Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 PSIST9,10. 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 discssegmental instabilitymultifidus 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 (PSISS2,3,4) Sacrotuberous: prevents nutation (PIISS2,3,4 & ischial tuberosity) Sacrospinous: prevents nutation (sacrumischial 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)SupinateExtend wrist, fingersER 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 forearmFlex wrist, thumb fingers & Ulnar deviation Abduct arm Ear to shoulder SD-Ex-IR/Pronate-Fl/Ul-Ab ULNT 3: Ulnar N Extend wristSupinate forearmFlex elbowShoulder depressionER 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 40mmHgHold 10 seconds (breathe normally) o Progressive: Toe liftsTiny stepsMarchingAlt knee extAlt UEsDouble OH UEsAlt or double OH UEs + Alt LE unsupported BridgeBridge + steps Bridge + Alt knee extBridge + Alt knee ext + opposite UE flexion abdominal crunchLeg press Leg Loading test o Device under side of LS testing. 40 mmHgheel slide (opp leg support) leg ext (opp leg support)unsupported heel slideunsupported 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