S1 – Flashcard
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"the skilled passive movement to a joint"
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Manipulation "Paris" 1979
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"the skilled passive movement to a joint with a therapeutic intent"
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Manipulation "Paris" 2004
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"A manual therapy technique comprised of a continuum of skilled passive movement to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude high velocity therapeutic movement."
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Manipulation/Mobilization "Guide"
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An unpleasant sensory experience and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
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What is pain?
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When you don't know why you are in pain
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What is suffering?
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1. Pain Assessment 2. Initial Observation 3. History ; Review 4. Structural Inspection 5. Active Movements 6. Neurovascular Assessment 7. Palpation for Condition 8. Palpation for Position 9. Palpation for Mobility 10. Upper ; Lower Quarter Assessment 11. Radiologic, other tests ; medical data 12. Summary of findings 13. Interventions/Rx plan 14. Explanation ; Prognosis
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Spinal Examination 14 Steps
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Step at level above slip
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Spondylolisthesis (Fatigue Fx)
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Step at same level as slip
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Spondylolisthesis (Facet degeneration)
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Grade 1 ; possibly Grade 2
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Of the 5 grades of spondy slippage, which ones can we treat?
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Grade 1 - 1/5 slippage (relatively symptom free) Grade 2 - 2/5 slippage (symptomatic) Grade 3 - 3/5 slippage (3 or higher = surgery) Grade 4 - 4/5 slippage Grade 5 - 5/5 slippage
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5 Grades of Spondy
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Dermatomes Myotomes* Neural Tension Reflexes
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What do you need to test to confirm disc bulge?
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-lysis is a fx, but no slippage
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Difference between spondylolithesis ; spondylolysis?
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40 degrees = Surgery (usually after growth spurt)
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Scoliosis Curves
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Shift towards
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Lateral Shift - Medial Bulge
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Shift away
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Lateral Shift - Lateral Bulge
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Describes those motions that we normally perform in the course of a day.
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Functional Motion (physiologic)
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Describes those motions which are not normally performed.
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Non-Functional Motion (non-physiologic)
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FCO states BB should be attempted by all patients to help restore the neutral erect and encourage motion. 1. Gate control theory 2. Elevates water content of disc 3. Mobilizes the facet jt (stretches facet more than FB) 4. Promotes circulation generally relieving irritability 5. Helps relieve fear of movement 6. Neural tension is reduced 7. Over time disc protrusion loses its proteoglycans and thus its ability to attract water and so begins to shrink.
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How might backwards bending relieve pain?
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1. Smooth regardless of speed 2. Adequate relaxation of antagonists 3. Range is full - according to body type 4. Pain free 5. Muscles are of normal strength 6. Passive range is greater than active range
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Characteristics of normal motion
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1. Limited range 2. Unwillingness to move 3. Pain during or at end range 4. Painful arc 5. Compensatory or "trick" movement 6. Signs of instability
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Characteristics of abnormal motion
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Capsular restriction causes limitation in motions involving upslide. Myofascial restriction limited in only 1 movement (forward bending).
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How to differentiate between a capsular restriction ; a myofascial restriction?
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Sign of instability - Pt has to "walk" themselves up from a forward fixed position.
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What is Gowers Sign?
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Myotomes because you can test ; the pt not realize
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What gives the most reliable information upon neural examination - dermatomes, myotomes, reflexes, neural tension?
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Capsular pattern limited in upslide ; gapping; painful entrapment limited in downslide and compression
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How to differentiate between capsular pattern ; painful entrapment?
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Age (younger / older) Mechanism of injury (acute injury / degeneration) Movements/positioning (stenosis - FB feels good) Dermatomes ; myotomes (below / above)
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How to differentiate between disc ; stenosis?
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1. Contraction, binding ; proliferation of collagen 2. Generalized loss of segmental flexibility ; function -; liability to further injury 3. Nutrition of the disc reduced due to restricted osmosis ; filtration 4. Degeneration of synovium...pannus like ingrowth of synovium 5. Disuse of supporting musculature 6. May create hypermobility leading to instability in adjacent structures
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Results of Restricted Motion (hypomobility)
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1. Manipulation for joint stiffness 2. Posture Correction 3. Exercise to support joint instabilities 4. Myofascial stretching for adaptive shortening 5. Heat, massage, exercises for muscle tone ; condition 6. Back school for prevention of recurrence
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Dysfunction is reversed by
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1. Persistent strain of supporting tissues -; increased ligamentous stress/sensitivity, altered neuromuscular control, fatigue fx of bone (spondy), weakness/delaminating of the annulus fibrosis of disc 2. Pain -; mechanical determination of innervated tissues, muscle chemical guarding
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Results of Hypermobility/Instability
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1. Physical - examine for and list dysfunctions, restore function 2. Rational - explain physical findings, reproduce "find" patient's pain 3. Emotional - touch & caring (listening*), explanation in positive and realistic terms, avoiding fearful expression, give a prognosis and reassurance
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Three aspects of pain & treatments
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1. Stable = was a fx that resulted in elongation, no movement -> step stays in prone 2. Unstable = step in standing that disappears in prone
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Stable vs. Unstable Spondy
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Angle between PSIS and ASIS ~ 30 degrees, or 1 inch
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Angle of inclination
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Area of skin that is mainly supplied by a single nerve root
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Define Dermatome
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C4 - top of AC joint C5 - Lateral side of upper arm (delt) C6 - Volar surface of 1st and 2nd digit of hand C7 - Volar surface of 3rd digit C8 - Volar surface of 5th digit T1 - Medial surface of lower forearm T2 - Medial surface of arm
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Upper Quadrant Dermatomes
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L2 - Lateral upper thigh/anterior mid thigh L3 - Medial surface of the knee L4 - Medial surface of calf to medial malleoli L5 - Lateral lower leg S1 - Lateral forefoot and heel
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Lower Quadrant Dermatomes
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group of muscles that a single spinal nerve innervates 0 - no contraction 1 - trace 2 - poor 3 - fair 4 - good 5 - normal
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Define Myotome
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C1-2 - APR chin in C1-2 - PPR chin up C3 - Lateral cervical flexion (rarely done) C4 - Shoulder shrug (UT) C5 - Elbow flexion (biceps) C6 - Wrist extension (ECRL/ECRB) C7 - Elbow extension (Triceps)/Wrist flexion C8 - Thumb extension (EPL) T1 - Spread/squeeze fingers (hand intrinsics)
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Upper Quadrant Myotomes
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L2 - Hip Flexion L3 - Knee Extension (quads) L4 - Dorsiflexion (tib anterior) L5 - Great toe extension (EHL) S1 - Great toe flexion (FHL) or PF (gastroc) S2 - Knee Flexion (hamstrings)
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Lower Quadrant Myotomes
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Involuntary and instantaneous movement in response to a stimuli. Deep tendon reflexes - provide information on the integrity of the central nervous system (hyper) and peripheral nervous system (hypo). 0: absent reflex 1+: diminished 2+: normal 3+: increased 4+: clonus
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Define Reflex/DTR/Ratings
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C5-6 - Biceps C5-6 - Brachioradialis C7 - Triceps L4 - Knee Jerk/Patella S1 - Ankle Jerk UMN - Babinski UMN - Clonus
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Reflexes
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Trouble with upslide and gapping FB = cause deviation to LEFT SBR = Limited RL = Limited SBL = Free RR = Free
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Facet Capsular Pattern in Lumbar Spine (Ex. Left Facet)
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FB = possible deviation to LEFT SBR = Restricted RR = MOST restricted SBL = Relatively free RL = Relatively free
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Facet Capsular Pattern in Cervical Spine (Ex. Left Facet)
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1. History or demonstration of tissue relax/creep -> inability to sit still for long periods, discomfort increase as day wears on, relieved by movement or rest 2. Increased muscle tone while standing 3. Presence of "step" or rotation (spondylolisthesis, retrolisthesis or spondylolysis 4. Disappearance of muscle tone, step or rotation on prone lying 5. Shaking "juddering" while FB 6. Difficulty coming up from FB (Gower's sign) 7. Grade 5 or 6 on PIVM 8. Radiological evidence of motion studies for FB/BB showing both increased angulation between the vertebra and more important still - excessive translation
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Clinical Signs of Instability
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1. Multifidi 2. Ligamentum flavum 3. Intra-articular menisci
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What are the three structures that keep the facet capsules from getting entrapped (see Paris 1983)
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1. "Bosses and bars" on lower vertebra from sharpey's fibers of the outer annulus 2. Narrowing of lateral foramen 3. Retrolisthesis of superior vertebra
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What are the effects of loss of disc height?
