Download fco notes - USA Blue Class

FCO NOTES
{look at anatomy, muscles, myotomes/dermatomes, draw p. 10, S1 notes}
CHAPTER 1 re-read
ORTHOPAEDICS: Branch of PT which is especially concerned with preservation, enhancement, and restoration of the neuromuscular system, its
articulations, and associated structures.
JOINT DYSFUNCTION: state of altered mechanics, either an increase or decrease of motion from the expected normal, or the presence of aberrant
motions.

Classical Movements: Osteokinematic motion that takes place around a joint, either active or passive.

Accessory Movements: movements that occur at the joint surfaces
o
Component Movements: motion that take place in a joint during active motion; absence of one or more of these will result in
dysfunction
o
Joint Play: joint movements not under voluntary control which occur in response to an outside force

Distraction: separation of 2 articular surfaces perpendicular to the treatment plane

NonThrust: joint is oscillated within the limits of accessory motion or taken to the end of its range and oscillated or stretched; includes
isometric manipulation

Thrust: sudden, high velocity, short amplitude motion is delivered at the pathological limit of accessory motion

Strain : mild overuse injury

Sprain: moderate injury with separation of fibers and elongation of structure

Rupture: severe injury resulting in separation in torn ends of a structure

Stress: resistance of a tissue to deformation

Strain: deformation that occurs due to loading of tissues/stress

Tone: degree of tension in the muscle

Hypertonicity: state of increased tone

Spasm: involuntary contraction of a muscle; sudden twitch
CHAPTER 2: HISTORY

Joint manipulation is an ancient art/science; practiced by PTs, chiropractors, osteopaths

PT has always had a close relationship with medicine and developed its knowledge base and practice from the medical profession

W the 1960s PTs have developed their own body of knowledge in manipulation

Chiropractors: independent origins in 1895; not practiced in cooperation with medicine
o
Uses manipulation originally to correct spinal subluxation
o
Spinal adjustments used to allow for the free flow of nerve energy to relieve most human ailments
1
o
Straights defend the subluxation theory and mixers do not; this change in perspective has brought them in closer alignment to
PT; many chiropractors use PT practices, but are not allowed to call themselves PTs
Manual Physical Therapy: clinical approach using skilled, specific hands-one techniques to diagnose and treat soft tissues/joint structures to
modulate pain, increase ROM, reduce inflammation, improve contractile and non-contractile tissue repair, facilitate movement, improve function

Mobilization is frequently used to mean non-thrust techniques and manipulation for thrust techniques

Due to PTs trying to separate themselves from chiropractors in the 1960s
THE BEGINNING

Manipulation/massage began with self-cracking of joints, stretching of muscles, walking on each other’s backs

Hippocrates: (460-355 BC) father of medicine; 1st person in recorded history to describe and illustrate joint manipulations/traction
o

Wrote 3 books on bones and joints; “On Setting Joints by Leverage” in which he talked about reducing dislocated shoulders
Galen: (131-202 AD) famous Italian surgeon, who wrote extensively and 18 of his 97 surviving works detail/illustrate Hippocrates
manipulative techniques
MIDDLE AGES/RENAISSANCE

Middle Ages represent a decline in medical knowledge throughout the Western World; church became responsible for most healing

Andreas Versalius: (1543) began the renaissance in medicine by describing in detail, the entire human body and outlined the anatomy of
the disc

Ambrose Pare: (1579) famous surgeon to 4 kings; raised the standard of orthopedic surgery; used a considerable amount of
manipulation; knew to put a person in prone if they had posteriorly dislocated vertebrae

William Harvey: (1628) gave the 1st accurate description of the circulation of blood
DAWN OF MODERN MEDICINE

John Hunter: (1728-1793) taught the value of movement to joints after injury in order to prevent stiffness and adhesions
o
Believed that adhesions remained as an end product of inflammation and should be stretched

Percivall Pott: (1717-1788) Pott’s disease (TB of the spine) and Pott’s fracture; condemned extension exercises and manipulation as
useless and dangerous in management of spine

Dr. William Harrison: (1784) got a good reputation using manual medical procedures like manipulation

Nicholas Andre: (mid 18th century) coined the word orthopedics from ortho (straight) and paidos (child)

Parkinson: (1817) became interested in cervical spine as possible cause of spinal disease; not given much attention until Brain and
Wilkinson in 1956, who showed how advanced cervical spondylosis can result in myelopathy and mimic MS

J. Evans Riadore: (1842) London MD who practiced manipulation; wrote that an organ that was insufficiently supplied with blood or
nervous energy would be endangered

Morton: (1846) began use of ether as an anesthetic

Lasegue: (1864) described the posture that was common with sciatic leg pain

Bonesetting: (17th/18th centuries) believed that little bones could be clicked into place by manipulation; bonesetters and barber surgeons
were the forerunners of orthopaedics and surgery in the UK; replaced by osteopathy and PT in the 20th century

Sir James Paget: (1867) said that too much rest leads to a delayed recovery after injury to joints, and the surrounding body parts
2

Wharton Hood: (1871) published “On Bonesetting” which was the 1st published by an orthodox practioner; Hood felt the snapping sound
was due to adhesions beign snapped, not little bones going back into place (pre- Hood, many MDs disdained manipulation/bonesetters)
o
1870:
manipulation was firmly established in contemporary medicine
OSTEOPATHIC MEDICINE



Founded in America by Andrew Taylor Still in 1874
o
He was an eccentric and made a lot of people mad, but he noticed that normalizing locked joints caused some conditions to
improve; had disdain for medicine as 3 of his children dies of plague
o
Still believed in blood and nerve “flow” and coined the phrase “The Law of the Artery” : if blood flow is impeded disease will
occur
Osteopathic concept has three main parts
1.
The body is a unit
2.
Structure and function are reciprocally interrelated
3.
The body possesses self-regulatory mechanisms; can heal itself
Osteopathy grew and developed, embraced the advances made by medicine; became more orthodox in practice; 1970 all osteopaths
were considered equal to doctors, and focus their energy on medical knowledge over manipulation
o
Left a void to be filled because they did not claim to be a cure all
CHIROPRACTIC

Daniel David Palmer founded chiropracty in 1895; former green grocer and practicing magnetic healer

Wrote a book called “The Chiropractor’s Adjustor” in 1910 and stated that he learned how to manipulate from Jim Atkinson (MD)

o
Said the art of manipulation had been around for 1000s of years
o
Later said that he was the first to put displaced vertebrae back into place using SP and TP as levers
Theoretical Basis of Chiropracty (Janse, Houser, Wells)
1.
Vertebrae may become subluxed
2.
Subluxation tend to impinge on other structures (nerves, vessles, lymphatics travellign through intervertebral foramen)
3.
The impingement impedes the function of the corresponding spinal cord segment and the nerve impulse is impaired
4.
Innervation to some body parts become functionally or organically diseased due to this
5.
Adjustment of the subluxed vertebra removes the impingement, restoring innervations to diseased parts of the body; this
is called the “Law of the Nerve”

Target for MDs because it claimed to be a cure-all for everything

1970: chiropractors redefined manipulation to include nearly all known dysfunctions of the spine; allowed them to receive $$ for tx

1981: Chester Wilkes DC, sued the AMA and got them off chiropractors backs
PHYSICAL THERAPY AND MEDICAL MANIPULATION
3

PT was created by medicine to provide rehabilitation aides; MDs provided the training

1899: PT was founded in England

James Mennel MD (1907) instructed joint and soft tissue manipulation techniques at the Chartered Society of Physiotherapy
o
(1949) awarded the Golden Keys with Life membership of the American Congress of Physical Medicine and the APTA
o
First person to coin the term “manual therapy”

He and Edgar Cyriax worked together, and were way into manual techniques

Cyriax published a paper called “Manual Treatment of the Cervical Sympathetics” in 1917; advocating TFM to the
cervical ganglion to stimulate their function

1921: PT founded in the USA as the American Women’s PT Association”

1922: Granger wrote about possible treatments: heat, massage, stretching to break adhesions, forceful manipulation, exercise

Thomas Walmsley: (1927) introduced the concept of arthrokinematics and noted the close-pack position of joints
o
Kaltenborn would later take this information and apply it to manipulation

Leadbetter: (1930) suggested using manipulation for SI dysfunction in Physiotherapy review *

Humphris and Stuart-Webb: (1932) defined PT as massage, manipulation, active and passive exercises*
o
Frank Romer: wrote a chapter on manipulation and said it should be swift and firm

Ghormley: (1933) described the “Facet Syndrome” arthritic changes in the facets or narrowing of the intervertebral foramen due to facet
problems caused sciata; would be overshadowed by disc protrusions

Mixter and Barr: (1933) proposed the concept of herniated disc and surgery to treat it; changed the way people look at back pain

Frieber and Vinke: (1934) described the “Piriformis Syndrome” in which sciatica is produced by inflammation of the piriformis

EA Codman: (1934) wrote a book called “The Shoulder” and advocated repetitive pendulum motions to joints to decrease
pain/inflammation

Ober: (1934) proposed that fascia lata can produce LBP; fasciotomy developed for its cure

Mary C Thornhill: (1936) wrote a paper stating that manipulation may be carried out even if the pt is large, to reduce spasms

Burrows and Coltart (MDs): (1939) wrote that manipulation is concerned with passive movement to a joint and falls in the world of PT*

Sir Morton Smart: (1946) wrote extensively on adhesions that form in joints after injury; wrote on “end-feel”

Lindblom: (1948) described the 1st dicography

Leube and Dicke: (1948) wrote “Massage of the Reflex Zones in the CT”; based on McKenzie’s work and the forerunner of CT massage
and myofascial release

James Cyriax: (1948) published the “Textbook of Orthopedic Medicine”; spoke about his beliefs regarding the disc
o
Sudden onset of pain due to a crack and displacement of the annulus that could be manipulated back into place
o
Gradual onset of pain due to protrusion of nucleus which would be best treated with traction
o
Popularized the word “end-feel” to draw attention to the resistance felt at the end range of joints; he distinguished between
normal and abnormal end-feels
4
o
Trained PTs and felt that PTs are the best people to go to for manipulative techniques

Steindler: (1955) wrote a book that introduced Walmsley’s concept of arthrokinematics to America

Cave: (1955) said that Von Luska joints in the neck are common sites for OA

Harrington: (1960) used rods to fix scoliosis

1960: British Medical Association made a statement to the Health Committee that was proposing a Chiropractic Bill, that spinal
manipulation should be carried out by orthopaedic surgeons or physiotherapist under direction of medical direction*

John Mennell: (1960) son of James Mennell; wrote a book called “Joint Pain”; felt that joint pathology and pain came from synovial joints
not the disc, supporting the work of his dad
o
1st person to use the term “joint play” to describe the joints ability to withstand aberrant forces/motions; called it the wiggle or
slack that is present in all mechanical and biomechanical structures; also wrote “Foot Pain” and “Back Pain”

Freddy Kaltenborn: (1961) first person to relate manipulation to the new knowledge of joint arthrokinematics; wrote a book called
“Extremity Joint Manipulation” *

1962: 1st meeting of Congress on Manual Medicine

1963: 1st meeting of British Association of Manual Medicine; Dr. James Cyriax still said PTs were the best practitioners to perform
manipulation *

Stanley Paris: (1963) “The Theory and Technique of Specific Spinal Manipulation” wrote that degeneration follows loss of motion
because other joints above and below have to compensate for the loss of motion; called spinal lesions “dysfunctions” *

o
Met with John Mennell in 1966 to advocate manipulation by PTs
o
1966: met with Maitland, Grieve, Kaltenborn to talk about setting up an international body to exchange educational ideas and
maintain standards in manipulative therapy
o
1976: published “Mobilization of the Spine” in Physical Therapy, presenting the indication, contraindication, and biomechanical
basis for manipulation
o
1982: wrote a paper on reliability of PIVMs with Gonnella and Kutner
Geoffrey Maitland: (1964) uses oscillatory manipulation to treat “reproducible signs”; wrote “Vertebral Manipulation” and “Peripheral
Manipulation” *
o

1995: received the Mildred Allison Award (highest award) at the World Confederation of PT
Melzack and Wall: (1966) proposed the Gate Control Theory of Pain, stating that large nerve fiber simulation from joints and muscles can
block the transmission and perception of pain
o
Led to TENS and other modalities to gate pain; provided an explanation for the neurophysiological effects of manipulation

1966: World Confederation for PT (WCPT) founded

1968: North American Academy of Manipulation Therapy founded; Paris was chair

McCaleb: (1969) influenced Mennell; stated that manipulation was used for joint dysfunction, and that dysfunction is the partial or total
absence of motion at a joint

1974: Orthopedic Section of APTA formed; Paris was 1st president

1974: International Federation of Orthopedic Manipulative Therapy (IFOMT) founded

Mariano Rocabado: (1976) introduced American PTs to the diagnosis and management of TMJ disorders
5

1978: IFOMT became the first specialty sub-section of the WCPT, allowing increasing acceptance for joint manipulation in PT

Robin McKenzie: (1970s): popularized spinal extension for treatment of LBP; believed that centralization of pain follows repetitive
motion because it helped reduce the disc protrusion

Farrell and Twomey: (1982) showed that duration of LBP symptoms were significantly shorter in patients who received mobilization and
manipulation compared to standard PT (diathermy, isometric abs, ergonomic instruction)

Richard Deyo: (1983) wrote that manipulation was controversial in the US because of chiropracty, but not so in other countries

Ben-Sorek and Davis: (1988) surveyed PT school; 37% taught manipulation as a separate course; 60% as part of another course
o
Most prevalent techniques taught: Kaltenborn/Maitland 73% > Paris 70% > Cyriax 58% > Mennell/Grimsby 54%

Setcliff: (1998): 100% of PT school teach non-thrust techniques and 21% include thrusts

Mulligan: (1990s) manipulation with movement facilitates return to normal function

1991: American Academy of Orthopedic Manual Physical Therapy founded (AAOMPT); established residency standards for manual
therapy training in US
PRESENT DAY

Osteopathy: has abandoned manipulative techniques; many refer out to PT and DCs; does not have a record of opposing other trained
medical practitioners from using manipulation

Medical Manipulation: most docs refer out for manipulation

Chiropractic manipulation: realize that they need to treat the movement of joints and not position of vertebrae; 2 biggest schools still
teach traditional techniques; shift to mixers occurred in 1975 at the National Institute of Neurological Disease and Stroke

o
In 1997 Craig Little, DC wrote a letter to the chair of the Orthopedic section of the APTA and defined mobilization and
manipulation separately
o
Manipulation: thrust to a joint to move it past the physiological ROM without exceeding the anatomical limit
o
Mobilization: movement applied singularly or repetitively without imparting a thrust to maintain mobility
o
DCs have seen the shortcomings in isolating themselves to manipulation
Physical Therapy Manipulation: PTs have used manipulation, along with other techniques, since the inception of the practice
o
Since the 1950s, PT have built upon medical knowledge in the areas of arthrokinematics and neural tension to devise new
techniques and management strategies; these used to be unique to PT but are now being adopted by DC
o
Kaltenborn, Maitland, Grieve, Paris, McKenzie, Elvey (neural tension), and Mulligan have added to a body of knowledge
o
Manipulation is not practice in isolation in PT, and is coupled with exercise, education, and supportive modalities
o
“PT to accept that they shall not use the term manipulation is to separate themselves not only from their traditional practice,
but from reimbursement”
o
PTs followed the medical model, and incorporated joint mechanics, movement science, exercise, and education into
manipulation
CHAPTER 3: CONTEMPORY SCHOOLS OF THOUGHT REGARDING MANIPULATION
6
The most important fact differentiating between the groups that use manipulation is the reason/purpose that they use manipulation




Manipulation philosophies based on relieving nerve root pressure
o
Bonsetters: purpose is to click bones back into place; techniques were specific; bonesetting has been replaced by PT,
chiropracty and osteopathey
o
Traditional Chiropractic: purpose is to move vertebra to relieve nerve root pressure; non-specific techniques
o
Cyriax: purpose is to move the disc and relieve nerve root pressure; non-specific techniques that effect many tissues such as
muscle/facet
Manipulation therapies bases on relieving pain
o
Maitland: oscillations use to create reproducible signs; specific
o
Maigne: derived from osteopathic techniques; specific; manipulations must produce “no pain”
o
McKenzie: repetitive motion used for centralizing pain; many people misinterpret as centralizing the disc
Manipulation therapies based on normalizing joint mobility
o
Osteopathy: joints are mobilized to increase motion; specific
o
Mennell: emphasis on restoring normal “joint play”; specific for extremities, but not spine
o
Kaltenborn: emphasis on arthrokinematics, esp. convex-concave rules; very specific; eclectic
o
Paris: emphasis on restoration of normal arthrokinematics, esp. component and joint play motions; pain de-emphasized;
specific and eclectic
o
Mulligan: promotes natural facet (apopyseal) glides by assisting the motion being performed with pt in WB position;
mobilization with movement
Current status of joint manipulation
o
Joint manipulation an integral part of PT and becoming more accepted by MDs, but chiropracty is also acceptable with more
orthopedic surgeons
o
Chiropractic has moved from positional faults to motion faults and has embraced medical science rather than working against
it

McKenzie Extension: not considered a manipulation (skilled passive movement to a joint) but does play a role in centralizing pain

Clinical Scientists: future of physical therapy; defined as one who relates science to the clinic and hold the clinic accountable to science
o
We must have support for what we do, and to explain our effectiveness
CHAPTER 4: PHILOSOPHY OF USA
1.
Joint injury, including OA, instability, and after effects of sprains/strains, are dysfunctions rather than diseases
2.
Dysfunctions are manifested as increases or decreases of motion from the expected norm, or by presence of aberrant movements.
3.
PT’s primary role is the evaluation and treatment of dysfunction; MD is diagnosis and treatment of disease; complimentary roles in
healthcare.
4.
Dysfunction is the cause of pain, so the primary goal of the PT should be to treat the dysfunction rather than the pain unless the pain is so
intense that is inhibiting ability to treat.
o
Pain follows dysfunction; it can not precede it
7
5.
If the dysfunction is identified as a hypomobility the treatment of choice is manipulation to joint structures, stretching of muscles/fascia,
and promotion of activities that encourage full ROM.
6.
If the dysfunction is identified as a hypermobility, laxity, instability, the treatment of choice is stabilization by instruction of correct
posture, stabilization exercises, and corrections of any limitations of movement in neighboring joints that could be causing hypermoblity
7.
Primary cause of DJD is joint dysfunction; the presence of DJD is due to failure or lack of accessibility to a PT
8.
The key to understanding dysfunction (and being able to evaluate/treat it) is knowing biomechanics and anatomy. PTs should become
very knowledgeable in these areas to assume leadership in treatment of non-operative management of musculoskeletal disorders.
9.
Pt’s responsibility to restore, maintain, and enhance their health. PT should serve as an educator, to be an example to the patient, and to
reinforce a healthy and productive lifestyle.

DYSFUNCTION: “ a state of altered mechanics, either an increase or decrease from the expected normal, or an aberrant motion”

In physical therapy, we find objective measures/impairments via the PT exam, establish a PT diagnosis, and treat those impairments
o

Using the terms dysfunction or impairment allows us to use the term diagnosis less often, and avoid drama
Good orthopedic treatment stems from an understanding of anatomy, biomechanics and tissue pathology
o
Very important to realize that structure dictates function
o
Treatment is an art; understanding the body is a science
OSTEOKINEMATICS
KINEMATICS
ARTHROKINEMATICS
KINETICS
DYNAMICS
POSTURE/EQUILIBRIUM
STATICS
SOLID MECAHANISMS
BIOMECHANICS

BIOMECHANICS: study of forces and energy and their effects on the body

KINEMATICS: study of geometry of motion, independent of kinetic influences responsible for that motion

o
OSTEOKINEMATICS: study of gross motion of limbs or other body parts in relationship to each other/environment
o
ARTHOKINEMATICS: study of the relative motions that take place between articular surfaces and related joint structures
KINETICS: study of effect of forces on a body or system
o
DYNAMICS: study of bodies/systems in motion, particularly when they are not in equilibrium
o
STATICS: study of bodies/systems in equilibrium

EQUILIBRIUM: state of a body/system at rest or in constant motion; to be in equilibrium, the sum of forces acting on
the body must be zero, the sum of moments/torques must be zero, and no acceleration present

SOLID MECHANISMS: study of the mechanical properties of materials

STRESS: resistance of a material to deformation; occurs in response to an applied load

STRAIN: deformation that occurs in a material in response to the application of an external load
8
CHAPTER 5: ARTHOLOGY
TYPES OF JOINTS



FIBROUS: made of intervening CT between apposed bones that make up the joint
o
Sutures: fibrous joints that have interlocked/overlapped bones; skull
o
Syndemosis: fibrous joint without interlocking bones; distal tib-fib
CARTILAGENOUS:
o
Synchondroses: temporary joints of hyaline cartilage that get fused later in life; growth plates
o
Symphysis: cartilaginous joints that have hyaline cartilage on the surfaces on the apposed bone with a large mass of
fibrocartilage connecting them; permanent joint; intervertebral discs and pubis symphysis
FIBROCARTILAGE: primary constituent of symphysis joints
o
Also found in intra-articular menisci and as a transitional structure in ligaments/tendon insertion into the bone
o
Fibrocartilage has a very large concentration of fibrillar collagen in its extracellular matrix: Type I and Type II collagen both
found in varying concentrations based on structure
o
Cells are fibrocytes or chondrocytes; water makes up 70% of the wet mass of fibrocartilage; collagen makes up 60-70% of dry
mass
o
Proteoglycans abundant and lots of cross-links; avascular and aneural


Human intervertebral discs have the highest concentration of non-reducible cross-links of any vertebrae CT
SYNOVIAL: characterized by a lack of intervening CT connecting the apposed bones; highly movable
o
Bones covered with articular cartilage (hyaline)
o
Also characterized by articular capsule, synovial membrane, ligaments, and articular discs (sometimes)
COMPONENTS OF SYNOVIAL JOINTS:
Bone: made of osteocytes (resident cells); osteoclasts (reabsorb bone); osteoblasts (build bone)

Diaphysis is the shaft of the bone, epiphysis is the end of the bone, and metaphysic is in between the two

Cortical bone is 5-30% porous; compact bone; forms the exterior of all bone; lamellar and haversisn systems

Trabecular bone is 30-90% porous; cancellous/spongy

65% mineral, 30% collagen, 5% proteoglycans
Articular Cartilage: covers WB surfaces of bone; cellular portion is made of chondrocytes; 3 zones:
1.
Superficial Zone: porous and deformable; fibers aligned with surface; 10-20% of thickness of articular cartilage; helps distribute load
2.
Intermediate Zone: open meshwork of randomly oriented; 40-60% of thickness
3.
Deep Zone: tight meshwork of fibers; attached to bone and resist compression forces

Articular cartilage is 60-87% water, 10-30% collagen, and 3-10% proteoglycans, which can compress
9

Functions to transmit and disperse load, reduce friction, and minimally absorb shock
Fibrous Articular Capsule: connects the bones together by anchoring the bones just beyond the articular surfaces by Sharpey fibers

Creates a closed compartment for synovial joints and defines the intra-articular space

Provides soft tissue support for the joint and may be reinforced with thickenings known as capsular ligaments

Dense, irregular CT composed of mostly collagen, but some elastic fibers and groundn substance

Capsules have sensory receptors important for proprioception

FUNCTIONS: provide a defined joint space, contains synovial fluid, maintains the volume and the vacuum providing stability, site for
mechanoreceptor function, helps guide movement, helps restrict excess motion
Type I
Type II
Type III
Type
Postural
Dynamic
Inhibitive
Location
Capsule
Capsule
Capsule ligament
Type IV
Nociperceptive
Most tissues
Fired By
Oscilllation, graded or progressive
Oscillation, graded or progressive
Stretch or sustained pressure
Thrust
Injury and inflammation
Synovium: Joint cavity is lined by synovial lining that produces synovial fluid to lubricate the joint

