Download MS Part 2 Outline

Traction
Affects of traction
 Distract/separate vertebral bodies
 Distract/glide facet joints
 Tense ligaments
 Widen IV foramen
 Straighten spinal curves (sketchy…..)
 Stretch spinal mm
Asterisks
 Joint glides, ROM, neuro signs (numbness, tingling, reflexes)
Lumbar Traction
 Minimum: 25% of body weight
 Maximum: none; patient comfort (50%?)
 Sequence: Fit belt according to desired tension (anterior/posterior pull, supine/prone position), place patient in
desired position on table, attach superior and inferior belts with pillow case/towel at sensitive areas except where
skin contact is necessary, give patient panic button, turn on machine
 Intermittent: sub-acute, chronic (DDD)
 Static: acute or irritable (especially acute HNP)
 Disc herniation position: prone w/ anterior pull if tolerable, supine anterior pull with legs neutral
 DDD position/Facet position: supine 90/90 if tolerable
 Contraindications: fusion, tumor, infection, instability, osteoporosis
 Duration: 3-5 min first day
 Types:
o Long axis traction via LE: uni or bilateral. Uni for facet.
o Cotrell: put them in posterior rotation to promote extension???
Cervical Traction
 Minimum: 5 lbs. day 1, poundage can be greater for chronic compared to acute
 Maximum: none, patient comfort
 Angles: mid-upper C spine: neutral (up to 20 degrees). Lower C spine: 25-30 degrees.
 Intermittent: sub-acute, chronic (less irritable) (chronic mechanical neck disorders, radicular findings,
degenerative changes)
 Static: acute (more irritable, severe)
 Duration: 3-5 min first day
Position
 Prone posterior: if more comfortable
 Prone anterior: DDD, HNP
 Supine posterior: nerve root compression, stenosis
 Supine anterior: HNP if can’t get into prone
Pull
 Posterior pull: if flexion is desired.
 Anterior pull: if extension is desired.
Syndrome
 HNP: separate vertebrae- decreased pressure at discsuction force
o Sustained or long hold/rest intermittent (60 hold/20 rest).
o 5-10 min
 DDD: decreased intradiscal pressure. Optimal mode of regeneration for nutrition
o Short hold/rest intermittent
 Hypomobility: form of mobilization that involves passive movement of joints
o Short hold/rest intermittent
 Facet impingement: to release restriction of facet joints
 Mm spasm: decompress or separate painful joint structures. If pain is relieved w traction, mm spasm will be
relieved secondary to relaxation of nociceptive reflexes.
Evidence based practice
 Effects are short term (< 5 weeks)
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Benefit pts with acute (< 6 weeks) radicular pain
CPR: Success of LBP mechanical traction
o Low level fear-avoidance beliefs
o No neurological deficit involvement
o Age older than 30
o Non-involvement of manual work
Effective for pts w leg symptoms, signs of nerve root compression, and either peripheralization with extension
movements or crossed straight leg raise
Contraindications: structural disease secondary to tumor/infection, osteoporosis, condition where movement is
contraindicated, vascular compromise, RA, TMD
Caution: acute sprains/ strains, inflammatory condition that might be aggravated, joint instability, pregnancy,
osteoporosis, hiatal hernia, claustrophobia
Cervical Spine
Origin
 Whiplash/MVA, sports collisions, overuse, sleeping posture, excessive computer use, infection, tumor, OA, disc
degen., disease processes
 Improper mechanics: C spine, scapula, shoulder, and/or posture
Cervical curve
 Child lifts head at 3-4 months
 Head and eyes remain oriented fwd
 Shock absorbing: for axial compression of head weight
Anatomy
 Facets
o Horizontal joint angle: avg=45º. Upper c-spine=35º. Lower= 65º
 Uncovertebral (joints of von Luschka)
o C3-T1
 Intervertebral foramen
o Close: full extension + ipsilat side bend
st
 1 Rib
 Ligaments
o ALL: narrower in UCS but wider in Lower CS than TS
o PLL: broader and thicker in CS vs TS/LS
 Muscles
o Trapezius: Accessory N (CN 11) and C3-4 ventral rami
o SCM: Accessory N (motor), C2-3 ventral rami (sensory)
o Levator Scapulae: ipsilateral rotation & side bend if scapula stabilized, bilaterally= CS extension
o Rhomboids
o Scalenes: attatch to 1st and 2nd ribs. If shortened TOS
 Neurology
o UCS: head and neck pain
o Mid-LCS: refer to shoulder, ant chest, UE, scapula
Biomechanics
 SB= ipsilat extension + contralateral flexion
 Rotation + ipsilat SB= ipsilat extension + contralat flexion
Examination
 Cloward sign: CS disc referred pain to interscapula area (~T3/4)
o Central=SC
o More medial=nerve roots
 Fwd head posture
o Causes neck mm to lose blood, suffer damages, fatigue, strain, cause pain, burning, fibromyalgia
o Shortening in posterior aspect, lengthening in anterior.
o Creep: tissues have undergone significant load for a sustained period and have remodeled.