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1. Joint Injury, including the conditions osteoarthrosis, instability, & the after effects of sprains/strains are impairments/dysfunction rather than diseases. 2. Impairments are manifested as EITHER increases or decreases of motion from the expected normal OR presence of aberrant movements. Thus, impairments are represented by abnormal movement. 3. Hypomobility impairments (or limited motion) are best treated by manipulation of joint structures, stretching to muscles/fascia, and promotion of activities that encourage full ROM. 4. Hypermobility impairments (or increased motion, laxity, instability) are best treated by stabilization via instruction of correct posture, stabilization exercises, and correction of any limitations of movement in neighboring joints that may be contributing to the hypermobility. 5. The primary cause of DJD is from long standing joint dysfunctions/impairments. Therefore, the presence of debilitating clinical joint disease is from the failure to provide timely PT interventions that reverse degenerative process, thus negating the need for surgery. 6. The PT's primary role is in the examination and treatment of dysfunctions, whereas that of the physician is the diagnosis and treatment of disease. These are separate but complementary roles in health care. 7. Since impairment is the cause of pain, the primary goal of physical therapy should be to correct the impairment rather than the pain. When however the nature of the pain interferes with correcting the impairment, the pain will need to be addressed as part of the treatment program. 8. The key to understanding dysfunction, and thus being able to examine and treat it, is understanding anatomy and biomechanics. It therefore behooves us in PT to develop our knowledge and skills in these areas, so that we may safely assume leadership in the nonoperative management of neuromusculoskeletal disorders. 9. Patient's responsibility to restore, maintain and enhance their health. Role of the PT is to serve as an educator, an example to the patient, and to reinforce a healthy and productive lifestyle. 10. Our body of knowledge is sufficiently unique and is of sufficient volume that to depend on referral for patients is no longer morally defensible.
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USA's Clinical Philosophies
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Classical- movement of one bone in relation to another bone Accessory- movement of joint surfaces in relation to one another
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Define classical (osteokinematic) vs. accessory (arthrokinematic) movements
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Component motion- movement of joint surfaces in relation to one another that is under voluntary control (glide, spin, roll) Joint play- movement of joint surfaces in relation to one another that is not under voluntary control (distraction)
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Define the 2 types of accessory movements
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If we accept the patient's description of pain and that it does exist, we need not waste time determining "if" the patient is in pain but rather set about to determine the causes of the pain and treat those causes as best as possible to restore normal function.
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USA's Pain Management Philosophy
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This term is used to describe the oblique view of the vertebrae in which a pars interarticularis fx is commonly seen in. The Scotty dog is made up of: EAR - superior articular process NOSE - transverse process NECK - fracture location BODY - spinous process and lamina FORELEG - inferior articular process
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What is the Scotty dog?
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(DOReST) D = Distraction Testing - inconsistent responses with the same test performed in different ways (ex. SLR + in supine but - in seated) O = Overreaction - Inappropriate or exaggerated responses Re = Regional disturbance - Nonanatomic findings with motor or sensory exam S = Stimulation testing - unexpected pain in distant sites (ex. pain in lumbar spine with shoulder rotation or axial loading) T = Tenderness - localized tenderness doesn't follow dermatomal or expected patter (ex. severe reaction to light touch).
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Waddell's Signs (look for 3 out of 5)
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Functional - rotation to same side in mid-cervical and SC spines Non-Functional - rotation to same side in mid-C and opposite in SC spines
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Functional vs. Non-Functional SB in C-spine
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Functional - rotation to the same side Non-Functional - rotation to opposite side
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Functional vs. Non-Functional SB in T/L-spine
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L/T - rotation and SB opposite C - rotation and SB always to same side SC - rotation produces SB to opposite side
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Rotation Rules
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- Subjective - Entirely private - Cannot be performed by two people in same location at same time - Need for validation studies and improved psychomotor learning methods (Nyberg, 2013)
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Scientific difficulties with palpation
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1. Skin - temp, moisture/dryness, scars, ulcers, moles 2. Subcutaneous tissue - edema, mobility (soft, firm), nodules 3. Muscle - tone, adaptive shortening 4. Ligaments (interspinous and supraspinous) - swollen or wasted, tenderness
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Palpation for Condition - findings
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Normal = warmest at Upper Thoracic and gradually cools, sharply cools over Iliac crests into glutes Warmth = acute Coolness = chronic
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What is revealed with Temperature
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1. Hypertonic States 2. Hypotonic States 3. Normal Tone/Shortened - adaptive shortening 4. Other - fibrositis, myalgia
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What are the altered muscle states according to Paris?
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1. Spasm - correction of underlying cause, posture correction 2. Hypertrophy - deep tissue massage, connective tissue massage, myofascial release 3. Involuntary muscle holding - correct the cause 4. Chemical muscle holding - hot packs ; massage, activities using muscle in healthy manner, muscle stretching 5. Voluntary muscle holding - should it be continued as in serious conditions?, if not get it moving (pendulums, lumbar ext), Oscillations Grade I/II
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Hypertonic States (Hypertonicity) ; Treatments
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1. Wasting ; fibrosis 2. Denervation 3. Disuse Atrophy
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Hypotonic States ; Treatments
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True shortening of a muscle = loss of sarcomeres Adaptive shortening must be treated by -; heat, massage and connective tissue techniques + SERIOUS stretching techniques (to add sarcomeres) = sustained stretch (15-20 minutes), inhibitive distraction, overpowering muscle, contract relax stretch (PNF). Stretching repeatedly in elastic range (typical 2 x 30 second type stretching, our failing, or avoiding plastic range because of patient discomfort) = lays down more tissue because of streaming potentials Need to go to plastic range and have patient maintain the range.
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Paris' Theory of Muscle Stretching
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Inflammation
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What does the scratch test look for? (Triple response of Lewis)
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1. Blanch 2. Reddening 3. Whealing
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3 stages of Triple Response of Lewis
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2 Vertebra & disc
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What makes up a motion segment?
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An increase in range of motion from the expected normal in that subject.
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What is hypermobility?
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A state of hypermobility that is clearly unstable. The joint usually looses its normal opposition of articular surfaces, may rest in an abnormal position and demonstrates instability of active motion.
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What is Instability and Luxation?
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Hypermobile/unstable joint to the degree that the normal anatomical relationship has been lost - such as in a flaccid hemiparesis. But, the key is that the joint can ben manually returned to its normal or rest position. Used in this senses, the cause is usually neurological.