Synovial fluid functions: provides nutrition to cartilage; lubricates the joint; prevents adhesions
o
Contains water, hyaluronic acid, minerals

Synovial fluid is present in 3 locations: synovial joints; bursa; tendon sheaths

Mechanisms for providing nutrition to cartilage
o
Compression squeezes water and mineral salts into cartilage
o
Hyaluronate remains outside of the cartilage and draws spent minerals and waste products out of the cartilage
o
Synovial fluid is replenished by the lining
Ligaments: Most synovial joints have ligaments; capsular ligaments are thickenings in the fibrous capsule of the joint; Extra capsular ligaments are
separate from the joint capsule and exist as distinct joint structures

Made of dense regular fibroelastic CT; 20% of the tissue volume are cells (fibroblasts); matrix is 70% water and 30% cells

Two ways that ligaments and tendons attach to bone:

o
Direct Insertions: perpendicular to the bone surface and occur when there is a small, localized area of attachment (LCL)
o
Indirect Insertions: large, diffuse attachments characterized by a large area of fibers that blend directly into the periosteum of
the bone; some of the fibers from the ligament pass through the periosteum as Sharpey fibers
Principle Function of Ligaments: limit movement in physiological directions or restrict non-physiological movement occurring at a joint;
ligaments are the last line of defense (muscles are the 1st)
o
Ligaments with high elastic content decelerate movement and assist with movement in the opposite direction
o
Function of Ligament: maintain relationship of articular surfaces; provide mechanoreceptor info; restrict excessive motion;
guide motion like the screw home motion; postural stability
o
Function of Tendon: connects muscle to bone; has an elastic energy storing capability
10
Skeletal Muscle: provides joints with the forces needed to produce movement, control movement, produce heat and stabilize/protect joints when
loads applied to them; ability of the muscle to contract dependent on efferent and afferent input
Meniscus-Articular Discs: some synovial joints have an articular disk

Fibrocartilagenous structures that are attached to the fibrous capsule peripherally and project into the joint
o


May or may not pass completely across the joint cavity
Help improve the congruence of the articular surfaces, increase joint stability, and reduce the unit stresses on articular surfaces
o
Also believed to help spread synovial fluid, absorb shock, facilitate combined motions, protect edges of articular surfaces
o
Found in spinal facet joints
Functions: improvement of fit; aide in lubrication; WB; protect capsule from impingement; protect articular edge; facilitate combined
movement; shock absorption
Other Random Structures:

Labrum: deepen cavity and increase stability

Nerve Function: provide impulse for mm function and visceral function; carries info centrally

Fascia: continuum within the body; surrounds all structures in the body and forms layers within the body for protection, movement,
compartmentalization
o

Functions: forms division within the body; attachments for muscles; surrounds and protects nerves; constitutes much of the
walls of the vessel; semipermeable; can be stretched with sustained force; can restrict motion depending on arrangement
Skin: largest organ in the body; contains tissue fluids; protects against infection; retrains motion
CHAPTER 6: SOLID MECAHNICS/STRESS AND STRAIN


SOLID MECHANICS is the study of the mechanical properties of (biological) materials
o
Fundamental concern of solid mechanics is the relationship between stress and strain
o
Mechanical properties are evaluated by applying a load to a material and measuring the resultant stress and strain
STRESS: resistance of a material to deformation; quantified in force/unit
o
The types of stresses created in the tissues due to a load, are opposite to the direction of force applied

If you compress/squish an object inward, the stress in the tissue trying to resist that force will be outward

STRAIN: the deformation that occurs in a material in response to the application of an external load; quantified as the % of change in
dimension of a material, usually length

LOAD: application of a force or moment to a material; types of loads:
o
COMPRESSION: equal and opposite loads applied into material, creating a compression stresses within the structure;
shortening and widening of structure
o
TENSION: equal and opposite loads applied away from the surface; creates lengthening and narrowing of structure
o
SHEARING: opposing forces are applied in parallel to the surface of a structure; results in angular deformation of tissue;
scissors apply a fine shear load to paper
o
TORSION: opposing loads are applied to a structure that cause it to twist about an axis; creates a combination of compression,
tension, shear within the structure; wringing a towel
11
o
BENDING: combination of 3 or more loads applied to a structure, that cause it to bend around an external axis; compression on
concave side and tension stresses on convex side; can have 3 or 4 point bending
o
COMBINED: 2 or more loading modes applied to the structure at the same time, like torsion-compression
STRESS/STRAIN CURVE

TOE REGION: structure is lengthened and there is a settling of the collagen bundles into a more compact arrangement; crimp in collagen
is straightened out; “taking up the slack”

ELASTIC REGION: tissue is stretched, but the deformation that occurs is totally reversible and the tissue can still return to its original
shape
o
Linear portion of the stress-strain curve
o
Hooke’s Law: states that stress is directly proportional to the strain, as long as the elastic limit has not been exceeded (which is
why the tissue can return to normal once the load is removed)
o
Young’s Modulus: measure of a stiffness of a material, measured by the slope of the elastic region of the curve

YIELD POINT/ELASTIC LIMIT: end of the elastic region where tissue begins to undergo damage as a result of the loading

PLASTIC REGION: microfailure begins to occur in the tissues and the tissue begins to lengthen at a rate disproportionate to the stress
o
Causes permanent deformation in non-biological tissues
o
Biological tissues have “biological memory” which allows them to slowly contract back to their original length, even after plastic
deformation

ULTIMATE STRESS: peak of the curve; maximum load a tissue can tolerate

NECKING REGION: point where tissue start to fail, and follows the ultimate stress; slope of the curve becomes negative

FAILURE POINT: point where tissues fail; strain (deformation) increases even if there is a sudden decrease in stress; structure is rendered
incompetent

If a tissue is taken to the end of the elastic limit, and then released (load/unload), the tissue will return to its normal resting length

o
This is called Pre-Yield Testing
o
Energy is lost between loading and unloading and is called hysteresis, and is usually lost as heat
o
The increase in temperature can directly affect the mechanical properties of the tissue being tested
If a tissue is taken just to the edge of failure and released, it will not retain its normal shape; called Pre-Failure Testing
FATIGUE:

In non-biological materials, fatigued is determined by the magnitude of the load + the number of times the load is applied
o

More load means less repetitions to fatigue, and low load takes more repetitions
In biological tissues, the RATE of the loading is the most important determinant factor in fatigue
o
Biological tissues have the ability to adapt and heal, which allows them to counteract the cumulative effects of repetitive
loading
o
If the rate of cycling is too high, the tissues don’t have time to adapt, and tissues will fail (stress fractures/overuse syndromes)
12

Effects of Temperature:
o
Most substances are less stiff with higher temperatures, so tissues can be heated to increase extensibility, or cooled to make
them more brittle
VISCOELASTICITY: time dependant behavior of a material during the application of a load; elasticity is the tissues ability to stretch and return back
to its original state; viscous characteristic is the ability of a structure to “flow”; viscosity is the resistance to flow; all biological tissues, including
bone, are capable of significant viscous deformation



CREEP: progressive deformation of a structure under the influence of a constant load
o
The initial deformation that takes place when the load is applied is the elastic deformation
o
Viscous deformation continues beyond that point and is responsible for the time dependent characteristics of a tissue’s
mechanical properties
o
Examples include progressive stretching of the posterior portion of the intervertebral disc with prolonged sitting
o
Deformation increases with time
STRESS RELAXATION: decrease in the stress of a structure in the presence of a constant strain
o
Occurs when dynamic splints are used to increase joint ROM  when first put on, the level of stress stretching the tissues is
uncomfortable; over time there is a decrease in resistance to the stretch, and this is stress relaxation
o
Stress decreases with time; this is due to the viscous flow of the structure, which accommodates to the imposed deformation
Viscous Deformation from Viscous Loading: the progressive lengthening of the posterior capsule of the knee due to hyperextension in
people with quad paralysis is an example of viscous deformation with cyclic loading
o
Affected by the magnitude of the load and temperature
ISOTROPHY: measure of the uniformity of the mechanical properties of a material as it is loaded from different directions (steel)

Biological tissues are ANISOTROPIC because they have different stress/strain curves when loaded from different directions
o

A tendon that is tensed in the direction along its longitudinal axis offers high resistance, but perpendicular to the fiber
orientation offers low resistance
Tendons > Ligaments > Capsule
o
Tendons take loads in one direction, ligaments in a variety of directions, and capsules even more so leading to greater
irregularity of tissues
CHAPTER 7: TISSUE BIOMECHANICS

In tissue biomechanics, the phrase “structure determines function” is a crucial concept to understand
COLLAGEN: a major component of all musculoskeletal tissues

Principle structural component of ligaments, tendons, joint capsules, tendons and the major component of the matrix of bone, muscle
and cartilage

All collagen is designed to resist tensile loads, but is also found in the matrix of tissues designed to resist compression

TYPE I COLLAGEN: found principally in structures exposed to tension
o

Skin, tendon, capsule, muscle, annulus fibrosis, menisci, bone
TYPE II COLLAGEN: found in structures exposed to compression
13
o

Collagen based structures contain the following items, from greatest to least:
o

Nucleus pulposus, articular cartilage
Water > collagen fibers > ground substance (proteoglycans [glycosaminoglycan and glycoprotein] and hyaluronic acid) >
fibroblasts
Collagen based structures have characteristics of tensile strength and extensibility
o
Extensibility is due to strain of collagen fibers (6-8% before failure); uncrimping of collagen fibers; glide between fibers and
fibrils; water content redistribution
BONE: composite material with two principle structural components: connective tissue matrix and minerals

Mineral gives bone its hardness and ability to withstand compression forces

Ability to withstand tensile forces comes from the minerals and the matrix components of bone

Bones are made of: mineral > water > Type I collagen > proteoglycan

Determinants of the mechanical properties of bone (trabecular or cortical) include:
o


Size/density of bone; mechanical properties of the bone substance; geometric characteristics of bone; type of load applied; rate
of loading; frequency of loading
TRABECULAR BONE:
o
Moderate to low ultimate strength and stiffness
o
Anisotropic
o
Fractures at 7% strain
o
Strength is lower than cortical bone, but depends on porosity
o
Stiffness and ultimate load increase with speed of loading
CORTICAL BONE:
o
Very high strength in compression and tension

Compression strength = 15,000 PSI
Tensile strength = 12,000 PSI
o
Very high stiffness
o
Fractures at 2% of strain
o
Stiffness and ultimate load increase with the speed of loading
Shear Strength = 4,000 PSI

Fatigue fractures occur do to magnitude, number, or frequency of loading, so management of stress fx must decrease one of these

Stress on bone comes from WB and muscle loading
CONNECTIVE TISSUE STRUCTURES: TENDONS, LIGAMENTS, JOINT CAPSULES

Connective tissue structures are principally designed to withstand tension stresses
o

Their mechanical properties are very poor with any other type of loading
Density and regularity of CT structures are determined by the strength required, and the uniformity of direction of loads
o
As the regularity of CT increases, they become stronger and more anisotropic
14
o
As the organization of the collagen fibers becomes more random, they become weaker and more isotropic
Dense, Regular
Dense, Irregular
Loose
Tendons, ligaments
Capsule, fascia
Investing fascia of almost all structures, subQ tissues

Components of CT: water > Type I collagen fibers > ground substance > elastin fibers > fibroblasts

Determinants of the mechanical properties of CT:
o


Size and density of structure; properties of the collagen/elastin fibers in the structure; proportion of collagen/elastic fibers;
orientation of fibers
Mechanical Properties
o
Anisotropic
o
Tensile strength = 12,000 PSI
o
Fail at strains as low as 9% for structures with no elastic fibers (extremity tendons) and up to 70%for high elastic content
(ligamentum flavum)
o
Ultimate load/stain increase with increasing speed of loading; stiffness does not increase
o
Exhibit significant viscoelastic properties, especially in first 6-8 hours of loading
Clinical notes for CT
o
Aging significantly affects CT because there is a loss of collagen with maturation; but there is greater cross-linking
o
Relaxin hormone released during last trimester of pregnancy, and results in loss of strength and stiffness
o
Non-steroid, anti-inflammatories can increase the tensile strength of CT
o
Failure of CT is due to loads that are too large, too numerous, or too frequent (tendonitis); tx requires removal of one of these
o
CT tissues are very responsive to heat

Most effective method of heating tissues is through exercise, particularly exercises that involve the area being treated
CARTILAGE:

Three basic types of cartilage:
o
HYALINE: synovial joint articular surface
o
FIBROUS: symphysis joints, meninsci, labrum
o
ELASTIC: ear, nose, epiglottis

Mainly designed to withstand compression loads, but hyaline sustains shear (joints), fibrous sustains torsion (discs), elastic sustains
bending

Components of cartilage: water > type II collagen > type I collage (fibrocartilage) > elastic > proteoglycans
o

Annulus of the disc is Type I collagen and nucleus is Type II
Mechanical Properties: anisotropic; biphasic, having a fluid phase from water and a solid phase from collage/proteoglycans; capable of
large viscoelastic deformation due to fluid exudation and fluid redistribution
15


LUBRICATION: the most important aspect of cartilage biomechanics
o
Boundary Lubrication: monolayer of glycoproteins carries the load and provides the separation of the cartilage surfaces for
lubrication
o
Fluid Film: fluid pressure provides separation of articular surfaces and lubrication
Clinical Notes for Cartilage
o
Cartilage is avascular and alymphatic; can only receive nutrient by diffusion and pumping of fluids by
compression/decompression
o
Aneural: can’t send pain signals, so by the time an injury or dysfunction is present, the damage is bad
o
Healthy cartilage contains its proteoglycans, disallowing them to bind to all the water they want to; damaged cartilage releases
its proteoglycans, attracts water, swells
MUSCLE

The most important aspects of stress/strain in muscle are produced within the muscle

Muscle force production is determined by muscle architecture; fiber types; muscle length; speed of contraction; recruitment of motor
units (p 95)

Clinical measures of muscle biomechanics are measures of performance rather than the biomechanical potential of the muscle
NERVE

Nerve tissue should only be exposed to minimal mechanical stress/strain
o

Axoplasmic flow and blood supply to the nerve are affected by too much loading on a nerve
Possible Stages of Compression/Interference with Nerve Function
1.
Axon plasma flow is impeded, resulting in weakness to static contraction
2.
Arterial deficiency, resulting in weakness on repeated effort and neurogenic claudication
3.
Venous deficiency, resulting in weakness and subsequent pain on continued effort
4.
Possible rapid recovery of function following relief of stress or strain
5.
Release Phenomena: acute discomfort/pain following release of prolonged pressure on a nerve; described by Cryiaz in
TOC and Paris in spinal nerve root pressures
General Considerations for Tissue Biomechanics:

Normal Stress is Good
o
Stress stimulates all tissues to become stronger
o
No stress leads to atrophy because the tissues are not stimulated to remodel
o
Astronauts have rapid depletion of bone mineral and loss of muscle tone/strength
CHAPTER 8: KINETICS
KINETICS: the study of the effects of forces on bodies and systems
16

The application of force to a body will cause one of the following to occur:
o
Change in motion of the body, as in dynamics
o
Deformation of the body, as in solid mechanics
o
It will be matched by a reaction force, as occurs in static systems

Statics: study of bodies and systems in equilibrium

Forces: pushes or pulls on a body that, when applied, will cause an acceleration or a deformation of the body it is applied to
o
2-D quantities with magnitude and direction; represented by vectors
o
Characteristics of a force: magnitude, direction, point of application, line of action
o
Mechanical Forces: forces imposed on a system by direct physical contact
o
Electrical, Magnetic, and Electromagnetic Forces: non-mechanical forces; their magnitude is miniscule compared to
mechanical forces
o
Reaction Forces: Newton’s 3rd law, for every force there is an equal/opposite force; represent the resistance of a body to
acceleration or deformation that the applied force could potentially cause

o
Two types of reaction forces commonly discussed in PT are ground reaction forces (force that the ground exerts on
the foot as it strikes the ground) and joint reaction forces
Friction Forces: mechanical forces that occur when two adjacent bodies come into contact with one another; tangential tot eh
surfaces in contact with one another

Lubrication: a strategy used to reduce friction forces that occur between 2 surfaces

Boundary Lubrication: dependent on the chemical properties of the lubricant, as the lubricant must bind to the
surfaces



In joints, the glycoprotein called lubricin is absorbed (adhered) tot eh surface of the articular cartilage and
provides a boundary lubrication

Lubricin molecules help carry the load across the joint surfaces, reducing friction at the articular surfaces
Fluid Film Lubrication: surfaces never actually come into contact with one another and are not subject to wear as
long as the lubrication holds up

Hydrodynamic: occurs when tangentially moving surfaces are not parallel to one another, resulting in a
hydrodynamic lift and separation of the surfaces; the greater the velocity, the more effective the lubricant

Squeeze Film: occurs when the surfaces move perpendicularly towards one another; lubricant between
them is pressurized and will keep the surfaces separated until the lubricant is squeezed out

Elastohydrodynamic: believed to be the dominant form of lubrication in healthy joints; WB increases the
pressures in synovial fluid, and traps the lubricant, resulting in a boost of lubrication and decreased unit
stresses; elastohydrodynamic lubrication only occurs on deformable surfaces

Hydrodynamic and squeeze film lubrication apply to rigid WB surfaces
Coefficient of Friction: 0.02 in healthy joints; magnitude of the friction force is independent of the surface area of
contact
o
Ff (friction force) = FN (normal force; force perpendicular to the planes) x Cf (coefficient of friction)
17

o


Prevent articular injury

Hasten the recovery of motion

Improve restoration and longevity of articular cartilage
Tangential component: perpendicular to the bone the muscle is attached to; causes a rotation at the joint

Can cause shearing at the joint if the motion is not efficiently converted into an angular motion

Will manifest themselves as translations of articular surfaces; anterior shear of the tibia during resisted knee
extension is an example of this

Muscle energy techniques use this shearing force to produce therapeutic joint glides
Radial component: parallel to the bone the muscle is attached to; causes a distraction or compression at the joint

Radial component will stabilize the joint if it is directed towards the center of rotation

Destabilize the joint if it is directed away from the center of rotation

Radial and tangential forces are inversely related; one gets bigger as the other gets smaller
Centrifugal and Centripetal Forces: forces that oppose one another when an object is moving in an angular fashion (around an axis
of rotation)

Centrifugal: directed outward from center of rotation

Centripetal: directed inwards; provided by ligaments and muscles; if structures are altered there will be an unwanted
linear displacement like anterior drawer in ACL tear
Equilibrium: occurs when a body/system is at rest or in constant motion; sum of the forces and moments acting on the object must
equal zero for it to be in equilibrium
o


Muscle Forces: the result of muscle contractions and their affect on joints; two components:

o
Understanding the principles of friction and lubrication will allow PTs to
Must be no acceleration; posture is considered an equilibrium state
Free Body Diagram: used in biomechanical analysis of static systems; diagram of the all of the forces acting on an object
MOMENTS: result of forces acting in an angular motion system; synonymous with torque

Calculated by multiplying the magnitude of the force by the length of the moment arm, which is the perpendicular distance to the line of
action of the force
T (torque) = F (force) x dp (distance)

Can also be calculated by taking the tangential component of force (perpendicular to the bone) and multiplying it by the actual distance
between the center of rotation and the application of force
T = Ft x d
o
this is more frequently used in PT because the moment and force arm are easily measured
LEVERS

Created whenever the motion of a solid object is restricted by the presence of a fulcrum
o
Fulcrum: point of attachment to a rotating object that serves as a fixed center of rotation
o
All levers have a beam and a fulcrum
o
When forces applied to a lever they create moments
18

When the forces applied to the lever are the same, they are in equilibrium

When one is bigger than the other, the one with the longer moment arm is said to have a mechanical advantage
o
Mechanical advantage is a force’s effectiveness at producing a moment

Levers and fulcrums are in constant use in manipulation techniques used to stretch joint capsules/adhesions

Three types of levers:
1.
First Class Lever: has motive force (force that wants to move the lever in a certain direction) and resistance force (opposes motive
force) on opposite sides of the fulcrum
a.
2.
Second Class Lever: the motive and resistive force are on the same side of the fulcrum
a.
3.
Most often used in therapeutic applications
Motive force has the longer moment arm, thus greater mechanical advantage
Third Class Lever: motive and resistive forces are on the same side of the fulcrum
a.
Resistive force has the mechanical advantage (farther away from fulcrum)
b.
Most common type of lever in body
APPLICATION OF FORCES TO THE BODY

When forces are applied to the tissues of the body, very predictable mechanical responses result

Application of force is known as the “loading” of the structure; 5 types:
1.
Compression: occurs with gravity and muscle contraction
o

Bone is exposed to the most compression forces and best at tolerating these loads
2.
Tension: common in the body and occur most in musculotendinous units, ligaments, bones
3.
Torsion: involve a twist or wringing and occur as result of a torque; can result in tension/shear/compression; bone
absorbs most torsional loads
4.
Shear: occur at right angles to the long axis of a structure; tissues are very vulnerable to shear, but we don’t experience
too much of it
5.
Bending: common in body and most significant in bone; 3 forces required to produce a bending motion and 2 must be in
opposition to one another; bending produces a combo of compression/tension
The response of body structures to stress include the following:
o
o
Stress: generated in tissues

Reaction force that occurs in response to load application

Resistance of the tissue to deformation that the application of the load tends to produce
Strain: produced in tissues

o
Deformation that occurs due to the load
Bioelectrical Currents: generated in all biological tissues when loads are applied to them; 2 forms:
19


Piezoelectric Generation: generated when crystalline structures are deformed; happens most in bone; very small
amplitude and short lived; may be too miniscule to be biologically significant

Streaming Potentials: occur due to a differential flow of ions in tissues

All tissues have a lot of collagen, which has a lot of proteoglycan (-) charge

Surrounding fluids have a (+) charge

When a load applied, the fluid is squished and caused to flow around tissues, carrying their (+) charge with
them

This flow of (+) charges results in the production of a current, called the streaming potential

Streaming potentials are probably the dominant electrical activity in all tissues (Gross, Williams)

Healthy cartilage has good streaming potential; gradual loss of potential with degeneration (Frank)
Compression Loads on Joints: compression loads created by muscular contraction are far greater than those created by gravity
o
GH joint has huge compression forces when it abducts
o
Joint cannot be actively moved without them becoming load bearing, so describing a joint as WB or NWB is misleading
o
During all activities, the joints are load bearing
CHAPTER 9: POSTURE

Ectomorph: slender build; small flat joints; limited muscle bulk; low body weights; thin muscles and subQ with slightly developed viscera;
Raynauds; if they have thoracic outlet, suspect a cervical rib

Mesomorph: intermediate build; lots of muscle, bone, CT; heavy hard physique of rectangular outline; greatest life expectancy; most
people are mesomorphs; suspect raised 1st rib with thoracic outlet

Endomorphs: stocky; soft roundness; large viscera, accumulations of fat with tapering limbs; decreased motor skills; large
concave/convex joints making them stable; muscle bulk; shorter; lumbar spinal stenosis (pot belly and excessive lordosis)
o


Football players, wrestlers, weight lifters, sprinters
Subtypes and Associated Dysfuntions:
o
Obese: joint strain/OA of LE
o
Hypermobile: dislocations and early OA
o
Hypomobile: inflexibility leads to sprains
o
Muscular: restricted joint ROM
o
Thermosensitive: Raynauds
o
Hormone Imbalance: obesity and lethargic
o
Neurotic: craniomandibular disease
PT is concerned with the effects that different postures have on the health of the musculoskeletal system, and promoting functionally
efficient postures
20
o
o
o
Traditional perspectives on posture only consider it from a static point of view, which creates a shortcoming in regards to
functionality

