Physiotherapy and rehabilitation
We will present the most common spine injuries in detail. Every pathology or spine injury comes with a description of general facts, causes that led to the development of the injury, characteristics of the symptoms, diagnosis, and the course of treatment.
A herniated disc or spinal disc herniation is a common painful pathological state of the spine that is one of the specific causes of back pain. Intervertebral discs are rubbery structures between the vertebrae in the spine that consist of a soft (pulpous) nucleus and a tougher (fibrous) ring. The function of the intervertebral discs is to act as a cushion in the spine.
A herniated disc occurs when the pulpous nucleus pushes into the tears of the fibrous ring which form as a consequence of degenerative changes. Spinal disc herniation typically occurs at levels L5-S1 and L4-L5, it is less common at level L3-L4, whereas herniations in the upper segments of the spine are rare. The intervertebral disc most often bulges in the posterolateral direction, where the fibrous ring is the weakest. The direction of herniation determines which nerve root is affected.
Types of spinal disc herniation:
Some of the symptoms of disc herniation in the lumbar spine include back pain of varying intensity that can spread down the leg and decreased muscle strength. Bigger problems mostly appear when standing or sitting. Lying down usually improves the symptoms.
A cause of disc herniation are longer lasting incorrect posture and body positions, for example sitting in the office, sitting on the bicycle, sitting while driving, etc. A herniated disc is rarely a consequence of a one-time situation, it is oftentimes a longer process of a combination of poor lifestyle and poor muscle function. Risky moves that can cause disc herniation are: bending forward, sitting, and incorrect weight lifting technique.
Pain occurs during activity that involves bending forward or backward, side-bending left or right, lifting loads, sneezing, or coughing.
The intensity of pain depends on the position of the body and the location of the herniated disc; in general, it is one of the strongest pains of orthopaedic origin.
The patient feels the pain in the lumbar segment, moreover, it often spreads to the buttock, groin, thigh, shin, or even to the foot.
Pain and neurological symptoms are present in one or both feet; considerably reduced muscle strength of the lower extremities may also appear, along with a change in the sensitivity of the skin and tingling. More severe disc injuries may also result in bladder or bowel incontinence.
The majority of patients undergo a conservative treatment of disc herniation since specialised conservative rehabilitation with exercises has a good prognosis for treatment.
Absolute indications for surgical treatment are rare, for example, bladder or bowel incontinence or complete loss of sense of touch in lower extremities. Despite clear indications for surgical treatment, the decision for surgical intervention remains difficult. Surgical intervention means immediate relief of pain that is often unbearable, which is why many patients opt for surgical treatment.
Conservative treatment means that pain subsides more slowly in intensity, and it can take months for it to completely disappear. Either way, a 6-month rehabilitation treatment with specialised exercises is necessary for long-term success and it can be performed postoperatively or as an entire process of conservative treatment.
If spinal stenosis is not present, conservative treatment is mostly successful and fast.
Intervertebral disc protrusion is the first stage of disc herniation, where the protrusion of the intervertebral disc is eccentric. Intervertebral disc protrusion is the most common out of all intervertebral disc herniations. In protrusion, the pulpous nucleus does not break through the fibrous ring, instead, it causes micro-injuries to it.
A cause of disc protrusion are longer lasting incorrect posture and body positions, for example, sitting in the office, sitting on the bicycle, sitting while driving, etc.
If the bulge appears directly on the back side (central protrusion), the symptomatic pain appears in the lumbar segment. If the bulge appears in the direction of the back and the side (posterolateral disc protrusion), the pain appears in the lower back and the buttock, and it may spread down the leg to the foot.
If disc protrusion occurs in the extreme lateral direction where the sciatic nerve is (lateral protrusion), the typical symptomatic pain that spreads to lower extremities only appears. Bigger problems mostly appear when standing or sitting. Lying down usually improves the symptoms.
The majority of patients undergo a conservative treatment of disc protrusion since specialised conservative rehabilitation with exercises has a good prognosis for treatment. Absolute indications for surgical treatment of disc protrusion are rare, for example, bladder or bowel incontinence or complete loss of sense of touch in lower extremities.
Despite clear indications for surgical treatment, the decision for surgical intervention remains difficult. Surgical intervention means immediate relief of pain that is often unbearable, which is why many patients opt for surgical treatment.
Our system of conservative treatment of disc protrusion consists of 4 phases:
Osteoporosis is a bone disease characterised by a gradual decrease in bone mineral density and organic matrix of collagen structure, which presents itself as bone brittleness.
In rare cases, osteoporosis may appear early at a young age, however, the first symptoms most commonly appear after the age of 50. In the first half of life, bone density increases (this occurs most rapidly between the ages of 11 and 20); peak bone density is reached by the age of 25. After 35 years of age, a slow decrease in bone density occurs in both sexes but is accelerated in women in the first few years after menopause due to lower secretion of female sex hormones.