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What is subluxation?
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Joint surfaces have lost their normal relationship and are unable to return to their normal position actively or with gentle passive motion.
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What is dislocation?
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L4/5 Mid Thoracic Upper Thoracic Upper Cervical
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Most common sites for positional faults
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Lateral to TP of C7 Posterior to Clavicle Anterior to Spine of Scapula Medial to Acromion
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How to locate 1st rib?
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Synovitis/Hemarthrosis
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What could thickening of the articular pillars indicate?
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"freedom of segmental movement - both in terms of quantity & quality"
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What is PIVM looking for?
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1. P/A T10 2. P/A T10 3. Rotation L T9 on T10
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Manipulation to correct T9/T10 positional fault: 1. FB 2. BB 3. RR
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0- Ankylosis (needs x-ray to confirm otherwise Grade 1, ignore as manip may fx, tear, rupture) 1- Considerable restriction/hypo (non-thrust/gentle stretching) *Paris dissection S1 pg.152* 2- Slight restriction/hypo (non-thrust and thrust) 3- Normal 4- Slight increase/hyper (dynamic muscular stab, nothing) 5- Considerable increase/hyper (external stab + muscle, treat neighboring hypomobilities) 6- Unstable (support, fusion/surgery)
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PIVM Grading Scale + interpretation + treatment
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1. Psychological = touch (caring/intelligent hands), induced movement, pop/snap 2. Neurophysiological = gate control, centralization of pain, muscle inhibition (Type III), movement & hence nutrition 3. Biomechanical (Grade III - V) = Stretch the restrictions w/n the capsule (restore fiber glide & restore ability to elongate/crimp), stretch or snap adhesions between the capsule & bone ends, alter positional relationships 4. Chemical = Probable release of endorphins (act as painkillers) -> explains why multiple thrusts to non-involved joint may give best temp relief [not advocated]
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Primary Effects of Manipulation
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- Gas (mostly nitrogen) is released from the synovial fluid and remains intracapsular - Gas distends the joint and stretches it (remains for 15 minutes) - Distended capsule fires Type III -> relaxes muscles relieving tension - Gas seen on x-ray
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What is the pop?
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- Continuing stretch on capsule (15 min) - Firing of type III mechanoreceptors & GTOs of attaching musculature (multifidi) - Results in reflex inhibition of muscle tone in neigbhoring muscles
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Beneficial effects of pop
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1. If already hypermobile, may become more hypermobile 2. Increased stress on disc 3. Dependency brought on by the feeling of immediate relief & perhaps the release of endogenous hormones 4. Muscle Inhibition
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Possible Negative effects of pop
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1. Relief of discomfort = by oscillation & repetitive motions to gate, by mechanically increasing ROM -> enables gating of discomfort & hastens repair of tissues 2. Restore normal motion = by mechanical methods -> aid in restoration of motion, helps gate pain, assist in nutrition & repair, increase tolerance to insult
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Indications for Manipulation
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Few if any absolute (eg Grade I) 1. Instabilities 2. Fractures 3. Tumors 4. All diseases (RA/OA/Down's/Prego), likelihood of causing osseous and ligamentous damage 5. Rotation techniques - presence of ligamentous (annular disc weakness)
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Precautions for Manipulation
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1. Ectomorph (slender build) = small flat joints, limited muscle bulk, relatively low body weights 2. Mesomorph (intermediate) = between ecto ; endo, greatest life expectancy 3. Endomorph (stocky) = decreased motor skills, large concave-convex = stable joints, plenty of bulk, usually shorter
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Principle Body Types
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1. Non-Thrust A. Maitland i. Grade I - sm amp @ beg of range ii. Grade II - lg amp within range (not end) iii. Grade III - lg amp to end range iv. Grade IV - sm amp @ end range B. Traditional = Stretch C. Paris = Progressive Oscillations D. Mulligan = Mobilization with Movement 2. Thrust A. Traditional ? B. Maitland = Grade V 3. Distraction A. Traditional i. Manual - via hands a. Grade I - unweighting joint surfaces b. Grade II - slack of capsule is taken up c. Grade III - capsule/ligs stretched ii. Mechanical - mechanical appliances deliver force (sustained or intermittent) B. Paris = Positional Distraction
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Techniques of Spinal Manipulation (summary)
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1. Increased kypholordosis at lower levels 2. Stiff upper back and "hump" 3. Subcranial restrictions (atlas stuck posterior) 4. Dental malocclusion (jaw recedes) 5. Possibly decreased blood supply to brain 6. TOS - due to adaptive shortening and lowering of clavicles 7. Shoulder dysfunction - decreased ABD ; ER + harder endfeels *FHP reliability measurement (Watson 1993) - tragus of ear line vs. C7 horz line
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Dysfunctions associated with forward head posture (FHP)
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1. Weakened - Deep Neck Flexors (longus capitus/coli) 2. Weakened - Scap stabilizers, depressors, retractors 3. Uninhibited/Overactive - UT/LS 4. Uninhibited/Overactive - Pectoralis group
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Upper Cross Postural Syndrome (from FHP)
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State of muscle at rest. It is a response to our palpation. Our touch by pressing on muscle spindles causes the surrounding fibers to contract and thus we feel this increasing recruitment of fibers as an elastic response, i.e., the firmer we press the more fibers are recruited and thus the firmer the tone feels. It is an elastic response which we call normal.
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Define tone
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Chiro: Traditional = purpose of moving vertebra is to relieve nerve root pressure, techniques are surprisingly non-specific (neuro ; chemical effects). Modern = need to treat movement of joints. Define manipulation as thrust and mobilization as non-thrust. PT (Paris): Emphasis is on restoration of normal arthrokinematics, especially component and joint play motions. Pain is de-emphasized. Techniques are specific and eclectic. Manipulation and mobilization synonymous.
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Chiropractors vs. PTs
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It allows for stretches in easy stages during which the clinician can note the tissue changes and decide to continue or to cease. Typically the first oscillation begins at the first stop, the second and third take the joint to the second stop, and the fourth and final oscillation, pushes the joint beyond the second stop (true barrier) to change its end feel. A stretch is necessary to increase range restricted by a "tight" capsule but by adding the oscillations and presumably firing more mechanoreceptors (Type I and II) and thus closing the "gate" to nociception, the technique is more comfortable to the patient.
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What is the benefit of progressive oscillations?
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Opens the intervertebral/lateral foramen, temp reduction of disc bulge, relief nerve root pressure ; provide relief for nerve root ischemic pain. PRE-REQS: segment localized, segment mobile, pt comfortable, no muscle guarding, tx monitored, placement obeys mechanical laws. Start with 5 minutes, increase in 5-10 minute intervals till 40 minutes is reached. Release Phenomenon - releasing pressure on the nerve can produce painful numbness and tingling, maybe due to re-vascularization.
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Positional Distraction
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Type I = Postural (slow adapting) -; capsule -; fired by oscillations Type II = Dynamic (quiet until movement) -; capsule -; fired by oscillations Type III = Inhibitive -; capsular ligaments -; stretch/sustained pressure/thrust (Grade III/IV/V) Type IV = Nociceptive (unmyelinated C-fibers) -; most tissues (not brain, SC, hyaline cartilage, nerves
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Mechanoreceptors
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1. Toe Region - Settling of collagen bundles and straightening of crimp in collagen as structure is lengthened 2. Elastic Region - Linear portion (1:1) of curve, reversible lengthening of structure 3. Elastic Limit (Yield Point) - Limit of stress and strain to which the structure can be exposed without causing plastic elongation 4. Plastic Region - microfailure begins to occur 5. Ultimate Stress - Point where max resistance is offered by tissue. Critical point where structure lengthens with decreasing resistance. Beyond point microfailure occurs at a much faster rate 6. Necking - slope of curve becomes negative ; structure begins to give way to load -; catastrophic failure is imminent 7. Ultimate Failure - Structure completely failed, little or no connection between disrupted ends.