Traditional, static posture involved bringing all of the body parts as close as possible to the line of gravity, resulting in
a straight, vertical orientation of the body parts in a rigidly defined posture

Plumb-line approach; use minimal physical effort to maintain a maximally functional position
Dynamic posture is a functional way to look at posture and is based on the following biomechanical assumptions:

Functional posture is dynamic because we are always moving

All functional movements require that the head and neck be in an upright position, and trunk too, which requires
muscular effort to stay upright

Stress/strains vary with different postures, and no posture can completely eliminate them

Stress on body structures can be detrimental

Due to viscoelastic properties of tissues, stress/strain on structures in time dependent
Three biomechanical parameters that must be considered when evaluating posture: energy consumption; stress/strain on
body tissues; functionality required to do activities

Ideally we want to decrease energy and stress and increase functionality

Dynamic postures stress the tissues on an intermittent basis stimulating cellular activity for repair/adaptation

Static postures result in prolonged stresses that fatigue structures and result in cumulative changes that weaken and deform them
o
Postures should not be static because it impedes circulation; changes the physiological environment of tissue (loss of
piezoelectric and streaming potentials); allows progressive strain of tissues; results in muscle fatigue; leaves a person more
vulnerable to perturbations/unexpected movements
o
Postures should be changed often or on the diagonal (active alert), and require minimal muscular effort
STANDING POSTURE (active alerted): diagonal posture; weight distribution changes often; minimal muscle effort; distributes stress better through
feet; knees are better balanced; better body alignment; and avoids hanging on ligaments

Put dominate foot behind and put 80% of weight on it, balancing weight on arches

Put 2 fingers on upper lip and push back until uncomfortable, and then push back to be comfortable

Arms by side, relax, hold

POOR STANDING POSTURE: forward head, rounded shoulders, excessive lordosis, tight fascia lata, hyperextended knees, flexed hip,
pronated feet
SITTING POSTURE: change frequently; intermittent slouching is fine; minimal muscle effort; retain lordosis; back support wide spread, not local;
arms/wrists supported; feet on floor; beware of bifocals
LYING POSTURE: require least amount of muscular effort; make sure joints are in neutral position; supportive soft tissues are relatively slack;
muscles relaxed and neutral length; normal spinal curves are supported but not exaggerated; hips and knees are slightly flexed
EXCESSIVE SPINAL CURVES: KYPHOLORDOSIS

FORWARD HEAD: caused by fatigue, poor postural sense, using bifocals
o
Consequences: subcranial motions may become restricted; locked in BB and may not be able to FB; dental malocclusion;
hypermobility in mid-cervical spine resulting in osteophytes; reduced blood supply to brain; reduced shoulder abduction
21

ROUND SHOULDERS: caused by fatigue and poor postural sense; large breast development; habitual sport/occupation
o

HYPER LUMBAR LORDOSIS: caused by genetics, tight iliopsoas, obesity in men
o

Consequences: tight pecs; thoracic outlet; shoulder dysfunction
Consequences: posterior disc and facet strain; spndylolisthesis
STRAIGHT SPINE: caused by tight hamstrings, lock of subcranial region in BB, idiopathic
o
Consequences: loss of shock absorption; frequency of reversed thoracic curve (myagia); high incidence of headache
EXCESSIVE LATERAL CURVE: SCOLIOSIS



UNLEVEL SACRAL BASE: caused by
o
Short leg: failure of equal growth (metaphysic); old fracture; or pronated feet
o
Hip deformity: faulty angle neck of femur or slipped femoral epiphysis
o
Pelvic anomaly: asymmetry of growth; ilial rotation in forward or backward torsion; ilian upslide
LEVEL SACRAL BASE
o
Caused by bony anomalies; diseases of the lumbar or thoracic spines; subcranial rotation or SB fault
o
idiopathic
SI POSITIONAL FAULTS
o
In women, the SI joint is posterior and superior to the hip joint
o
If the ilium is in forward torsion, the iliac crest is “raised up” on that side, creating a scoliosis in the lumbar spine

o
The opposite is true for the backward torsion of the ilium, which is more common and caused by ligamentous laxity
Can also occur with an upslip of the ilium, which is the same as the downslip of the sacrum

It can be argued that scoliosis aids in the absorption of compressive shocks and in the performance of limb dominant activities

But excessive curves to impose undue strain and lead to dysfunction

Most excessive curves will result in subcranial strain because the eyes want to be level and face the front
GOOD POSTURE
(Feldenkrais/Alexander)

Includes how you are when you sit, stand, walk, sleep

Begins with being responsible to yourself and wanting to feel/function better

Is as much a point of pride as dress, make-up, smile
POOR POSTURE

Creates unnecessary loads on ligaments

Restricts motion in some parts of the spine, and increases motion in other parts which may lead to osteophyte formation

Rounded shoulders leads to stiff upper back and “dowagers hump”; instability and osteophytes in neck; malocclusion of the dental bit;
stress on the TMJ; reduction of blood supply to the brain; headaches

Sitting unsupported on a chair leads to : stretched ligaments; weakened discs; fatigued and weakened muscles
22

Posture is a reflection of your attitude on life

Head position is key to posture and whole body alignment due to Type I mechanoreceptors (postural) that dominate the upper cervical
spine, arm, chest, and respiratory action  affected by head position
CHAPTER 10: KINEMATICS
Our primary challenge as PTs is to: understand movement; explain movement; maintain movement; restore movement; enhance movement



OSTEOKINEMATICS: study of the gross motions of limb relative to one another, the body, and environmental references
o
Movements described as flexion, extension, add/abd, IR/ER
o
Limb motion; measured by a goniometer; measuring the change in joint angle
ARTHROKINEMATICS: the study of the relative motions that take place between articular surfaces and related joint structures within a
joint
o
Describes as roll, glide, spin
o
Joint motion
Motion is relative and changes with reference points, so to make clinical measurement of motion useful we must follow these standards:
o

Describe motion in terms of anatomical condition; distal segment moving on stabilized, proximal segment; spine motions
described by adjacent segments
Motion can be described as linear [translator in nature; distance and time] or angular [described in relation to arcs of motion and time]
OSTEOKINEMATICS

Describes movements of limbs in orthogonal/cardinal planes
o
o

These types of motions are non-functional or non-physiological because most movements occur on a diagonal, and around a
moving axis

Flexion/extension: mvt in a sagittal plane, around a medio-lateral axis

Abduction/adduction: mvt in the frontal plane, around a sagittal axis

Rotation: mvt in a horizontal plane, around a vertical axis
Codman’s paradox illustrates how normal motion works in diagonals: flex 90, abd 90, add 90 and you end up with ER arm
Joint osteokinematics are determined by:
o
Geometry of the joint surface: type of synovial joint, arc of the surfaces, curvature of the joint surfaces (location of axis of rot)
o
Geometric relationships of muscle to joint
o
Geometric relationship of non-contractile joint tissues
JOINT TYPE
Plane Joint
Hinge Joint
DESCRIPTION
Small articular surfaces, and so are the displacements
Translations are the dominant type of motion
Both joint surfaces are planar
Concave-convex
Dependant on collateral ligaments to control motion
Angular motions dominant
EXAMPLE
Intercarpal joint of wrist
Elbow
IP joint of hand/foot
23
Pivot Joint
Condyloid Joint
Saddle Joint
Ball and Socket Joint

Radiocarpal joint of wrist
1st CMC joint of thumb
Hip joint
GH joint
ROM of synovial joints is determined by the arcs of the two articulating surfaces

o
Arc is a distance along a curve; a measurable part of a curve
Arc of curvature of convex joint surface – concave are = joint ROM

Example: humerus arc (320 ̊) – ulnar arc (160 ̊) = 160 ̊(ROM of elbow)
INSTANT CENTER OF ROTATION
o
The axis that joints move around, except plane joints
o
CIRCULAR ESTIMATION
o
o
o

Proximal radioulnar joint
AA joint
ARC OF SURFACES
o

Concave-convex
Ligamentous sling around convex surface to control motion
Angular motions dominant
1 surface convex in both planes; 1 surface concave in both planes
Loose ligamentous support to permit mvt in 2 perpendicular planes
Angular motions dominant; large amount of motion in each plane
Rotation prevented
In one plane of motion, one joint surface is convex and the other
concave; reversed in perpendicular plane of motion
Loose ligamentous support
Angular motions dominate; large amount of motion in each plane
Rotation prevented
Convex-concave
Radius of curvature is the same for all parts of articular surfaces
Angular motions are dominant
Very loose ligamentous support

Estimation of the center of rotation, taken by finding the geometric center of the curvature of the convex articular
surface; use an X-ray, draw a circle and pinpoint its center

Tells us where the center of rotation should be, not where it actually is
METHOD OF REULEAUX

2nd method used to calculate center of rotation

Joint center calculated from 2 points placed on an X-ray (X,Y); joint moved through a small arc of motion (10 ̊), and
2nd X-ray taken (X2, Y2)

Two lines are drawn, and the instant center of rotation is the point of intersection of the perpendicular bisectors
We can use instant center studies to see if a certain joint has tendencies towards gouging (compression), instability
(distraction), or gliding (normal) as one articular surface moves across another

Line drawn from the center of rotation to the point of contact; then a line drawn perpendicular to this line (p 136)

2nd line should be parallel to the joint surface; points up = unstable; points into bone = gouging
Center of rotation is important clinically because many mechanical AD devices use by pts

Center of rotation of the device should be aligned with center of rotation of the joint

If they aren’t aligned (orthosis), there will be discrepant motions, such as slippage or preloading to the joint
TILT: occurs when one side of the joint moves around an artificial center of rotation at the edge of the concave articular surface
24
o
Compression at the point of contact (pivot point)
o
Distraction everywhere else
o
Can only occur in response to an outside force, so it is a joint play
o
Clinical example: valgus/varus stress test at the knee to test integrity of collateral ligaments
ARTHROKINEMATICS

ACCESSORY MOTIONS: motions available at the joint that accompany classical motions, but can also be produced without classical
motion; essential to full ROM and painless function
o
COMPONENT MOTIONS: motions that occur naturally at the joint to facilitate a particular active movement



o
JOINT PLAY MOTIONS: motions not under voluntary control which only occur in response to an outside force
o
JOINT STABILTY: stability of a joint is its inherent resistance to abnormal motions/arthrokinematics
A stable joint will offer great resistance to abnormal arthrokinematics

Passive joint stability: determined by the geometry of the articular surfaces and the support of capsule, ligament,
resting muscles; inversely proportional to the amount of joint play available at a joint

Dynamic stability: stability provided by the active contraction of muscles around the joint; contraction of muscles
also influences the adhesive quality of the synovial fluid by compressing it
o
Geometry of joint surfaces (congruence of surfaces; arc of surfaces; radius of curvature of surfaces)
o
Type of motion occurring
o
Geometric relationship of muscles to joints
o
Geometric relationship of joint restraining structures
Congruence: amount of touching of 2 articular surfaces in a joint; state of coming together; more congruence = more stability
Joint surfaces are incongruous except in one special position (Walmsley, 1927)  close-pack position is the point of maximum
congruency, thus stabilty
Radius of curvature: instantaneous center of rotation is located at the center of the radius of curvature of the convex surface (outside of
the circle, used to find center of circle)
o


Joint arthrokinematics are determined by:
o

GH ER the head moves anteriorly; knee extension the tibia moves anteriorly
Joints with larger radius of curvature are larger, less stable joints
Arc: as the arc of curvature of the concave surface increases, the joint becomes more stable and has less joint play
Types of Arthorkinematic Motions Occurring at Joint Surfaces
ROLLING
GLIDING/SLIDING
SPIN
One joint moves on the other, but with no relative motion occurring
Occurs when friction is high
One joint moves on the other with relative joint motion
Can be translatory (moves) or tangential (moves around axis)
In translator glides, the point of contact is continually changing; in
tangential it stays the same
Special case of gliding when one surface pivots on the other
25

All joints have components of both rolling and gliding that occur simultaneously during movement

Type of motion occurring between joint surfaces influenced by: geometry of joint surfaces; congruency; friction; shape of surfaces; ovoid
and sellar surfaces
o
Increased congruency = increased rolling at joint
o
Increased friction = difficulty gliding; increased rolling
o
Arc of curvature of concave surface increases = rolling decreases
o
Ovoid: surfaces that are either concave or convex
o
Sellar: saddle surfaces which are concave in one direction and convex in the other
o
Even flat joints are not truly flat due to cartilage
o
Convex surfaces have more cartilage in the center of joint; concave surfaces have more cartilage at the periphery
CONCAVE/CONVEX RULE

Because the dominant type of motion at a joint is angular, the dominant type of joint interaction is tangential gliding

Convex on concave = direction of joint glide is opposite to physiological motion
(GH joint)
o
So manipulating force would be in the opposite direction to the movement of the limb
o
Can be looked as a lever (GH); to create rotation (angular motion) the motions on either side of the fulcrum must be in opposite
directions (p 143)

Concave on convex = direction of joint glide is same as physiological motion

Direction of joint rolling is always the same direction as physiological motion

Treatment Plane: where joint motions occur (glides); component motions/glides occur parallel to treatment plane, and distractions/joint
plays occur perpendicularly to joint plane

Location of Joint Glide and Osteokinematic Motion


(MCP joints)
(p 144; really confusing)
o
Joint glides are described at the articular surfaces in a spot that is in line with the center of rotation
o
Osteokinematic motion is described on a spot on the moving bone that is in line with the center of rotation
o
When the concave partner of the joint moves, the treatment plane constantly changes
o
When the convex partner of the joint moves, the treatment plane remains the same

But the point of contact changes

Convex surface will always have to be bigger than concave surface
Exceptions to the Concave/Convex Rule
o
Planar joint movements; intercarpal joints
o
Pivotal motions; flex/ext of shoulder
o
Joints with deep concavities; hip
Concave/convex rules only define component motions, not joint plays
CLOSE-PACK POSITION
26

Maximum congruency between joint surfaces

Max tightness of ligaments/capsule

Joint surfaces locked in screw home position

Intra-articular volume is less in this position

Statically efficient for load bearing; requires minimal muscle activity

Can by dynamically dangerous, vulnerable to injury in close-pack
LOOSE-PACK POSITION
(p 146)

Capsule/ligaments most slack

Minimum congruency between joints

Joint surfaces unlocked

Intra-articular volume is its greatest

Statically inefficient for load bearing; requires lots of muscle

Dynamically safe because it accommodates perturbations

Best position to use distraction techniques
KINETIC CHAIN: series of rigid segments connected together by movable joints

Closed Kinetic Chain: both ends of the chain are significantly constrained in the manner in which they are allowed to move
o
No link of the chain can move independently of the others
o
Maximum displacements and velocities are small
o
Forces generated can be large
o
Whenever the limbs are in WB, they function in a closed chain fashion (LE, spine)


Ex: gastroc changes from PF of foot in open chain to knee extensor in close chain
Open Kinetic Chain: one end of the chain is free to move in space
o
Functional when one of the ends is stabilized or fixed (UE)
o
Any link in the chain can move independently of others
o
Very large displacements/velocities are obtainable
o
Small force generation
o
Spine functions as open chain in horizontal position

Throwing is an open chain activity (small object, high velocity) and pushing is a close chain activity (large object, slow velocity)

Non-functional SB is closed chain; functional SB (SB and rotation coupled in same direction) is open chain
Interdependence of Joint Motion
1.
If mvt in one segment is limited, adjacent segments will compensate
27
2.
Compensation usually occurs more proximal to hypomobile joint
3.
Restriction in one segment may disproportionately affect motion in the entire limb/spine
4.
Interdependence may produce a chain of events in the same segment

Stiff facet  degenerative facet arthritis  reduced disc nutrition  disc degeneration  disc instability facet “remobilizes
 segmental instability  advanced degeneration  fusion

Functional Sharing: multiple structures one together to create one action; screw home mechanism

Coupled Motion: always occur in the same fashion
o

Mid-cervical SB is coupled with rotation to same side, whether functional or non-functional
Combined Motions: can be altered by changing the activity
o
Combined motions usually occur together, but not always
o
Non-functional SB in lumbar spine usually occurs with rotation in opposite direction
NORMAL MOTION: smooth, relaxation of antagonists, full ROM, pain free, muscles have normal strength, PROM > AROM

If PROM = AROM, then the joint has lost its joint play motions; dysfunction
ABNORMAL MOTION: limited ROM, unwillingness to move, painful arc, compensations, crepitus, signs of instability (juddering), PROM < AROM

Frozen joints caused by: exaggerated response to pain; psychological disturbance; fused joint; dysfunction somewhere else in the chain

Clinical Signs of Spinal Instability:
o
History of tissue relaxation/creep; like a lateral trunk shift
o
Inability to maintain a single position for long periods of time
o
Pain worsens with normal use
o
Inappropriate muscle tone
o
Spondy
o
Juddering with FB

Men: greater incidence of LBP and disc disease; prone to lateral shift and loss of lumbar lordosis

Women: ectomorphic female more likely to have cervical ribs, thus thoracic outlet; TMJ 10x more than men; more SI disabilty
CHAPTER 11: SPINAL MOTION

Motions of the spine include FB, BB, SBL, SBR, rotation, translation (translation occurs with FB and BB)

Functional Motion: occurs on a diagonal; head and neck SB and rotate to the same side as the motion in cervical spine

Non-Functional Motion: head and neck SB and rotate to the same side, due to coupling of motions
o
But to keep the eyes straight ahead, there is a rotation to the opposite side at the AA joint
o
A person that can’t non-functionally SB may not be restricted in SB/rotation mid-cervically, but may be restricted in rotation at
the AA joint
o
Non-functional SB is in the pure frontal plane
28

SIMPLE MOTIONS: motions that occur alone (FB/BB)

COMBINED MOTIONS: can be altered by changing the nature of the activity; motions that usually occur in conjunction with one another
o
Example: SB in lumbar spine is usually accompanied with a rotation to the opposite direction, but SB can still occur without
rotation or with rotation in the same direction

COUPLED MOTIONS: always occur in the same fashion; mechanically forced to occur together

Motion in the spine is always defined by the displacement of the more superior/cephalad segment
LUMBAR SPINE


FORWARD BENDING
o
Components: vertebra rocks over nucleus; facets slide up with 40% displacement; posterior disc is drawn taut and may
become concave; nucleus deforms posteriorly, but bulges anteriorly; intervertebral foramen enlarge; motion limited by
posterior ligaments, disc, myofascia
o
Precautions: places lots of stress on posterior disc; may enlarge an existing tear or rupture and may extrude a disc fragment
o
FB May Cause Harm: by stretching the posterior ligaments and cause progressive elongation; may delay healing; will cause the
disc to wedge hydrodynamically
FB in standing significantly increases the load on most spinal structures, especially returning from a FB position

If FB is lost, it could be due to myofascial tightness, facet restrictions, pain

FB as a repeated exercise does not appear to be of any benefit
BACKWARD BENDING
o


(re-read p 164)
Components: vertebra rocks over nucleus; facets slide down and contact the lamina below; nucleus distorts/deforms
anteriorly, but bulges posteriorly; anterior disc drawn taut; top vertebra translates backwards; intervertebral foramen narrows;
with continued BB, the facets become a fulcrum, the disc space undergoes distraction and the facet capsules are stretched

Viscous fluid in the disc will take the path of least resistance

Anterior annulus becomes tight with BB, and posterior annulus slackens
o
Precautions: BB further extrudes an extruded prolapsed; narrowing may comprise neurovascular tissues (nerve roots); BB
overloads the facets; in post-laminectomy pts it can cause a fracture of articular processes; contraindicated in spondys
o
BB May Cause Harm: may overload facets; increase nerve root pressure
o
Uses of BB: appears to be the best movement to gate pain; necessary to restore a lost lordosis secondary to a change in the
hydrophilic fluid balance of the disc; should be attempted in all patients to help restore neutral erect and to encourage motion
FB and BB as Treatment:
o
Repetitive Motion has long been recognized to have beneficial therapeutic effects

Codman (shoulder); McKenzie (back extension); Williams (forward flexion)
1.
GATES PAIN: Codman realized that repetitive motion in the shoulder centralized pain by reducing muscle guarding; did not
attempt to mobilize a tight capsule or snap an adhesion
2.
NUTRITION AND REPAIR: movement aids in nutrition and repair; Salter proved it with rabbit’s knees
3.
CHEMICAL CHANGE: movement increases the nutrition to the disc; painful discs have a lowered pH, and movement may
change this balance
29

SIDE BENDING:
o
o
Components of Non-Functional SB: facet on same side slides down and facet on opposite side slides up; disc bulges on same
side and flattens on opposite side; vertebra rotate to opposite side; few precautions if any

The vertebra rotates the other way because the loaded facets naturally move away from the load

SB and rotation take place to opposite side
Components of Functional SB: legs and/or feet pivot to place subject on a diagonal; facet of opposite slide up and same side
slide down


SB with some rotation to the same side
ROTATION
o
Components of Rotation: gap and compression; only half of the layers of the annulus resist the rotational stress
o
Precautions: rotation puts a lot of stress on the discs, and shears the lumbar discs; only half of the annulus can resist the load
THORACIC SPINE

Discs are thin; facets are aligned vertically; ribs all affect the motion in the thoracic spine

The motions associated with FB, BB, SB, and rotation are the same as with lumbar spine
CERVICAL SPINE


Subcranial Motion
o
Nodding and SB takes place at both joints, OA and AA
o
Rotation takes place at the AA joint
o
ATLAS: functions like a meniscus between the occiput and axis; occiput/atlas/axis function as one joint; atlas moves in the
same direction as the motion taking place
Mid-Cervical Spine C2-C7
o
Components of FB: facets slide anterior/superior; anterior translation occurs at the lateral interbody articulation; vertebral
canal narrows
o
Components of BB: facets slide post/inferior; posterior translation at the lateral interbody articulation; spinal canal narrows
more than in FB; ligamentum flavum infolds into the vertebral canal; possible spinal cord compromise; tilt and distraction on
full BB

o
Precautions: osteophytes combined with ligamentum flavum and canal narrowing (BB) can impair circulation to the
cord; people who have habitual forward head posture or sleep with inappropriate pillows may be putting themselves
at risk for spinal cord damage
SB and Rotation: occur to the same side in MC spine in all motions, despite functional or non-functional motion

In non-functional SB, SB and rotation occur to same side, so to keep the eyes level there must be a rotation at AA in
opposite direction

In rotation to one side, SB occurs to the same side, to keep the eyes level, there must be SB to the opposite side (OA)

Important to know the component motions of the spine to assess/treat it properly

Differential diagnosis example, SBR:
30

o
If chin turns R with SBR, there is a restriction at A/A L rotation
o
If pt can increase range of SBR by turning the head R, the problem is at A/A L rotation
o
If they can’t increase range by turning head to the R, the problem is in the mid-cervical spine
Upper Thoracic Spine (C7/T1-T3/T4)
o

Buffer/shock absorber for the more mobile cervical spine; 1st two vertebrae similar to cervical vertebrae
Atlas Position and Scoliosis
o
The eyes will be level and will face the front; position of atlas often overlooked
o
If the atlas is stuck/rotated in one direction and motion is restricted, the pt will rotate the mid-cervical spine to bring the eyes
to neutral
o

When the mid-cervical spine rotates (to the left let’s say) to compensate for an atlas that is rot R, coupled motions
`force the MC spine to SB L as well

Then the upper thoracic spine will have to SB to the R to compensate for the SBL in MC, producing a scoliosis
Suspect a subcranial dysfunction if: pt presents with a head tilt; pt more comfortable talking with head to one side; SB is limited
in neck; scoliosis is present even though lumbar spine is straight (high scoliosis)
SACROILIAC SPINE


