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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 discsuction 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) 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 Atlasocciput: ALLA AO M o Axis occiput: PLLTectorial membrane Alar lig: densocciput. Resists flex, contralat SB & rotation. Attaches to occiput slightly anterior, posterior or neutral o AxisAtlas 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 massocciput 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: rotationextensiontraction (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 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 + rotationopposite 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 elevationIncreases 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 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 stiffnessfusion 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 (S2C7) o Fingertip to floor= 2cm Extension=20-30 degrees Rotation=45 (F=center of head, S=iliac crests, M=acromion processes) SB= 35 (S2C7) o Fingertip to thigh=20cm Lumbar: Flexion= 5-8cm (S215 superior) Extension= 1.5cm (25 degrees) Rotation= SB= 25-30 degrees