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Stress Strain Curve Regions
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Female / Male: 1. light, thin / heavy,thick 2. joint structure small / large 3. muscle attachments indistinct / well-defined 4. pelvic inlet oval / heart-shaped 5. Pelvis outlet large / small 6. 1st sacral seg occupies 1/3 / 1/2 of sacrum 7. Sacrum short, wide, flat, forward curve / long, narrow, smooth concavity 8. SI facet shorter (2 seg down) / longer (3 seg down) 9. Acetabulum small / large 10. Ischial tuberosity everted / inverted 11. Obturator foramen oval /round
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Differences Between Male and Female Pelvis
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1. Smaller joint surfaces (2 segs vs. 3 segs) 2. Flatter, smoother articular surfaces 3. Hip joint farther away (increased leverage) 4. Joint further behind hips (more back torsion) 5. Stress of childbirth 6. Stress of intercourse 7. Hormonal changes 8. Habitual one-legged standing
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Why SI dysfunctions are more common in females:
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L4-S2/3
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What is the innervation of the SI joint?
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Torsion- rotary motion of the ilium on the sacrum Nutation- rotary motion of the sacrum on the ilium
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Differentiate torsion and nutation
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1. Ischial tubes separate 2. Iliac crests roll in 3. Sacrum nutates
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Mechanics of Pelvic Squatting
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Backward: one-legged standing, fall on ischial tube, vertical thrust on extended leg, intercourse positions Forward: golf swing, horizontal thrust of flexed knee, hip hyperextension Muscles: - backward- glute max, hamstrings, abdominals - forward- iliacus, rec fem
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Causes of forward and backward torsion Muscles that produce each torsion
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1. Ligamentous strain/sprain 2. Hypermobility/Instability 3. Displacement
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Primary SI Syndromes
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Diseases: - ankylosing spondylitis - Paget's disease - TB - female reproductive disorders - GI disorders Dysfunction: - torsional stress - joint strain - laxity (hypermobility) - invariably backward rotation - displacement - positional faults
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Causes of SI Pain
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1. Pain unilateral below L5/S1* 2. Pain accentuated by springing/provocation (>3-4)* 3. No sx centralization with BB* 4. No central pain 5. No consistent pain pattern 6. Pain altered by torsion 7. Ipsilateral tension in multifidus and erector spinae 8. Ligaments tender to touch
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Principle S/Sx of SI Dysfunction
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Anatomy- 2 innervated synovial joints Attachments: - Sacrospinous lig - glute max, coccygeus, spinchter ani, levator ani mm.
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Anatomy of Coccyx and attachments
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- Sprains: direct trauma from fall - Fractures: childbirth, direct trauma - Indirect stress: hypermobile SI via sacrospinous lig, disc pressure on dura matter causing pull on filum terminale (2nd piece of coccyx)
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Causes of Coccygeal Dysfunction
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History - trauma, sitting, defecation - localized pain and tenderness Palpation - tender to direct pressure & passive motion - restricted mobility - tender to resisted glue max (indirect stress) Radiology - fracture or displacement
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Coccyx Examination (history, palpation, radiology)
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Standard tx via stress reduction: - pillow or pads (square or rolled up newspaper) - avoid climbing stairs - avoid sling-type chair (i.e. airplanes bad) Manipulation: - gloves, lube, escort by same sex colleague - index finger rectum, opposite thumb on outside - Long axis distract 3-5 times - conclude with US - 2nd-3rd sessions repeat distraction and US - if unsuccessful --> consider thrust
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Standard coccyx treatment & manipulation technique
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Leave along for 10 days post injury (unlikely to see them at this time)
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What do you do if you have a patient with acute coccygeal synovitis/hemarthrosis?
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YAH: - meet patient, establish relationship - find probable cause and contributing factors - explain findings to patient - provide emotional comfort - some self-treatment instruction (MAYBE some tx) NAH: - feel you must tx - feel you must complete entire exam - not obtain sufficient objective data to give advice
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What to do and not to do on patient's first visit:
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- 20 categories - categories signify various involvements: vascular, nerve, bone, muscle, chemical, normal emotion, abnormal emotion *Normal = 1-2 words in 3-5 categories *Emotional = 2 or more words in 6-12 categories *Problem = 2 or more words in 10 or more categories *Impossible = 1 or more words in 18 or more categories OR 1 word in every category
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Paris' Interpretation of McGill Pain Questionnaire
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Start- "Tell me in your own words..." End- "Is there anything else you wish to tell me..."
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What questions do you start and end an examination with?
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1. Bizarre hx - something not right 2. Unusual hx - not within your experience 3. Pain came on at night, worse at night 4. Not relieved by rest 5. Not aggravated by movement 6. Other health problems 7. Change in bladder/bowel function 8. Throbbing/burning pain 9. Chest pains 10. Pains in nape of shoulder, sternum, T/L junction
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Red Flags during examination
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In order of importance 1. Injury - fault, compensability, lawyers 2. Self-Efficacy - pt predicted disability 3. Demographics - income, education 4. Pain hx - back at work? duration? 5. Job - satisfaction, employer attitude to light duty, physical reqs
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Yellow Flags
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1. Observe for symmetry of jaw and face 2. Open & Close jaw - lateral swing? mid-range difference & swing into c-curve (meniscus) 3. Measure range in open/close & side to side - if significant 4. Palpation - over TMJ & auditory meatus
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TMJ Overview
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Causes = poor head posture, dental problems, anxiety/stress, trauma S/S = local pain/tenderness, painful movement, clicking jaw, headaches
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Craniomandibular System Dysfunction
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1. General aging changes 2. Joint space/bone density - degeneration 3. Anomalies - congenital/developmental 4. Movement films/videos 5. Stress films
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What PTs look for in imaging
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... (look in FCO)
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SLR Confusion
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1. Myofascial States 2. Facet dysfunction 3. SI impairment 4. Ligamentous Weakness 5. Instability 6. Disc dysfunction 7. Spondylolisthesis 8. Lumbar Spine Stenosis - Central Spine Stenosis 9. Lumbar Spine Stenosis - Lateral Foraminal Stenosis 10. Cervical Spine - Central Spine Stenosis & Myelopathy 11. Cervical Spine - Lateral Formainal Stenosis 12. Whiplash - Acceleration & Deceleration 13. Elevated First Rib 14. TOS 15. Headaches 16. Lesion Complex 17. Lumbar Spine - Kissing Spines (Bastraps Disease) 18. Cervical Spine - Kissing Lamina 19. Thoracolumbar syndrome (Maignes Syndrome)
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Principle Syndromes of the Spine
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Nerve Spinal Cord Disc (other than outer annulus)
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What tissues are non-innervated?
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Outer annulus of disc (especially posterior annulus) Some branches around beginning of nerve root Facets - strain/sprain Sacroiliac - strain/sprain Muscles - chemical muscle holding, tear, ect Ligaments - strain/sprain Bone - compression fracture
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What tissues are innervated?