Movements described by the ilium moving on the sacrum; look as ASIS
o
Backward torsion: happens when you bring your knee to your chest
o
Forward torsion: when you lay supine and extend legs, or extend legs behind you in standing
Kapandji talks about the sacrum moving on the ilium, and called it nutation (nodding)
o
His reference is the top (called the base) of the sacrum, so the motions are opposite of standard ones
o
Base of sacrum moves forward in FB = nutation = backward torsion of ASIS
o
Nutation occurs when we FB the trunk, BB, squatting; nutation good for childbirth/pooping because it increases the A-P and
lateratl dimension of the pelvis
SUMMARRY OF SPINAL KINEMATICS

Functional range > non-functional range

Passive range > active range

Movement is lessened if 2nd motion already present

Movement is greater opposite a fulcrum or above a fixed point

Respiration affects range

Eyes will always face forward

Facet capsules, posterior ligaments, and myofascia limit FB

Facet joints, SP, lamina, ALL limit BB

Ligaments, ½ the annular rings, facet capsule/cartilage, ribs limit rotation
31

Ligaments, ribs, facets limit SB

If movement is limited in one segment, the adjacent, usually superior, vertebra will become hypermobile; dysfunction starts a series of
bad events

Normal Spinal Movement: smooth; adequate relaxation of antagonists; full ROM; pain free; PROM > AROM

Abnormal Spinal Movements: limited range; unwillingness to move; painful arc; compensatory motions; crepitus; signs of instability; mm
dysfunction; juddering; pain at end range; Gower’s sign; PROM < AROM
o
Spinal Instability: normal integrity of spinal ligaments/muscles are insufficient to prevent normal forces from producing
aberrant motions

Causes: chronic misuse/abuse; poor posture; self “popping”

Clinical Signs: hx of tissue relaxation/creep (inability to sit still, pain worse later in day, catches/twinges); increased
mm tone with standing; step; mm tone or step disappears in prone; juddering with FB; Gower’s sign; Grade 5 or 6
with PIVM
CHAPTER 12: LIFTING

No lifting method is best for all situations, and the appropriate lift task must be determined by the characteristics of the lift task
o
5 basic lift types

Normally, people move in diagonal planes to perform ADLs; lifting is usually taught in just the sagittal plane, limiting mobility and
decreasing efficiency
1.
STOOP LIFTS: Bend forward with spine/pelvis; lifting task requires a reversal of FB; open kinetic chain activity

Advantages: Large objects can be moved without changing foot position; Light objects moved quickly; Little energy expenditure
o

2.
Minimal stress on joint of LE; LE in position of greater mobility and adaptability of perturbations
Disadvantages:
o
Large load on spine and high disc compression
o
Stresses on ligaments high because muscles become silent at 2/3 max flexion; muscular silence also inhibits reactivity
to perturbations
o
Potential for rotation = increased stress on facets/discs
o
Body less stable because COG above ground
o
Loads lifted have to be small and can’t be lifted between legs
SQUAT LIFTS: Lower trunk with legs; low stress on spine; closed chain activity
a.
b.
SQUAT LIFT WITH LUMBAR SPINE IN NEUTRAL LORDOSIS
o
Advantages: low stress on spine; muscle activation continuous, providing continuous protection and dynamic
responsiveness; lower COG providing better balance; can lift large loads between legs
o
Disadvantages: high stress on LE joints; slow speed; activation of erector spinae and multifidi is maximal, so more
likelihood of muscular problems; limited mobility while lifting; moderate disc compression; high energy expenditure
SQUAT LIFT WITH LUMBAR SPINE IN FORWARD BENDING
32
3.
o
Advantages: low stress on spine; compression stresses on the disc are lowest in this type of lift; COG close to ground;
large loads; lift b/tn legs
o
Disadvantages: LE joint load high; slow speed; mm silence during first part of lift, so less able to respond to shifts in
load/perturbations; limited mobility during lift; stress on posterior ligaments higher that squat neutral but less than
stoop
DIAGONAL LIFTS: one foot placed in front of the other; in the stoop only one hand used
a.
b.
DIAGONAL STOOP LIFTS:
o
Advantages: this lift offers the most mobility; most compatible with walking; one hand free; low energy expenditure;
minimal stress on LE joints; performed safely at faster speed than any other lift; maintains muscular activity, so no
reliance on spinal ligaments
o
Disadvantages: rotation component; ankylosis can’t use; loads on spinal structures relatively high; can only kift light
loads
DIAGONAL SQUAT LIFTS: same as squat, but one foot forward
o
Advantages: heavy objects can be lifted in two stages; object closest to body; loads low on spine compared to stoop
lift; COG close to ground; largest BOS for feet; heavy loads
o
Disadvantages: joints of LE under high stress; slow speeds; high energy expenditure; people may lift beyond means

All lifts should be planned

Loads should be kept close to body

Avoid twisting

Use legs as much as possible when bending to reach object

Have a good grip on object

Lift with a steady motion, not jerky

Make sure you have good footing and wear proper clothing

Lift heavy objects with back in neutral lordosis to avoid viscoelastic effects on ligaments

When you have to FB to lift, do it quickly to avoid viscoelastic effects on ligaments

People with ligamentous injuries (posterior annulus) should lift with neutral spine

Herniations = avoid lifting; neutral spine increases disc pressures and FB gaps posterior disc

Stoop lifts are only appropriate when the object is light and easy to handle

If lifting a lot, try to change lift types up; have pt show you in clinic
CHAPTER 13: INJURY, REPAIR, IMMOBILIZATION

PTs can effect structural and functional change of the body, including regeneration/repair of articular cartilage, with changes in posture
and activity

STRESS: mechanical or physiological challenge to a body structure
o

Result in transient response from the tissue; an injury; or a stimulus for an adaptive change in the structure
STRAIN: a mild injury to a tissue or structure; microtrauma without lasting deformation; analogous to a 1st degree injury
33

SPRAIN: moderate injury to a tissue or structure; some deformation to the structure that will not heal; disruption and separation of
some of the supporting fibers; analogous to 2nd degree injury

RUPTURE: severe injury to the tissue with substantial disruption to tissue; little to no connection remaining

SUBLUXATION:
o
Chiropracty: bone is out of alignment
o
Dorland’s Medical Dictionary: partial dislocation
o
Orthopedic Surgery: altered position due to a degenerative process, like a vertebral subluxation of a degenerative disc
o
FCO: state of hypermobility in which the normal relationships of joint surfaces is easily lost, but can be easily restored to normal
by change in position or outside support; caused by repeated trauma leading to laxity, degenerative changes and
neuromuscular insufficiency

INSTABILTY: spinal instability is a condition where the ligaments and muscles don’t have enough power to prevent normal forces from
producing aberrant motions, like slips, slides, buckling, juddering

DISLOCATION: disruption of the normal relationship of joint surfaces that cannot be restored without the aid of an external force;
usually caused by a trauma

FIXATION, BLOCK, LOCK, or HITCH: joint has become stuck; usually occurs at the end of the joint range and does not return to normal; a
strong flick or tug usually returns the joint to normal
MECHANISMS OF INJURY/TISSUE DYSFUNCTION

TRAUMA: high energy injuries that cause a lot of damage from one event
o
Crush Injuries: occur at slow velocities (less than 6.5 miles/hour); tissue compression reaches about 35%; require a large,
persistent force
o
Viscous Injuries: occur at speeds of 10-45 miles/hour; tissue deformation from 30%-50%; damage due to redistribution of fluids
at a greater rate than the tissues can handle; the moving fluid causes the damage
o
Blast Injuries: high velocity injuries that occur at speeds greater than 45 miles/hour; causes the tissues to explode because they
are unable to dissipate the energy of impact

OVERUSE: caused by fatigue failures of the tissues

POSTURAL : viscous injuries of structures that are slowly deformed over time, and results in the deformation of the tissue itself

o
In traumatic viscous injuries, the damage comes from the rapid redistribution of tissues
o
In postural viscous injuries, the damage comes from the deformation of the tissues over time, due to repeated cyclic loading in
an abnormal fashion
IMMOBILIZATION: this type of dysfunction is a result of normal adaptations to disuse, and lack of mobility
EARLY RESPONSE TO TISSUE INJURY

Release of intracellular material into the extracellular space causes an increase in tissue permeability
o
Serotonin and histamine

Vasodilatation occurs after release of these materials

Bradykinin is released next which increases tissue permeability and causes local capillary “leakiness”
34

Concentration of cells and proteins in wound space increases

Prostaglandins are synthesized by the cells in the wound; they attract leukocytes and may control both and early and late reparative
process
STAGES OF HEALING

Inflammation: first 72 hours

Fibroplasia: first 21 days

Remodeling: 3 to 12 months
GENERAL RESPONSES TO IMMOBILIZATION: loss of GAGs in connective tissues; increase in crosslink formation in connective tissue; poor
orientation of newly deposited collagen fibers; fatty fibrous infiltration of edematous area; pannus formation inside of joints; generally atrophy of
all types

This results in capsular contractures, ligament shortening, muscle incompetence
GENERAL REPSONSES TO EXERCISE AND MOBILIZATION: increases in GAG in connective tissues; braking up of crosslinks in CT; improved
orientation of collagen fibers in CT
INJURY, REPAIR, IMMOBILIZATION, MOBILIZATION BY JOINT STRUCTURE



BONE: 6 phases of bone healing:
o
Trauma: includes hematoma formation and necrosis of loose bone fragments (1-2 days)
o
Inflammation: lasts until necrotic tissue has been removed (2-5 days)
o
Early Repair: includes soft callus formation, begins when pain/swelling subside, increase in vascularity, bony fragments become
jointed by fibrous tissue or cartilage (4-12 days)
o
Early Callus: trabecular bone replace soft callus and begins to make a bony bridge between the ends of the fracture (17-40
days)
o
Maturation of Callus: soft callus completely replaced by bone, bone becomes more dense/remodels (25-100 days)
o
Restoration to Normal Structure: cortical bone forms between the ends of the fracture; shape of bone restored to normal (50 +
days)
LIGAMENT: type of injury is determined by the rate of loading to the ligament tissue
o
Slow rate = avulsion
o
Three phases of ligament healing
Fast rate = ligament failure

Phase I: acute/inflammation (72 hours)

Phase II: repair and regeneration (72 hours – 6 weeks)

Phase III: remodeling and maturation (6 weeks to 12 months)
o
Immobilization leads to rapid weakening of ligaments
o
Remobilization restored the mechanical properties of ligaments
TENDON: 3 phases of tendon repair (complete cut with ends approximated)
o
Initial response: wound fills with blood/debris; stump attaches by paratenon; fibroblasts invade; type I collagen produced by
day 3; day 10 collagen is 10-20x normal; early motion is necessary to prevent adhesions to surrounding structures
35

o
3rd and 4th Week: fibroblasts and collagen deposition continues; tissues align along lines of stress
o
20th Week: minimal difference between healed and adjacent sites
o
FLEXOR TENDON STUDIES:

3 groups tests ( immobilization, delayed immobilization, early intermittent passive motion)

The 3rd group, motion group, was 2x as strong as non-movers; scar formation reduced; no adhesions
MUSCLE
o
Rupture of muscles happens in young people and rupture in tendons in older people
o
Muscles are repaired by regeneration, which happens in four phases

Ischemica/Necrosis: muscle fibers die (1 week)
2.
Fragmentation: macrophages clear away debris & blood vessels begin to invade the area (1-3 weeks)
3.
Myotube Formation: satellite cells differentiate into myoblasts, which form myotubes (3-5 weeks)
4.
Muscle Fiber Maturation: myotubes fuse and form muscle fibers (5 weeks – 6 months)
o
Muscle injuries don’t require surgery unless there is some sort of gapping in the tissue; if the scar tissue that fills the hole is too
much it can cause loss of function
o
Length adaptations of muscle are nearly always reversible (like after immobilization)


1.
Muscle lengthen or shorten by increasing or decreasing sarcomeres
JOINT CAPSULE
o
Synovitis is harmless; joint can increase 10-20x in size
o
Hemarthrosis is deadly because fibrinogen leads to adhesions in the swollen joints; muscle tone is inhibited; produces reflex
muscle wasting

Effusion in the joint may passively stretch and weaken the capsules and ligaments

Forced motion in the presences of an effusion may cause tissue relaxation and tear the capsule
ARTICULAR CARTILAGE
o
Hyaline cartilage is a tricky tissue; muscles can be lengthened and capsules manipulated, but hyaline cartilage is thus far hard to
regenerate once injured/degenerated
o
Cartilage can be injured by loss of proteoglycans or direct trauma
o
OA may be caused by injury, immobilization, repeated stress, weak/poorly coordinated muscles, incongruous surfaces,
excessive wear/tear, burst type trauma
o

According to Salter/Pauwels, full thickness cartilage defects can heal with continuous passive motion

Partial thickness cuts/tears do not heal
Cartilage needs to remain in contact with cartilage or the synovial will proliferate and destroy it

Prolonged compression should be avoided; 3 hydrocortisone shots and 6 weeks of immobilization can kill cartilage

4 weeks of constant mobilization helps restore cartilage from holes drilled in it
36


INTERVERTEBRAL DISC
o
Disc injury may be caused by misuse, abuse, loss of motion in a segment, sustained postures that destroy the annulus, twisting
actions (not clearly understood)
o
Disc has capability to heal, as evidenced by: outer annulus has a neurovascular capsule; tears begin at the periphery; scar tissue
NERVE
o
Neuropraxia: loss of nerve function due to pressure changes with no disruption of the nerve substance
o
Axonotmesis: disruption of axon and myelin sheaths; no disruption to CT fragments


Leads to degeneration of the axons distal to the site of injury; regeneration is spontaneous and of good quality
o
Neurotmesis: (no definition)
o
Severance of Nerve: (no definition)
o
PTs can not help heal nerves, but we can help by removing nerve pressure by: posture, traction, stretching muscles,
maintaining function, e-stim, exercise, manipulation
FASCIA: can become infected in an open would; heals by fibrous protein synthesis; if severely damaged, may require transplantation
CHAPTER 14: SPINAL ANATOMY
[re-read page 211-245 due to copious anatomical descriptions]

Before any joint can be treated, it must be examined and the examination must be based on knowledge of anatomy and mechanics

Spine is comprised of a number of movable links held together by ligaments and muscles

Functions: support, shock absorption, movement; Gracovetsky believes spine is more important for walking than legs

33 vertebrae, 25 mobile segments, 4 spinal curves that serve to increase load-bearing capacity of the spine
o
Curves allow 10x load as vertical column, as long as curves are not too excessive and shock absorbance/damping
o
Curves are a result of the shapes of the vertebral bodies/discs

Cervical region = discs thicker anteriorly, creating cervical lordosis

Thoracic region = discs uniform in height, so the kyphotic thoracic curve is due to the shape of the vertebral bodies

Lumbar region = discs larger posteriorly in upper lumbar; larger anteriorly in lower lumbar; L5 disc is 2x as big
anteriorly

Body type, weight, muscular development, posture can affect the curves as well (menopause, handed-ness)
SPINAL SEGMENT: adjacent halves of 2 vertebrae; disc; related contents of spinal canals and intervertebral foramen; ligaments; facet joints; skin;
muscles; fascia that relate to that level

Functional unit of the spine

Function of the vertebral body is to transmit weight, provide a flexible structure for muscles to act on, and provide attachment site for
muscles

o
Vertebral body is actually the “cushion” when a motion segment is compressed, not the disc
o
Disc is responsible for equalization and distribution of stress, not absorption of stresses!!!
Articular processes (2 superior/inferior facets) arise from the junction of the pedicle and lamina; interzygapophyseal joints
37
o

Spinous process project out dorsally at the union of the two lamina
Blood supply to the vertebral body is primarily from the radicular arteries that divide into 2 branches once they enter the spinal canal
o
One branch feeds the body above, and one feeds the body below; they enter v. body near posterior longitudinal ligament
o
Also some blood supplied to the vertebrae from outside of the spinal canal, anteriorly; vertebral artery in cervical spine
INTERVERTEBRAL DISC

No discs between the occiput, atlas, and axis; many people believe the disc to be the principal source of LBP

In 1933, Mixter and Barr wrote a paper noting that discs can herniated, and can be treated surgically

Of all of the structures of the spine, the disc carries the greatest responsibility for the preservation of the function of the vertebral
column

o
Disc makes up 25% of total length of spine; as disc size increases in relation to the vertebral body, more ROM is permitted
o
Disc is thicker anteriorly in cervical and lower lumbar spine; even in thoracic spine
Disc has three principle functions:
1.
Bind the vertebral bodies together
2.
Permit movement within the segment
3.
Transit loads across the segment
Paris classifies the disc into five distinct zones (rather than three) because his studies have shown that the outer annulus is rich in nerve endings,
and have a blood supply, thus the ability to heal
(p 218)
1.
2.
NEUROVASCULAR CAPSULE
o
Blood supply is richer than the MCL of the knee
o
Innervated by recurrent nerve, sinu vertebralis, direct branches from the mixed spinal nerves, and gray rami communicans
FIBROUS OUTER ANNULUS
o
Made of 6-10 concentrically arranged touch fibrocartilagenous rings, also called lamellae; transforms into less fibrous annulus
o
Fibers of each circle run obliquely across the disc, and the fibers of adjacent lamellae run in opposite directions
38
o
Fibers are angles from 30-70 ̊ on the outer portions, and nearly vertical in inner rings of annulus

o
3.
4.
5.
FUNCTIONS: contain the nucleus, permit deformation, and resist tensile forces, return back to original shape

Containment of Nucleus: enhances ball-bearing action and incompressibility of nucleus during movement

Stabilization: alternating layers of annulus binds the two cartilaginous end plates, vertebral rim, and vertebral bodies
together, thus limiting motion especially rotation/torsion

Permission of Movement: disc arrangements allow many planes of movement; torsion/rotation shears disc

Minimal Shock Absorption: less than vertebral body; when nucleus is compressed, the annulus pulls in and restores
disc to previous state
INNER LESS FIBROUS ANNULUS
o
Loosely arranged fibrous tissue that surrounds the nucleus propulsis
o
No distinct structural interface between the annulus and propulsis
NUCLEUS PROPULSIS
o
Remnant of the embryological notochord; sits in between the cartilaginous end plates and is surrounded by annulus fibrosis
o
Made of a network of a delicate collagen and reticular fiber mesh, set within a mucoprotein gel, rich in polysaccharides and a
high % of water (70-80%); a colloid
o
When compressed, the nucleus alters shape but not volume, which allows it to distribute forces equally in all directions
o
Nucleus is centrally located in cervical and thoracic spine; posteriorly located in lumbar spine (possible reason for lumbar
protrusions)
o
FUNCTIONS: redistribute compressive forces within the spine

Imbibition: the nucleus propulsis colloid allows the process of imbibitions, and can suck up 3x its weight when
annulus torn

Nutrition: nucleus draws water/nutrients in from vertebral bodies through the endplates, via osmosis; expands at
rest, squishes out with compression

Transmission of Force: is incompressible but capable of deformation within the elastic and restraining fibers of the
inner layers of the annulus; incompressibility allows for transmission of weight across motion segment

Equalization of Stress: distributes stresses equally across disc, even if force is applied in a finite area

Movement: acts like a ball-bearing by providing a rocking component to motion; as the nucleus dehydrates with
aging, it allows too much motion  instability, which may be countered by ligaments, muscles, bones
CARTILAGINOUS END PLATE
o
Located between each disc and its adjacent vertebral body; made of hyaline

o
Blood supply at birth; become avascular by 10 and leave small canals that can turn into fissures
FUNCTIONS: protect the end of the bone; transmit weight; allow fluid exchange between the disc and vertebral body


This arrangement of obliquely running lamina permit motion in many directions
If the end plate ruptures, the nucleus will pass into the vertebral body and cause pressure atrophy
Discs can not “slip” because they are firmly attached to the 2 adjacent vertebrae by Sharpey’s fibers
39
o

Sharpey’s fibers are extensions of the fibrocartilagenous outer annulus and they blend with the vertebral periosteum and
posterior longitudinal ligament
BLOOD SUPPLY/NUTRTION TO DISC
o
No blood vessels in the disc, except the outermost layers of the annulus, so nutrition to disc by diffusion of lymph and WB

o
In degenerating discs there is an ingrowth of blood vessels from their vertebral end plates
For proper nutrition to take place, the vertebral segment must be able to move and expand

Muscle/fascial tension, facet joint restriction, incorrect posture with bed rest can interfere with proper disc nutrition by
compressing the posterior portion of the disc

Paris believes that discogenic pain may come to be an abnormality in chemistry inside the disc, fixed by motion
FACET JOINTS (Interzygapophyseal articulations)

Facet dysfunction can be a source of minor back pain, and later produce the end result of disc prolapsed

Inferior articular processes are closer together than the superior, so when articulated, the superior processes “embrace” the inferior ones
LEVEL
CERVICAL
THORACIC
LUMBAR
FACET ANGULATION
Lie in plane midway between frontal and horizontal planes; superior facets face post/sup; 45 ̊
Frontal plane; superior facets face posterior and slightly lateral
Sagittal plane; superior facets face medially

Hyaline cartilage at facet joints is smooth, shiny, and uniform; becomes less compressible with aging

Articular capsule consists partly of while fibrous tissue and part yellow elastic tissue
o

Elastic components of the capsule prevent it from getting pinched in facets, keeps facets in close contact with each other,
stabilizes the spine by returning it back to neutral after motion
The synovial lining has inwardly projecting villi
o
Putti (1927) noted they were variable in size and had blood vessels
o
Levinhtal (1961) was the first to use the term “intra-articular menisci” and thought they provided stability in the newborn
o
Lewn feels they are WB in nature because they don’t have synovial cells
o
Menisci are present at all spinal levels; biggest in lumbar; smallest in thoracic

Blood supply to facets is via the periarticular plexus

FUNCTIONS: permit, guide, and limit motion within a segment; motion determined by shape and direction of the facet joints
o
Although the disc is a unique structure that permits movement and transfers load, it has no ability to direct movement; only the
facet has the ability to direct movement
o
Minor alterations in the facet joint can have major effects on the intervertebral disc
VONLUSHKA JOINTS

Lateral interbody articulations, uncinate, uncovertebral (1870)

Joint between the surfaces of the lateral margins of the cervical vertebrae, C2-C7; this joint is innervated
40

Prevents translational motions with FB
SPINAL LIGAMENTS
(p 230)

Primary function is to modify movement occurring at the spinal motion segments; resist postural and traumatic strains; elastic ligaments
help the spine return to neutral

Anterior Longitudinal Ligament: strongest ligament in body; runs on anterior surface of the vertebral column, attaching to the discs
anteriorly


o
Starts at tubercle of occiput  sacrum
o
High resistance to distraction of the vertebrae; taut with BB; slack with FB
Posterior Longitudinal Ligament
o
Inside of the spinal cord; does not attach to vertebral bodies
o
Becomes thin in the lumbar spine and provides little restraint to prolapsing nucleus
Suprapinous Ligament
o
Runs over tips of spinous processes; blends with interspinous ligament becomes the ligamentum nuchae in the neck
o
L3/L4 termination

Ligamentum Nuchae: continuation of supraspinous ligament at C7; high elasticity

Interspinous Ligament: segmental; often paired; fibers run upwards and backwards from the superior aspect of one spinous process to
the inferior aspect of the spinous process above; some studies find them deteriorated in older spines, and some find them well
developed

Ligamentum Flavum: segmental; paired ligaments that forward/upward from bottom lamina to the lamina above
o
Contain yellow elastic fibers, allowing a lot of FB and then help the spine return to neutral; can stretch 50-70%
o
Significant in the lumbar spine because it exerts a constant force on the capsule of the facet joints and prevents the
capsule/menisci from getting pinched
o
It can get weak in cervical spine with age and it can fold inward on itself into the spinal canal, eventually causing myelopathy

Intertransverse Ligaments: segmental and found in between neighboring transverse processes

