Chapter 15: The Spine: Management Guidelines

Introduction

In theory, treating impairments and activity limitations related to the tissues of the spinal column and trunk is the same as treating tissue injuries of the extremities. The major complicating factor in the spine is the proximity of key structures to the spinal cord and nerve roots. The challenge for the therapist is to recognize the complex functional relationships of the facet and intervertebral joints, the muscles, the fascia, and the nervous system and know how to examine and evaluate the individual who presents with pain and activity limitations. Activity, rather than prolonged bedrest, has long been accepted as important in the management of patients with spinal and postural pain² but defining what are beneficial and safe activities during the process of healing and rehabilitation is the task of the therapist.

The medical model of diagnosis does not lend itself to direct therapeutic exercise intervention strategies, particularly because patients’ complaints of back or neck pain often do not relate to specific pathologies. Efforts are being made to determine the most effective way to categorize patients with symptoms affecting spine and trunk function in order to be more accurate with outcome research.^{65,92,138,186,187,231,242} In addition, results from research studies have provided some criteria for predicting outcomes in subgroups of patients with back and neck pain so therapists can better identify the interventions that are more likely to result in positive outcomes.^{15,33,53,126,221,226,273,290} The approach described in this text supports the importance of treatment based on the presenting structural and functional impairments that result in activity limitations while respecting the pathomechanics, pathophysiology, and precautions of specific medical diagnoses. It is also important to recognize that chronic back pain is a complex condition¹³⁸ and involves not only a biological approach as presented in this chapter, but also psychosocial considerations that are beyond the scope of this text.

The content of this chapter has three major emphases. The first section reviews the pathology and pathomechanics of spinal structures. The focus of the second section is on principles and guidelines for managing patients with impaired function in the spine. This section includes principles of interventions for the broad categories of tissue injury in the spinal region that are in the acute, subacute, and chronic phases of healing and also expands on specific interventions for impairment-based diagnostic categories and their relationship to the Clinical Practice Guidelines.^{24,48,64,68,223} Techniques geared toward treating specific impairments are described in these sections.

The third major section contains medical diagnoses unique to the thoraco-lumbopelvic and upper thoraco-craniocervical regions. Because the function of the temporomandibular joint (TMJ) is closely related to the cervical spine, physical therapy management guidelines for impairments related to the TMJ conclude the chapter.