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THE SPINE PTA 216 ORTHOPEDICS IN PTA The Spine • The functions of the spinal column include: – Supporting the majority of body weight – Supporting the head, trunk, and UEs against the forces of gravity – Protection of the spinal cord – Shock absorption – Providing a stable structure by which we can maintain an upright posture Magee, 2008. pg. 92 Spinal Design • 33 vertical segments, divided into 5 regions: – – – – – Dutton, 2012. pg. 259 Cervical (7) Thoracic (12) Lumbar (5) Sacral (5 - fused) Coccygeal (4 - fused) Spinal Design • 2 functional pillars that assist spine functionality • Anterior Pillar: vertebral bodies and intervertebral disks provide hydraulics, weight bearing ability and shock-absorption • Posterior Pillar: consists of articular processes, facet joints, transverse processes, and spinous processes. This allows spinal movement and serves as the attachment for posterior musculature. Dutton, 2012. pg. 260 Anatomy of vertebrae THE INTER-VERTEBRAL DISC • • The inter-vertebral disc fibro-cartilagenous tissue – in between vertebral bodies consisting • an outer layer (annulus) • an inner layer (nucleus pulposus) • The inter-vertebral disc provides: – – – – Shock absorbtion Movement between vertebrae Separation between the vertebrae To allow passage of nerve roots through the intervertebral foramina Magee, 2008. pg. 516-517 Spinal Mobility • Flexion: – Occurs in the sagittal plane – Anterior portion of the vertebral bodies approximate and the spinous processes separate • Extension: – Occurs in the sagittal plane – Anterior portion of the vertebral bodies separate and the spinous processes approximate Dutton, 2012. pg. 262 Spinal Mobility • Lateral Flexion – Occurs in the frontal plane – The vertebral bodies approximate on the side toward which the spine in bending, and separate on the opposite side • Rotation – Occurs in the transverse pain – The body of the vertebra will rotate towards the side in which the person is moving as the spinous process moves toward the opposite side Dutton, 2012. pg. 263 Spinal Mobility • Shear – Occurs in sagittal, frontal, and transverse planes – When the body of the superior vertebra translates over the body of the inferior vertebra • Distraction/Compression – Occurs in the transverse plane – Result of longitudinal forces – Vertebral bodies move either towards or away from other vertebral bodies Dutton, 2012. pg. 263 Anatomy, Pathology and Treatment Options CERVICAL SPINE Cervical Spine • Consists of 37 joints, allowing more motion than any other region of the spine • Vulnerable to direct and indirect trauma • Accounts for 15-34% of all outpatient physical therapy referrals. Dutton, 2012. pg. 267 Cervical Spine Injuries to the cervical spine may manifest themselves as localized – “pain in the neck” – or – radicular • symptoms that travel away from the site of injury down one or both upper extremities Radicular symptoms from the cervical spine may affect the – – – – – – Face Head Neck Shoulder UE Peri-scapular region Magee, 2008. pg. 133 Dutton, 2012. pg. 268 Cervical Sprain/Strain • Result from an overload to the cervical muscle-tendon unit by way of excessive forces – Causes elongation and/or tearing of muscles or ligaments, edema, hemorrhage, and inflammation – Patient complaints: • • • • Pain Stiffness Tightness in upper back and/or shoulder Occipital headaches Dutton, 2012. pg. 281 Intervention for Cervical Sprain/Strain • Pain management – Cryotherapy and electrical stimulation • • • • • Possible cervical (Philadelphia) collar Gentle range of motion Strengthening as tolerated Postural education Self care/ Home Management Dutton, 2012. pg. 281-282 Cervical Spine Torticollis • an abnormal twisting of the neck • the head is rotated toward the side that muscular tightness is found. – may be congenital or acquired – In many situations of torticollis, the anterior scalene musculature will be visible when viewing a patient from the front. Torticollis • Treatment for infants with torticollis – Parent education – Patient positioning – Manual stretching activities Acute Torticollis (Wry Neck) • Effects young and middle –aged adults • Typically happens overnight as a result of an injury to the muscles, joints, or ligaments while sleeping • Patient will complain of painful muscle spasms which will be visible and/or palpable • Patient will demonstrate significant limitations with neck mobility • Patient will most likely hold head in a position of comfort (leaning towards the side of the involved muscles) Dutton, 2012. pg. 285 Acute Torticollis (Wry Neck) • “Hanging Head” method – Patient in supine with head in 20 degrees of extension with or without manual traction for approx. 