Iliolumbar Ligaments: anchor the spine to the pelvis; starts out as a muscle and transforms into a ligament in the 20s, completing the
transition by 40

o
TP of L5 to SI joint/illium in males; men suffer from lateral shift 19:1 to females
o
In females, there is an additional cord running from the tip of L4 TP, which may allow for increased spinal stability in females
FUNCTION OF SPINAL LIGAMENTS: limit range of movement in spine to protect the underlying articular structures
o
Provide very little support except at end range
o
Have a rich supply of mechanoreceptors for postural reflexes
o
Once stretched, via creep, ligaments can not return to their original length; this makes posture corrections difficult (lax)
o
All ligaments have some elastic component; can stretch 25-30%; interspinous in cervical spine can stretch 200%
41
SPINAL & INTERVERTEBRAL CANALS

Form a functional unit that acts to protect the neural tissues (spinal cord/nerve roots) while permitting motion

Brain, Moir, Dickman showed that changes in the spinal cord can occur due to compression of the anterior spinal artery and its branches
due to a protruding disc

o
Other authors have noted that with BB of cervical spine, compression of the spinal cord can occur, leading to stenosis
o
Disc degeneration, facet arthritis, swelling/hypertrophy to ligamentum flavum can injure the cord/roots
SPINAL CANAL
o
o


Made of a series of interlocking rings superimposed on one another and held together by ligaments

Anterior spinal canal: formed by posterior part of vertebral bodies and PLL

Posterior spinal canal: lamina and ligamentum flavum create posterior border

Lateral border: pedicles, capsule of facet joints, intervertebral canals
In the cervical spine, the spinal canal is smaller in diameter, but the cord is bigger than in the lumbar region
INTERVERTEBRAL CANAL
o
Also called the foramina
o
Floor and roof of the canal is made by adjacent pedicles; posterior border is made of superior/inferior articular processes;
anterior wall is made of the back of the vertebral bodies
o
Canals are short; contain the spinal nerves and radicular blood vessels; recurrent nerve (branch off sympathetic trunk)
SPINAL CORD & NERVE ROOT (p 235)
o
31 pairs of spinal nerves
o
In cervical spine, they exit above the vertebrae; C8 spinal nerve exits below C7, above T1
o

In the cervical spine, a stenosis and disc problem will press on the same nerve root b/c roots exit in parallel

C5 stenosis = C5 nerve root affects

C5 nerve root compression due to stenosis or disc protrusion at C4/C5
C5 disc problem = C5 nerve root affects
In the thoracic/lumbar spine, the nerve roots exit below the vertebra; stenosis and disc problems present differently due to the
angulation of the root as it exits the canal (S/D)
[verify this info. in notes]

L4 nerve root compression due to a disc occurs at L3/L4

L4 stenosis root compression due to a narrowing occurs at L4/L5 (L4/L5 disc problem crushes L5 nerve root)
Type of Neural Structure
Role/Function
Brain Stem
Connects the spinal cord to other parts of the brain.
Spinal Cord
Carries nerve impulses between the brain and spinal nerves.
Cervical Nerves (8 pairs)
These nerves supply the head, neck, shoulders, arms, and hands.
42
Thoracic Nerves (12 pairs)
Connects portions of the upper abdomen and muscles in the back and chest
areas.
Lumbar Nerves (5 pairs)
Feeds the lower back and legs.
Sacral Nerves (5 pairs)
Supplies the buttocks, legs, feet, anal and genital areas of the body.
Dermatomes
Areas on the skin surface supplied by nerve fibers from one spinal root.
o
Spinal cord begins at inferior edge of medulla oblongata (atlas)  L1

Enclosed in 3 meninges (dura mater, arachnoid mater, pia mater)

Space between the dura and walls of the spinal canal = epidural space

o
o
o
SPINAL DURA MATER: continuous with the cranial dura; outer layer terminates at the foramen magnum; spinal dura is firmly
attached to foramen magnum, the PLL, C1, C2

Tough non-elastic membrane of dense, fibrous tissue

Runs to S2, then continues on to coccyx as the “external filum terminale”

Dura surrounds the nerve roots as they exit the cord
ARACHNOID MATER

Middle layer; touch and elastic membrane

Attaches to dura and pia maters by the dentate ligaments (20 of them); these ligaments come from the cord and attach to
the dura mater, which suspends the cord in the canal

Runs with dura and also surrounds the nerve roots
PIA MATER

Innermost lining; highly specialized membrane made of loosely arranged cells

Elastic content; maintains the shape of the spinal cord and permits diffusion of various substances from the subarachnoid
space to the endoneurium of the nerve roots and spinal cord

o
Filled with fat and CT to pad the cord
Subarachnoid space is between the arachnoid and pia maters

Surrounds the rootlets; ends with the cord at L1 where it forms the internal filum terminale for insertion into the coccyx

Space between the end of the spinal cord and the end of the dura (S2) is called the cistern and is occupied only by the
nerve roots (cauda equine) as they pass to their respective intervertebral canals

Acts as a resovoir for cerebrospinal fluids

Spinal taps occur at levels below L2 to avoid damage to the cord
At birth, the spinal cord and canal are the same length, so the nerve roots pass horizontally to their respective intervertebral canals

After birth, the column grows faster than the cord, and cord ends at L1

This means that the nerve roots must descend in increasing obliquity to exit the spine
43

o

Cervical roots pass virtually horizontal from the cord, and are about 3mm at C1; T1 = 29 mm; L1 = 91mm; S1 = 185 mm;
coccygeal nerve = 261 mm
Nerve root have an anterior motor root and a larger posterior sensory root

Each nerve root arises as a continuous series of nerve root filaments surrounded by pia mater (not just one big root)

Dorsal segment of nerve root has a dorsal ganglion before it meets with the motor component to create the mixed nerve
BLOOD SUPPLY OF SPINAL STRUCTURES
o
SPINAL CORD

Cord is supplied by 5 longitudinal arteries and the radicular arteries

Largest supply to the cord: anterior vertebral artery

o


Supplies 2/3 of the cord in the cervical spine

Brain and Wilkinson (1965): point pressure on the anterior artery, which may be caused by an advance
cervical spodylosis, may totally occlude the blood supply to a large portion of a spinal segment, resulting in
sclerosis

If this occurs at multiple levels, it can present as multiple sclerosis; they believe it to be the most common
cause of neurological changes in the spinal cord after mid-life

Has been difficult to prove in the lab due to all of the anastomoses in the area
Veins of spinal column form an intricate plexus running its whole length; can be divided into and external and internal
systems

Do not have valves; aren’t assisted with muscle pump; anastomose freely (explains the rapid spread of
inflammation and metastatic disease)

Because they don’t have pumps, they can engorge to the point of obstructing the inferior vena cava
(Rothman 1975)
SPINAL NERVE ROOT BLOOD SUPPLY: not much written in FOC; lots of recurrent intrinsic vessels in dorsal root ganglion;
vulnerable to damage from torsional strain
INNERVATION OF SPINAL STRUCTURES
o
Most structures in this region are innervated, but the nerve roots and spinal dura have very little innervations

o
Pain from nerve root compression is due to ischemia, rather than from pressure on nociceptors
Lumbar spine; work of Paris and Nyberg
(p 239: draw it)
1.
Each structure of the spine is innervated by at least 3 segmental nerves
2.
The PLL and anterior dura may have more than 3 segmental levels innervating them at any one point
3.
Laminectomy removes a disc protrusion, but also substantially denervates the posterior spinal structures
a.
This removes pain from facet joints, posterior ligaments and muscles, at least temporarily
4.
A spinal fusion would have similar, but more extensive effects to a laminectomy
5.
Spinal fusions often denervate the SI joint
44
6.
o
The result of #4 and #5 is that a surgeon who discounts the SI as a source of pain and instability may actually be
treating (though not correcting it) with a fusion
Nerves listed in diagram in FOC: L4 medial branch of posterior primar rami; descending branch; L5 medial branch of the
posterior primar rami; muscular branches; local branch; one or two ascending branches from the S1 nerve
MUSCLES OF THE SPINE

Function to activate motion, restrain motion, support

Hollinshead: muscles of the back are not clean-cut entities like the muscles of the limbs, and most of them work together

Overly strong spinal musculature is not desirable, as indicated by the frequency of neck aches in wrestlers/weight-lifters

o
These bulky muscles just cause huge compression forces
o
The ideal spinal musculature is moderate development with good postural tone (Paris 1965)
Beal and Beckwith: muscles serve to activate motion and antagonistic groups restrain motion, acting as a variable resistor
o
In a painful pathology, the variable resistance is increased to produce muscle gaurding

Support provided by muscles is done so by the tone of the muscles, where the flexors and extensors work in an interplay with one
another

Kraus & Williams: place considerable emphasis on developing spinal muscles and treatment of back/neck pain
o
Cyriax (1975) argues against strengthening spinal muscles because it adds compression to the facet joint
o
“…strong muscles do not prevent internal derangement at a lumbar joint, rather the contrary. Stability here is determined only
by the interlocking of the facets and the strength of the many ligaments.”
o
Nachemson and Lind (1969) and Battie (1989) agree that strength of abs and lumbar muscles do not deter back pain


Paris believes that the reason exercise programs work for back pain is that they end up mobilizing a painful restriction of motion, free an
impacted synovial lining, or add nutrition to a disc
o

He believes that in most cases of backache, the muscle pathology is secondary to disc or ligamentous pathology
EMBRYOLOGY & DEVELOPMENT:
o
Notochord gets encased by a segmented column being supplied by segmental arteries of the aorta; chondrification occurs
o
10th week: notochord becomes segmental, and eventually becomes the nucleus propulsus
o
Ossification begins in 2nd month; typical vetertbrae has 3 ossification centers, one in body and two in TPs

Lumbar vertebrae has two more in the mamillary bodies

Axis has 6 centers
o
Neural arches unite in the vertebral spine by the 3rd year in cervical spine; may take 6 years in lumbar spine
o
Tips of TP and SP are still cartilaginous by puberty, and ossification centers can be found here


Battie found that people with greater isometric lifting strength are at greater risk of injury (lifters)
These centers fused by 25 years of age
Mulitfidus: bipennate origin and bipennate insertion; runs between transverse and spinous processes, skipping 2-4 vertebrae
45

o
Origin: two mamillary processes, the adjacent superior capsule below, and the inferior capsule above (p 240)
o
Insertion: inferior tip of spinous process above
o
Action: extends spine bilaterally; rotates to the opposite side; runs from C2 to sacrum
Transverse Abdominis
o
Origin: T12-L4 vertebral bodies and associated intervertebral discs
o
Insertion: linea alba and pubic crest
o
Action: compresses abdomen bilaterally; unilaterally is rotates the trunk to the same side
CHAPTER 15: COMMON DYSFUNCTION ENTITIES AND THEIR PRINCIIPLES OF TREATMENT
Famous People and Their Beliefs About Cause of Back Pain

Cyriax/McKenzie: attribute back pain to the disc

Maitland: reproducible signs

Kaltenborn: arthrokinematics

Chiropractors: vertebral subluxation/rule of the nerve; now segmental mechanics

Paris: ecclentic approach; functional approach with an arthrokinematics emphasis; management by syndrome experiences/evidence
Sources of Spinal Pain:

Non-innervated tissue: nerve, spinal cord, disc other than outer annulus

Innervated tissue: outer annulus of disc, especially posterior lateral; some branches around the beginning of nerve toot; facets; SI;
muscles, ligaments, bone
Principle syndromes of the spine:
MYOFASCIAL STATES

TONE: state of rest of a muscle

HYPERTONICITY: increased resting tone

HYPOTONICITY: decreased resting tone

SPASM: an uncontrolled involuntary jerk/twitch

FIBROSITIS: none entity; none have been found in cadaver; trigger points

FIBROMYALGIA: better name than fibrositis

DEPOSITS: fibro-fatty and calciferous deposits that can be found in otherwise healthy muscle

1st layer of back muscles are actually extremity muscles

2nd layer are the long extensors, or the long compressors, namely the erector spinae
o
These muscles can load up the spine but offer little in the way of protections (stabilization)
46
o
Unable to resist buckling
o
Most developed in weight lifters who have one of the highest incidences of instability (spondy)
o
Erector spinae fibers cross the midline below the L3 spinous process and in doing so, replace the supraspinous ligament that
ends at L3 (Paris)

This fascia tends to be tight in a lot of people, and there is no reversal of the lumbar curve if it is tight

When the tendons of the erector spinae cross the midline (replacing supraspinatus ligament) they link up with the
middle 3rd of the glut max via the lumbo-dorsal fascia, which they both share

o
Posteriorly, the key stabilizers are the multifidus and the quadratus lumborum; intertransversus is believed to have a minimal
function in stabilization

o
Lats also influence across the midline in this complex
Multifidus is roughly the size of the triceps and must be retrained if inhibited
Quadratus lumborum: the lateral stabilizer of the trunk, especially in the female due to the wide pelvis and tendency towards a
Trendelenburg gait

Side plank can help strengthen
o
Psoas: hip flexor that will cause excessive lordosis if tight; no stabilizing effect on spine; more of a compressor
o
Piriformis: sciatic nerve passes through this muscle in 10% of people; can treat with CR stretch, passive stretch, stretch hip
capsule, hip on stool swivle
Altered Muscle States (Paris):

Hypotonic states: Spasm; hypertrophy; involuntary muscle holding; chemical muscle holding; voluntary muscle holding; psychosomatic
tension/stress

Hypertonic states: disuse atrophy; wasting and fibrosis; denervated

Normal tone/shortening: adaptive shortening

Others: myalgia/fibrositis
HYPERTONIC STATES:
1.
SPASM: “sudden, violent involuntary contraction of a muscle or group of muscles…producing involuntary movements and
distortions” (Dorlands)

This term is often misused and is not really due to an orthopedic condition, but generally more neurological

Can be seen in a spring test, spastic Torticollis, reaction to palpation; it is momentary and indicates an impairment and
nothing else

Caused by a painful movement that pinches sensitive tissues like a facet capsule or nerve root; a reflex response from a
facilitated segment; or neurological conditions

Symptoms are severe pain or tugging sensation

Signs include a flickering of the muscle

Treated by correcting the underlying cause or posture correction to avoid triggering the spasms
47
2.
HYPERTROPHY: increase in bulk from the normal, but is a normal physiological response to exercise; secondary to body building
activities; may be seen in some occupations; tends to over load joints and may limit ROM; not hypertonicity
3.
INVOLUNTARY MUSCLE HOLDING: state of muscle tone that may be palpated or observed; signifies an underlying lesion
4.

Patient is unaware of this occurrence, and some example include muscle banding with spondees, unilateral contraction of
the back muscles when the patient is prone and in a state of relaxation

Causes by joint or ligamentous dysfunctions; disc lesion or instability

Symptoms: none

Signs visual sighting of increased muscle bulk; hypertonicity; elevated resting tone; protective muscle guarding and loss of
“free” motion

Treated by finding the cause
VOLUNTARY MUSCLE HOLDING

Pt is aware of the discomfort from a joint or other tissue, and chooses to voluntarily restrict motion to try and reduce
pain/suffering
o

Causes by soft tissue or joint injury; individual concerns with pain; or reaching the pain threshold

Symptoms: pain on movement; fear and anxiety; mistaken impression that no movement is good

Signs: patient unable, unwilling, or refuses to move the body part; slow and guarding movement; pt moves trunk as a unit

Once it has been determined that the guarding is not due to a serious problem (fracture), get the part moving by pendular
movements (Codman’s) or by lumbar extension (McKenzie)
o
5.
Often follows involuntary or chemical states; happens a lot post-surgery; make sure to rule out a fracture
Do oscillations of Grade I/II
CHEMICAL MUSCLE HOLDING

Muscle appears to be swollen, and feel pudgy, dense, non-elastic to the touch; restricted and cramped movement; muscle
tightness not relieved by change in position; due to retention of metabolites
o

Metabolite stasis leads to a fullness/firmness of the muscle belly; no increase in EMG activity
Two main causes:
o
Unaccustomed overuse: packing to move or typing twenty million notes

o
o

6.
Muscles are unable to carry the waste products away from the muscle fast enough and make it tender
Involuntary guarding (Spinal instability)

Nociception from a weak annulus excites the spinal cord segment, resulting in increased muscle tone
(involuntary muscle guarding), which increases the spinal load

Muscle tone begins to aches when the level of retained metabolites becomes irritable
May lead to a compartmental syndrome
Treated with hot packs, massage to remove waste products; muscle stretching; have the pts use the muscles in a healthy
manner
PSYCHOSOMATIC TENSION/STRESS
48
7.

Caused by emotional stress that gives rise to neuromuscular symptoms

Clenching of teeth or bruxism of teeth leads to involuntary muscle hypertonicity

Treat with counseling
RESTRICTED LENGTHENING

A resistance to lengthening by muscles following injury or overuse that may be due to chemical holding, but may also
occur without muscle holding
o
8.
If left to persist it may lead to a loss of sarcomeres

Caused by over use or fatigue and microtrauma; minor adhesion development between the muscle and CT elements that
causes them to bind to each other

No symptoms, but the signs are loss of ROM due to functionally short muscles and poor posture

Treated with deep tissue massage, connective tissue massage and myofascial release
ADAPTIVE SHORTENING

Caused by persistent chemical muscle holding, which in turn leads to a reduction in sarcomere/muscle length

Frequently leads to an increased lordosis in the lumbar spine from back extensor and ilio-psoas shortening

Caused by poor posture (having muscles in a shortened position); joint injury, causing muscle holding; obesity/inactivity

Symptoms: minimal at first, but later pt will have loss of function and muscular/joint discomfort

Signs: normal tone; loss of ROM; accessory motion is free; altered function

Treated with myofascia stretching; heat; massage; inhibitive distraction; CR
Methods of Stretching a Muscle:
a.
Sustanined Stretch: fatigues the stretch reflex; must be in excess of fifteen minutes; to see a gain it must be several times a
day, like once an hour for one minute
b.
PNF: use contract/relax/stretch to stretch the collagen of a muscle when it is temporarily relaxed
c.
Inhibitive Distraction: use pressure over the origin or insertion of the muscle to stimulate the GTOs; inhibit
d.
Overpower the Muscle: can rarely be achieved; torticollis
HYPOTONIC STATES:
9.
DISUSE ATROPHY

Caused by underusing a muscle, immobilization

Signs/symptoms: loss of bulk on MRI, CT, ultrasound scan, to palpation

Treat with exercising the muscles and manipulating the stiffness
10. WASTING AND FIBROSUS

Caused by neurological dysfunction (paresis/disc prolapsed); more significant when a large disc protrusion is hitting 2
nerves; spinal cord tumor may compress 2 nerves; surgical rhizotomy
49

Signs/symptoms: rapid loss of muscle bulk; fibrous nature of the muscle because CT is still present but muscle fibers
shrunk

Treated with exercise as innervations returns; myofascial release; FES
OTHER MUSCULAR STATES/CONDITIONS

FIBROSITIS: little if any pathological evidence for this term if taken literally; no evidence of a fibrositis nodule (trigger points)
o
Nodules can be palpated in the living person, usually an ectomorphic female, especially in the long, broad, flat muscles thoracic
muscles; not present in death
o
Nodules represent a normal physiological response to touch/pressure, but could just be a spasm (some people call it a “jump
sign”)
o
There is a diffuse “muscular rheumatism” that exists, but a better term for it may be myalgia
o
There is a tendency for waste product to form and crystallize in some muscles, like the superior border of the scapula; they can
be broken down by TFM


FIBROMYALGIA
o
Tender points
o
Rheumatic disease of the soft tissue characterized by a history of widespread pain occurring for longer than 3 months in
combination with pain in 11 out of 18 specific bilateral tender points in muscular tissue
o
Cause: specifically unknown; sleep depravation; neurobiolgocal abnormalities; loss of sympathetic nervous system control;
local tissue factors; physical trauma; virus; psychological factors
o
Signs/Symptoms:
o


Primary: aches and pains, stiffness, swelling in soft tissues

Secondary: muscle spasm and nodules; UE weakness; tension migraines; headaches; B&B irritability; dysmenorrheal;
paresthesia; Raynauds; chest pains; anxiety; depression; swelling/numbness of extremities
Management: rather than treatment

Mulitdisciplinary: education on coping strategies, energy conservation, time management, nutrition, preparation for
sleep via relaxation/quieting

Medication: combination of SSRI, tricyclic antidepressants, NSAIDs

Exercise: posture; low load/low repetition strengthening; low impact aerobic conditioning; biofeedback focused on
lowering sympathetic tone; pool (Krsnich-Shiwise)
MYALGIA
o

Also at the PSIS we accumulate small encapsulated fat pads; no associated pathology, though they may be tender if
there is a nearby instability
May be a good term to describe the not uncommon, widespread tenderness in the intra-scapular and middle trapezius muscles
secondary to fatigue

Leads to chemical muscle holding, and may lead to segmental dysfunction of the mid-thoracic articulations

Often in people with a flat mid-thoracic spine
TRIGGER POINTS: related to fibrositic nodules; sites which can trigger a muscle spasm when palpated; little value except when wishing to
use palliative treatments like TENS or acupressure
50


ACUPUNCTURE POINTS: these points do exist
o
Can be electrically detected as points in the skin that give a lowered resistance to direct current
o
Well established in numerous scientific journals
o
By stimulating these points, they have a beneficial effect on the causative dysfunction
CRANIOSACRAL THERAPY
o
No valid research that supports the premise or outcomes of this form of therapy
FACET DYSFUNCTION (synovial joint)

Occur when the joint is forced beyond its normal constraints, or when the capsule is pinched
1.
SYNOVITIS/HEMARTHROSIS
o
Blood in the synovial fluid (serofibrinous exudates) is a serious matter because it will lead to adhesions between the capsule
and the bone and can damage the surface of the hyaline cartilage: hemarthrosis
o
Both of these conditions are caused by an awkward movement or catch; present with good but guarded movement and
involuntary or voluntary muscle holding; treated by rest, support, movement, soft collar, brace, sling, IFC, ice, elevation,
compression
o
o
2.

