Download MS Part 1 Outline

Acute (2-3 days), Sub-acute (2-3 weeks), Chronic (> 1 month)
Mobilization grading
 Grade 1-2 (1-2 bouts, 20-30 seconds)
 Grade 3,4 (3-5 bouts, 45-60 seconds)
Neuro Exam & Clearing
Examination:
Problem List
 Structures at fault and functional limitation
Asterisks
 Identify limitations
 Items you can reassess and/or is contributing to the current problem/complaint
 1 subjective, 1 passive, 1 functional
Mobes
 Unilateral: treat painful side first
 Rotation: treat c painful side up first
 Transverse: treat towards the side of pain
Level of symptoms & treatment choices
 CS: central PA, unilateral PA, traction
 UCS: unilateral PA
 TS: central PA, unilateral PA, transverse, traction
 Upper LS: central PA, unilateral PA, transverse
 Lower LS: central PA, unilateral PA, rotations, traction
Nature
 Disc/DDD: McKenzie protocol, central PA, rotations, traction
 Acute Nerve Root: gentle traction, rotations (I, II)
 Chronic Nerve Root: rotations, unilaterals, treat neurodynamic signs
 Acute Facet: rotations, unilaterals
 Chronic Facet: rotations, unilaterals, transverse
Anatomy, Biomechanics & Clinical Implication
 Facet Joints: Provide mobility AND stability. Synovial, plane joint.
 Motion segment: 1 disc, 2 facet joints, 2 bodies, surrounding soft tissue
 Ligamentum flavum: yellow ligament=80% elastic therefore goes thru degenerative changes that
cause nerve root compression
Trunk mm
 Local: provide stability. Respond to pain c inhibition.
o Stabilize segments. O & I on spinal column
o Multifidus, pelvic floor mm, diaphragm, TA, medial fibers-quadratus lumborum, lumbar
portions-iliocostalis/longissimus, posterior fibers of internal obliques that attach to TFL
o TA: global stability
 Global: provide mobility. Respond to pain c overactivation (spasms)
o Originate on pelvis. Insert on rib cage.
o Erector spinae, rectus abdominus, obliques, lateral fibers-quadratus lumborum, thoracic
part-lumbar iliocostalis
 Thoracolumbar Fascia
o PSIST9,10.
o Lateral: TA. Superior: Latissimus Dorsi. Inferior: Glute max
Motions of Spine
 Compression
 Distraction: intervention for disc, DDD/DJD, facets, Acute nerve root (gentle)

Planar motion:
o Flexion: facets glide superior & anterior=open facet. Anterior sagittal rotation. Anterior
sagittal translation. Limited by posterior column and facet joints **(bc facet surfaces come
together)
o Extension: facets glide inferior & posterior=close facet. Posterior sagittal rotation. Minimal
posterior translation. Limited by spinous processes and facet joints.
 Repetitive extension + rotation  injury to pars interarticularis
 Rotation: horizontal > coronal > sagittal
o CS: 45 from horizontal
 Rotation and some fwd translation
o TS: Coronal
 Upper 60 o
 Mid 90 o
 Lower 0 o
 Rotation. Prevents fwd translation
o LS: Sagittal
 Allows translation. Resists rotation
o L5-S1: Coronal
 Allows for optimal stimulus for disc and opening of lateral foramen
o Limiters to rotation: contralateral facet closing, ipsilateral facet capsule, disc (lateral
sheering)
 Translation: anterior, posterior, lateral. Involved in flexion & extension esp in lumbar spine
 Side flexion
o Ipsilateral facet glides inferior (ext)
o Contralateral facet glides superior (flex)
 Coupled motion: side bend + rotation (in neutral spine)
o CS: side bend + rotation SAME side
o TS:?
o LS: side bend + rotation OPPOSITE side
 Flexed or extended LS: side bend + rotation to SAME side
Intervertebral Disc
Nucleus Pulposus:
 70-90% water. 15-20% collagen type II (cartilage). 65% dry weight is proteoglycans.