5-10 minutes • Moist heat • Massage • Postural education – -including sleeping with painful side on low, firm pillow • Gentle range of motion – Upper extremities and cervical spine • Cervical collar PRN for first 24 hours • Medication as per MD – Muscle relaxants and analgesics Dutton, 2012. pg. 285 Cervical Spine Thoracic Outlet Syndrome • compression of blood vessels and/or nerves coming from the spinal cord as they pass through the space between the clavicle and upper ribs – Brachial plexus and/or subclavian artery or vein Dutton, 2012. pg. 283 Thoracic Outlet Syndrome • Chief Complaint: diffuse arm pain • Other complaints: – Pain in neck, face, head, upper extremity, chest, shoulder, scapula – Upper extremity parasthesia, weakness, heaviness, edema, ulceration, or Raynaud phenomenon Dutton, 2012. pg. 284 Thoracic Outlet Syndrome • Conservative Treatment – – – – Correction of postural abnormalities Strengthening of weak muscles Stretching shortened muscles Mobilization by the PT of hypomobile joints of the shoulder complex, clavicle, and first rib Dutton, 2012. pg. 284 Special Tests for the Cervical Spine Vertebral Basilar Instability (VBI) Test • The patient is interviewed for signs of VBI. • Prior to other testing/examination, the practitioner performs end range cervical rotation in either sitting or supine and holds test position for 10 seconds while observing for signs and symptoms of VBI. • Head is put in neutral for 10 seconds, followed by rotation to the opposite side for 10 seconds. Cook, 2013. pg. 129 Special Tests for the Cervical Spine Vertebral Basilar Insufficiency (VBI)Test Positive results are identified by: -Dizziness -Diplopia -Dysphasia -Dysarthria -Drop Attacks -Nausea -Nystagmus Patient should be referred for an appropriate medical consult following a positive response. Cook, 2013. pg. 129 Special Tests for the Cervical Spine FORAMINAL COMPRESSION TEST • The patient is seated on a plinth with the examiner resting the palmar surface of his or her hands on top of the patient’s head. • The patient will then laterally flex the head while the tester applies a downward pressure. – This is to be done with lateral flexion bilaterally Konin, 2006. pg. 11 Special Tests for the Cervical Spine Foraminal compression test • Positive Finding – increase in pain on the same side that the head is laterally flexed to – demonstrating possible nerve root compression. • This would then be compared with dermatomal distribution to find the level of lesion. **This test should be performed carefully and with caution, especially in patients previously diagnosed with OA, RA, osteoporosis, and spinal stenosis.** Special Tests for the Cervical Spine Foraminal Distraction Test • The patient is seated and the examiner places one hand under the patient’s chin and the other hand around the base of the occiput. • The examiner distracts the patient’s head from the trunk while the patient remains relaxed. Konin, 2006. pg. 14 Special Tests for the Cervical Spine FORAMINAL DISTRACTION TEST • Positive if the patient reports – decreased pain – and/or elimination of pain with distraction • indicative of nerve root compression with normal positioning/posture *****This should not be performed on a patient who has vertebral instability.