Cervical: rest, soft collar and careful movement (slow circumduction circles: Codmans), consider IFC for swelling

Lumbar: rest, soft corset, careful movement

Let symptoms calm down for 7-10 days
SYNOVITIS:

SYMPTOMS: gradual onset of swelling; passive range limited but the joint can move quite freely; uncomfortable;
warm joint

TREATMENT: rest from further activity while maintaining function; ice, elevation, and compression if desired;
manipulation after 10 days
HEMARTHROSIS:

SYMPTOMS: swelling within minutes; passive movement sluggish; painful; hot joint

TREATMENT: rest, support, aspirate; ice, elevation, compression; manipulation after 10 days
STIFFNESS or RESTRICTION:
o
CAUSE: resolved synovitis or hemarthrosis; not symptomatic; adhesions within the capsule or between the capsule and
bone ends
o
SYMPTOMS: no obvious symptoms because stiff joints don’t hurt; lowered tolerance to insult so pain, if there, may come
from current strain of the joint or neighboring hypermobility
o
TREATMENT: manipulation to restore the fiber glide/crimp in capsule to normalize movement
o
o
Don’t do a thrust on a grade I hypomobility because it can tear tissues
Capsular Patterns of Restriction:
o
LUMBAR: deviate to restricted side with FB; limited SB to opposite side; limited rotation to same side
51
o
3.
CERVICAL: deviate to restricted side with FB; limited SB and rotation to opposite side
PAINFUL ENTRAPMENT
o
CAUSE: Awkward movement in the eccentric range
o
SYMPTOMS: Unable to extend of move joint into close packed position; unable to slid inferior articular process down;
head held away from painful side; downglide hurts
o

Sudden onset with no neurological signs

Cervical: BB, SB to same side, rotation to same side causes pain

Lumbar: BB and SB to same side causes pain
TREATMENT: distraction to joint surfaces to release impingement of capsule

Cervical: multifidis isometric manipulation; 10#

Lumbar: multifidis isometric manipulation or positional distraction as a last resort ; 20#

4.
5.
(not rotation b/c no downglide in lumbar)
In lumbar, contralateral stimulation fires the ipsilateral multifius, so for L entrapment resist R leg ext
MECHANICAL LOCKING/BLOCK
o
CAUSE: idiopathic; loose body; impaction; degenerative joint surfaces; stuck in an upslide; no neurogenic symptoms
o
SYMPTOMS: sudden onset; block to the motion; relatively pain free, not painful
o
TREATMENT: manipulation using distraction or by exaggerating the positional fault to release the hitch; mechanical block
is fixed by gapping the joint

Cervical: strong manual traction with SB away and rotation towards to the blocked side

Lumbar: rotational manipulation over a bolster to further open up the affected side; lumbar roll; positional
distraction
ARTHROSIS: OA
o
CAUSE: use and abuse; old age; poor posture; trauma
o
SYMPTOMS: early morning and initial motion stiffness; stiffness gives way to pain at the end of the day; dull ache with
localized pain
o
TREATMENT: manipulation for full range in adjacent areas; exercise for joint support (flexion biased to gap joint); posture
to lessen stresses; PIVM everything and make sure you look at the hip and at posture; use a good overall program with
strengthening and stretching
o
Degenerative Cascade: Kirkaldy-Willis described 3 phases to the degeneration process: Dysfunction, Instability,
Stabilization
o
They believe that pathology will affects all of the structures of a segment, not just one
o
Disc and facet joint degeneration leads to dynamic spinal instability
o
Typical initiating even is the loss of internal disc integrity either congenitally, aging, trauma; perhaps the disc is
prolapsed or the pt has chronically bad posture
o
With the loss of segmental support is the development of segmental dysfunction
o
Disc degenerate  vertebral bodies slide down/back  foramen narrows  nerve compression
52
SACROILIAC IMPAIRMENT
o
SI provocation tests are 86% reliable: compression/distraction; gap/shear; and Fabers
o
Women have more SI problems than men, primarily due to gravity pulling behind the hip joint, through the SI joint, and holding babies on
hip
1.
STRAIN/SPRAIN

Cause: fall on ischial tuberosity; bumping/falling down stairs; awkward twist and reach

S/S: well localized, deep pain over the SI joint; unilateral symptoms
o

Treatment: strengthen multifidus; IFC; ice; rest; education to avoid one-legged standing and pretzel sitting
o
2.
Do not need manipulation; be cautious of muscle inhibition
HYPERMOBILITY/INSTABILTY

Cause: repetitive minor trauma; one-legged standing; sex strains; childbirth

S/S: provocation tests will be positive

3.
Provocation tests usually negative for strains/sprains
o
Dull ache on backward torsion, like in standing; reference posterior leg; lowered iliac crest in standing; hypermobilie
symphysis pubis; positive spring test
o
Be sure to ask if their SI problem is correlated with their period; if worse may be due to relaxin and they can wear an
SI belt for 4 days
Treatment: support via a scultetus maternity binder or an SI belt; SI belt must be low, below the PSIS and above the greater
trochanter; wear the belt when doing exercises
o
Postural instruction; remember to check out the joints above and below
o
Hip manipulation if restriction found
o
Stabilization exercises to glut max, multifidus, and abs
o
Sclerosing for pain reduction; surgical fusion
DISPLACEMENT

Cause: hypermobile joint over-rides the articular prominences; severe forces to the joint; possibly hypermobile; possible
rupture of the pubic symphysis
o

S/S: constant or nearly constant low grade pain, even with bed rest; raised or lowered iliac crest; restricted passive motion;
positive supine to sit test (long to short = anterior rotation; short to long = posterior rotation)
o

Usually not seen on X-rays unless there is something obvious with the pubic symphysis
All tests would be positive; constant pain; landmarks are off; mobility deficits
Treatment: manipulative reduction; stabilize if hypermobile; with a symptomatic SI joint, start on the symptomatic side
o
Anterior and posterior torsion of the ilium on the sacrum
COCCYGEAL DYSFUNCTION

Coccyx has 2 synovial joints, both of which are innervated and have sensitive periosteum
53

Attachments to the joints: sacrospinous ligament; glut max; coccygeus muscle; sphinter ani; levator ani

Causes: sprains from direct trauma from a fall


o
fractures from childbirth or trauma
o
indirect stress due to a hypermobile SI via sacrotuberous ligament or disc pressure on dura mater causing a pull on the filum
terminale to the 2nd piece of the coccyx
Examination
o
History: trauma, sitting, pooping, sex hurts; localized pain and tenderness
o
Palpation: tenderness to direct pressure at the sacrococcygeal junction; tenderness to passive movement; restricted mobility;
indirect stressing like tenderness to resisted glut max contractions; tons of muscle guarding
o
Radiology: fracture or dislocation
Standard Treatment: stress reduction using coccygeal pads or pillows
o
Donut rings don’t work very well but the cut out cube-like coccygeal pillow works ok; rolled up newspaper will work in an
emergency
o
Avoid stair climbing, bucket seats, sling-like chairs, airline seats; can put a pad under each ischial tube to help

Acute Synovitis/Hemarthrosis: leave alone for 10 days post injury; we don’t usually see acute patients

Chronic Discomfort:
o
Most likely caused by adhesions that keep being aggravated (can be treated with manipulation), or periostitis, which needs to
be treated with stress reduction
o
Ionto and US work well; ionto great after manipulations; can also use C-R to calm down the area of the pelvic floor muscles, hip
rotators, and keigels with abd/ER in prone position
o
Manipulation to break the adhesions via long axis distraction, long axis plus correction

o

3-4 session maximum
Prognosis is excellent with proper instruction and care over time
Coccyx Manipulation Technique
o
90 seconds; use gloves and lubricant; have a colleague with you that is the same sex as the patient
o
Insert index finger into rectum, and use thumb of other hand to give external counter pressure over the coccyx

Pt should be prone, with IR of legs to inhibit the gluts

Hook the coccyx and push up with the inside hand, while pushing down with outside hand
o
Pull in long axis of coccyx; repeat 3-4 times and conclude with US or ionto
o
Repeat up to 3 sessions; if ineffective, try the coccyx thrust manipulation
o
50% improvement 1st try; 85% improvement with 2nd try
LIGAMENTOUS WEAKNESS

Ligamentous weakness/laxity is a potentially serious condition that may lead to joint instability or disc protrusion; pre-discal condition
54
o
A gymnast or acrobat with obvious ligamentous laxity and joint hypermobility (ROM believed to be excessive to the joint in
question) may not be unstable due to their superb neuromuscular control
o
If their muscles fatigue, they may become unstable
o
Instabilty, therefore, is weher the osseo-ligamentous structures and the neuromuscular control systems are unable to hold a
spine in neutral and during motion against buckling and slippage/shear

CAUSES: postural misuse/abuse; obesity; repeated minor strains; vibration

SYMPTOMS: pain on assuming a fixed position; dull and achy localized at 1st, progressing to diffuse pain that worsens over time; difficult
to sit still or find a comfortable position; pain relieved by cracking the back (increases weakness) or changing positions; supraspinous
ligament is sensitive to touch

TREATMENT:
o
Early stages: stabilization; postural re-ed; back school
o
Later stages: rest and controlled activity; support such as a corset, brace, tape; correct neighboring restrictions; educate them
about approximating the tear in BB if a disc condition should occur
INSTABILITY: “ instability is wehre the osseo-ligamentous structures and the neuro-muscular control systems are unable to hold a spine in neutral
during motion against buckling and slippage/shear.”


CAUSES: ligamentous stress and strain from sports and poor posture
o
Lack of neuromuscular training and exercise
o
Surgery, like a wide laminectomy from a fusion above or chymopapin
CHARACTERIZED BY: ligamentous weakness and laxity; muscle weakness and neuromotor atrophy; fatigue; poor posture; pain on
assuming fixed positions; chronic pain
o


Look for a hypomobility near the hypermobility and check the SI and hip when dealing with lumbar spine; check ribs, scapulahumeral rhythm
EXAMINATION:
o
History: pt reports history of catches and twinges, sudden pain, pain on prolonged sitting/standing
o
Structural Appearance: obesity and poor posture; spondy; involuntary muscle guarding (hypertrophic banding); step on
standing that disappears in lying
o
Active Movements: uneven with slipping or juddering; pain at end range; poor balance and neuromuscular control
o
Palpation: tenderness to palpation of ligaments; Grade 5 or 6 on PIVM; positive prone instability test
o
Gold standard for instability is a radiograph
TREATMENT:
o
Ensure slow, continuous improvement
o
Train for health, not performance (endurance and local motions)

Muscle endurance, not strength; stop smoking; motor control awareness; motivation; frequent rests for disc
nutrition; educate on stability and over-load on movement and exercise; instruct in all manner of ADL and ANL;
flexion is bad and loading is good; torsion is the worst
55

o
CPR Stabilization (Hicks): pt that responds the best will be less than 40, with abherent motions, good hamstring
length, and (+) prone instability test
Exercise

Abdominal setting (transverse abdominis: Jull)

Multifidus (look at exercises on p 155); need neutral spine; don’t let patients open up too much or drop pelvis
(dropped pelvis signals weakness)

Quadratus lumborum, especially in females

Quads, abs, and gluts

To work on endurance make sure to do lots: 100 ab exercises x 10 second holds in 3 weeks
o
Manipulate neighboring hypomobile joints if neccesary
o
To stabilize cervical spine, avoid BB, neck rolling, isometrics because they cause translation and slippage, further aggravating
the instability

Treat by strengthening the longus coli (Jull) and multifidis; keep all ROM activities within range; upper thoracic manip

In the cervical spine, an anterior shear of the vertebrae causes it to slide in to the spinal cord
DISC DYSFUNCTION
MCNAB SURGICAL CLASSIFICATION


Disc Protrusion: Bulging Annulus
o
Type I: localized annular bulge
o
Type II: diffuse annular bulge
Disc Herniation: Torn Annulus
o
Type I: prolapsed nucleus; annular fibers intact
o
Type II: extruded nucleus; whole annulus tear
o
Type III: sequestered nucleus; chunk has broken off and left a free body
DISC ANATOMY/PATHOLOGY (good pictures p 157)

L4 disc protrusion hits the L5 nerve

L5 disc protrusion usually hits the S1 nerve

o
An unusually large L5 disc protrusion can hit the L5 and the S1 nerve roots producing extensive muscle wasting and loss of skin
sensation; can suspect a spinal cord tumor
o
Total prolaspse of L4/L5 with cauda equina involvement will result in bladder retention or loss of control; emergency situation
o
BB is the tx of choice unless it causes periphralization of pain; goal is to centralize pain; do neutral spine if BB hurts
o
Discogenic conditions are usually a younger person’s disease
Since 1983, Paris has researched the possibility of disc healing
56
o
Mounting evidence in the literature that support this view; if discs can heal than timely detection of minor disc problems should
lead to an effective treatment of the disc that avoids surgery

Outermost layers of the annulus are vascular (presence of blood indicates ability to heal); each layer of fibers run in two diagonal
directions to resist excess motion

Tears can only begin at the annulus
o
A nucleus that is seen to migrate in a discogram is able to do so because the outer annulus is already weakened or torn

Usually takes 3-4 weeks to feel better with a discogenic problem, but 3-6 months to be totally healed

Paris disc prolapsed story: hx of hypermobile, but not unstable; 2002 he swung an ax and avulsed the iliolumbar ligament and 2 ½ inch
pieces off the iliac crest; this sharp pain blocked the pain of the ruptured L3 disc that he didn’t know he had; 45 minutes later he had
numbness, tingling, loss of reflexes due to swollen/migrated disc; slated for surgery but refused and used tx of stabilization and positional
distraction
PARIS TREATMENT CLASSIFICATION
1.
2.
3.
Pre-prolaspe: Instability
o
Pre-discal; ligamentous laxity, no signs of classic discogenic condition, achy
o
History: dull muscular ache on sitting; need to get up and move around; hx of self cracking; low back pain occasionally radiating
into the butt; no frank neurological signs
o
Physical: demonstrates many signs of instability; PIVM shows grades of 5 or 6
o
Treatment: stabilization to decrease load and increase endurance; back school to educate as to postures, ergonomics, work;
manipulations to joints and myofascia that are tight; instruction in first aid (BB if injury should occur)
Immediate injury: Tear or herniation
o
Tear or sprain
o
History: hx of pre-prolapse; sudden unguarded motion resulting in acute but deep pain, usually from flexion/torque; pt may say
they felt a tear, rip, or giving out
o
S/S: sudden, deep pain; referral to butt; very guarded motions
o
Physical: PT unlikely to be present; no FB or rotations; neurological will be negative for 1st 30 minutes
o
Treatment: goal is to heal the outer annulus and approximate the tear; go immediately into lordosis and stay there for a
minimum of 2 weeks; support and reinforce behavior with taping or even a corset initially; if can’t go into BB without
pain/peripheralization then treat as an acute prolapsed; back school; stabilization exercises; myofascial techniques

no manipulation; no rotation for 3 weeks; no bike for warm up

treadmill for warm-up; massage; floss nerve; approximate tear
Acute and subacute prolaspe
o
S/S: classic neurological signs, fatigue and disability
o
Acute: days 1-4

Try to gain lordosis and treat as an immediate injury; may be too late for BB to be effective

Minimal bed rest because the disc will swell with rest: 3 days max

Medical palliative measures (prednisone); education for pt to move, don’t rest too long, and use laxitives
57

o
Subacute: day 4 and improving

4.
5.
Once pain abates, can move onto other treatments
Initiate movements; myofascial manipulation; corset; stabilization; avoid aggravating the prolapsed
Settled prolaspe

3-4 weeks; slow improvement; ambulatory

Commence positional distraction with caution and teach as HEP

Stabilization and life style/healthy back regime

Goal is to prevent chronicity by encouraging activity and managing any fear of avoidance behaviors
Chronic disc disease
o
No great solutions for this problem
o
History: serious debilitating back pain with hx of neurological signs; possible failed surgery
o
Physical: sad and depressed pt on meds; often obese, smokes, very unfit, diabetic; ROM restricted due to pain; PIVM
combination or restrictions and instability; myofascial restriction and poor tone/condition
o
Treatment: life style education; stabilization; positional distraction if neurological present; try neural mobilization; manipulate
joints/fascia; fitness training and work hardening principles; counseling
o
Pt may have a lot of compensations; goal is to change lifestyle; if they don’t get better discharge them
o
Chronic back problems are the hardest ortho problems to treat
SPONDYLOLISTHESIS

A spondylolisthesis is a forward slippage of a vertebral body

Grading system for spondys:
o
Grade I: relatively symptom free
o
Grade 1+ : symptoms develop
o
Grade II: invariably symptomatic
o
Grades III/IV: surgical conditions
TYPE I: SPONDYLOLYSIS

Fatigue fracture of the pars articularis

Pt has a step when standing that appears to be one level above the level of defect

o
T his is because the fractured spinous process stays put, while the vertebral body, and all of the vertebrae superior to the
fracture slide forward with the weight of the body
o
The step will disappear in prone if it is unstable
Pt will have hypertonicity at the affected level (hypertrophic banding); ligamentous dull ache; rotational component if the fracture is
unilateral [deviates towards the fracture side, so the spinous process swings to the opposite side of the fracture]
58

Caused by repetitive overload; most prevalent in gymnasts, weight lifters, divers; combination torque motions that involve extension and
rotation

Treated with stabilization, manipulation to the joints above/below; work on co-contraction to create a muscular brace
o
No BB exercises; no prone hip extension; need pillows under abs in prone
TYPE II: DEGENERTIVE

Facet arthrosis and tropism

Due to an alteration of the planes of the facets (tropism) or due to the wearing down of the J-shaped lips of the facets, allowing the
vertebra to slide anteriorly; no fracture

Step will appear at the level of the defect
o

The step is commonly missed on X-rays because there is no fracture; X-ray must be performed in standing and at the end of the
day
Treated with stabilization and manipulation to the joints above/below; myofascia in the psoas
TYPE III: ISTHMIC SPONDYLOLISTHESIS

The pars interarticularis (isthmus) lengthens, allowing the vertebra above it to slip forward; “stretch” spody

Usually happens in developing bones of obese children

S/S: X-ray may show the elongated pars or fracture of the pars

Treated with stabilization, manipulations, weight control
UNSTABLE SPONDY

Signs/Symptoms: dull, ligamentous ache at the end of the day; step that disappears in prone; muscle guarding in standing that
disappears in prone; rotational fault in unilateral spondy

Treatment: stabilization; manipulation to joints/fascia to reduce stress; education to reduce loading and avoid extension activities

Surgical: indicated if therapy cannot stabilize an advancing condition, expecially if neurological signs are presenting; fusion or pedicle
screws often used
LUMBAR SPINE STENOSIS: Central and Lateral Foramina Stenosis

Stenosis is a narrowing of an opening
o

Risk of compression to spinal cord; stenosis is multi-factorial in causation
The discovery of stenosis came with the introduction of CT and MRI
CENTRAL SPINE STENOSIS

Causes: degeneration; wear and tear; poor posture; abdominal protrusion/lordosis; tight iliopsoas; tight lumbar spine myofascia
o

Disc protrusion, prolapsed (37% are asymptomactic)
S/S: chronic dull LBP; bilateral pain in both legs with walking any distance; neurogenic claudication
o
To determine the cause of claudication, you can use the bike test or the treadmill test
o
Treadmill: have the pt walk upright and note time of onset of pain; have pt walk on 8% inclined treadmill and note onset of pain
59

o

If it is neurogenic claudication, the incline will feel better; if vascular claudication the incline will start symptoms faster
Bike: have pt ride in upright position and then in a flexed position
Treatment: myofasical manipulation and stretching to psoas, low back muscle
o
Increase physical fitness in pool or unweighted treadmill

Focus on flexion biased exercises; Hugo walker; negative heels to create a posterior pelvic tilt
o
Lifestyle changes: smoking, posture, obesity
o
Surgery: fusion with foraminectomy and/or “360” fusion (expensive: posterior plate with 3 screws); surgery is the last choice
after PT; pt usually older, diabetic, fat, poorly motivated, not in best health

Can also have an anterior interbody approach surgery that goes in through the abdomen and restores the height
between the vertebrae; opens the posterior intervertebral foramen without having to open up the pt posteriorly
LATERAL FOAMINA STENOSIS


Causes: lateral disc protrusion; loss of disc height; degenerative changes to ligamentum flavum and facets; discs become dry as we age
and bones/ligaments of the spine swell due to chronic inflammation
o
Effect of loss of disc height: “bosses and bars” due to Sharpey’s fibers
o
Losing disc height (due to loss of motion, etc.) allows the superior vertebrae to move posteriorly (retrolisthesis) and narrow the
central canal
S/S: lateral symptoms such as pain, subjective numbness, hyper neurological responses similar to a pre-prolapse nerve root irritation
o

True neurological signs: paresis > skin sensation > reflexes > neural tension (SLR)
Treatment: posture education; healthy back living; stabilization; stretch myofascia of back and psoas; manipulate stiff joints; positional
distraction; possible heel lift on unaffected side to open up affected foramen
CERVICAL SPINE: Central Spine Stenosis & Myelopathy

Cervical myelopathy was not suspected until 1970s and was not paid attention to until 1990s, when it became recognized that
degenerative changes in the cervical spine canal may mimic MS, ALS, and even Parkinsons
o
BRAIN (and Wilkinson): cervical myelopahty is the most common disease affecting the spinal cord after mid-life

Osteophytes are one of the causes of narrowing and cord pressure; bosses and bars (large ridges); discs in cervical spine can split in two,
which never happens in lumbar spine  due to the shearing motion of FB/BB in cervical spine

Causes: congential narrowing of cervical spinal canal; hypermobility/instability; resultant bosses and bars into the spinal cord; enfolding
of the ligamentum flavum
o
Contributing Factors: forward head posture; cervical stress, strain, sports, MVA accident; compensatory hypermobility (?) to
upper thoracic spine, kyphosis/stiffness; instability mostly at C2/C3 and C5/C6
o
Instability on BB causes encroachment of vertebrae on the coed

S/S: bilateral UE symptoms (central); vague transient neurological signs into arms and sometimes legs; test LE for UMN signs like Babinski
and clonus

Treatment: axial extension with posture changes; stabilize the cervical spine via deep anterior neck flexors; avoid BB in sleeping, cyclinb,
basketball, breaststroke, etc; manipulate UT spine to reduce mid-cervical stress
o
Surgery can be used to remove impingements and fuse vertebrae
60
CERVICAL SPINE: Lateral Foraminal Stenosis

Radiculopathy

Causes: degenerative changes; osteophytes from lateral interbody articulations (uncinate processes/Von Luschka joints); thickening of
ligamentum flavum; arthosis of facet joints
o
Contributing Factors: upper thoracic slouch an stiffness, leading to mid-cervical hypermobility and instability

S/S: neck and arm pain/paresthesia; frank neurological signs and symptoms (motor, sensation, reflexes); positive ULTT: positive Spurling

Treatment: joint and myofascial release; posture; positional distraction

Surgery: foraminectomy; most often surgeon will tell the patient they performed a disc surgery while is misleading but understandable
Neurological Signs Origin
Lumbar Spine
Cervical Spine
Patient Characteristics
Discogenic
Ages 28-50
Males > females
Spondylogenic degenerative arthrosis that has progressed to lateral
foraminal stenosis
Age 50 +
WHIPLASH/ACCELERATION –DECELERATION

Causes: motor vehicle accidents; falling down stairs; being struck by a yacht boom

S/S: very unreliable; often minimal initially; minor to bizarre symptoms; sympathetics

Treatment:

o
Rigid immobilization for 2 weeks
o
Plastic collar at 1 week if symptom free
o
Soft collar at 4 weeks if symptom free
o
No traction ever, until 8 weeks out
o
Minimal movement 1st 2 weeks; no exercise for 4 weeks; no resisted exercise for 8 weeks
Interspinous ligament and the ligamentum flavum can be torn, which will not be seen on an X-ray
o
Only 1 in 22 fractures seen in X-rays (Raushnig)


He saw all of the following in 1 mm slices from cadevers that would have been missed on and X-ray (and MRIs) aren’t
usually given: fracture of articular facet on atlas, rupture of ligamentum flavum with bleeding causing pressure on
cord, avulsions, fractures
o
Could also have tears to muscles, nerve, esophagus, trachea, bleeding around brainstem and behind the eye
o
Most odontoid fractures are found via X-ray but not all; beware of pt who holds the neck rigidly and complains of instability
(Paris had 3 pts with odontoid fractures that didn’t show up on X-rays)
Netter has illustrated soft tissue injuries that would not show on X-ray
o
Traction on larynx/esophagus leading to hoarseness and dysphagia
Forceful displacement of brain that may produce hemorrhage, headache, dizziness, concussion
61
Stretch/tear of scalene/longus coli resulting in pain and stiffness of neck, injury to sympathetic trunk (nausea, blurred vision,
dizziness, Horner’s syndrome)

Well-fitted cervical collar plus local heal and analgesics is curative for mild injuries in 2-4 weeks
ELEVATED FIRST RIB (nothing in S1)
THORACIC OUTLET SYNDROME

Compromise of the neurovascular structures of the upper extremity

Functional Causes: hypertrophy or adaptive shortening of the anterior scalene muscles; elevation of the first rib; hypertrophy of the
subclavius; adaptive shortening of the pec minor
o
Congenital Causes: broad insertion or two-banded insertion of anterior scalene muscle; fibrous slip running from anterior
scalene to mid-scalene muscle; presence of a cervical rib or a fibrous band from C7
o
Other Causes: bony exostosis of the 1st rib from an old fracture; tight clavi-pectoral fascia