Annulus fibrosus:
 60-70% water. 50-60% dry weight is collagen type I (tensile strength, tendons). 20% dry weight is
proteoglycans.
 Lamellae: 60-65o from vertical to prevent tension in all directions
 Sensor Innervation: Recurrent sinuvertebral nerve. OUTER 1/3 of annulus & PLL. Role in
proprioception
Vertebral End-Plates
 .6-.1mm cartilage. Part of disc (NOT vertebral body)
 nerve endings sense pain
Sharpy’s Fibers
 attach outer annulus to vertebral body
3 sources of pain
 PLL, outer annulus, end plate
Disc characteristics
 Cervical Spine: Nucleus is absent at age 20. No disc b/t OA & AA joint
 Thoracic spine: Small NP
 Lumbar Spine: Thicker disc than CS, TS
Functions of IV
 Transmits load from body to body (shock absorption)
 Allows movement b/t bodies.
 Proprioception (to prevent injury. Deteriorated discssegmental instabilitymultifidus wasting
bc stimulation to outer annulus led to contraction of multifidus)
 Separate vertebrae to allow nerve roots to branch off
Disc mechanics
 Tension occurs c rotation, compression, and sheering
 Compression:
 Distraction: decrease pressure on NP but puts tension on annulus
 Shear: most detrimental to disc
 Rotation:50% of annulus fibers are on tension c right rotation. Other 50% to left.
 Rocking: increase pressure anterior, decrease posterior
Nutrition
 Passive: imbibition (diffusion). Outer 1/3 better vascularization
 Active: spinal motion (optimal stimulus for regeneration)
o Annulus=rotation
o NP= intermittent compression/decompression
Pathologies
 DDD
 Disc herniation
o Intra-spongy: NP migrates into vertebral body 2 o fracture in vertebral endplate. May heal
w/o Sx or result in schmorl’s nodes
o Protrusion: (contained) migrate laterally
o Prolapse/ extrusion: migrate laterally. NP escapes AF & PLL but is attached to disc.
Radicular Sx.
 Source of pain: nerve root, outer 1/3 AF, PLL, inflammatory process.
o Sequestration: migrate laterally. Free fragment of NP that migrates and likely impinges
on nerve tissue. Radicular Sx.
Protective Scoliosis (pg 155 netters)
 Bulge LATERAL to nerve root: shift to OPPOSITE side (most common)
 Bulge MEDIAL to nerve root: shift to SAME side
Lumbar Spine Exam
GH questions: identify red flags
 Cauda equina, vertebral artery-UE, discogenic pain-cough/sneeze
PAIVMS
 Stresses disc, soft tissue, neural arch
 Unilateral PA: pts c nerve root or facet problems
o Facet joint @ lumbar
o TP @ cervical, thoracic
PPIVMs
 Indication: LS objective exam sequence and pre-cursor to stability testing
 Hip needs to be more flexed as palpate down spine-i.e. L4/L5
Serious spinal pathologies: spinal tumor, infection, fracture, cauda equina syndrome. PTs canNOT do
anything about this
Sciatica: back-related LE symptoms
Pathologies
Spinal stenosis: narrowing of foramen
 Neurogenic claudication: neural compromise 2o obstruction of blood flow to nerve or dural
sleeve=ischemia to spinal N

Pain gets worse c walking/standing because of close packing of facets and narrowing of
foramen. Eases c flexion.
 Flat back posture
 Flexion eases symptoms. Extension increases symptoms.
Vascular claudication: compromised circulatory system 2o PVD
 Caused by plaque build up along arterial walls causing decreased circulation. Blood flow can’t
meet increased demands w walking.
 Flexion DOESN'T ease symptoms & rarely have back symptoms
Facet Joint
 Innervated by medial branch of dorsal primary ramus. Supplies its own level & 1-2 levels
above/below
 Acute: mechanical problem therefore shouldn't have shooting pain down leg. Mechanical block
from meniscoid. Increased pain w stretch/compression of joint (limited side bend & ext)
 Chronic
Nerve root
 Acute: irritation/inflammation, compression, or tension to nerve root disc possibly 2o
pathology or degenerative changes. Distal>proximal.
