Changes in the Spine As We Age: Advances in Spine

Rehabilitation

By: Dr. Connie D’Astolfo, DC, PhD(cand)

Dr. Connie D’Astolfo, DC, PhD (c)

• Clinical Director of SPINEgroup®

• PhD candidate at York University (Health Management & Outcomes Evaluation)

• Former health policy advisor for MOHLTC

• Peer reviewed articles and a chapter author for two texts: recent chapter “Research Perspectives on the Role of Informatics in Health Policy and Management”

• Research Project: Clinical and economic impact of back pain in the long term care (LTC) population

• D'Astolfo CJ, Humphreys BK: A record review of reported musculoskeletal pain in an Ontario long term care facility. BMC Geriatrics 2006, 6:5

What is SPINEgroup?

• A recognized leader in rehabilitation services & healthcare performance management and publicly funded physiotherapy clinic

• Expertise in Senior rehabilitation and Spine Care with Dr. Connie D'Astolfo

• Our goal is to achieve the best clinical outcomes. SPINEgroup® accomplishes this through our innovative “performance based” approach. (Current research project with Kensington Gardens LTC)

• Interdisciplinary health services backed by EMR system and nurse-led case management for complex patients

• OHIP Funded for Physiotherapy for Seniors over 65 years of age, kids under 19, ODSP and OW recipients.

• Our OHIP funded Physiotherapy services rely on best rehabilitation practices with a strong emphasis on patient education and self management.

Presentation Objectives

• Normal Anatomy of the Spine

• Changes to the Spine As we Age

• Common Spinal Conditions and Health Considerations

• Clinical and Economic Impact of Spine Pain

• Evidence based Management of Spine Pain Conditions

• Exercise for the Aging Spine

Questions to Consider:

• Do you have back pain for more than 3 months?

• Do you have leg pain?

• Do you have numbness/tingling or weakness in your legs?

• Do you stumble, fall or have problems with balance and stability?

• Is your back pain due to recent trauma, like a car accident?

• Do you have changes in bowel or bladder function?

• Do you have back pain with no apparent cause?

• Do you have pain at night?

• Do you find yourself taking excessive pain medication for your back pain?

• Are you suffering with depression or anxiety due to your back pain?

• Have you stopped doing your regular activities due to your back pain?

• Are your symptoms unaltered by body position?

• Do you have a previous diagnosis of cancer?

• Do you have recent or significant weight loss?

Facts about the Spine

The human spine has:

• More than 120 individual muscles

• 220 specialized ligaments

• Over 100 intricate joints

• 24 movable vertebrae

• 5 sacral and 3-5 coccygeal vertebrae

• 31 pairs of spinal nerves

• 23 intervertebral discs

• 3 major types of joints

How your Spine is Built

Normal Anatomy of the Spine

Spinal Cord-Cauda Equina

Facts about Spine Pain

• Prevalence of spine pain in Ontario is estimated at 64% of the adult population per year

• Four out of five adults will experience low back pain sometime during their lifetime

• There are approximately 150 different causes of back pain • After the common cold, low back pain is the most frequent cause of lost

workdays in individuals over 45 years of age • Back pain ranks second to headaches as the most frequent location for

pain • The estimated cost of back pain in Ontario is 2.4 billion dollars per year

considering lost productivity, medical expenses and worker’s compensation benefits

• Back Pain is a significant cause of ER visits and hospital stays among seniors

• Back Pain is a significant cause of falls related injuries in the same population

• Back pain is highly correlated with many chronic diseases including diabetes, hypertension and depression/anxiety

Changes in the Spine As we Age

Reactive bony and cartilaginous hypertrophy – Thickening or calcification of the spinal ligaments (posterior longitudinal ligament and ligamentum

flavum – Thickened lamina and facets

Changes in micro-vasculature in the spine endplates and surrounding vascular structures (atherosclerosis, narrowing and changes to vessel elasticity)

Change in posture: Excessive lordotic and scoliotic curves

Changes in bone matrix Change in flexibility of ligaments & tendons, shortened muscles Changes in reflexes (diminished or hyper/pathological if there is spinal cord compression)

Degenerated spinal discs Excessive mechanical loading on other lumbo-pelvic joints, i.e. LS base and SI joints (common areas of pain)

Changes in the Vertebral Segment

Changes in the Facet Joint

Vascular Compromise

Vertebral Endplates

Common Spine Related Conditions As

We Age

• Mechanical Changes

• Degenerative Disc Disease

• Osteoporosis

• Neurogenic-claudication (Lumbar Spine Stenosis)

Other Considerations for Seniors • Multiple chronic Disease (co-morbidites) including cardiovascular disease,

arthritis, diabetes, dementia, depression) • Cognitive decline • Hypertension • Chronic Pain • Anxiety • Inactivity • Instability • Frailty • Low Dietary Intake • Low fluid Intake • Decreased Social Interaction • Multiple Pharmaceuticals

What Causes Back Pain?