Symptoms: pain and paresthesia in UE; deep aching at times; intermittent claudication; Raynaud’s phemonena; intermittent edema,
venous engorgement, cyanosis; dorsal scapular pain

Treatment: depends on what is found, but may include the following:
o
Manipulation of the 1st rib or other restricted joints
o
Myofascial manipulation for tight muscles
o
Postural re-education with attention to head and scapular positions
o
Instructions in diaphragmatic breathing
o
Home program of self-stretching and mobilizing
o
Special treatment for release phenomena
HEADACHES

Pain begins in the cervical or thoracic spine

Headache can be affected by change in position or movement

A history of trauma preceding the headaches

Physical or emotional stress brings on the headaches

RED FLAGS: very short history; new headache that they have not had before; headache that is worse than ever; behavioral and mood
changes
LESION COMPLEX


Similar to Kirkaldy-Willis’s degenerative cascade
o
Paris’ idea: while one entity may predominate, others will soon present themselves over time
o
Any attempt to create a diagnosis that identifies one structure to be at fault (disc protrusion) will fail to tell the whole story
o
PTs are not limited to making one diagnosis, and should create an impairment list after our evaluation
Treatment of the lesion complex focuses on treating each individual syndrome
62
IMPAIRMENT
Soft tissue restriction
Limited facet/segmental motion
Restricted hip function
Instability
Poor general condition
Short right leg
TREATMENT
Myofascial techniques
Manipulation
Manipulaton
Stabilization routines
General conditioning exercises
Heel lift
KISSING LAMINA
LUMBAR SPINE


Baastrup Disease
o
Artificial joint between the spinous processes in lumbar spine; not an uncommon source of LBP in short, stocky middle aged
men
o
Not technically a disease, but an impairment
Cause: spinous process rubbing in posterior mid-line; inflammatory reaction is the source of pain
o
Contributing Factors: poor posture; pot belly; excessive lordosis; short stocky males

Treatment : pelvic tilt; stretch psoas and myofascia; weight loss; healthy back living

Surgery: removal of a portion of the spinous process; denervation of medial branch of posterior primary rami; sclerosants = phenol to
deaden the nerve
CERVICAL SPINE

Cause: friction between the lamina and vertebra
o
(Paris 1965)
Contributing Factors: excessive mid-cervical lordosis; stiff UT spine; hypermobility of mid-cervical spine; loss of disk height;
collapse of lateral interbody joints

S/S: central neck pain

Treatment: posture and stabilization; avoid BB and circumduction; manipulate stiff UT spine
THORACOLUMBAR SYNDROME: Maignes Syndrome

Pain over the lateral thigh and occasional giving away of the leg; often confused for a hip impairment

Cause: instability at the thoraco-lumbar junction involving the lateral femoral cutaneous nerve to the thigh

S/S: pain over the lateral thigh; spontaneous giving way of the leg; tenderness over the iliac crest laterally

Treatment: stabilize the T/L junction via multifidus exercises
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------OSTEOARTHRITIS AND OSTEOARTHROSIS: usually OA, as there is no associated inflammation; stiff joints are not painful, so this condition
frequently goes unnoticed; degenerative process affects both the capsule and the cartilaginous joint, so over time cartilage is destroyed, bone is
exposed and pain ensues

Treat by restoring function and ROM; establish good muscle support; establish correct pattern of use
HYPERMOBILITY: term applied to a ROM believed to be excessive to the joint in question
63

Can be caused by genetics, response to repeated stresses like one legged standing (SI joint hypermobility), or a compensation for loss of
motion at a neighboring joint

Signs and symptoms: ligamentous type of pain, dull ached on assuming a fixed position; excessive ROM

Treat by manipulating hypomobile joints, postural instruction, and stabilization exercises
SUBLUXATION AND DISLOCATION:

DISLOCATION: joint surfaces have lost their normal relationship and cannot easily and of their own accord be restored to the neutral rest
position

SUBLUXATION: joint surfaces, due to hypermobility or loss of normal muscle tone, have assumed a rest position that is beyond normal
for that joint; flaccid hemiparesis
TENOSYNOVITIS: synovial sheath around a tendon becomes inflamed, which may cause synovial crystals to be deposited in the tissues

Caused by unaccustomed overuse or incorrect use

Symptoms: crepitus and pain

Treatment: TFM and US
NERVE ENTRAPMENT SYNDROMES: pain caused by entrapment of a nerve over, against, or between structures

Caused by degenerative conditions like disc disease/stenosis, bad posture, or myofascial restrictions

Symptoms: myofascial hypertrophy in athletes; pain reference is vague and intermittent; altering a position may increase or decrease
symptoms; increased activity increases pain; pins/needles

Classic neurological signs: loss of skin sensation; weakness of muscle (remember that reluctance to move, thus disuse atrophy are not
neurological); altered reflexes; transient neurological deficits typical of lumbar spinal stenosis

Treatment: posture, myofascial stretches (TOC), positional distraction (disc protrusion)
OVERUSE SYNDROMES: occur when stress to the tissues is greater than the tissue’s ability to respond by repair or increasing strength; common
examples are stress fractures to the tibia and fibula

FIRST LEVEL: discomfort comes on a few hours after use; due to vascular inefficiency to carry waste products away ; normal response
o

SECOND LEVEL: pain comes on during or immediately after use; not normal
o

Treatment: do not increase level of activity; rest 1-2 days between exercising; take aspirin before activity; heat, massage, hot
tub after activity; stretch muscles after
Treatment: same as 1st level, but check for dysfunction in motions/faulty techniques; fix faulty techniques
THIRD LEVEL: pain present even at rest; damage has been done and athlete must stop activity to avoid worsening
o
It is ok to exercise through muscular discomfort but it is never acceptable to exercise to or through the point of pain
o
Treatment: same as 2nd level; rest; cross-train; aspirin
POSTURAL SYNDROMES: positions that we sit, sleep, and stand in are recognized as contributing factors to pt’s clinical syndromes

Causes: bad postural sense; injury; age; pain

Symptoms: few primary symptoms but cause other conditions such as TOC and TMJ dysfunction

Signs: bad posture; slouching MTC
64

Treatment: education and release of tight myofascia
SEGMENTAL FACILITATION AND SUMMATION: These 2 items are closely related


SEGMENTAL FACILITATION: a spinal cord segment is said to be “facilitated” when there is a reason for nociperceptive impulses to be
referred to the spine
o
Nociperception may come from injury to a muscle, joint, or any other structure innervated by that spinal cord segment
o
As a result, that segment is in a state of excitement, or facilitation
o
May see involuntary muscle holding, exaggerated reflexes, tender spinal ligaments, trigger points
o
The source of the original dysfunction causing the segmental facilitation may be a distant joint, like a knee or diseased viscera
SUMMATION: observed when more than one segmentally related dysfunction is present
o
Example: patient with mild carpal tunnel involvement may not be aware of their symptoms
o
Pt with mild carpal tunnel, moderate TOC, and a narrowing of intervertebral foramen secondary to poor posture or
degenerative changes will have pain

Due to the summation of all of the nociperceptive input from all of the sources

Cause of their pain is therefore, carpal tunnel, TOC, and foraminal encroachment

Removal of any of these will reduce the pt’s nocipercpetion below the pain threshold

PT should treat all three:

Mobilize the wrist; manipulate 1st rib, related muscles and UT spine; posture correction
CHAPTER 16: PAIN AND PAIN MANAGEMENT

Pain, not dysfunction, brings patients to the clinic but in order to resolve pain we must treat the dysfunction.

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such
damage. (Nolan 1990)
o
Unpleasant experience
o
Perceived in terms of tissue damage

If we accept that pain is whatever the patient says it is and exists whenever he says it does, then we need not spend time determining “if’
someone has pain, but rather concentrate on determine the causes of pain and treating them. (Journal of Nursing)

Three aspects of pain:
o
Physical: actual physical cause of pain, like spraining of tissues
o
Rational: patient’s ability to understand the nature of their condition
o
Emotional: patient’s concern about the intensity, duration, and effects of the condition on their lifestyle
COMPONENTS OF PAIN

Physiological: includes the anatomical and physiological sources of pain

Perceptual: unpleasant sensory experiences of the pt; when the pt perceives pain they relate it to a previous painful experience

Affective: emotional and psychological aspects of pain
65

Cognitive: patient’s knowledge of pain, and significance to him (rationale)

Acute pain will have greater physiological, perceptual, and cognitive components of pain, while chronic pain is more affective domain.
MELZAC (1990) described two neuroanatomical pain systems:

Lateral Pain System:
o
Phasic pain that occurs shortly after an injury
o
Short lived pain; very rapidly conducting; well localized
o
Provides sensory qualities like throbbing, burning, cramping, stinging
o
Activity is rapidly dampened by endorphins and enkephalins via connections to the periaqueductal gray matter, where they are
produced

o


Allows quick recovery so that the pain doesn’t debilitate during a fight or flight response
Quickly develops tolerance to intervention, especially morphine
Medial Pain System:
o
Tonic pain that is chronic and can exist for many years
o
Poorly myelinated small nerve fibers make up this conductive system; pain is diffuse
o
This pain is responsible to emotional components of pain (affect/motivation) due to its direct link to the limbic system, where
emotion, depression, and affect are controlled
o
Little tolerance to intervention; does not require increasing dosages of meds to create a therapeutic effect
If a PT cannot find the source of pain, he is ethically prohibited from continuing beyond one or two treatments
o
Teach posture education and exercises
o
Novice PT could seek professional consultation or refer the pt back to referral source
MYTHS ABOUT PAIN

Pain is not a warning sign: It is a symptom of damage that has been done

Pain is not related to morbidity: Minor things can be excruciating, and serious problems can be painless

Pain is not related to progress: Pain can lesson as nerve root pressure goes from a mild irritation to a complete palsy

Pain is not referred into dermatomes: Pain cannot travel down a sensory nerve into its skin dermatome
o
All pain is in the head, interpreted by the brain
o
Referred pain: when the brain interprets pain as coming from one spot when it is coming from another spot
o
Rather than saying that pain is referred into the L3 dermatome, we can say it is referred into the anterior thigh
o
Knowing dermatomes can tell us which sensory nerve has had its pathway compromised
o
Because a dermatome is an area of afferent skin supply, it can only conduct sensation from distal to proximal, not the other
way around
o
Pain reference does not follow a dermatomal pattern (Kellgren)
66
EXAMINING PAIN: Goal of examination for pain is to determine the cause of pain and satisfy the patient’s needs to explain their pain

Evaluation Methods for Pain: body chart; McGill Pain Questionnaire; history; provocation via palpation

Treatment of Pain: use the 3 circles of pain; conduct a “physical” examination of the patient, explain their pain to them so they can
“rationalize” and lower their “emotional concerns”
o
While treating the patient, avoid reproducing the pain because it can do more harm to the tissues; install a painful memory;
facilitate the pathway for pain, making it easier to fire; establish a self-serving loop
o
Focus on behavioral psychology, where PTs reinforce positive behavior and ignore pain behavior


Do not reward pain behavior with attention and compassion!
o
Can also use existentialist philosophy, that teaches us that we are all responsible for what happens to us
o
Make the patient set goals for physical therapy treatment
Once acute pain has been thoroughly evaluated, do the following:
o
Turn the patient towards function: do not inquire about their pain, but comment on progress
o
The second greeting: don’t ask how they are, tell them to come on back and you will tell them how they are doing
o
Make treatment visits condition dependent, not pain dependent: keep scheduled appointments as is
o
Do not enhance pain memory: don’t reproduce their pain
o
Turn off pain behavior: ignore painful grimaces, etc. tell them that you know the cause of their pain and you are treating it, not
the pain
o
When to treat pain, rather than dysfunction: when pain is so severe that it is interfering with treatment
o
If we increase pain during treatment: this is to be expected; best treatments often hurt more the next day
o
If no causes can be found: we cannot treat the patient
o
If we are unable to help: treatment should be discontinued

Dr. Paris suggests making pt sign a VAS scale that states at what level they are willing to go back to work; if they don’t improve, treatment
stops; linear pain scales are good to manage pain

Dr. Paris feels that PTs have no role in a pain clinic, unless they strive to find the cause of pain and treat it
o
Purpose of pain clinic: to have the patient accept that nothing can be done by others; to teach coping skills; to train in behavior
modification; exercise therapy like aerobics/Tai Chi
o
Patient should not receive: any medical or surgical procedures; any hands on PT including massage; new medications

o
May have acupuncture or TENS if used as a control mechanism, not a treatment mechanism
What’s wrong with most pain clinics: improper patient selection; run by those who still want to treat; behavioral psychologists
should be in charge
CHAPTER 17: TOUCH AND PALPATION: read in FCO
CHAPTER 18: PRINCIPLES OF EVALUATION

GOALS OF PATIENT EVALUATION: establish a rapport; gain their confidence; assess the nature/extent of pt’s disability; rule out “red
flags”; identify the dysfunction; develop a plan for pt management; arrive at a prognosis; be consistent, confident, professional
67
o
Goals of First Visit: meet the patient, look for physical findings, explain what you have found, provide emotional comfort

o

Have a professional environment, demeanor staff; empathize don’t sympathize; have open door policy
Do Not Do on First Visit: feel that you have to treat the patient or complete the evaluation
Bias is the enemy of decision making
14 STEP SPINAL EVALUATION
1.
2.
PAIN ASSESSMENT

Believe that the pt is experiencing pain if they say they are; pain brings the pt to the clinic; evaluate the pain; find the source of
pain; explain their pain to them

Body chart, McGill Questionnaire (count words/categories), functional status (NDI, Oswestry)
INITIAL OBERVATION

Look for pt position, guarded motions, pain/dependency behaviors, trick maneuvers, sitting posture, gait, handshake, getting
into/out of chair/table
3.
HISTORY
4.
STRUCTURAL INSPECTION

5.
6.
8.

Subcranial: forward nodding, backward nodding, SB each way

Mid-Cervical: FB, SB both ways, rotation both ways

Lumbar: FB 3 times, observing from the side, behind, from behing with pt eyes closed
NEUROVASCULAR ASSESSMENT
Test skin sensation, muscle strength, reflexes, neural tension tests
PALPATION FOR CONDITION

Look at skin for temperature changes, moisture/dryness, scars/ulcers; look at joints for swelling

Look at muscle condition
o
Involuntary: hypertonic but otherwise normal to touch; limb feels heavier; disappears when adequately supported
o
Chemical: tone remains even when supported; doughy; limited range
o
Voluntary: no doughiness; movements restrained
o
Adaptive shortening: normal tone; limited ROM
PALPATION FOR POSITION

9.
Look at general posture, forward head, rounded shoulders, paunch, obesity, flat feet, stance, pelvic tilt, deformities, swelling,
atrophy, cane, crutches, corsets
ACTIVE MOVEMENTS

7.
(p 305 – 310)
Common sites to examine: SI, L5 spondy, L4 on L5 lateral shift in males, mid-thoracic rotations and BB, upper thoracic
rotations, upper cervical locks in the atlas
PALPATION FOR MOBILITY
68

PIVMs
10. UPPER/LOWER QUADRANT ASSESSMENTS

Low back patients: always examine the hip and the SI in addition to the low back

Neck patients: always look at shoulder, thoracic outlet, TMJ

END FEEL: term used in manual therapy to mean the quality of resistance that the PT feels when passively taking a joint to the
clinical limits of range
o
Region of motion being tested is between the first stop, when we feel 1st resistance at the end of range, and the 2nd
stop (Kaltenborn) where going further may change the nature of the end feel by treating it or harming it
o
End feel is a test of the joint play in the joint, as it exists beyond the control of muscles
o
A joint may have a normal range of motion via the goni, but without a joint play range greater than the active range,
that joint will not have a tolerance for outside forces
o
Without a normal end feel, rehab is not complete because the joint will likely have a recurrence of dysfunction from
minor trauma or strain

Cyriax coined the term, and used it to describe 3 normal and 3 abnormal states

Paris has identified 5 normal and 10 abnormal end feels; Patla has shown that the Paris normal classifications have excellent
intra and inter-reliability (p 318 – cross check with other materials)
NORMAL END FEELS
SOFT TISSUE APPROXIMATION
MUSCLE
Soft and spongy
Elbow flexion
Elastic reflex resistance with no
discomfort; SLR
Firm arrest of movement with no
creep/give
Abduction of extended knee
Sudden stop but not hard
Elbow extension
Firm arrest of movement with
creep
Hyperextension of elbow
LIGAMENT
CARTILAGE
CAPSULE
ABNORMAL END FEELS
ABNORMAL CAPSULE
BONY BLOCK
DISPLACED MENISCUS
Springy rebound
LIGAMENTOUS LAXITY
Loose
JOINT ADHESION
Sudden sharp arrest in one
direction; common in knee joint
Abnormal elastic resistance;
guarding
Soft, crunchy; synovial infold or
trapped fat pad at elbow
Empty end feel; boggy due to
synovitis, hemarthrosis
Pain before end feel reached;
suspect disease, abscess, bursitis
Rough, grating; chondromalacia
ABNORMAL MUSCLE
PANNUS
SWELLING
PAIN
BONY GRATE

Acute/chronic inflammatory
Tight resistance/painful muscle
guarding
Sudden hard stop short of normal
range; myositis ossificans/fx
Identification of the tissue that has been injured is accomplished by mechanical provocation of tissues/structures
o
Not useful to try and illicit pain in a nerve compromised situation
o
Increased tissue damage and associating pain with movement are two risks in using provocation
69



Provocation is accomplished by passively moving body parts in carefully selected directions to stress the target tissue or by
providing resistance to active movements
o
Pain with active and passive movements in same direction = non-contractile tissue at fault
o
Pain with active and passive movements in opposite direction = contractile tissue at fault
o
Pain with all movements = emotional problem or serious pathology
Example: ligament
o
Pain with normal ligamentous end feel and no laxity = minor ligament damage
o
Pain with normal/slightly loose end feel and slight laxity = moderate injury
o
No pain with empty end-feel = complete tear
Capsular Patterns of Restriction: occur if the entire capsule is involved, and follow these common themes:
o
Restriction of ROM follows a characteristic pattern
o
Active and passive motions are painful in same direction
o
Pain may come on as limit of range is approached
o
Resisted movements do not hurt
o
Inert structure at fault
11. RADIOGRAPHS

Needed with acute trauma or long-term chronic conditions

Leave the X-ray until end of evaluation to determine what is wrong in your own mind and eliminate bias

MD: looks for disease, fracture, displacement

PT: looks at joint space, bone density, calcification of soft tissues, range and sequence of motions
12. SUMMARY OF FINDINGS/ASSESSMENT

Assessment is where we draw together and list significant findings

PTs do not diagnose: we list objective findings
13. TREATMENT PLAN

Once the significant findings have been listed, treat these impairments
o
Poor pain behavior = behavior modification
o
Poor posture = postural instruction
o
Elevated 1st rib = manipulation
o
Painful arc = educate in correct use/tape
14. EXPLANTION/PROGNOSIS
70

Outline significant findings to the patient; give them a timeline of improvement and number of expected visits; outline what
you expect the patient to do (HEP, cooperation); ask the patient their functional goals

Always make sure to rule out non-musculoskeletal problems/red flags
CHAPTER 19: MANIPULATION THEORY AND TECHNIQUE

Manipulation: Manual therapy technique comprised of a continuum of skilled passive movements to the joint and surrounding soft
tissues applied at varying speeds and amplitudes, including a high velocity low amplitude therapeutic movement.

Active movements cannot be considered manipulation because it is not a passive movement, but they can be considered therapeutic
maneuvers
o
When a movement/exercise is performed against resistance, including isometrically, joint motion will occur even if there is no
angular motion
o
To restore knee flexion, we can manipulate by producing the component motion at the knee, a posterior glide of the tibia


Or, we can resist active knee flexion isometrically to fire the hamstrings, which will pull on the tibia posteriorly
We can manipulate throughout the anatomical limits of the joint
MOVEMENT CLASSIFICATION
1.
2.
ACTIVE MOVEMENT: movements that are performed using muscles
a.
Isometric: mm activation and force generation without a body part moving through a ROM
b.
Isokinetic: speed is held constant
c.
Isotonic: constant resistance and movement through the partial or full range
d.
Repetitive: can be used to centralize pain, relax surrounding musculature, facilitate return to function
-
Began with Codman in 1934
-
Due to firing of Type I and Type II articular mechanoreceptors, which gate pain perception (Melzack/Wall 1965)
-
McKenzie applies repetitive motion to the spine to centralize pain
PASSIVE MOVEMENT: performed on the subject by application of external forces
a.
Range of Motion: passive production of osteokinematic motions, performed without regard to arthrokinematics
-
3.
Can’t be considered skilled or a form of manipulation
MANIPULATION MOVMENT

Skilled passive movement to a joint used to restore accessory motion, either component or joint play, and can take place within
or at the end of the available ROM
a.
NON THRUST: low energy manipulations at slow speeds; used 90% of the time
-
Include traditional steady stretch (most commonly used) and oscillations, which have been made popular by Maitland
-
NON SPECIFIC: not specific with no locking maneuver; joints are stretched at many levels, somewhat randomly; least
restricted joints usually undergo the most stretch, while most restricted joints undergo the least stretch
o
General Steady Stretch: Take the limb through the full ROM, usually in both directions, and apply a series
of strong stretches; by strict definitions, these are not manipulations; Cyriax and Bourdillon have both
published on this technique
71
o
-
SPECIFIC WITHOUT LOCKING: attempt to isolate the energy of the manipulation to the exact site of the dysfunction;
because there is no locking, the manipulating force and stabilizing counterforce must be applied only to the joint
being manipulated
o
Stretch: applied at the end of available range of an accessory motion (component or joint play); purpose is
to stretch the capsule into the plastic range to increase length of tissues and improve motion; example
would be an anterior drawer of the knee to restore extension without locking the foot
o
Progressive Oscillation: series of 3-5 medium amplitude oscillations that progressively deepen, with the 1st
oscillation at mid-range and the last oscillation at end range (Paris uses this a lot)
o
Grades Oscillations: widely promoted by Maitland; he described 4 grades of oscillations
o
-
-

Grade I: small amplitude movement at beginning of range (25%)

Grade II: large amplitude movement within range but not reaching the limit of range (50%)

Grade III: large amplitude movement performed to the limit of range

Grade IV: small amplitude movement performed at the limit of range (75-100%)
Isometric: muscles are used to produce a component motion between the joint surfaces; called muscle
energy; does not fit the strict definition of manipulation because not passive, but unlikely to occur without
skilled PT; mulifidus entrapped facet
SPECIFIC WITH LOCKING: attempt to isolate the energy of the manipulation to the exact site of the dysfunction;
joints adjacent to the joint being mobilized is made stiff to protect them from the mobilizing force
o
Ligamentous Tension Locking: moving the joints to be locked into a position that engages the ligaments to
prevent further motion from occurring with manipulation; most common lock in spinal manipulation
o
Facet Apposition Locking: locking is accomplished by moving the joints in a way that causes their articular
surfaces to be apposed, causing forces to be transmitted through articular surfaces rather than capsule or
ligament
PATIENT ASSISTED: non-thrust, patient assisted, specific techniques; Mulligan
o
b.
Overstretch: Additional stretch added to the end of the range of a steady stretch if steady stretch was pain
free
Nags and Snags: usually performed in sitting; the patient actively performs the motion in the direction of
the restriction with the PT assisting with a NAG (natural apophyseal glide) to the restricted joint. SNAG is
where the NAG is sustained
THRUST: sudden, high velocity, short amplitude motion applied to a joint; thrusts require increased force, increased velocity,
and short amplitudes
-
NON SPECIFIC
o
Gross/Non-Specific: bulk of chiropractic techniques are specific to a vertebra, but are non-specific to a joint
because the history of chiropracty had more to do with vertebrae than with motion; chiropractic techniques
also tend to span several levels
o
In PT, our emphasis is on the joint we focus on the joint to be manipulated, rather than manipulating the
vertebra and affected all joints (12 on thoracic for example)
o
Non-Specific Surgical: usually to an extremity and under anesthesia; not trained in arthrokinematics and
tend to thrust the joint through its classical range; indicated when the pt is unwilling or unable to relax,
involuntary muscle guarding; low pain tolerance
72
-
c.
SPECIFIC: manipulation in an arthorkinematic fashion to restore one of the accessory motions and to isolate the
maneuver to one joint; PTs use “fractional” approach to try and break one adhesion at a time and cause minimal
damage
o
Impulse: fast, non-forceful thrust; will not break any major restrictions; similar to spring test
o
High Velocity/Short Amplitude: goal is to move one vertebra/joint to make a change in position or to snap
an adhesion; PT has ensured the joints above and below are not at risk and no locking needed