***** Therapeutic Intervention STRETCHING ACTIVITIES FOR THE CERVICAL SPINE Stretching activities for Cervical Spine Corner Stretch: Pectoralis Minor Note: Avoid forward head posture during stretch Dutton, 2012. pg. 288 Upper Trapezius Stretch (Self) Ensure that the shoulder is in a depressed position Dutton, 2012. pg. 289 Upper Trapezius Stretch (Manual) Stabilize scapula into depression and downward rotation Dutton, 2012. pg. 289 Levator Scapula Stretch (Self) Education tip: Have patient look at their opposite hip to ensure appropriate stretch Dutton, 2012. pg. 289 and 292 Levator Scapula Stretch (Manual) Can also be performed in sidelying Massage -Can be performed on any muscles in the cervical spine -Goal is to place the patient in position where the muscles are non – weight bearing Dutton, 2012. pg. 291 Anatomy, Pathology, and Treatment Options THORACIC SPINE Anatomy of Thoracic Spine • 12 thoracic vertebrae • Each vertebrae is involved in at least 6 articulations • Decreased mobility in order to protect the thoracic viscera Dutton, 2012. pg. 298 Anatomy of Thoracic Spine • The rib cage in conjunction with the thoracic spine provide stability – Influences motion in other areas of the spine as well as the shoulder girdle – Provides assistance with weight bearing – Increases potential for postural impairments Dutton, 2012. pg. 298 Thoracic Spine • Prone to both postural and biomechanical dysfunction • Treatment goals: – Decrease pain, inflammation, and muscle spasm • • • • • Cryotherapy Electrical Stimulation Gentle exercises Possible bracing Heating agents after 48-72 hours – Promote healing of tissue • Join mobilization as performed by PT • Massage • Ultrasound – Increase pain free range of vertebral and costal motion • Diaphragmatic breathing with stretching Dutton, 2012. pg. 300 Postural Dysfunction • Create an imbalance between agonists and antagonists. – Results in adaptive shortening and muscle weakness – Not typically reproducible with physical examination – Pain is typically aggravated by stress, fatigue, and possibly change in weather. Dutton, 2012. pg. 304 The Spine Kyphosis: • an increase in the thoracic convexity • resulting in a rounded back with protracted scapulae – Also know as the “hump-back deformity” Therapeutic Interventions STRETCHING ACTIVITIES FOR THE THORACIC SPINE Supine Shoulder Sweep -Important for the patient to maintain contact with their arm on the plynth. -Manual assistance may be used on the scapula or rib cage - Perform with diaphragmatic breathing Dutton, 2012. pg. 301 Thoracic Spine Flexion -Cat/Camel Stretch Dutton, 2012. pg. 301 Thoracic Spine Extension over foam roll -Allows focus to be made over a specific vertebral segment Dutton, 2012. pg. 302 Supine Thoracic Spine Rotation Keeping shoulders, trunk, and feet on the plynth, drop legs down to one side together as far as comfortable and then repeat on the opposite side Dutton, 2012. pg. 302 Supine Thoracic Rotation using one leg Progression as patient’s tolerance increases Dutton, 2012. pg. 302 Anatomy, Pathology, and Treatment Options LUMBAR SPINE Lumbar Spine -almost entirely flexion and extension -minimal rotation and lateral flexion -Motions occur in sagital, coronal, and transverse planes Dutton, 2012. pg. 315 Low Back Pain Did you know that it is…. • the 2nd leading cause of physician visits in the United States • affects approximately 80% of the adult population at some point in their lives • one of the leading causes of Physical Therapy referrals in the orthopedic setting Some of the primary causes of low back pain include: • Muscle Strains • Ligamentous Sprains • Disk Injuries • Spondylolisthesis • Spinal Stenosis • Spinal Fractures The Inter-vertebral Disc • Health of the intervertebral disc maintains the health of the integrity of the mechanics of the spine • Low back pain may be due to – Aging • Reduces the moisture content in the disc – Reduces overall height – account for 20-25% of the total length of the vertebral column – natural degeneration of the disc – trauma, inter-vertebral discs can be responsible for causing low back pain in many individuals. Magee, 2008. pg. 516 The Inter-vertebral Disc 1 Disc Herniation A general term used to describe when there is any change in the shape of the annulus 2 Disc protrusion The nucleus of the disc bulges against an intact annulus 2 Extruded disc The nucleus of the disc bulges through the annulus however remains within the posterior longitudinal ligament 3 Sequestrated disc The nucleus of the disc breaks through all barriers and is free within the spinal canal Magee, 2008. pg. 369 Dutton, 2012. pg. 338-339 Inter-vertebral Disc Herniations Treatment will depend upon – – – – – – Pain Flexibility Strength Dermatomal and myotomal involvement Pain with movement Patient understanding • This may include: – – – – – – – – Shankman, 2011. pg. 371 physical agents