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Compressive Patterns Anatomy Possible symptomatic structures Ligamentous capsule Intra -articular structures - synovitis Muscle – may be inhibited or tight Nerve Causes of symptoms Wear and tear changes Bony proliferation Habitual poor posture Disc degeneration Change in activity Acute injury Bogduk noted that a reductionist approach to chronic low back pain requires an anatomical diagnosis. Bogduk identified four factors necessary for any structure to be deemed a cause of back pain: a nerve supply to the structure; the ability of the structure to cause pain similar to that seen clinically in normal volunteers; the structure's susceptibility to painful diseases or injuries; and demonstration that the structure can be a source of pain in patients using diagnostic techniques of known reliability and validity. The facet or zygapophysial joints of the spine are well innervated by the medial branches of the dorsal rami . Facet joints have been shown capable of causing pain in the neck, upper and mid back, and low back with pain referred to the head or upper extremity, chest wall, and lower extremity in normal volunteers . They also have been shown to be a source of pain in patients with chronic spinal pain using diagnostic techniques of known reliability and validity. Conversely, the reliability of physical examination in diagnosing the specific cause of back pain has been questioned. Further, it has been shown that medical imaging provides little additional useful in identifying a precise anatomical diagnosis. Symptoms of facet joint dysfunction Tenderness localized over one or more facet joints, Diffuse referred pain over the buttock and sometimes posterolateral thigh pain. (Not radicular) Exacerbation of pain with any sustained posture, Loss of lumbar lordosis, or paraspinal muscle spasm Exacerbation of pain with hyperextension. Assessment Subjective history Extra-articular structures tend to be damaged by strains or overuse injuries. Pain will be intermittent and reproduced at end of range Intra-articular structures e.g. trapped synovium give pain early in range and are often accompanied by aching. Acute injuries – pain throughout range Chronic conditions – pain at end of range There will always be exceptions to this. Objective examination In addition to a standard spinal assessment combined movements can be used to reproduce symptoms. Combining movements of examination can therefore increase or decrease compressive or stretching effect on the IV segment. This results in recognising the movement response in patients with mechanical disorder of movement. These responses are - Regular - Irregular REGULAR RESPONSE These are responses in which similar movements at the IV joint produce the same symptoms whenever the movement is performed. Tend to be single structure and non traumatic E.g. discogenic; stretch/compressive pattern facet joint; compressive capsular; stretch Example of regular compression pattern Right lateral flexion in the lumbar spine may produce right buttock pain. This is made worse when the movement is performed in the extension and eased when performed in flexion. . Regular stretch pattern Stretching response- if the symptoms are present on the opposite side from that to which the movement is directed. e.g Right lateral flexion in the lumbar spine produced left buttock pain. This is accentuated when the movement of right lateral flexion is performed in flexion and eased when performed in extension. Irregular patterns e.g. 2- extension of the lumbar spine increases right buttock pain. When right lateral flexion is combined with this movement, the pain is decreased, but when left lateral flexion is combined with extension, the pain is increased. • Irregular pattern – tends to be multistructural and traumatic( e.g. following motor vehicle accident) e.g. combination of disc, capsular, ligamentous and intervertebral foramina. • Irregular or inconsistent pattern are common IRREGULAR RESPONSE All responses which are not regular, fall into the category of irregular response. With irregular response there is not the same consistency of symptoms and stretching and compressing movement do not follow any recognizable response. There is random reproduction of symptoms despite combining movement with similar mechanical effects. Treatment of acute pain In the acute category with regular or compressive movement, the direction of the initial procedure is always towards the opposite quadrant. E.g.- a patient presenting with left buttock pain, with regular compressive movement response. Left lateral flexion is the primary movement, restricted to one quarter range. Left lateral flexion in extension is the primary combination restricted to one eighth range . The first technique chosen is R Lateral flexion in flexion. Treatment of chronic symptoms Regular compressive movement responses Pain in the left buttock. Primary movement is extension. And primary combination is left lateral flexion in extension. The first technique chosen is:- ( L ) Lateral flexion in neutral Progress to ( L ) Lateral flexion in extension Facet joint injections These can be used to relieve symptoms or to accurately locate a symptomatic joint. A combination of local anaesthetic and steroid are injected into the joint. Useful Utube clip Chris McCarthy Combined Movement Theory – Lumbar Spine Muscle Energy Technique Ann Dennis Band 6 IST Nov 5 th 2012