People with osteoporosis have an increased risk of:
When the diagnosis of osteoporotic bones is made, it is essential that the patient start special guided exercise that will slow down the loss of bone mineral density and maintain the appropriate activity of the muscular system.
Among the exercises for the management of osteoporosis are exercises for the improvement of active joint stability, exercises for gaining awareness of the position of the pelvis, maintaining aerobic endurance, and the progressive overload training programme that includes isolation exercises as well as more complex strength exercises. Adapted strategies for the consumption of dietary supplements and the elimination of factors that accelerate the loss of bone mass are also recommended.
Arthritis is a general term that describes numerous inflammatory joint diseases.
Arthritis is a rheumatic condition and a common joint disease that most often affects the population after the age of 65.
The most common forms of joint arthritis are:
Symptoms of arthritis are joint pain of high intensity, oftentimes accompanied by swelling and redness at the site of inflammation. Other common symptoms include stiffness and immobility of the joints, small joint abnormalities, fatigue, low-grade fever, grinding sensation in fingers.
What is typical of joint arthritis is that joint stiffness is most intense in the morning, but the pain appears later during various daily activities.
The treatment of joint arthritis includes a combination of instrumental therapy and therapeutic exercises; low frequency pulsed electromagnetic therapy and laser therapy are most effective.
If the patient is overweight, aerobic exercise in combination with an individually adapted eating strategy may be used to achieve lower body weight.
It is a common form of joint arthritis that is caused by the wear of cartilage in the joint.
Joint wear or arthrosis leads to the uneven surface of the cartilage and bone spurs that grow on the edge of joint surfaces, causing inflammation.
Cartilage wear is the result of a natural aging process, and it affects 60% of people above the age of 65, who consequently face the symptoms of osteoarthritis (OA).
Osteoarthritis most commonly affects the joints that carry the body weight, namely the knee and hip joints; former joint injuries also pose a risk of developing osteoarthritis. Oftentimes, the lumbar and cervical spine are also affected.
What is characteristic of osteoarthritis is that signs of inflammation are less intense than in rheumatoid arthritis, the morning joint stiffness is also shorter.
Symptoms of osteoarthritis typically worsen when putting a strain on the affected joint.
What is typical of osteoarthritis is that in the initial stage of pathology, the pain is not always present, instead, it is provoked by straining a specific movement.
As cartilage wear progresses, muscle looseness also appears, overburdening the joints even more. The symptoms include a tender and slightly enlarged joint with limited mobility. If osteoarthritis appears in the knees, poor joint control or knee instability typically occurs.
Osteoarthritis is managed conservatively, using therapeutic exercises and instrumental physiotherapy.
In the final stages of joint wear, joint replacement or reconstruction is possible, however, in the initial phases of joint arthrosis and osteoarthritis, treatment with exercises and therapy sessions is recommended.
Conservative treatment of osteoarthritis aims to slow down degenerations of the joint and reduce acute inflammation or symptoms. It is important to educate the patient about the disease and to maintain joint mobility.
If the patient is overweight, aerobic exercise in combination with an individually adapted eating strategy may be used to achieve lower body weight.
Spinal stenosis is a pathological narrowing of the spinal canal, caused by degenerative changes of intervertebral discs, facet joints, and vertebrae.
Degenerative changes of the spine are the result of a natural aging process that can be accelerated by the factors of an unhealthy lifestyle. Degenerative changes of the spine appear in 95% of individuals over the age of 50.
Symptoms of spinal stenosis mostly appear in older people, usually after the age of 60. The size of the spinal canal is hereditary; individuals with a narrow spinal canal are more prone to develop spinal stenosis when degenerative changes of the spine appear.
The narrowing of the spinal canal gradually causes mechanical compression of nerve fibres and the spinal cord, which causes intense pain and functional disorders of the lower extremities.
Sciatica is a term describing a set of symptoms in the lower extremities that are a consequence of compression of the sciatic nerve (Nervus ischiadicus), which is the longest and thickest nerve in the human body.
Nervus ischiadicus consists of individual nerve roots that group together forming the main nerve fibre, which runs down the lower extremities.
The fourth and fifth lumbar nerves join together with three sacral nerves into the sciatic nerve.
Symptoms of sciatica include:
The symptoms may radiate from the buttocks to the foot, depending on the compression of the sciatic nerve.
In the progressive form of sciatica, drop foot or loss of neurological function of the foot may occur.
Sciatica pain originates in the lumbar spine and spreads through the buttock down the leg; the pain can also appear in isolation in the lower extremity.
The treatment of symptoms of sciatica depends on the type of degeneration that causes it and its progression.
It is important to keep in mind that sciatica is not a disease, but only a term used to describe the symptoms that accompany degenerative changes of the spine which are treated with instrumental physiotherapy and therapeutic exercises in the initial stages.