 Chronic: proximal>distal.
Instability
 Structural: defect in pars interarticularis
o Spondylolysis=defects in PI. Typically caused by stress Fx. Causes spondylolisthesis
o Spondylolisthesis=slippage of the vertebrae anteriorly. Caused by Spondylolysis
(pediatric) or DDD (adults)
 Most common at L5-S1
 <25%=Grade 1
 25-50%=Grade 2
 50-75%=Grade 3 (requires surgery)
 75-100%=Grade 4 (requires surgery)
 Functional
o 2o ligament or mm injury or poor motor control
o Abnormal movement of one vertebrae on another. Inability to maintain neutral zone.
Constantly moving positions trying to get away from end ranges.
o DON'T do central PAs because already too much motion. But look at segments above
and below.
o Most common at L5-S1
Anterior Instability Test
 Indication: to confirm subjective info of possible instability or hypermobility. Can’t sit still. When
come out of flexed position may have trouble standing up. Too much of a flexed
position=thoracolumbar fascia & supraspinous ligament is taught??
 Integrity of supraspinous ligament
o L5/S1 is most instable ligament
 Held for 15-20 seconds or until end feel is achieved or pt reports reproduction of symptoms
 At least 3 segments (above and below desired level)
 Findings: pain, mm spasms, increased mobility, lack of firm end feel, crepitation (severe case)
SIJ Exam
Anatomy
 Lumbosacral junction=L4,L5,S1
 Dense superior articular process of S1 contributes more to WB than LS
 Iliolumbar ligament: restricts all planes of movement especially ext and contralateral side flexion
Joints
 Anterior SI: diarthodial (syovial)
 Posterior SI: syndesmosis (non-synovial)
Articulating surfaces
 Sacral: hyaline cartilage (type II)
o Short arm: cranial-caudal (S1)
o Long arm: Ant-post (S2-S4)
 Iliac: fibrocartilage
o Arms same at sacrum
 Pubic Symphysis: fibrocartilage
Ligaments
 Ventral SI: prevents anterior gapping
 Interosseus: prevents posterior gapping
 Long posterior dorsal SI: prevents counternutation (PSISS2,3,4)
 Sacrotuberous: prevents nutation (PIISS2,3,4 & ischial tuberosity)
 Sacrospinous: prevents nutation (sacrumischial spine)
Palpation
 PSIS=medial & inferior to dimples
 S2=medial to PSIS
 Sacral sulcus: medial & superior to PSIS (multifidus is largest here)
SIJ mobility Tests
 LS extension
o PSIS moves inferior and medial (ilium=posterior rotation)
 Hip (testing ilium on sacrum=iliosacrum)
o Flexion (Gillet)
 PSIS=inferior & medial (Ilium=posterior rotation)
o Extension
 PSIS=superior & lateral (ilium=anterior rotation)
Motion
 SI motion= sacrum moves on ilium during lumbar motion
 Iliosacral motion= ilial movement on sacrum during hip movement
Trunk Flexion
Trunk extension
Remain in nutated
Sacrum
Nutation--> counter
position
Innominate Anterior
Posterior
Hip flexion
(unilateral)
Hip extension
Sacrum
Nutation
Counternutation
Innominate Posterior
Anterior
Trunk rotation (right)
Sacrum
Right
Innominate Left= anterior
Right=posterior
Sacral flexion=nutation
 Inferior & anterior (osteokinematic)
 Inferior & posterior (athrokinematic)
Sacral extension=counternutation
 Superior & posterior (osteokinematic)
 Superior & anterior (athrokinematic)
Sacral stability
 Pushing inferior & anterior (counter nutation) in prone position
 Form closure: passive stability. Articular surfaces and ligaments.