 Disc=groggy and stiff in the morning

Classifications: clusters of meaningful clinical findings
o Benefit from Thoracic manip?
o Mobility patient: Manip, mobilization, ROM and ex
o Headache patient: Mobilization, manip, ex
o Exercise and conditioning patient: Neck mm and surrounding mm (Exercise, still some mobility and
mobilization)
o Centralization patient: Traction and cervical neck retractions
o Pain control patient: Modalities, ROM ex, +/- avoid immobilization
 Combined motion testing
o Closing restriction: restriction of cervical extension, SB, and rotation ipsilaterally
o Opening restriction: flexion, SB and rotation contralaterally
Intervention
 Postural re-ed, neck specific strengthening, stretching ex, mobilization, work ergonomic changes
Syndromes
 Cervical Disc: Cloward sign, ache stiffness, slow (guarded) movements, not associated w incident (sustained
posture), slow onset or wake w pain, flexion limited, painful ipsilat ext, SB, rot, painful central PA>Unilat.
Traction, central/Unilat PAs
 Spondylosis: hypo/hyper can cause DDD/DJD. Suprascapular fossa pain referral. Agg by sustained flex, quick
movements, EOR mvmts. Long history of neck pain. Traction and central/Unilat PAs. Scap stab, TS ext, pec &
cervical stretch, breathing ex, UE ex.
 Acute Nerve root: Caused by trauma or degenerative changes. Pain distal>proximal. Poss Cloward.
Constant/latent. Agg by any movement esp closing of foramen and UE movement. Awakes at night. Hx of neck
stiffness of scapular area. Traction & joint mobes (if decreased severity and irritability)
 Chronic nerve root: Degenerative changes. Proximal> distal pain. Intermittent. Agg by sustained flex and
movements that narrow foramen. Nagging but able to sleep. Hx of neck stiffness. X ray: degenerative facet
changes or foraminal encroachment. Joint mobes, traction, neurodynamic Tx
Work environment
 Make sure to ask about this!
 Adaptive equipment: phone head set
Studies
 Subjects with chronic neck pain had decreased ability to contract the deep neck flexors
 Evaluation of outcomes in patients with neck pain treated with thoracic spine manipulation and exercise: a case
series
Upper Cervical
Anatomy
 Bones
o C1-C2 facets: biconvex (allows C1 to slide down with rotation)
o Inferior articular facets are shaped as the rest of the C-spine (45 degrees to the horizontal).
o
 Ligaments
o Atlasocciput:
 ALLA AO M
o Axis occiput:
 PLLTectorial membrane
 Alar lig: densocciput. Resists flex, contralat SB & rotation. Attaches to occiput slightly
anterior, posterior or neutral
o AxisAtlas
 Transverse lig: resists ant-post movement of AA joint
 Muscles
o Suboccipital: Superior oblique (rotate to opp side like SCM). Inferior oblique rotates ipsilat
o Posterior: Rectus capitis anterior (lateral massocciput base. Head flexion and minimal rotation) and
lateralis (ipsilat side-flexion)
o CS mm have high density of mm spindles (for proprio of head position on neck)

Nerve
o C1-3 dorsal & ventral rami: mm, OA/AA/C2-3 Z joints, lig, vertebral As
Biomechanics
OA
AA
Occipital con glide post on C1
-C1 moves inferior on C2
Flexion
-C2 glides forward on C3
Occipital con: Anterior
-C1 moves superior
Extension
-C2 move backwards on C3
Ipsilat condyle glide posterior.
