or cervical fusion - August 9, 2007 1:59:57 PM
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Kaden
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Hey folks.
thanks for the replies. I agree that the immediate joints above and below tend to become hypermobile and my question was not pertaining to these joint as much but joints several levels above and below.
I was just curious how people are mobilizing these while still protecting excess motion at the fusion site.
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RE: Joint mobilization after lumbar or cervical fusion - August 13, 2007 6:29:41 AM
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ginger
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Not only do I doubt the joints adjacent to fused ones become hypermobile, I challenge anyone to show that ANY facet joint can become that way, short of dislocation resulting from extreme trauma. Agree with JLharris, mobs to facet joints near the fusion site will assist a return to normal mobility, comfort and with it normal local patterns of recruitment to musculature nearby.
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RE: Joint mobilization after lumbar or cervical fusion - August 13, 2007 10:24:14 AM
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Shill
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From: Madison WI USA
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A nice literature review on it, not sure if it meets your requirements for showing hypermobility, but it does indicate a strong likelihood of adjacent segment dysfunction.
Bull NYU Hosp Jt Dis. 2007;65(1):29-36.
Links
Adjacent segment degeneration following spinal fusion for degenerative disc disease.
Levin DA, Hale JJ, Bendo JA.Spine Service, NYU Hospital for Joint Diseases,Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York 10003, USA.
PMID: 17539759 [PubMed - indexed for MEDLINE]
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RE: Joint mobilization after lumbar or cervical fusion - August 13, 2007 11:11:59 AM
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jddufault
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Nice article Shill. Thanks.
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RE: Joint mobilization after lumbar or cervical fusion - August 18, 2007 3:49:42 PM
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Kaden
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Okay Ginger. Seriously are there still some people out there who doubt that hypermobilities really exist. Sad
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RE: Joint mobilization after lumbar or cervical fusion - August 19, 2007 1:08:13 AM
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ginger
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kaden, The instruments I use to negotiate first contact with a spinal segment are sensitive , though by no means fail safe. They will easily detect, with the help of my brain , differences in movement and resistance when passive mobs are attempted to joints, particularly facet joints.
In dealing with painfull joints, invariably , there will be a degree of resistance to mobs. Resistance which I argue , is a product of a protective response, where tone of paravertebral small muscles increases to 'lock up " to some degree , a spinal segment.
It is by first reversing this tonic response that best results are obtained with mobs. I am yet to come across a facet joint, which has pain with attempts at passive mobs, which does not have a degree of increased tone holding it still. It would be fair to say that this is one of those ubiquitous elements of spinal pain.
Testing and retesting with both active and passive movements to spinal joints pre and post mobs, give me a more detailed impression of movement quality. Nowhere however , in my observations of facet joint behaviour, has there been a moment when I have observed too much movement , prior to or after treatment.. To be more precise, in every case ,where mobility is associated with pain, it is hypomobility associated with hypertonic muscle which best explains my pretreatment observations and results.
Can you describe how your testing and retesting of facet movements has given you an impression of hypermobility. I'm not so concerned with trials or other research in my question , but would be keen to hear about your own experiences in this regard.
Always willing to step outside my worn track , just need a reason .
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RE: Joint mobilization after lumbar or cervical fusion - August 19, 2007 6:43:00 PM
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Kaden
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I agree that muscle is often the "gaurd" to movement. However, I often will perform a MET if I think the muscle is the main culprit and then retest to find that segment moves more than 2-3 segements above and below. When I test those glides of the other joints they do not offer resistance so I do not assume hypomobility and thus assume hyper of the segement I just treated.
What are your thoughts on instability then. Can this not exist. Often a joint that is percieved to be subluxed can be unstable. Once the joint is maniped and then retested I will often find this joint has significant play and the play is what most likely led to the subluxation/fixation.
Believe me, I wish there wher only hypomobile joints b/c my job would be a lot easier. Mob it and move on. I wouldn't have to spend a lot of time doing specific local stabilization techniques.
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RE: Joint mobilization after lumbar or cervical fusion - August 19, 2007 7:36:01 PM
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ginger
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If a segment moves well , without resistance or pain either passsive or active , then I would observe that as normal movement, free of protective responses and therefore not requiring treatment. I see no reason to consider these observations to be the hallmark of irregular movement . Certainly when compared to other protected joints.
I do no 'specific local stabilisation techniques' , can't imagine what they might be, unless you are talking trunk exercise, , please expand.
The notion of subluxation crept into your description of events , methinks a few 'Palmerite' notions have invaded your inner spaces. I entirely and wholeheartedly reject such ideas as well and truly past their use by date.
I'm not a fan of the idea of instability. I do see plenty of people who , because of injury or biomechanically driven protective responses , improve with core strengthening exs. I don't percieve these as evidence of 'instability' , rather than reducing pain /inhibition related weakness as a driver for tonic changes.
It's a fine point, but fits in general with the favoured notion that weakness is a by product of pain , rather than the initial driver for it.
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RE: Joint mobilization after lumbar or cervical fusion - August 19, 2007 9:13:04 PM
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Kaden
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What about a segment moving more than adjacent segments and also the segment that is the pain generator.
We may have to agree to disagree as we are obviously miles apart in treatment concepts.
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RE: Joint mobilization after lumbar or cervical fusion - August 19, 2007 10:00:26 PM
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jesspt
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Kaden - how can you tell that this particular segment is the pain generator? If you use movement relative to adjacent segments, how can you tell which segments move just right, and which move too much? And, if we're talking about a functional segmental instability, how can you possibly use a passive assesment technique (joint glide assesment) to assess what must be a symptom provoking situation that occurs during active movement.
I certainly see patients who benefit from stabilization exercises, but whether they are actually suffering from segmental instability is something that is difficult for me to ascertain.
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RE: Joint mobilization after lumbar or cervical fusion - August 19, 2007 10:32:34 PM
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Kaden
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Okay Jesspt - lets not get off the point I was arguing with ginger and that is that segmental hypermobilities and instabilities can exist.
PPIVM would just be one thing I would use to try and coordinate with AROM, PPIVM, PAIVM etc. How am I not able to use a joint glide to asses a pain response. Who says only an active movement can produce the pain of a functional instability.
If extension in AROM is painful to the patient and I see hinging at a particular level I can go in and glide the joint into extension unilaterally or bilaterally to asses specifically which joint is the problem.
We do this all the time in peripheral joints but somehow many can't seem to carry this over to the spine. We have all seen the shoulder that is painful into ER (excessive) and then test the joint glide compared to the other non painful shoulder and find that the painful shoulder has an increased glide.
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