 Force closure: active stability. Intrinsic/extrinsic forces including mm, fascia, ligaments
o Inner tube mm: diaphragm, TA, multifidus, pelvic floor mm
o Outer tube
 Longitudinal: erector spinae, bicep femoris, TLF, sacrotub lig
 Anterior oblique: internal/external oblique, adductor, abdominal fascia
 Posterior oblique: lat dorsi, glue max, TLF
 Lateral: glute med/min, adductors
SIJ body chart
 Unilateral pain, butt pain, LBP (L4-S1) or posterior leg pain to knee joint (looks very similar to
lumbar problem)
Dysfunction: Hypomobile
 Anterior rotated ilium: difficulty w activities that require posterior ilium movement. Functionally
LONG leg.
 Posterior rotated ilium: “ “anterior motion. Functionally SHORT leg.
 Upslip: entire ilium higher. May have decreased anterior & posterior rotation. Decreased hip
Abductor strength.
 Inflare/outflare: named by position of ASIS to midline
 Sacral torsion/rotation: one side deep, other side shallow.
MET: Correction for rotated ilium
 If anterior rotated ilium=affected leg in 90/90, ham & glute contraction, 3x10 seconds
 If posterior rotated ilium=isometric hip flexion c leg flat
Hypermobile Pelvic Girdle:
 Deep shift/clunk, positive stability tests (form/force closure, posterior/superior shears).
 Tx: SI belt, stabilization ex (inner, outer tube mm to increase compression of joint)
Exercises:
 If hypermobile: TA, multifidus, glutes
 If hypomobile: MET
SIJ Manip
 Side bend towards, rotate away from side to be manipulated
 Indicated for lumbosacral dysfunction
 Clinical prediction rules
o Fear Avoidance Behavior Questionnaire work subscale score <18.
o Duration of symptoms 15 days or less.
o No symptoms distal to the knee.
o Lumbar spine hypomobility at any level.
o Either hip with greater than 35 degrees of internal rotation.
 Success= a 50% reduction in the Oswestry score in less than 5 days
o 4/5 symptoms=95% success
o 3/5= 68% success
o 2/5=unchanged (45%)
o 45% overall success
Neurodynamics
Concepts
 NS responds to pressure, absence of movement and lack of blood supply
 Sick nerve: ischemia, inflammation, disruption of axoplasmic flow
o Alteration of ion channels on axon may cause pain
o Substance P release increased mechosensitivity even under low stress



Double crush: compressed proximally distal lesion or symptoms
Reverse double crush: distal compression proximal symptoms
Causes: trauma, posture, overuse/microtrauma, arthritic changes, soft tissue, scarring,
compression, chronic condition
Testing
 Response: stretching, burning, tingling, numbness (can be normal response) but MUST be related
to pts symptoms (paine, ache, pull)
 ***Positive test: reproduction in symptoms, abnormal/asymmetrical resistance, less available
ROM, change in Sx c sensitizing maneuvers, asymmetrical response to test
 Determine symptoms response, quality of movement, and ROM compared to other side
Contraindications:
 Malignancy, instability of vertebral column, recent worsening of neuro Sx, cauda equina syndrome,
tethered spinal cord, unstable disc lesion, diabetes or other pathological conditions involving NS,
irritable
Appropriate pts
 Radiating pain, carpal tunnel, chronic pts (especially these pts!), disc pathology
 Not appropriate for acute inflammation
LE : SLR
 >70 degrees is most due to hamstring
 Crossed straight leg sign= indicates large disc protrusion
o SLR produces pain in contralateral leg but not when contralateral is raised
o SLR produces pain in both legs
o SLR of either leg produces pain in contralateral limb
 Bilateral SLR
o + passive neck flexion + doriflexion=indicates central protrusion
 Dorsiflexion = Tibial N
 Dorsiflexion + inversion = Sural N
 Plantarflexion + Inversion = Peroneal N
 Hip adduction + Internal Rotation = Lumbosacral Plexus
 Passive neck flexion = to elicit some
UE
ULNT 1: Base test
 Fist above pts shoulder to maintain neutral position
 Abduct (110o)SupinateExtend wrist, fingersER shoulder Extend elbow
 Ab-S-Ex-ER-Ex
ULNT 2a: Median N
 Pt diagonal