therapeutic exercise therapeutic activity strengthening flexibility training patient education body mechanics training manual intervention Surgical Intervention for lumbar disk disease • Discectomy – Surgical removal of the herniated disk material • May also be performed with laminectomy • Microdiscectomy – Surgical removal of only the portion of the disk that is impinging on the spinal nerve root • Requires decreased recovery time • Percutaneous discectomy – Decompression of the disk performed through needles Dutton, 2012. pg. 343 The Spine • Scoliosis – a lateral curvature of the spine – usually demonstrated by an abnormal curve and a second curve that results due to compensatory movements in the opposite direction. • This results in a deformity resembling the letter S. Shankman, 2011. pg. 337 The Spine • Functional scoliosis – not caused by an actual spinal deformity • secondary to another condition – such as leg length discrepancy • The curvature usually resolves itself when the primary condition is addressed. Dutton, 2012. pg. 307 The Spine Non-functional (structural) scoliosis • the opposite of functional scoliosis • the curvature is incorporated into the natural growth and development of the spine • curvature and the vertebral bodies are rotated toward the convexity. The Spine More severe cases of scoliosis • may require bracing • to prevent further curvature of the spine from occurring – bracing is not intended to correct the curvature already in place – prevents further curvature • minimal correction may occur Shankman, 2011. pg. 338 The Spine Lordosis: • an abnormal anterior convexity of the lumbar spine • Persons with lumbar lordosis will present as if they are sticking out their stomach and their buttocks. **Both Kyphosis and Lordosis can be congenital, neuromuscular, or postural** The Spine What effects can these have on a person clinically? – Pain – Poor posture – Change in functional mobility – Decrease in muscle strength – Respiratory difficulties – Neurological symptoms – Psychological concerns Muscle Strains and Ligamentous Sprains can be caused by: • Sudden movements • Rapid Stretching • Overuse injuries • Treatment goals include: – Decreasing pain and edema – Increasing flexibility and strength – Improving aerobic fitness to achieve prior level of function Treatment Plan for Sprains/Strains Physical Agents as needed for • Pain • Inflammation • Muscle guarding Therapeutic Exercise • Core stability • Flexibility training • Strength training Manual Therapy • Joint and muscle flexibility • Soft tissue massage Patient education • • • • Posture Body mechanics Aerobic capacity/fitness Home exercises Piriformis Syndrome • The sciatic nerve runs through the muscle belly of the piriformis as opposed to underneath it – occurs in approximately 15% of the population – characterized by pain reported deep in the buttocks – may be irritated by sitting Magee, 2012. pg. 696 Spondylolisthesis • condition in which one vertebrae anteriorly glides over another • usually occuring at the L4-L5 and L5-S1 levels • graded through X-ray • measured by the percentage of displacement noted Shankman, 2011. pg. 374-375 Spondylolisthesis • Congenital – Results from dysplasia of the 5th lumbar and sacral arches and zygapophyseal joints • Isthmic – Caused by a defect in the pars interarticularis resulting from an acute or stress fracture or an elongation of the pars • Degenerative – Usually affects older population – Most common at L4-L5 level • Traumatic – Occurs with fracture or dislocation of the zygapophyseal joint • Pathologic – Resulting from a systemic disease causing weakness of the pars, pedicle, or zygapophyseal joint Dutton, 2012. pg. 346 Grading for Spondylolisthesis: Grade 1: 0-25% Grade 2: 25-50% Grade 3: 50-75% Grade 4: 75-100% Example: Grade 2 Shankman, 2011. pg. 375 Spondylolisthesis • Patient complaints – – – – – Chronic midline pain at lumbosacral junction Pain worsened with activity Pain alleviated with rest Pain exacerbated by repetitive extension Possible reports of radicular symptoms Dutton, 2012. pg. 346 Spondylolisthesis Treatment Options Conservative Treatment -pelvic positioning -lumbar stabilization -flexibility of rectus femoris -flexibility of iliopsoas Surgical Intervention -remove pressure on spinal nerves -provide stability Dutton, 2012. pg. 347 Spinal Stenosis • Narrowing of the spinal canal secondary to degenerative changes or trauma to the lumbar spine. – Facet joint arthrosis and/or hypertrophy – disc bulging – spondylolisthesis • Most common in middle-aged and older males Shankman, 2011. pg. 374 Dutton, 2012. pg. 343 Spinal Stenosis • • • • Postural education Flexibility Core stabilization Aerobic conditioning Dutton, 2012. pg. 344 Spinal Fractures • Lumbar spinal fractures are usually a result of a traumatic event and may be classified according to the mechanism of injury (compression, flexion, extension, etc…) • Compression fractures are most commonly noted in the osteoarthritic population as a result of a rapid deceleration when transferring to a seated position. Shankman, 2011. pg. 330 Spinal Fractures • Spinal fractures will most likely be immobilized – Casting – Bracing – until such time that physical therapy intervention is appropriate Shankman, 2011. pg. 330 Special Tests for the Lumbar Spine Special Tests for the Lumbar Spine WELL LEG RAISE TEST: – the patient lying supine on a plynth – the examiner holds the calcaneous of the uninvolved leg and places their superior hand on the anterior surface of the patient’s thigh to prevent knee flexion – the examiner passively flexes the patient’s hip while maintaining the knee in extension Cook, 2013. pg. 301 Special Tests for the Lumbar Spine • A positive result for the Well Leg Raise Test is demonstrated with complaints of pain on the involved side, indicating vertebral disk damage. Special Tests for the Lumbar Spine SLUMP SIT TEST: – The patient sits at the end of a table with the arms behind the back and legs together. – The patient slumps as far as possible, producing full trunk flexion – If no changes are noted, the examiner asks the patient to extend their knee or passively extends one of the pt’s knees, symptoms are assessed – If no changes are noted still, the examiner passively dorsiflexes the pt’s ankle with the knee in extension, symptoms are assessed. – Neck flexion is then added to assess symptoms, then released to see if symptoms subside – This is to be performed on bilateral LE’s Cook, 2013. pg. 302 Special Tests for the Lumbar Spine SLUMP TEST • Positive Findings – Concordant reproduction of symptoms, sensitization, and asymmetry findings. Special Tests for the Lumbar Spine VALSALVA’S MANEUVER: – The patient should sit with the examiner next to the patient – The tester asks the patient to hold their breath and bear down as if having a bowel movement • This test is considered positive if – increase in pain secondary to the increase in intrathecal pressure. – May indicate: • herniated disk, tumor, or osteophyte in the lumbar cana. • pain may be localized or referred to a corresponding dermatome Konin, 2006. pg. 132 Special Tests for the Lumbar Spine • FABER TEST: (also known as the Patrick Test) – This test is used to determine iliopsoas, sacroiliac, and/or hip joint abnormalities. • The patient lies supine on a table • The examiner passively flexes, ABDucts, and externally rotates the involved LE until the foot rests on top of the opposite knee. • The examiner then provides a gentle, downward pressure on both the knee of the painful side and the ASIS of the nonpainful side Cook, 2013. pg. 333 Special Tests for the Lumbar Spine FABER’S TEST Concordant pain is assessed -location -type of pain Treatment Interventions STRETCHING ACTIVITIES FOR THE LUMBAR SPINE Single Knee to Chest Dutton, 2012. pg. 344 Lower Trunk Rotation Hamstring Stretch Childs Pose Stretch Gastrocnemius Stretch Piriformis Stretch Quadriceps Stretch Lumbar Spine CORE STABILITY EXERCISES Posterior Pelvic Tilt Dutton, 2012. pg. 328 Bent leg fall out Dutton, 2012. pg. 329 Bridging Dutton, 2012. pg. 332 Quadruped Activities Dutton, 2012. pg. 331 Bibliography • Dutton, Orthopaedics for the Physical Therapist Assistant. Jones&Bartlett. 2012 • Shankman, Fundamental Orthopedic Management for the Physical Therapist Assistant, 3rd edition. Mosby.2011 • Konin, Wiksten, Isear, Brader, Special Tests for Orthopedic Examination, 3rd edition. Slack. 2006 • Cook, Hegedus, Orthopedic Physical Examination Tests, 2nd edition. Pearson. 2013 • Magee, Orthopedic Physical Assessment, 5th edition. Saunders. 2008