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State of rest of a muscle
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Tone
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Increased resting state
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Hypertonicity
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Decreased resting state
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Hyptonicity
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An uncontrolled involuntary jerk/twitch of a muscle: - Spastic torticollis - Reaction to a spring test - Reaction to palpation It is momentary and indicates an impairment and nothing more
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Spasm
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Non entity-none have been found
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Fibrositis
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Better name than fibrositis - fibro-fatty & calciferous deposits can be found in otherwise healthy muscle
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Fibromyalgia Deposits
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Extremity muscles
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First layer of back muscles
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Extensors or Compressors - namely the erector spinae Can load up spine, but cannot stabilize - unable to resist blocking
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Second layer of back muscles
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Multifidus & QL
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What are the key stabilizers posteriorly
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1. Increase in bulk from the normal 2. Normal physiological response to exercise 3. Secondary to muscle & body building activities 4. May be seen in some occupations 5. Tends to overload joints 6. May limit range of motion
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Hypertrophy
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Cause: - Injury/Dysfunction S&S: - Hypertonicity - Protective muscle guarding - loss of "free" motion - Elevated resting tone - Abnormal elastic response to touch Intervention: - Treat the cause of impairment
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Involuntary Muscle Holding (Guarding)
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Cause: - Sustained involuntary guarding - May possibly lead to a compartmental syndrome S&S: - Doughy to touch - Limited ROM Intervention: - Heat & massage (deep finger kneading) - Think compartmental syndrome - multifidus
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Chemical Muscle Holding
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Cause: - Pain or fear of pain - Often follows involuntary & chemical states S&S: - Slow & guarded motions - Trunk moves as a whole Intervention: (Once sure nothing serious e.g. fracture) - Ignore, give reassurance - Movement - repetitive motion
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Voluntary Muscle Holding (Guarding)
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Cause: - Underused muscle - Place an arm in a sling & the muscles will waste - Place a back in a brace & the same may happen - Stiff joints in the spine lead to disuse atrophy S&S: - Loss of bulk on MRI, CT, ultrasound scan, to palpation Intervention: - Manipulate stiffness - Exercise the muscles - walking, etc
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Disuse Atrophy
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Cause: - Neurological as in paresis from disc prolapse - More significant when from a large disc protrusion getting 2 nerves - Spinal cord tumors getting 2 or more nerves - Surgical S&S: - Rapid loss of muscle bulk - Fibrous nature of muscle Intervention: - Exercise as innervation returns - Myofascial release to fascia of muscle
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Wasting & Fibrosis
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Cause: - Chemical muscle holding - Slouching posture (e.g. sub-cranial extensors) S&S: - Normal tone - Shortened length, loss of ROM - Altered posture - increased lordosis secondary to psoas shortening Intervention: - Myofascial stretching
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Adaptive Shortening
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1. Sustained stretch - fatigues the stretch reflex - must be in excess of 15 mins 2. PNF - Uses contract/relax/stretch to stretch the collagen of the muscle when it is momentarily relaxed 3. Inhibitive distraction - Uses pressure over the origin or insertion of the muscle to stimulate the GTO's ; thus cause the muscle to relax prior to the therapeutic stretch 4. Overpower the muscle - Can rarely be achieved - exception is hemiparetic pts
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4 Methods of stretching a muscle
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A rheumatic disease of the soft tissues characterized by a history or widespread pain occurring for longer than three months in combination with pain in eleven or more of eighteen specific bilateral tender points in muscular tissue
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Fibromyalgia definition
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Causes: - Specifically unknown - Deprivation of restorative sleep - Neurobiological abnormailites - Loss of sympathetic nervous sys control - Local tissue factors - Physical trauma ; viruses - Psychological factors S;S: Primary: aches ; pains, stiffness, swelling in soft tissues, tender points, muscle spasm ; nodules, upper body weakness Secondary: excessive fatigue, non-restorative sleep, chronic tension migraine, headaches, bowel ; bladder irritability, dysmenorrheal, paresthesia, Raynaud's phenomenon, chest pains, anxiety, depression, swelling & numbness of the extremities
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Fibromyalgia Syndrome - Causes and S&S
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Multidiciplinary: education on coping strategies, energy conservation, time management, stress management, nutrition, preparation for sleep techniques Medication: combination of SSRI's, tricyclic antidepressants, short term NSAID's Exercise: posture, low load - low repetition strengthening, low impact aerobic conditioning, biofeedback focused on lowering sympathetic tone
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Fibromyalgia Management
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Perform the treadmill or bike test - Position 1: no incline TM and upright on bike - Position 2: incline on TM and lean forward on bike - Interpretation: - Decrease in tolerance/time 1 > 2 = vascular - Increase in tolerance/time 1 > 2 = neurogenic
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Differentiate between vascular and neurogenic claudication
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1. Synovitis/Hemarthrosis 2. Stiffness 3. Painful Entrapment 4. Mechanical Block 5. Chronic Facet Arthrosis
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5 Types of Facet Dysfunction
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Cause: - Awkward movement or catch - Gross trauma S&S: - Good but guarded movement - Involuntary & voluntary muscle holding Rx: - Lumbar: rest, soft corset, careful movement - Cervical: rest, soft collar, careful movement - circular, consider interferential for swelling
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Synovitis/Hemarthrosis
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Cause: - Resolved synovitis/hemarthrosis (not symptomatic) S&S - none - stiffness does not hurt - Lowered tolerance to insult hence strain & associated pain if from: - Current strain of joint - Neighboring hypermobile joint may become symptomatic - unstable Rx: - Manipulation
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Stiffness
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Cause: - Awkward movement in eccentric range S&S: - Unable to slide inf. art. process down - Head held away from painful side - torticollis Rx: - Isometric manipulation (cervical & lumbar) - Rotation manipulation over bolster (lumbar)
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Painful Entrapment
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Causes: - Idiopathic - Loose body - Impaction S&S: - Sudden block - Block to motion - Relatively pain free Rx: - Cervical - strong manual traction with side bending away & rotation to the blocked side - Lumbar - rotation manipulation over a bolster to further open up the affected side
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Mechanical Block
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Cause: - Poor posture - Trauma - Over use S&S: - Dull ache - Local pain - Stiffness (worse in morning, eases throughout day) Rx: - Posture - Mobilize adjacent areas
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Chronic Facet Arthrosis (FCO = OA)
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Cause: - Repeated minor strains, obesity, poor posture, vibration S&S: - Pain on assuming a fixed position - Pain relieved by changing position - Relieved by "cracking" the back increasing the weakness - Ligaments (supraspinatus & SI) sensitive to touch Rx: - Early Stages - exercise, stabilization, posture, back school - Later stages - Pre-discal, rest/controlled activity, corset, braces, taping, instruction in first aid
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Ligamentous Weakness
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Instability is where the osseo-ligamentous structures and the neuromuscular control systems are unable to hold a spine in neutral and during motion against buckling and slippage/shear.