 Scapular depression Extend elbow ER shoulder Extend wrist, fingers, thumb Abduct
shoulder (20 o) Ear to shoulder
 SD-Ex-Er-Ex-Ab
ULNT 2b: Radial N
 Pt diagonal
 Scapular Depression Extend elbow IR should, pronate forearmFlex wrist, thumb fingers &
Ulnar deviation Abduct arm Ear to shoulder
 SD-Ex-IR/Pronate-Fl/Ul-Ab
ULNT 3: Ulnar N
 Extend wristSupinate forearmFlex elbowShoulder depressionER shoulder Abduct
Spinal Stabilization
Stabilized spine
 Passive support (osseoligamentous), active support (mm), control of mm system by CNS
Segmental instability:
 inability to maintain intervertebral neutral zones within physiological movements so that there is
no neuro dysfunction, no major deformity, and no incapacitating pain
 abnormal movement of one vertebrae on another 2o increase in neutral zone which leads to
mechanical back pain (which can lead to neurological pain)
 Passive: Spondylolisthesis, spurs, disc degeneration. Tested w passive intervertebral or accessory
testing
 Active: unstable at low loads, decreased contraction, decreased feedback, mm fatigue
Predictive success for spinal stabilization
 Age: <40, (+) prone instability test, aberrant spinal movements (almost gowers), SLR: >91 (avg)
o 3 or more of these=67% success
Predictive Failure
 (-)prone stability test, absence of aberrant movements, absence of lumbar hyPERmobility, >9
FABQ
Lumbar stabilization
 Training TA and multifidus. SUBMAXIMAL contraction that should occur 24/7
Lumbar Stabilization Training
 Prone:
o 70mmHg decrease 6-10 mmHg hold 10-15 seconds (breathe normally!)
 Supine (hooklying):
o 40mmHgHold 10 seconds (breathe normally)
o Progressive: Toe liftsTiny stepsMarchingAlt knee extAlt UEsDouble OH
UEsAlt or double OH UEs + Alt LE unsupported BridgeBridge + steps Bridge + Alt
knee extBridge + Alt knee ext + opposite UE flexion abdominal crunchLeg press
 Leg Loading test
o Device under side of LS testing. 40 mmHgheel slide (opp leg support) leg ext (opp leg
support)unsupported heel slideunsupported leg ext
McKenzie
 Mechanical evaluation that assesses the effect of repetitive movements and/or static loading on
pts Sx
Syndromes
 Postural: end range stress of normal structures
o No effect c repeated measures (
 Dysfunction: end range of shortened structures
o Loss of ROM compared to postural. Worse in AM but gets better. Repeated movements
reproduce Sx but don’t get worse (amber)
 Derangement: anatomical disruption or displacement within the motion segment or IV
o Addresses disc. Will respond well to McKenzie. Mechanical Deformation
o Repeated symptoms can worsen or improve Sx (central/peripheralization)
Pain
 Chemical: must be enough pain to activates nociceptive system. Constant pain, inflammation,
infection. Not abolished by positioning
 Mechanical: force to tissue activates nociceptive system. Intermittent pain, movement changes
intensity. Driver for MeKenzie method.
Centralization vs peripheralization
 Centralization: Distal Sx will assume position proximally due to certain movement.
o Only in derangement syndrome
o Strong indicator of discogenic pathology
o Good prognosis for recovery
 Peripheralization: Proximal Sx will assume position distally due to certain movement.
Directional preference?
o Will cause symptoms to shift either proximal or peripheral
o Flexion vs extension
 Flexion: nerve root adherence or entrapment?
Repeated movement
 Red Light, Amber light, Green light
 Gives good indication to whether or not they are a responder
 Responder vs non-responder? 52 (back might get worse)
o Non-responder= Pain gets worse and increases peripheries
o Responder= back might get worse but peripheral got better (centralized)
 Not good for chronic? Bc wont get good feedback
Treatment
 Prone lying: 5-10 minutes
 Prone lying on elbows: 5-10 min
 Prone Press ups: x10
 If can’t be prone: standing extension: hold 20 seconds, 3-5 reps
Contraindications
 Increasing peripheral symptoms, severe pain or spasms, no position or movement causing
comfort or reduction of pain=non responder