• Mechanical Dysfunction • Disc Injuries • Arthritic Disease • Trauma • Vascular Causes • Malignant Disease • Infection • Metabolic Disease • Auto-immune Conditions • Psychological Causes • Visceral Referred Pain

Mechanical Dysfunction

(Simple Back Pain)

• Muscle Strain

• Facet Joint Sprain

• Sciatica (Piriformis Syndrome)

• Sacro-iliac Sprain

Arthritic Causes

Osteoarthritis

(Degenerative Disc Disease)

Osteoarthritis (Degenerative Disc Disease)

Spinal Stenosis

• Narrowing of the spinal canal • Typically occurs in the cervical

and lumbar spine, more commonly in the lumbar spine

• Characterized by back pain with progressive leg pain and weakness

Spinal Stenosis: What Your Clients May Report

• Leg weakness and pain while walking or standing, relieved while sitting or riding a bike

• Some patients bend over

as they walk because they have learned that their leg or legs hurt less in that position. Bending forward (flexion) makes the spinal canal larger and may relieve pressure on the spinal nerves and reduce the symptoms.

Symptoms of Spinal Stenosis-Neurogenic Claudication

• Back pain

• Burning pain in buttocks or legs (sciatica) Numbness or tingling in buttocks or legs

• Weakness in the legs or "foot drop."

• Less pain with leaning forward or sitting

Cauda Equina Syndrome

Emergency!!!

• Compression of the spinal cord at the tail end

(cauda) causing loss of balance, strength, sensory changes, motor control, urinary and bowel control

• May lead to permanent neurological loss if surgical decompression is not done immediately

• May be caused by any lesion compressing the cord including disc herniations, tumors, fractures of the spine

Neurogenic vs Vascular Claudication

Differentiation of Vascular and Neurogenic Claudication

Signs and Symptoms Vascular Neurogenic

Walking Distance Type of Pain Relief at Cessation of Activity Back Pain Pain Relief Posture Provocation Walking Up Hill Bicycle Riding Pulses Trophic Changes Muscle Atrophy

Fixed Cramps, Tightness Immediate Rarely Standing Uncommon Pain Pain Absent Likely Rarely

Variable Dull Ache, Numbness Delayed Occasionally Flexion and Sitting Common No Pain No Pain Normal Absent Occasionally

Osteoporosis

Changes to Posture/Kyphosis

Risk of Fractures

Impact of Spine Pain

High Prevalence • With the aging population, the prevalence of back pain is

expected to rise to 20% of the Canadian population, resulting in approximately 7 million or 1 in 5 Canadians by 2031 (Public Health Agency, 2010)

• Adults over the age of 65 report back pain prevalence rates higher to persons in the age 45 to 65 age demographic, about 24% (Canadian Community Health Survey, 2003; Deyo, 2006; Feyer, 2012; Goertz et al, 2013)

• The sequelae of back pain in this patient population may have a greater impact on physical function and quality of life than back pain in younger groups (Hicks, 2008; Rudy, 2007).

Prevalence of Back Problems in Age 65+ (Sourced from Stats Canada, 2003)

Impact of Spine Pain Conditions

Chronic Disease and Comorbidities: • Preliminary research suggests that there may be

a ‘back pain domino effect’ or destabilizing effect of back pain on other chronic diseases.

• Spine pain may worsen the course of other chronic diseases including depression, anxiety, diabetes and heart disease thereby increasing the impact of these conditions both clinically and economically.

Impact of Spine Pain Conditions

ED Visits/Transfers:

• Across Canada, ED utilization rates for back pain in the senior population were strikingly high. Back pain was reported as the 9th most common problem for emergency department visits in the senior 65 +age group, accounting for 30,000 cases in 2011. (CIHI, 2012).