-Ipsilat facet moves posterior
Rotation
Contralat condyle anterior
-Contralat facet move anterior
-C1 translates to contralat side
Ipsilat condyle glides anterior
Side Bend
*(SB and rotation of OA is opposite)
 Osteokinematics
o OA: yes joint (flex/ext)
o AA: No joint (rotation) 50% of rotation occurs at AA
 Couples motions
o SB and rotation occur in opposite directions
o R Rotation=
 R rot + L SB of Occiput & C1
 R rot + R SB of C2 & down
o R SB
 R SB + L rot of Occiput & C1
 R SB + R rot of C2 & down
Vertebral A
 Causes: MVA (extension), trauma (compression), instability/fx, manip or sudden neck movements
 S&Ss: 5Ds= Drop attack, dizziness, diplopia, dysarthria, dysphagia (and paresthesia of lip, tongue, hemi-facial).
Present with gait disturbance
 Progressive occlusion of contralateral VA: rotationextensiontraction (ipsilat may be occluded if rotation >30
degrees)
 Heals in 6-8 weeks (VA testing should be withheld for at least 6 weeks post trauma)
Syndromes
 Poor posture: lower CS is flexed, UCS is extended. Causes shear forces to CS as the center of pressure shiftL
anteriorly. Lead to increased compression to posterior elements such as facet joints and neuronal structures,
specifically the C2 dorsal root ganglion and shortening to posterior muscles
o Glide: do post glide bc OA is already in end position
o Correct posture, soft tissue work, stretching, strengthening, glides
 Posture should be initiated by thoracic spine extension rather than dorsal glide of CS
 Head ache
o Vascular=pounding HA, dizziness, visual disturbance (not for PT)
o Neurological= intense nerve type pain (not for PT)
o MS= posture, position, or activity related (cervigogenic).
o Cervicogenic HA: Hx of neck pain, unilateral HA (If mechanical, it is unilateral and doesn't switch from
side to side.) Pain in neck, shoulder, arm. Variable pain, mod intensity, non-throbbing. Pain reproducible
w neck movement, posture, position. Ease w change in position, posture, lying down. Decreased neck
movements.
 Caused by pressure on OA, AA, C2-3, Hypo/hypermobility, trauma, mm shortening, DJD, joint
capsule tightening
 Referred pain O, C1, C2, C3, C4, C5, C6
o Tension HA
 Caused by stress or lack of sleep (tightness anywhere on cranium or Suboccipital region). Not agg
by physical activity.
 Bilateral, trigeminal distribution.
 MVA: whiplash or CC.
o Factors predicting impact & recovery: direction of force (hypertext most damaging because nothing to
stop extension), velocity of impact (8mph can cause concussion, 30mph intracranial bleeding), curvature

of CS (less curve=less shock absorption), Sx present immediately or later, # of accidents, head position.
Best for head to be in neutral and rear ended?
o Acute: pain is main complaint. Guarded AROM, associated w dizziness. May do UE movement.
Palpation is deferred. Lig test if tolerable. Goal is to protect structures and mobility within tolerance.
Cervical collar for instability. NWB ROM ex.
o Sub acute: Stiff and pain at EROM. Stability testing. PPVIMS & PAIVMS to assess hyper/hypomobility.
Goal is to gain mobility. ROM, stabilize, isometric ex. Mobilize stiff segments.
o Chronic: limited motion. Intermittent pain. Weak mm, postural changes. Palpate, Neurodynamic testing.
Detailed biomechanical assess. Same goal as sub acute.
Other Traumatic Injuries
o A-O dislocation: 100% fatal, shear force of occiput on atlas
o Fracture of posterior arch of atlas: result of vertical compression, results in massive suboccipital HA.
o A-A dislocation: rupture of transverse ligament (RA, Downs Syndrome). Look for cord compression
signs.
o Jefferson fracture: fracture of ant and post arches of C1; break in four places; usually from blow to back
of head.
o Dens fracture: common in MVA; picked up with open mouth x-ray
o Hangman’s fracture: C2 pedicles fracture + C2 body dislocation on C3. Results in dens into brainstem;
not always fatal
o Rotary A-A Subluxation: face mask injury
TMJ
TMJ: synovial joint
 Superior cavity – b/t the mandibular fossa & the superior aspect of the disc, translation occurs here
Inferior cavity – b/t the inf aspect of the disc & mandibular condyle, condyle rotation occurs here
Common signs & symptoms
 Pain in pre-auricular area, TMJ, or mm of mastication
 Limitations/deviations in mandibular ROM
 Clicking, deviation, fatigue but no disability
 Severe pain with severe disability
 Clench jaw, headaches
Onset
 Insidious onset, chronic pain
o Majority of pts we see in clinic. History of TMD.