Surgical treatment is performed when conservative therapies do not significantly improve the symptoms and the quality of life over the period of 3 to 6 months.
There are also some indications (cauda equina syndrome) that require rapid surgical intervention. Most patients improve symptoms of sciatica by following an adequate movement programme that aims to teach the correct exercise techniques, strengthen the core and control the movement of the pelvis.
Spondylosis of the spine is a type of degenerative disease that describes the formation of bone deformations or spurs (osteophytes) on the edges of the vertebrae of the spine where they adjoin the intervertebral discs.
Spondylosis is often referred to as spinal osteoarthritis.
The symptoms of spinal spondylosis depend on the segment of the spine where it appears.
Cervical spondylosis oftentimes causes pain in the back of the head that can radiate to the jaw, shoulders, and earlobes, and consequently, the mobility of the cervical spine, muscular strength, and muscle mass of the cervical spine can be reduced. Strong migraines may also occur.
Facet joints are small joints of the spine in between the vertebrae. They are in posterolateral position on the arches of the vertebrae; the facets of the upper and lower vertebrae in each pair are connected with each other.
Each vertebra of the spine has a total of 4 facets, two on each side, above and below.
Fibres of the muscle group multifidus that play an important role in the stabilisation of the spine grow attached to small facet joints. The articular capsule of facet joints is also attributed and important proprioceptive function due to the rich presence of mechanoreceptors.
Before treating the pain that originates from facet joint injury or wear, it is important to establish an accurate diagnosis, because various degenerative conditions of the spine cause similar symptoms.
The pain that is caused by facet joint degenerations grows more intense with specific movements, such as turning the torso or the head, whereas disc herniation irritates the symptoms mostly when sitting, which oftentimes makes it worse in the morning hours.
With disc herniation, the pain occurs on the other side of the lump, whereas facet joint injury causes ipsilateral pain symptoms. When injuring a facet joint of the cervical or thoracic spine, the neurological symptoms do not spread to the arms as is typical with disc herniation on the same level.
The pain which is a consequence of facet joint injury or degeneration is usually present in the immediate vicinity of the damaged tissue next to the spine. In the case of cervical facets, the pain may radiate from the back of the head; in the case of thoracic facets, the pain frequently appears between the shoulder blades.
The pain when rapidly moving or jerking the cervical or thoracic spine is usually burning or stinging, long-lasting positions often make the pain dull and difficult to determine.
The treatment of symptoms that are a consequence of facet joint wear begins after the initial MRI and/or x-ray imaging and after performing clinical tests.
Conservative treatment aims to slow down the degeneration of bone and cartilage surfaces and stop the lowering of the intervertebral discs.
It is important that adequate instrumental physiotherapy is being performed to alleviate acute symptoms, as well as exercises to strengthen the deep stabilizing muscles of the spine and preservation of mobility in vital segments that have been affected.
The conservative programme is performed intensively during the period of 3 to 6 months, then it enters the maintenance phase or the management of degeneration that should be performed as part of a less intensive programme, for example twice a week, for a longer period of time.
Sacroiliac joint is a joint between the sacrum and the ilium, responsible for the optimal transfer of forces from the area of the lumbar spine to the lower extremities and is primarily designed to provide stability in the lumbar-sacral region of the spine.
Gluteal muscles and muscles of the group erector spinae provide stability to the sacroiliac joint.
The cause of the majority of pain symptoms in the lumbar segment of the spine are intervertebral disc degenerations and in 20% of symptoms in the lumbar segment, the cause is connected with sacroiliac joint defects.
The pain that originates from the sacroiliac joint can be a consequence of traumatic injury, repetitive strain, lumbar spine stiffness, giving birth, or it can occur as a consequence of degenerative changes.
The symptoms can appear on one side or both sides. Sacroiliac joint pains oftentimes appear in younger women after giving birth due to the movement of pelvic bones.
The symptoms that originate in the sacroiliac joint include discomfort when putting full body weight on the lower extremities in a standing position; the pain can radiate to knee level and may appear even after walking a shorter distance. The typical symptom is the inability to lie on the side of the affected joint. SI joint dysfunction can cause symptoms similar to those of sciatica, which means that the pain can radiate through the buttock into the lower extremities.
Before the treatment of SI joint dysfunction can begin, it is necessary to perform an accurate differential diagnosis, which can be used to eliminate certain degenerative spine injuries that cause similar symptoms. Issues with the SI joint are mostly treated with conservative therapy and lifestyle changes. In the event of a severe traumatic injury to the SI joint, it is possible to surgically insert titanium implants designed to stabilise an unstable sacroiliac joint.