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Instability Definition
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Causes: - Ligamentous stress & strain from sports and poor posture - Lack of neuromuscular training & exercise - Surgical such as in a wide laminectomy or secondary to fusion - level above - Medical/surgical such as with chymopapain Sx: - Ligamentous weakness - Muscle weakness & neuromuscular atrophy - Fatigue - Poor posture - Pain on assuming fixed position - Chronic pain
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Instability causes & sx
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History: catches and twinges, sudden pain, pain on prolonged sitting/standing Structure/appearance: - Obesity and poor posture - Spondylolisthesis - Involuntary muscle guarding - Step on standing that disappears on lying Active Movements - Uneven, slippage, juddering - Pain at end of range - Poor balance and neuromuscular control Palpation: - Tenderness to palpation of ligaments - Grade 5 or 6 on PIVM - Positive prone instability test
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Instability Physical Exam
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1. Ensure slow continuous improvement 2. Train for health and performance: muscle endurance, motor control, diet & nutrition (no smoking), motivation, frequent rests for disc nutrition, educate, ADL instruction 3. Exercises: abdominal setting (TA), multifidus, QL (esp. females), quads/abs/glutes 4. Manual Therapy: according to what is found -> manipulations, minimal use of modalities
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Instability Treatment Principles
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Causes: - Lateral disc protrusion - Loss of disc height - Degenerative changes to lig flav & facets S&S: - Lateral symptoms - pain, subjective numbness, hyper neurological responses - True neurological signs, paresis > skin sensations > reflexes > neural tension Rx: - Posture education - Stabilization - Stretch myofascia (back & psoas) - Manipulate stiff joints - Positional distraction - Possible heel lift on unaffected side to open up affected foramen
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Lumbar Spine - Lateral Foraminal Stenosis
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Causes: - Congenital narrowing of cervical spine canal - Hypermobility / Instability - Resultant bosses & bars into spinal canal - Enfolding of ligamentum flava Contributing factors: - Poor posture - Cervical stress, strain, sports, MVA - Compensatory hypermobility to UT kyphosis/stiffness - Instability mostly at C2/3 & C5/6 S&S: - Bilateral upper extremity symptoms - Vague, transient neuro signs - arms & maybe legs - Test lower extremities for UMS signs Babinski & Clonus Rx: - Posture - axial extension - Stabilize cervical spine - deep ant. muslces - Avoid backward bending - sleeping postures, cycling, basketball, breaststroke, ect. - Manipulate upper thoracic region to help reduce MC stress -Surgery - removing impingements & then fusion
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Cervical Spine - Central Spine Stenosis & Myelopathy
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1. Patient < 40 yo 2. Abherent motions present 3. Good Hamstring length 4. Positive prone instability test
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CPR for lumbar stabilization
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Begins at ~ L3/4. Total prolapse could result in cauda equina involvement -> bladder retention or loss of control = Emergency surgery within hours to reverse damage
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Cauda Equina Involvement
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Disc Protrusion - bulging annulus: - Type I: Localized annular bulge - confined to one side - Type II: Diffuse annular bulge - bilateral, can be contained by some extent by PLL Disc Herniation - torn annulus: - Type I - Prolapsed nucleus - confined solely by the outermost fibers of annulus - Type II - Extruded nucleus - breaks through the outermost fibers of annulus and lies underneath PLL - Type III - Sequestered nucleus (free body) - nuclear material breaks through PLL and be free in spinal canal
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Disc Dysfunction - McNab Surgical Classification
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Posture: - Mostly axial extension - Keep all ROM within range Avoid: - BB - Neck rolling - Isometrics - cause translation/slippage = aggravates instability Treatment: - Strengthen longus coli (deep neck flexor training) - Multifidus strengthening
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Cervical Spine stabilization
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He believes a disc can heal due to mounting evidence = timely detection of minor disc problems -> effective treatment to avoid surgery. Should a protrusion occur, pts can be made asymptomatic until they are reabsorbed.
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Paris' philosophy on disc healing
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From out -; in: ALL/PLL -; Sharpey's fibers & Neurovascular Capsule -> Annulus (6-10 concentrically arranged going from tough fibrocartilage outermost -> loosely arranged fibrous tissue in innermost) -> Central Zone -> Nucleus Pulposes From top/bottom -> in: Hyaline cartilage on vertebra (weak link) -> Cartilage end plate w/ bony cap over nucleus and behind cartilage end plate -> Annulus/Nucleus
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Disc Anatomy
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Starting on pg 217 of FCO
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Need more on the DISC
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1. Pre Prolapse - instability 2. Immediate Injury - tear or herniation 3. Acute & Sub Acute Prolapse 4. Settled Prolapse 5. Chronic Disc Disease
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Paris Treatment Classification
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History: - Dull muscular ache on sitting - Self-cracking - LBP w/ occasional buttock radiation - No frank neuro signs Physical: - Many signs of instability - Grade 5 ot 6 to PIVM Treatment: - Stabilization - dec load, inc endurance - Back school - education - Manipulation - joint/myofascial - Instruction on 1st Aid (BB upon injury)
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Disc Pre Prolapse Stage
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History: - History of pre prolapse - Sudden unguarded motion resulting in acute but deep pain (FB + rotation/torque) - Pt may say it tore, ripped, gave out S&S: - Sudden deep pain - May refer to buttocks - Very guarded motions Physical: - PT unlikely to be present - Don't do a physical such as FB and rotation - Neuro signs will be negative for 1st 30 min Rx = go heal outer annulus - Immediately into lordosis (min 2 wks, 3 -4 wks best) - Support/reinforce with taping/corset - If not in lordosis -; try to gain it -; if can't be gained without S&S go to Acute Stage - Back School - Gentle stabilization exercises (muscle fusion) - Myofascial techniques
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Disc Immediate Injury (tear/herniation)
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S&S: - Classic neuro signs - Fatigue and disability Acute = day 1 - 4 - Try to gain lordosis, if gained go to Immediate stage - Min bed rest (3 days max) -> disc swells with rest - Try BB, probably too late - Medical palliative measures - Education = move, don't rest too long, laxatives Sub-Acute = day 4 ; improving - Initiate Movement - Myofascial manipulation - Corset - Stabalization - Avoid aggravating prolapse
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Disc Acute ; Sub Acute Prolapse
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Settled = 3-4 weeks, slow improvement (ambulatory) - Commence positional distraction w/ caution (HEP) - Stabilization - Healthy back regime as lifestyle - Goal = prevent chronicity by encouraging activity ; managing fear
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Disc Settled Prolapse
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No great solution/hardest to treat History: - Serious debilitating back pain w/ hx of neuro signs - Possible failed surgery or surgery + reoccurence Physical: - Sad, depressed, on meds, obese, smokes, un-fit, diabetic - ROM restricted due to pain - PIVM = instabilities and restrictions - Myofascia restrictions ; poor tone/condition Rx: - Life style education - Stabilization - Neuro = positional distraction - Careful neural mobs - Manipulation - joint ; myofascial - Fitness training/work hardening - Counseling
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Chronic Discogenic Back Pain
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1. Type I = Fatigue Fx of pars 2. Type II = Degenerative - facet arthrosis ; tropism 3. Type III = Isthmic
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3 Types of Spondylolisthesis
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Causes: - Pars interarticularis (isthmus) lengthens = vertebrae above slips forward - Precipitating factors are childhood obesity S;S: - X-ray may show elongated pars/isthmus - X-ray may also show fx of pars and thus the initial cause (isthmus or pars stretch) is often missed Rx: - Stabilization ; Manipulations (usually jt above + myofascia like psoas) -; same as Rx for Type I ; II - Weight control
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Isthmic Spondylolisthesis
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S;S: - Dull ache - ligamentous - towards end of day - Step in standing that disappears in lying - Muscle guarding on standing that disappears on lying - Rotational fault if just one side (spondylolysis) Rx: - Stabilization - Manipulation to joints and fascia to reduce stress - Education to reduce loading ; Ext activities - Surgical if PT cannot stabilize esp. if neuro signs = fusion, pedicle screws
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Unstable Spondylolisthesis (all types)
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Cause: - Degeneration, wear and tear, poor posture, abdominal protrusion/lordosis, tight iliopsoas, tight lumbar myofascia - Disc protrusion, prolapse (37% asymptomatic) S;S: - Chronic, dull low back pain - Leg pain on walking any distance - neurogenic claudication (DD vascular, do bike/TM testing) Rx: - Myofascial manip ; stretching (psoas, low back) - Increase physical fitness (pool, unweighted TM) - Life style changes - smoking, obesity, posture - Surgery - fusion with forminectomy and/or "360" (consider anterior approach)
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Lumbar Spine - Central Spine Stenosis
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Radiculopathy Causes: - Degenerative changes - Osteophytes from lateral interbody articulations (U-joints) - Thickening of ligamentum flavum - Arthrosis of facet joints Contributing Factors: - U/T slouch and stiffness - Mid-Cervical hypermobility/instability
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Cervical Spine - Lateral Foraminal Stenosis (Causes ; Contributing Factors)
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S;S: - Neck ; arm pain ; paresthesia - Frank neuro - muscle, skin, reflex - + ULTT, + Spurlings (see Wainner 2003) Rx: - Joint/myofascial release - Posture - Positional distraction - Surgery: foraminectomy, surgeon tells pts they did disc surgery
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Cervical Spine - Lateral Foraminal Stenosis (S;S, Rx)
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Lumbar - Discogenic - Younger 28-50 yo - Male ; Female Cervical - Spondylogenic degenerative arthrosis = lateral formainal stenosis - Older 50+ yo - Women ; Men?