o Research indicates many TMD pts have a history of previous cervical hyper extension or flexion injuries
 Acute Trauma
o Eating, impact jaw, dental procedures, yawning, etc
o Usually self resolving
 History of previous trauma/ DJD
o Most pts report their symptoms came on with no warning but typically have a trauma many years prior to
the onset of TMJ pain. Joint noise may occur
Etiology
 Microtrauma: clenching, grinding
 Macrotrauma
Pain due to:
 Inflammation of ligaments/capsule: due to clenching/grinding from malocclusion
 Internal derangement of ligament or disc: a torn ligament that tethers the articular disc
 Joint arthritis: usually a result of disc tear and subsequent displacement. Overtime the joint surface breaks down
 Mm imbalance: imbalance of soft tissue resulting in uncoordinated movement during mouth opening and closing
(may see an S shaped pattern of movement motion)
 Sensitization (peripheral or central)
o Isn’t necessarily direction related, NS is on high alert and everything sets it off
o If central, NOTHING makes it better
o If peripheral,
How is TMD similar or different than other MS disorders?
 Can be due to inflammation; it’s a joint; misalignment – something in the kinetic chain is expected to fail
 Ask same questions about hx, injury, etc
 Even if the pt is a foot person, you’re treating the knee and the hip; same thing for TMD
What does clicking mean? What is reciprocal clicking? What does it mean when chronic clicking has stopped?
 Clicking: Something going on with disc or ligament. Disc is dislocated and at some point during opening the disc
pops into place = clicking. Indicates internal derangement.

Anterior disc displacement with reduction
o Reciprocal click: loud lock on opening= disc reduction. Smaller click on closing = disc dislocation.
o Most classic pattern
 Anterior disc displacement without reduction.
o Click has stopped: progression has occurred. No longer capturing disc. Once disc is fully displaced
anteriorly and completely without reduction, there will no be no sound. Now limited range (locked
joint) OA
 Posterior disc displacement:
o Unable to close mouth and referred to as “open lock”. Rare but can occur after prolonged dental
procedures
 Single sound: can be the condyle
In what range of motion does mandibular rotation and translation occur during jaw depression? What is
maximum jaw opening and functional jaw opening?
 Depression: 4 finger widths max (40-50mm), 3 fingers functional
o Post rotation condyle (first 25mm) then anterior translation (25-35mm) occur simultaneously during
opening. No change in axis of rotation.
 Inf head of lat pterygoid produces mandible protraction
 Genio and digastric produce depression & retraction
 Mylo produces downward pull on body of mandible
What are the normal range of protrusion, retrusion and lateral deviation?
 Protrusion=6-9mm. Mandible and disc translate ant & inf.
 Retrusion=3 mm. Mandible and disc translate post
 Lateral dev=1/4 of depression. Rotation/spinning ipsilateral condyle and horizontal translation of the contralateral
condyle
What does muscle imbalance mean in the presence of pain?
Why is it difficult to classify the muscles of mastication as mobilizers or stabilizers?
What are some of the most important things you can do in the treatment of patients with TMJ?
 Want to work more on timing/sequencing than necessarily strengthening
 Looking to improve recruitment, firing pattern/synergistic function
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Work on people’s posture
Do non-fatiguing exercise. Not can they do it under load bc
Work on posture: Hyoids help with swallowing.
o Once your head gets so far away from the base of support, you’re using everything you’ve got to hold
your head up  pain; teach a person to get back to the normal kinetic chain
What does sound clinical reasoning mean? What are common pitfalls that many PTs make?
Thoracic
Anatomy
 Vertebra
o Wedge shaped bodies make up curve vs differences in IV disc (as w CS and LS)
o Vertebral foramen slightly smaller. Sympathetic can be compromised.
 Joints
o Costotransverse joint: Rib tubercle + articular facet on TP. not on T11-12 bc no ribs attach here.
o Costovertebral joint: Rib head + disc, vertebral body @ same level and level above
o Facet joints: restrain amount of flexion & anterior translation. Facilitate rotation.