According to insufficient or excessive mobility of the SI joint, suitable rehabilitation exercises are prescribed. If the mobility of the SI joint is insufficient, stretching and manipulation of shortened soft structures are recommended, whereas with excessive mobility, the focus is mostly on strengthening those muscle groups that are the primary stabilisers of the SI joint.
A progressive kinesiology exercise regimen is vital throughout the entire rehabilitation period of pain and SI joint injuries. The majority of symptoms of the pathological changes in the SI joint subside in the period of up to three months after performing an appropriately individually adapted rehabilitation program that includes a combination of outpatient physiotherapy and kinesiological exercises.
The exaggerated or straightened thoracic kyphosis denote an unnatural pathological position of the thoracic spine that usually affects the adult population as a consequence of long-term incorrect postures.
The majority of exaggerated thoracic kyphoses are developed throughout adolescence or later during adulthood, however, Scheuermann’s disease also causes congenital thoracic kyphosis, which is characterised by the anatomical change of the vertebrae.
The most common reason for the development of exaggerated thoracic kyphosis is asymmetric stiffness of the soft structures that enable upright posture and extending the thoracic spine.
When the trunk flexor muscles are too stiff on the front side, this leads to exaggerated thoracic kyphosis; when the muscle tone is pathologically increased on the back of the trunk, this leads to straightened thoracic kyphosis or the military posture.
The cause of pathological curvature of the thoracic spine can also be the irregular curvature of the lumbar spine that according to the chain reaction principle of kinetic chains establishes a postural compensation pattern in the thoracic spine which then assumes the incorrect position.
Symptoms of the milder form of incorrect position of the thoracic spine can include:
Progressive symptoms of a longer-lasting exaggerated or straightened thoracic kyphosis can entail an anatomical change of the spine that can no longer be corrected with exercises; neurological disorders in the upper extremities and the development of secondary degenerative conditions of the thoracic spine, such as disc herniation, facet joint wear, spinal stenosis…
Exaggerated or straightened thoracic kyphosis is treated with targeted kinesiological exercises that has to be based on individual exercise programme according to the specific causes of the patient’s pathological position of the thoracic spine.
If the kyphosis is exaggerated, then it is recommended to strengthen the extensor complex of the spine in the thoracic segment and to manually release the rigid structures on the anterior side, which are usually chest muscles, trunk flexors, and indirectly also hip flexors.
If the thoracic kyphosis is straightened, then it is recommended to strengthen the deep stabilizers of the spine and trunk flexors and to relax the spinal extensors. The training should aim to establish muscle balance and increase endurance in strength.
Scoliosis is a three-dimensional spine and body deformation.
A healthy spine assumes a levelled vertical position with bilateral symmetry in the coronal plane. A spine with scoliosis, however, has a lateral deviation from the normal vertical axis. In such a case, axial rotation of the vertebrae and physiological curves of the thoracic or lumbar spine occur.
It can develop due to birth defects in the development of vertebrae and the spinal cord, due to hereditary diseases of the neuromuscular system, due to severe trauma (car accident), or due to congenital and later defects of the connective tissue.
In the majority of cases, scoliosis has no negative effects on the quality of life. It is vital that its development is stopped in early childhood since an appropriate approach can stop the progression of the pathology that could cause symptomatic issues during adulthood if left untreated.
Scoliosis most commonly develops in children up to 16 years of age and progresses rapidly during body growth. The average prevalence of scoliosis is 2-3% in the child population.
Scoliosis oftentimes does not cause issues and leaves negative consequences on the individual’s lifestyle.
When scoliosis is left untreated during childhood or exceeds 45 degrees of curvature from the natural vertical position of the spine, it can cause severe consequences such as pulmonary and cardiac defects.
With the regular observation of scoliosis early in childhood we can stop the condition on time by performing adapted therapies.
Scolioses with 20 to 45 degrees of curvature have a higher risk of developing back pain and faster forming of degenerative conditions, which is why it is recommended to regularly perform the adapted exercises to maintain adequate strength of muscle stabilisers and muscle balance.
In individuals who developed scoliosis as a result of trauma or improper lifestyle, performing adapted kinesiological exercises is an important strategy of treatment.
Before treating scoliosis, it is advised to undergo x-ray imaging of the spine to obtain information on the exact state and structure of scoliosis. After imaging, an orthopaedics specialist determines the pattern or type of curvature, the stage of scoliosis, and the state of physiological curves. Scoliosis is diagnosed when the deformation of the spine from the vertical axis exceeds 10 degrees.
Scolioses with the deformation of the spine between 10 and 20 degrees are observed. If scoliosis starts deviating by 20 to 45 degrees, it is treated with a conservative approach of outpatient physiotherapy and therapeutic exercises that are individually adapted to the type of scoliosis, the age of the patient, and individual characteristics of the curvature of the spine. Surgical treatment is used for curvatures that deviate by more than 45 degrees.