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Neuro signs lumbar vs. cervical
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See Sterling 2014 Causes: - MVA - Fall down stairs - Struck by yacht boom (really?!) S;S: - Very unreliable - Often initially minimal - Minor to bizarre - Sympathetics Tx: - Rigid immobilization 2 weeks + min movement - Plastic collar @ 1 wk if symptom free - Soft collar @ 4 wks if symptom free + light exercise - NO TRACTION EVER until after 8 wks + no resisted exercises
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Whiplash Acceleration/Deceleration Injuries (WADs)
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- X-rays of dens for fx not always reliable (unless slight dislocation or begun healing) -; listen to pts c/o instability and feeling like they have to hold head on - ONNLY 1 in 22 FRACTURES WILL BE SEEN ON X-RAYS! - None of the tears to ligaments, muscles, nerves, esophagus, trachea, and bleedings around brain stem ; behind eyes will be seen on x-ray
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WAD Concerns
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Compromise of the neurovascular structures of the upper extremity
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TOS Definition
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Causes: - Functional - hypertrophy/adaptive shortening of anterior scalene, adaptive shortening of pec minor, hypertrophy subclavius, elevation of 1st rib - Congenital - Broad or two-band insertion of anterior scalene, fibrous slip from ant to middle scalene, cervical rib or fibrous band from C7 - Other - Old fx of 1st rib = bony exostosis, tight clavipectoral fascia
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TOS Causes
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Symptoms: - Pain ; Paresthesia in UE - Deep aching, ill-defined - Intermittent claudication - Raynaud's phenomenon - Intermittent edema, venous engorgement, cyanoses - Dorsal scapula pain Rx (depends on what was found): - Manips including 1st rib & myofascia - Postural re-ed - Diaphragmatic breathing - HEP - stretching & mobs - Special treatment for release phenomenon
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TOS S&S, Rx
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Signs that we can help: 1. Pain begins in the cervical or thoracic spine 2. Headache can be affected by change in posture/movement 3. Hx of trauma preceded headaches 4. Physical/emotional stress brings on headaches Red flags - Very short hx - New headache that they haven't had before - Worse than ever before - Behavior/modd changes Treatment Sites/Methods: - Sub cranial region - T1-T3 and T8-T9 - Inhibitive Distraction -Acupressure
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Headaches
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More than one structure syndrome. Refers to the fact that while one entity may predominate others will soon be present. Similar to Kirkaldy-Willis' "degenerative cascade."
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Lesion Complex Definition
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- Soft tissue restrictions = myofascial techniques - Limited segment (facet) motion = manipulation - Restricted hip function = manipulation - Instability = stabilization routines - Poor general condition = general conditioning excercises
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Summary of Treatments for Lesion Complexes
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Impairment not disease = artificial joint between SP & lumbar spine, arthritic joint forms between spinous processes. Causes: - SPs rubbing in post midline - Inflammatory reaction = source of pain Contributing factors: - Poor posture - Pot belly w/ excessive lordosis - Short stocky males, midlife
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Lumbar Spine Kissing Spinous Processes - Baastrups Disease (Cause/contributing factors)
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Rx: - Pelvic tilt - Stretch psoas/myofascia - Weight loss - Healthy back living Surgery: - Remove portion of SP - Denervation of medial branch post primary rami - Sclerosants - phenol to deaden nerve
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Lumbar Spine Kissing Spinous Processes - Baastrups Disease (Rx/Surgery)
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A condition of friction between lamina at one or more cervical levels. Cause: Friction between lamina or vertebra S&S: Central Neck pain Contributing Factors: - Excessive mid-cerv lordosis - Stiff U/T - Mid-cerv hypermobility, instability - Loss of disc height - Collapose of lateral interbody joints (U-joint) Rx: - Posture & Stabilization - avoid BB and circumduction - Manipulation U/T
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Cervical Spine Kissing Lamina
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Cause: - Instability at the T/L junction involving the lateral cutaneous nerve to thigh S&S: - Pain over lateral thigh - Spontaneous giving way of leg = often confused with hip impairment - Tenderness over iliac crest laterally Rx: - Stabilization T/L junction - multifidus exercises
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Thoraco-lumbar syndrome - Maigne syndrome
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- Restore ROM & thus function - Help abate pain - Improve nutrition - Decrease risk of re-injury
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Why do we manipulate stiff joints?