 Rule of 3s
o T1 – T3: SP and TP are at the same level
o T4 – T6: TP are half segment above its SP
o T7 – T9:TP are full segment above its SP
o T10 – 12: gradual return to the same level
 Ligaments
o ALL: narrower but thicker vs rest of spine
o PLL: Wider at IV but narrower at body than LS
 Ribs
o True: 1-7. Attach directly to sternum.
o Typical: 3-9. Costal grooves inferiorly, Angle between tubercle and shaft. Connects to body of sternum. 2
chrondral facets posteriorly.
o Floating: 11-12. No articulation anteriorly or with superior vertebrae.
o Costal cartilages of 1,6,7 attach to sternum via synchrondrosis
o 2-5 attach to sternum via synovial joint
 Blood supply: dorsal branches of posterior intercostal As. Anterior & posterior venous plexuses. SC region
between T4-T9 is poorly vascularized
Biomechanics
 Flexion
 Extension: inferior glide of superior facet of Z joint.
o 1-2º each thoracic segment. Total=15-20º
o Ribs go superior anteriorly and rotate inferior posteriorly
 SB: 3-4º each segment. Lower segment: 7-9º.Total= 25-45º
o Ipsilateral facet and rib moves inferior.
 Rotation:
 Coupled motion:
o CT region: SB + rotation same side
o TL region: SB + rotationopposite side
o Mid TS region: variable coupling of SB and rot. To same side?
 Respiration
o Pump handle=Upper ribs. For respiration (more so inspiration). Results in anterior elevation
Increases AP direction.
o Bucket handle=Mid/lower ribs (excluding free ribs). Results in lateral elevationIncreases lateral
excursion. (clinically: can help assist or resist mm of respiration)
Examination
 History (pain provoked or alleviated w…)
o MS pain: movement, posture
o Rib dysfunction or pleuritic pain: Respiration
o Rib dysfunction or cardiac pain: Exertion
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o Gastric pain: eating, drinking
TS manip for neck pain: CPR
o 1) Symptoms < 30 d
o 2) No symptoms distal to shoulder
o 3) CS ext doesn’t aggravate symptoms
o 4) FABQPA score <12
o 5) Decreased upper TS kyphosis
o 6) CS ext < 30 degrees.
o 3 out 6= 86% success rate
Syndromes
o Upper rib conditions: Rib elevation or TOS. Caused by fwd head, open mouth breather, CS trauma.
o Flattened Upper TS: Due to increased NS tension, stiff joint, neutral posture. Constant loading of joints,
mid back pain. Stiffness at CT junction and/or TS
o Generalized upper/mid TS stiffness: Prolonged acquired posture. Loss of elastic end-feel, limited UE
elevation, stiff/painful accessory glides. Rib screw mobe.
o T4 syndrome: Sympathetic rxn to hypomobile joint (T2-T6). Hx of trauma or posture. Agg by
pushing/pulling. Hypermobile adjacent segment, +/- slump/ULTT. Sleeve, glove, hat referred discomfort.
Pain between scapula. Manip, central or transverse glide.
o Upper/mid thoracic hypermobility: Hx of trauma or microtrauma (sport: ballet, gymnastics). Mid scap
pain. Pain w overhead lifting. Mobilize adjacent segment. Caution w manip. Avoid EROM.
o Costal joint derangement: reduced costal rotation. Agg by twisting, reaching. Pain w rot, breathing.
Unilat PA over CTJ. Stiff and painful rib mobility.
o Thoracic disc lesion: T7-9. Acute: forceful rotation. Chronic: degenerative. Pain shooting
around/through chest well. Agg w any movement, breathing, cough/sneeze
o Scapulocostal syndrome (Snapping scapula): scapular mm imbalance. Dysfunction of scapulothoracic
movement.
o Tietze’s syndrome: costochrondritis of costosternal joint (2nd rib). Rib/vertebral lesion posteriorly.
Anterior chest pain. Agg w breathing and trunk movement. Presents like MI even send radicular pain to
shoulder and down arm.
o Ankylosing spondylitis: systemic rheumatic ds. Inflammation of the spine. Starts in SI and moves up.
Progressive stiffnessfusion of joints. Mobility ex and active lifestyle
o Osteoporosis: Wedging and increased kyphosis. Compression fx of TL vertebrae and ribs. B12 and
calcium.
o Scherurmann’s Disease: wedging of multiple vertebral bodies. Thickened ALL. Rigid curved spine.
o Schmoral’s nodes: small herniation of disc material into endplate of bodies. Rigid curved spine.
Cervical Rehab Post-op
Imaging indications: don’t need imaging initially unless neuro deficit
Surgical indications
 Fracture, myelopathy, neoplasm
Surgeries
 Decompression: Laminectomy, discectomy
 Fusion
 Disc replacement: ideal pt=normal sagittal align. Compression at disc level only. No posterior compression.