Evidence based Management of the Spine

• Reduce pain through bracing and non drug interventions, i.e. Laser therapy, ultrasound, acupuncture, massage therapy, shockwave therapy

• Spinal Manipulation/Mobilization • Nerve Flossing • Improve connective tissue flexibility and tensile strength • Mechanical Spinal Decompression/Traction • Improve cardiovascular fitness (exercise) and circulation/blood flow. i.e cycling,

aqua fitness, swimming, walking, jogging, etc. • Spinal Stabilization Exercises: Increase strength in spinal muscles and core

muscles, stability training, balance, proprioception (Yoga and Calisthenics, Plyometric exercises)

• Weight Bearing Exercises for Increased Bone Density • Avoid pro-inflammatory foods and nicotine and caffeine (causes muscle spasms) • Alter pain behaviors (psychotherapy, CBT) • Decrease dependency on analgesics and Opiods

Canadian Exercise Guidelines for Seniors

Being active for at least 150 minutes per

week can help reduce the risk of: • Chronic disease (such as high blood pressure and heart disease) and,

• Premature death

And also help to:

• Maintain functional independence

• Maintain mobility

• Improve Fitness

• Improve or maintain body weight

• Maintain bone health and,

• Maintain mental health and feel better

• Can help with spine pain!!

www.csep.ca/guidelines

Exercise Considerations: Avoid Excessive Loading the Spine

Plough/Shoulder Stand

Loaded neck flexion can sprain cervical ligaments and damage discs, especially in those with spinal osteoporosis and arthritis

Double knee to chest: Reduces

strain on ligaments, spinal discs and

bone

Risk

Lunges Jump and Reach or Jumping Jacks CAT and COW (Flexion/Extension Mobilization) Back Extension (Cobra) Wall Angels (Scapular Retraction) Dead Bug (lying supine or in table top position) Downward Dog Child’s Pose Lumbar Spine Mobilization (Knee Windshield Wiping) Pigeon (prone) or Figure 4 (supine) Push Ups (Floor or Wall) Squats Chair Dips Calf Raises Plank Bridge *Exercises need to be selected based on spinal condition, i.e. extension may aggravate a facet strain or lumbar spinal stenosis

Recommended Exercises for Most Spinal Conditions

Red/Yellow Flags: Important Questions to be Considered

• Do you have back pain for more than 3 months?

• Do you have leg pain?

• Do you have numbness/tingling or weakness in your legs?

• Do you stumble, fall or have problems with balance and stability?

• Is your back pain due to recent trauma, like a car accident?

• Do you have changes in bowel or bladder function?

• Do you have back pain with no apparent cause?

• Do you have pain at night?

• Do you find yourself taking excessive pain medication for your back pain?

• Are you suffering with depression or anxiety due to your back pain?

• Have you stopped doing your regular activities due to your back pain?

• Are your symptoms unaltered by body position?

• Do you have a previous diagnosis of cancer?

• Do you have recent or significant weight loss?

Pay Attention!

Motion of Spine - Is there pain when you twist, bend, or move? Have you lost some flexibility?

Weakness - Do you report weakness or do you notice any weakness when preforming exercises?

Pain

Sensory Changes – Do you report feeling certain tingling sensations in specific areas of the upper or lower extremities, feet or hands?

Motor Skills – Do you report instability or balance problems? Have you fallen?

Ensure your Rehab Professional has the Following Skills:

• Skills in diagnosis of spinal pain conditions • Skills in the management of senior • Wide range understanding of complex nature of spinal pain with psychological factors with the ability to detect and manage psychological factors • Appreciation in minimalism of treatment in spine care • An understanding of the methods, techniques and indications of medical and surgical procedures • Public health perspective and co-morbidity relationship with diabetes, hypertension, obesity, dementia and depression • The ability to coordinate the efforts of a variety of providers; case management • The ability to follow patients over the long term to monitor and treat re-occurrence and educate patients in self-management • The ability to performance manage and assess outcome measures • Ongoing research in the detection and management of spine pain disorders

Key References • Australia Department of Health, Western Australia. Spinal Pain Model of Care. Perth:

Health Networks Branch, Department of Health, Western Australia; 2009.

• Canadian Institute for Health Information (CIHI). Patient Cost Estimator. 2010/11.

Retrieved August 21, 2013 from http://www.cihi.ca/CIHI-ext-

portal/internet/en/ApplicationNew/spending+and+health+workforce/spending/CIHI0

20209

• Canadian Institute for Health Information (CIHI), Quick Facts NACRS Database, 2011-

2012.

• Canadian Institute for Health Information (CIHI) co-funded the 2008 Canadian Survey

of Experiences With Primary Health Care (CSE-PHC), 2008

• Canadian Institute for Health Information (CIHI). Seniors’ Use of Emergency

Departments in Ontario 2004–2005 to 2008–2009, 2010.

• Canadian Institute for Health Information (CIHI). A Snapshot of Health Care in Canada

as Demonstrated by Top 10 Lists, 2011. 2012.

• Chronic Disease Prevention Alliance of Canada. The Cost of Chronic Disease in Canada,

2004

Thank You

Any Questions?

Please visit

www.spinegroup.ca

info@spinegroup.ca

905-850-7746