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*Deep neck flexors Function - mobility (control of IV joint motion and lordosis), - proprioception - support/stability Longus Capitus Attachments: C3-6 TPs to the occipital bone (basal) Innervation: C1-3 spinal nerves Function: flex head and neck Longus Coli Superior oblique portion: C3-5 TPs to anterior arch of atlas Inferior oblique portion: Ant vert bodies T1-3 to TPs C5-6 Vertical portion: Ant vert bodies C5-T2 to C2-C4 Innervation: C2-7 spinal nerves Action: Flexes neck, postural, control lordosis of c-spine
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Longus coli & Longus capitus
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Attachments: iliac crest to L1-4 TPs and 12th rib Innervation: L1-4 ventral rami Action: trunk extension, ipsilateral SB, eccentric control of SB contralaterally, and assists in inspiration (elongates thorax) Extra: Important muscle in females as they have a greater tendency towards trendelenburg gait
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Quadratus Lumborum
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- Measures the muscular endurance and strength of longus coli and capitus - Before test - assess neural tensioning, sub-occipital length, SC PIVM - Set-up - hook-lying, towel support head in neutral, deflated cuff folded placed under SC spine (C0/1/2), chin and ear line parallel, inflated to 20mmHg and ensure all pockets of cuff full STAGE 1 - analysis first to determine if training needed before testing; nod head slow and controlled, avoid overuse of global mm (SCM), assess at 22, 24, 26, 28, 30mmHg; compensations > train 1st! STAGE 2 - Testing; flexion NOT retraction; 10 reps or 10 secs at each increase in pressure (22, 24, etc..) NORMS: Asymptomatic subjects: 26-28mmHg Symptomatic subjects: 20-26mmHg Goal = 30mmHg b/c we want to reach better than average
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Cranio-Cervico Flexion Test (CCFT)
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End-feel = quality of resistance felt while passively taking a joint through range - Normals (5)- soft tissue approx, muscle, lig, cart, caps - Abnormal (10 FCO)- caps, adhesion, bony block, bony grate, springy rebound, pannus, loose, empty, painful, muscle Capsular Pattern = restricted pattern characteristic to that joint (upslide/gapping in spine) -A/PROM restricted -Pain maybe at end-range - No pain with resisted motion
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Define end-feel and capsular pattern
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Validity - Jull et al 2004 Spine Reliability - Chui 2005 JOSPT
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Research for CCFT
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General responses: - Loss of GAGs in connective tissues - Increase in crosslink formation in connective tissues - Poor orientation of newly deposited collagen fibers - Fatty fibrous infiltration of edematous areas - Pannus formation inside joints - General atrophy of all tissue types Leads to: - capsular contractures - ligament shortening - muscle incompetence
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Effects of Immobilization
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Disc - Neurovascular capsule = recurrent nerve, sinu vertebralis, direct branches of mixed spinal nerves and gray rami communicans Facets - medial branch of the dorsal ramus of the nerve (L3 & 4 innervates L4/5)
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Innervations of disc and facets
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1. Joint injuries are dysfunctions/impairments not diseases 2. Impairments are represented by abnormal movement (decreases or increases of motion) 3. When there is a hypomobility = manipulate 4. When there is a hypermobility = stabilize 5. DJD results from long standing dysfunctions/impairments 6. PT examines and treats dysfunctions/impairments not disease = primary care physicians of musculoskeletal system 7. Goal is to correct the impairment not pain 8. To understand dysfunctions we must know anatomy and biomechanics 9. The patient has a responsibility to maintain/enhance their health, we should set example 10. Because of our knowledge, referrals should not be needed
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Abbreviated USA Philosophy
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PAIN: 1. Gradual: Disc Protrusion (referred after 20 minutes) 2. Sudden: Entrapped Facet Capsule (may refer into leg) PAINLESS: 1. Gradual: involuntary muscle holding secondary to facet synovitis/hemarthrosis, poor posture, SI strain/disorder = ipsilateral multifidus guarding, late day or alternating (unstable lumbar spine - annular protrusion, post chemonucleosis, post laminectomy) 2. Sudden: facet stuck in upslide position (ex. shift left - right facet stuck) -- caused by loose body present, roughening of surfaces, wasting of cartilage -- includes SI displacement
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Differentiate between the causes of lateral shift (sign not syndrome)
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1. Typical disc protrusion = affects lower root (ex. L4/5 ? L5) If lateral disc bulge = lean away If medial disc bulge = lean towards 2. Large disc protrusion = affects both roots (ex. L4/5 ? L4 & 5) ? extensive muscle wasting and loss of skin sensation (need to DD with spinal tumor) 3. Total prolapse = cauda equina ? immediate surgery (can happen with sneezing, lumbar traction, twisting, etc.)
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Disc relationship to nerve root, how it affects injury
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Perform the treadmill or bike test Position 1: no incline treadmill and upright on bike Position 2: incline on treadmill and leaned forward on bike Interpretation: Decrease in tolerance/time 1 > 2 = vascular claudication Increase in tolerance/time 1 > 2 = neurogenic claudication
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Neurogenic vs. Vascular Claudication
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33 vertebrae 23 intervertebral discs Cervical articulations: C1 = 5; C2 = 9; C3-C7 = 10 Thoracic articulations: 12 total, 10 synovial Lumbar articulations: 6 total, 4 synovial Sacral articulations: 6 total, 1 synovial?
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Spine Stats
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SLR is positive if pain below the knee is present below 70 degrees of hip flexion, inclinometer best, goni okay. Hamstring tightness will present as muscle tightness above the knee with increasing hip flexion.
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+ SLR vs tight hamstrings
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- Vertebrae rocks over nucleus - Facets slide up ~ 40% displacement - Anterior disc is loaded and bulges anteriorally - Posterior disc is drawn taut and may become concave - Nucleus deform posteriorally - Intervertebral foramen enlarge in a vertical dimension - Motion limited by posterior ligaments, disc and myofascia
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Mechanics of lumbar FB
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- Vertebrae rocks over nucleus - Facets slide down and contact lamina below - Posterior disc is loaded and bulges posteriorally - Anterior disc is drawn taut - Nucleus distorts anteriorally - Top vertebrae translates backwards - Intervertebral foramen narrow both in AP and vertical directions - With continued BB facets become fulcrum, the disc space undergoes distraction, and the facet capsules are stretched (more so than in FB)
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Mechanics of lumbar BB
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- Facet on same side slides down - Facet on opposite side slides up - Disc bulges on same side, flattens on the opposite side - Vertebra rotate to the opposite direction
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Mechanics of non-functional lumbar SB
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- Facet on the side opposite the direction of rotation becomes a fulcrum - Vertebra translates to the same side - Same side facet joint opens in distraction - Disc is compressed as a result of the torque - Only ½ the layers of the annulus will be called upon to take the stress
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Mechanics of lumbar rotation
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Best results: - Acute facet impingement or block - SI displacement - Acute loss of lumbar lordosis Worst results: - Chronic disc - Stenosis - Delayed return to work
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Prognostics
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Type of biological current. Generated when crystalline structures are deformed, occurs the most in bone than any other body tissue, small amplitude and short lived currents, many believe they are not biologically significant.
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Piezeoelectric effects
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Dominant electrical activity in all body tissues, occurs as a result of differential flow of ions within tissues (all tissues have collagen and proteoglycans (- charge) which is offset by net + charge of surrounding fluids, the flow of + charges creates a current) **in articular cartilage, a direct relationship has been found between the presence of streaming potentials in healthy cartilage and the gradual loss of potentials with progressive cartilage degeneration. If only stretch into the elastic region of a capsule, may increase strength (ie. stiffness) due to Wolf's law...must stretch into the plastic region.
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Streaming Potential
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Causes: - Sacral base = unlevel: pelvic rotation, ilial upslip, effect on sacral base, hip dysfunction, short leg, pronated foot - Sacral base = level: bony anomalies in lumbar spine, idopathic, subcranial rotational or SB fault Surgeon looks for: LLD, radiologic anomalies, hearing/visual impairments PT looks for: pelvic, subcranial
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Scoliosis (causes)
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MD: traction, corrective jacket/braces, fusion, harrington rods, dwyer instrumentation PT: find cause, address cause, and then rotary component of remaining curve. Idiopathic = treat rotary component Behavioral corrections. Mechanical = rest, exercise ; pressure pads Pads = lower 1/2 of convexity -; lie on firm floor 15 min to 2 hours.
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Scoliosis (Rx)
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1. Avoid FB 2. No Long sitting 3. Lift vertically and use legs 4. Comfortable bed 5. Lie on your side to rise from bed 6. Keep moving, swing arms when walking 7. No vigorous activities 8. Appropriate PT instructed exercises 9. Avoid movements that hurt
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Back School - Lumbar
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1. Keep head up at all times 2. No neck rolling 3. Avoid excessive UE work especially overhead 4. Avoid lifting 5. No excess pillows 6. Don't prop neck up when lying down 7. Avoid movements that hurt
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Back School - Cervical