Unilateral radiculopathy. Negative Spurling’s maneuver
o Problems: peri-prosthetic ossification, migration of prosthesis
Approach:
 Anterior: preferred
 Posterior: usually more pain secondary to mm. Advantage: lateral herniations, bone spurs, avoids fusion.
Disadvantage: no fusion (continued disc collapse and pressure). May re-herniate. More difficult to perform.
Conditions & Surgical Approaches
 Cervical radiculopathy: nerve root impingement (pain, weakness, numbness in UE) secondary to HNP, bone
spurs or combo. MOI: hyper-ext, rotation, or combo. (-) Spurling’s will R/O radiculopathy.
o Conservative Tx: traction, nerve root injections for 3 months
o Discectomy: remove disc material. Progression towards fusion.
 Cervical stenosis: may be related to acute trauma (fx) or disc herniation. Multiple levels.
o Laminectomy
 Cervical myelopathy: caused by spinal cord compression. UE/LE weakness. Bowel bladder probs. Gait
disturbance
o Conservative Tx: little indication. Usually surgery indicated at presentation
o Removal of vertebral body + discs
Rehab
 Acute:
o Brace/collar for fusion pts. No ROM. HOB up (recliner). No lifting >5-10#
o Goals: Bed mobility, ambulation, stairs
 Outpatient goals:
o Quality of motion: intrinsic mm are weak or lengthened. Extrinsic are dominant, add to compression,
rotational, shear forces
o Posture: slumping effects
o

Shoulder girdle alignment: elevation vs depression (T2-T2). Abduction (3-4 inches). IR. Anterior tilt.
Lumbar Rehab Post-op
Indications for imagine:
 Severe back pain (<18 or >55 years), violent trauma, night pain, cancer Hx, systemic steroids, drug abuse, marked
morning stiffness (ankylosing spondylitis) , structural deformity, bowel/bladder probs, motor weakness, gait
disturbance, peripheral joint involvement, severe pain or restriction w motion
Conditions & Surgical Approaches
 HNP: Usually resolve w time. Epidural steroid injection. PT believed to exacerbate Sx.
o Surgical candidates: (+) SLR, imagining (extruded disc do better), 95% success
o Discectomy: dissect mm from bone, laminotomy, disc removed
 Candidates: cauda equina, severe motor deficit (1-2/5) within 3 mos, no LBP (no degeneration)
 Often results in subsequent surgery or re-herniation.
 Conservative: min 6 months, PT (directional preference), disc protrusion, annular disruption,
mild-mod weakness (3-4/5)
o Micro-discectomy: less mm dissected, +/- laminotomy
 Stenosis: age 50+, activity related leg pain, (-) SLR, neurogenic claudication, R/O vascular claudication
o Leg pain increased w walking, relieved w sitting, walking uphill, or pushing grocery cart
o Conservative: pain meds, bracing, activity modification, epidurals
o Surgery: decompression (laminectomy) (80% success)
 Usually have Spondylolisthesis or scoliosis and need fusion as well which increased morbidity
 Spondylolisthesis
o Degenerative, isthmic, dysplastic, post-op
o Leg and or back pain
o Conservative: bracing, meds, PT (for grades I, II), epidural
o Surgery: arthrodesis (fusion)(50% success), +/- decompression
 Fusions: 5 year re-op rate. Bone mineral density decrease, segmental instability (above or below)
Rehab
 Fusions: log roll, spinal orthotics, no hip flex >90, no bending/rotation/ fwd bending/ stooping, no lift >5-10#, no
sitting >30 min (compression)
 Acute: walking, bed mobility, transfers (most difficultly w supine<>sit)
 Outpatient: motor control and quality of movement. Surgery addressed source of pain, PT should address cause.
Find position of comfort and functional tasks. Address TA and multifidus endurance. Repetitive straight or bent
leg sit-up, bent-leg hanging, back extensions, prone leg and back extension (>3300 N) increase injury rates.
Evidence
 Surgical usually has better initial results and better satisfaction but is the same as conservative Tx several years
(~2) down the road.
ROM
Cervical:
 Flexion=50
 Extension=60
 Rotation= 80
 SB=45
Thoracolumbar:
 Flexion=10cm (S2C7)
o Fingertip to floor= 2cm
 Extension=20-30 degrees
 Rotation=45 (F=center of head, S=iliac crests, M=acromion processes)
 SB= 35 (S2C7)
o Fingertip to thigh=20cm
Lumbar:
 Flexion= 5-8cm (S215 superior)
 Extension= 1.5cm (25 degrees)
 Rotation=
 SB= 25-30 degrees