Ligamentous Tension Locking: lock em up and thrust em

Facet Apposition Locking: lock em up and thrust em
DISTRACTION: separation of joint surfaces
-
-
MANUAL: distraction is done through the hands
o
Inhibitory: compression is placed over muscles/tendons of insertion while the joint underneath is stretched
(subcranial distraction); pressure at the origin or insertion fired GTO and relaxes muslce
o
Graded I, II, III: (Kaltenborn)

Grade I: joint surfaces unweighted

Grade II: capsule slack is taken up

Grade III: capsule/ligaments are stretched
o
Manual Rhythmic: series of distraction motions alternated with periods of rest to gate pain or pump fluids
o
Manual Adjustive: (John Mennell) high velocity thrust often used at joints such as the hip
o
Positional: (Paris) most useful in spine, where 2 vertebrae are positioned to open up the intervertbral
foramen and take pressure off nerve root
MECHANICAL: (Hippocrates) mechanical appliances deliver a sustained or intermittent force
o
Long Axis:
o
3-D: table that allows the distraction force to the spinal level and the side that is desired (Kaltenborn, Paris)
o
Autotraction: pt performs the traction themselves against gravity (Chattanooga Table) or with the
assistance of a table that distracts (Paris table)
EFFECTS OF MANIPULATION
1.
2.
Psychological:
o
Providing a thorough examination, more so than any other practitioner, and we listen; caring confident hands
o
Having manually found the source of pain by palpation
o
Possibly being able to reproduce patient’s pain on examination; helps win their confidence
o
The ‘Pop’; shouldn’t be a goal, but it signals to the pt that the PT “did something”
Mechanical: Stretch tissues

USA believes that the best way to relieve a patient’s pain and return them to optimal function is to correct the causative
dysfunctions that resulted in the complaint of pain
73
o

Maitland approach concentrates more of the relief of patient’s pain or “reproducible signs” and only treat until that
goal is achieved; these techniques are less mechanical and more neruophysiological
Mechanical effects of manipulation are more significant than the neurophysiological and psychological effects and more long
lasting
o
Performed to mechanically elongate the CT structures around a joint
o
This is achieved by applying a force at the end of the ROM (classical or accessory)
o
Goals include: stretch out tight capsules; stretch out adhesions; snap adhesions; alter positional relationships

The mechanical effects of manipulation are best explained by the stress/strain curve

Toe region  elastic region  elastic limit  plastic region  ultimate stress (max resistance offered by tissue)  necking
(slope becomes negative and catastrophic failure is imminent)  ultimate failure

Stress/Strain: if adequate stress is applied to a structure it will deform; can be good or bad

Tissue Slack (Toe): the looseness of a structure; we move through the looseness to hit the first barrier of resistance, which will
be the elastic range

Elasticity and Plasticity of Tissue: all structures are initially elastic when a stress applied
o
Glass has a small window of elasticity and will shatter quickly
o
When we move a biological structure into its elastic range it will create a current in that structure

Bone: pizeo-electric effect, which serves to strengthen bone by stimulating cells to lay down more bone

Ligaments/capsules: streaming potential, which also stimulates more tissue lay-down

Any structure that is stretched in its elastic range will become stronger (stiffer); Wolf’s Law

So, to increase the range of a tight joint, you must move past the elastic range and into the plastic range (moving
into the elastic range will only make it stiffer, not improve ROM)
o
When we stretch repeatedly in the elastic range and fail to move in the plastic range we strengthen tight tissues by laying
down more tissue via streaming potential
o
We can stretch tight tissues by moving it into the plastic range and have the patient maintain that range
o
A healthy capsule must have elasticity and plasticity to allow and resist motion

When injured, the tissue is laid down in non-functional patterns that aren’t in accordance with Wolfs Law

Manipulation can break down unwanted cross-links but only if the plastic range is reached, creating deformation

Deformation loses energy, creating heat, which can be used as a benefit when stretching in plastic range


o
Heat produced in a curve is all in the plastic region
Heat allows structures to more pliable; series of 3-5 stretches for 3-5 seconds and followed by a bigger stretch
makes best use of this principle
Poissons ratio: when a structure gets longer it also gets narrower; this causes compression, which helps squeeze out water

Tissues deform slowly, and if the force is applied too rapidly for the fluids to escape or the heat of deformation to
soften the tissues then it will resist the stretch and may snap or tear
74

Ultimate Stress: can be felt as a giving away of the tissues without additional stress being applied; to continue beyond this is to
risk rupture

Necking: represented by a giving way of tissues, like a piece of stretched gum

Ultimate Strain: the structure gives way totally; bad for healthy tissue, but good for adhesion

Biologic Memory of Living Things: concept more than a fact; tissues can recover after deformation

CREEP: slow stretch applied to a capsule for a long period of time allows the water to be redistributed/extruded in the tissues

o
When the tissue is lengthened, it gets longer, causes a compression, and squishes out water
o
This allows the fibers to align in a direction more parallel to the force as the structure lengthens
o
If the force continues, even in low amounts the dried out tissue will start to have fiber separation and weaken, which is
great for contractures, but bad for healthy tissues
THRUST: often directed at adhesions with the goal of creating a quick snap

All structures become stiffer when loaded at higher speeds, and cooling it will make it stiffer still; this will allow the PT
to snap the adhesion earlier in the ROM

If a joint has a tight capsule and an adhesion, a slow stretch would cause both structures to gradually yield with plastic
deformation once the elastic range had been exceeded

3.

But, a high velocity stretch the adhesion would become stiffer first and snap first

High velocity movements do not give the tissue time to lengthen (squeeze water out) or warm up
We can use inertia to change the position of a structure
Neurophysiological: Gate pain and reduce mm holding

Movement to a joint: fires articular mechanoreceptors; fires cutaneous and muscular receptors; activates gat control; abates
nociception; centralizes pain; reduces hypertonicity and mm holding

Gate Theory (Melzack/Wall, 1966): large fiber proprioceptors in the joint cause a rapid and voluminous transmission of
impulses that closes the gate on slower, small fiber pain stimulation



o
Moving the joint fires receptors in the joint
o
Rubbing the skin, massage, TENS fires cutaneous and mm receptors
o
Wyke (1972) discovered articular mechanoreceptors
Maitland’s Grades of Oscillation: five grades primarily directed at relieving pain; they were not directed at restoring
arthrokinematic motions though they may do so
o
Grades III/IV have mechanical effect as well
o
We use Grades I/II/III/IV at USA; grade V is a non specific thrust
Repetitive Motions: Codman and McKenzie use oscillations and repetitive motions to help relieve pain
o
Fires Type I postural and Type II dynamic mechanoreceptors
o
Great for mm guarding/pain reduction
JOINT POP: fires Type III inhibitive mechanoreceptors, similar to the GTO
75
o
Popping sound is due to the release of nitrogen gas into the joint cavity when a sufficiently large negative pressure is
created
o
Nitrogen usually in the synovial fluid, but explodes out of solution with the negative pressure
o
When we distract a joint, the capsule sucks in to try and maintain the intracapsular volume

Once it gets pulled to a certain point, fluid or gas must enter the joint to maintain the volume, and it is
faster for gas to do it

Joint will remain swollen with gas until popped
o
Good Effects: more movement, less pain
o
Bad Effects: muscles relaxed and not in a position to protect the joint; ROM increases and may cause subluxation

4.
In the spine, rotation is needed to create the pop, which can cause trauma to the disc; lead to instability and
ligamentous failure; muscle guarding; desire to pop again; endorphin release
o
Pop should not be the goal of manipulation; increased ROM should be the goal
o
Good reasons for a PT to use cracks are to snap adhesions and gain relaxation of tissues to do more therapy
BioChemical: Release of endorphins

Very little known, but much presumed about the biochemical effects of manipulation; little proof that beta-endorphins are
released
INDICATIONS FOR MANIPULATION (2)
-
Relief of pain (neurophysiological)
o
-
-
Use oscillations within the range
Removal of restrictions (mechanical)
o
Use techniques at end range to promote arthokinematic motions, component or joint play
o
Steady stretch, progressive oscillation, grade IV oscillation, thrust
Not ethical to do manipulations just for psychological reasons
PRECAUTIONS FOR MANIPULATION
-
Weakened disc
-
Adjacent to an instability or hypermobility
-
Positive vertebral artery test (contraindication by many)
CONTRAINDICATIONS FOR MANIPULATION
-
No absolute contraindications (grades I/II)
-
Disease states
-
Hemarthrosis
-
Muscle holding
-
Joint replacements (not contraindicated once active movement has been authorized)
76
Question: Why Joint Manipulation?
Answer: Because it restores normal motion which:

Improves function and performance

Increases tolerance to insult

Aids in blocking of pain

Aids in nutrition and repair of joint structures
JOINT MANIPULATION AND MYOFASCIAL STRETCHING

Most joint capsule have muscles attached to them, so stretching the capsule will affect those joints:
-
Hip: rectus femoris
-
Knee: popliteus
-
Elbow: anconeus
-
Shoulder: rotator cuff
-
Spinal Facets: multifii

Muscle stretching passively will cause the muscle to contract to protect itself, thereby becoming an isometric contraction

You don’t have to stretch muscles before a gentle activity because they warm themselves up

o
Do warm them up for burst type activities
o
Stretch after activities
Two ways to lengthen muscles:
1.
Sustained stretch that fatigues the muscle spindle (takes 15-20 minutes)
2.
Contract/relax then stretch, where we trick the muscle into lengthening (2 second period to stretch into plastic range)
CHAPTER 20: PHYSICAL THERAPY – CONCEPTS IN MANAGEMENT
10 CONCEPTS IN TREATMENT THAT SHOULD BE APPLIED TO MANAGEMENT OF SPINE DYSFUNCTION
15. Cause of Back Pain in Industry: 50% of workers has insidious pain, though lifting is often listed as the #1 cause of back injury
16. Rate of Healing

50% in 2 weeks

What we do in the 1st two weeks to enhance recovery is very important

At 3 months, there is no healing
80% at 6 weeks
100% at 12 weeks
17. Formation of Intra-Articular Adhesions

1st day: bleeding stops
77

3rd day: adhesions formed

7th day: adhesions no longer vascular

10th day: adhesions firm

Acute injuries must be supported to minimize bleeding and maximize healing; patients may feel better at day 3 because the
adhesions provide support to the joint; ROM to joint may gate pain within 1st 7 days, but may also increase bleeding

Manipulation to increase range should wait until 10 days after initial insult
18. Rate of Return to Work

50% of workers return after 6 months off of work; 25% after one year off; 0% after 2 years off

Early effective treatment is the best approach; make treatment as hard as work; move to settlement while the sum is small
19. Most Injuries Get Better Within 2 Weeks All by Themselves

We don’t need to see everyone who hurts themselves, but if they have symptoms after two weeks we should
20. Most Musculoskeletal Injuries are Re-injuries

PTs should see all pts who have experienced a re-injury right away
21. Frequency of LB Surgery per 100,000 Population

10 in England; 12 in Sweden; 40 in US; 70 in LA

We operate too much in this country
22. Frequency of False Positive Findings of Disc Protrusions

A positive radiological test does not prove that the pathology visualized is producing the symptoms or needs to be surgically
interfered with
o
1985, Rothman; CT scan had 38% false positives
23. Webber’s Study in Norway of Operable Discs

At one year the operated group was doing twice as well as the non-operated group; at 2 years the operated group still did
better; at 3 years, no statistical difference between groups; 6 years the non-operated group did better than operated group

If you can wait/avoid surgery, do it
24. Natural History of the Disc

Disc is healthiest at 18 years of life; very hydrophilic with a tough annulus

25 +: annulus weakens rapidly

30 +: annulus weakens; nucleus still hypdrophilic, leads to disc protrusions

40 +: annulus weak, nucleus hydrophilic; prolapsed

50 +: annulus weakens; nucleus loses oomph: stenosis
o
If you are 25-45 you may elect for surgery
o
45+ you may elect to avoid surgery
25. Effect of Acute Back Pain on Mulitifidus
78

Multifidus muscle does not spontaneously recover (Hides et al)
o
Lack of localized muscle support may be one reason for the high recurrence of back pain after initial episode; all back
pain patients need multifidus strengthening
JOINT REACTIVITY: determined by severity of injury rather than time since injury (stage of condition)
 High Reactivity: painful response evoked before end range
o
Treat with rest, oscillation, ice, TENS, acupressure
 Moderate Reactivity: pain at end of range
o
Treat with progressive oscillations, gentle stretching of capsule, heat
 Low Reactivity: no pain at end range
o
Static stretch or Grade IV manipulation
CLINICAL PREDICTION RULES & EVIDENCE BASED PRACTICE
LBP costs about $ 86 billion in 2005 and makes up about 50% of our case load
Definition of Evidence Based Practice: The process of integrating the best research available with both clinical expertise and patient values


Pros of Evidence:
o
May provide a more accurate diagnosis
o
Has shown success rates with specific patient populations using particular interventions
o
Carries more weight than clinical experience or clinical opinion
o
Endorsed by APTA, Vision 2020
Cons of Evidence:
o
“cookbook approach” that does not require clinical thinking, which may lead to PTs losing ability to problem solve
o
Some of the contributing or causative factors may not be addressed/resolved
o
Does not provide guidance if the tx doesn’t work
o
Captures a small percentage of the general back pain population
Intake forms should be used with the patient examination

Medical History Forms
o

Help to rule out RED FLAGS: cancer (pts with family hx of cancer are 3x more likely to have cancer), spinal infection,
compression fracture, aortic aneurysm, ankylosing spondylitis, cauda equine syndromes
Oswestry Low Back Pain Questionnaire
o
Reliable and valid measure of the patient’s perceived level of function [written by Fairbanks, 2000; Fritz 2001 for modified
version]
o
Used frequently in research
o
Soft measure which is valuable in tracking pt progress; allows PT to make goals
79

Fear Avoidance Beliefs Questionnaire
o
The higher the number, the greater the fear and avoidance shown by the patient
o
Good reliability (Jacob, 2001)
o
Score less than 19 is one of the predictors of who will respond well to manipulation (Flynn, 2002)
o
Greater than 34 found to be useful in identifying patients at risk for prolonged work restrictions; yellow flags (Fritz, 2002)
o
YELLOW FLAGS: psychosocial issues thought to predict disability include: Perception of fault and compensation; lawyer
involvement; pt prediction of continued disability; household income; education; time off work (Frymoyer, 1992)

Neck Disability Index

Patient centered interviewing has been found to be associated with increased patient satisfaction, healing, and non-specific effects of
treatment (Smith 1994)

MDs do not allow their pts to complete their opening statement 69% of the time, and interrupted within 18 seconds (Beckman & Frankel,
1984)

WADDELL’S SIGNS: signs that have been proven to pick out malingerers if they show 5/8 signs
o
Axial loading causes scream of pain in low back
o
Won’t twist trunk but will use pelvic rotation to turn feel
o
Long sit with feet DF (90 degrees) but fake SLR
o
Superficial or non-anatomic tenderness
o
Over-reaction

Reliability: consistency or reproducibility

Validity: accuracy

Sensitivity: tests that can detect a condition when present (SnNOUT)

Specificity: tests that can classify a pt as negative when the condition isn’t present (SpPIN)
RANDOM RESEARCH BASED FACTS

Iliac crest height assessment are not reliable unless there is over 1 cm of difference; X-ray is the best way to note leg length discrepancies

Inclinometers have good reliability for lumbar ROM (FB, BB, SB)

LE pain with BB at 30 seconds associated with stenosis

CROM is best for cervical AROM; goni is ok

Sharp/dull test is most accurate sensation test

Motor tests have good intra and inter-rater reliability

Neural tension test: SLR (+) if pain below knee is reproduced under 70 degrees; inclinometer best way to measure SLR; goni ok (Kernig)
80

Babinski is the most accurate/reliable way to test for UMN lesion

Specificity of neurovascular tests are increased with clustered tests; show good specificity

Hip ROM has good reliability with goni; intra better than inter

Provocation tests are the most reliable/valid tests for SI joint: iliac compression/distraction and posterior shear

Faber, posterior shear, and resisted hip abduction exhibit high (+) predictive value for SI pathology (Broadhurst, 1998)

PIVM: mobility tests have fair intra-rater and poor inter-rater reliability (Inscoe)
o
Pain assessment for P/A mobility gliding more reliable than grading motion
o
P/A mobility testing found to assist in predicting those who respond to manipulation vs. stabilization (Fritz)

Treatment based classification of the spine is often categorized into 4 groups: manipulation, stabilization, specific exercise, traction
(good for radiculopathy)

75 articles demonstrate that mind-body healing is a true phenomena
o
Sham TENS reduces pain 20-40% of people with LBP

In an evaluation, rule out red flags, identify yellow flags, and determine if there has been neurological compromise (radiculopathy,
myelopathy, neurogenic claudication, cauda equine syndrome)

Functional tests are helpful as an objective measure of function: treadmill, step up, heel raise, mini-squats, partial curl, prone hip
extension, modified Sorensens (back ext over pillows)
CLINICAL PREDICTION RULES (CPR): A decision making tool that contains predictor variables obtained from pt history and examination

CPR is used to establish inclusion criteria

CPR guides diagnosis, prognosis, and the POC

CPR is developed in a 3-step process
o
Rule development: derivation study
o
Validation: randomized control trial
o
Impact Analysis

Cyriax (1950s) was the first person to perform gross spinal manipulation on patients who presented with a set of signs and symptoms

These techniques are making a resurgence, and focus on symptom relief rather than treating the underlying causes
CPR NAME
CPR: Lumbo-Sacral
Manipulation
INVENTOR
Flynn, 2002
INCLUSION RULES
Duration of symptoms less than 16 days
FABQW less than 19
Hip IR is greater than 35 ̊ in one leg
Hypomobility of P/A lumbar mobility
No pain below the knee
[not for discogenic pts or pts with hip
problems]
TREATMENT/RESULTS
Use the Chicago roll1
Patients with 4 out of 5 of these criteria had a
95% chance of responding favorably to the LS
regional manipulation
Validated by Childs2 and Cleland 3
CPR: Stabilization
Hicks, 2005
Under 41 years of age
Aberrant motions are present
SLR of more than 91 ̊
(+) prone instability test
If 3 out of 4 of these variables were present,
there is a 67% chance of success using
stabilization (Jull)
O’Sullivan4
Koumantakis5
Hides6
81
CPR: Thoracic Manipulation
for Neck Pain
Cleland, 2007
SI pathology
Laslett, 2003
Cervical Radiculopathy
Wainner, 2003
Symptoms for less than 30 days
No symptoms distal to the shoulder
No pain with cervical BB
FABQPA less than 12 (activity section)
Less than 30 ̊ of cervical extension
Diminished T3-T5 kyphosis
Combination of 3 (+) SI provocation tests
with no centralization or
peripheralization with repetitive
extension is indicative of pain coming
from SI joint
(+) ULTT
Cervical rotation is less than 60 ̊towards
side of pain
Distraction relieves symptoms
(+) Spurling’s test A: SB/ext towards
painful side hurts because it closes down
the lateral foramen
3 out of 6 variables present leads to 86%
probability of success with thoracic
manipulation (P/A)
Jull7
Difabio8
87% specificity
91% sensitivity
26. CHICAGO ROLL (lumbar spine regional manipulation):

Regional manipulation used for lumbar spine and SI joint

Treat the more painful side (L); looking for audible pops

Pt sidebends towards the painful side (L) and rotates away (R)

Impart a thrust through the ASIS
27. CHILDS: validated the lumbo-sacral CPR manipulation and inclusion criteria

Patients that were (+) for the CPR had a 92% change of successful outcomes based on Oswestry scores within 1-2 treatments,
using the lumbar spine regional manipulation
28. CLELAND: (2006) conducted a pilot study in JOSPT using lumbar rotation in side-lying (lumbar roll) to successfully treat patients who fit into
the CPR established by Flynn
29. O’SULLIVAN: (1997) reported that patients with spondylolysis or spondylolithesis experienced significant reductions of pain intensity and
Oswestry scores 30 months after a 10 week program of ab stabilization and education regarding use of ab stabilization during activity
30. KOUMANTAKIS: (2005) Patients with recurrent subacute or chronic LBP without signs of instability, responded just as well to general trunk
strengthening as a combo of general and specific exercise training
31. HIDES: (1996) multifidus is inhibited with LBP and does not recover spontaneously, but it can be restored with strengthening and
stabilization exercises
32. JULL (2002) Patients with cervogenic headache responded well to a regimen of manipulative therapy and exercise utilizing a pressure
biofeedback unit
33. DIFABIO (1999): at this time there is no evidence to suggest that thrust manipulation in the cervical spine is any better than the non-thrust
methods, so why take the risk?

Research is helpful in clinical practice but it captures a small % of our patients

Continue to use the impairment based approach and clinical reasoning, applying the evidence when applicable
82

Continuously re-evaluate the effect of interventions on motion and function; will guide future intervention based on patient response; goal
of restoring full pain free ROM and function
JULL: CRANIO-CERVICAL FLEXION TEST
CERVICAL SPINE
PURPOSE:

Provides mobility; most flexible region of the spine with 3-D movements

Provides mechanical segmental stability

Carries the load of the head

Provides stability for UE function

20% of stability comes from ligaments; 80% from muscles
The muscles/joints of the cervical spine are intimately related to the reflex system:
1.
Proprioceptive system: postural awareness and postural stability
2.
Vestibular interaction/balance strategies
3.
Eye-head coordination
4.
Head position awareness
-
There is a normal coordinated response between the mechanical, kinetic, and reflex demands of the neck
-
The oblique capitus inferior (242) and superior (190) have hundreds of muscle spindles per gram of muscle tissue, used for
proprioceptive input
-
Upper cervical facet joints C0, C1, C2 have the greatest density of mechanoreceptors
-
Impairments to the muscle system can cause pain, dizziness, or balance disorders due to the relationship with the reflex systems
Muscle System Response to Impairments: ROM deficits, especially in rotation and FB; deficits in strength and endurance of mm esp. neck flexors
and extensors; muscle fatigue; fatty infiltrates and atrophy

Superficial neck muscles without deep muscle activity results in buckling and unstable segments

Deep muscle activity stiffens spinal segments

Neck extensor muscles functions: mobility, proprioception, support, stability (multifidus and suboccipital mm)
o

Impairments in neck extensors affect the multifidus and suboccipital mm
Deep neck flexor function: mobility; proprioception; support and stability (longus capitis, longus coli, rectus capitus anterior and lateralis)
JULL STUDY

First study to use EMG to measure the contraction of the longus capitus and coli

When these muscles contract, the cervical lordosis flattens out

She found significant inferior performance on C-CFT in pts with whiplash, cerviogenic headaches, and idiopathic neck pain
o
These pts had increased activity of the superficial muscles such as the SCM and anterior scalene
83
o

It took these pts more mm activity to create the same amount of force on an EMG, and with comparable amounts of
electrical activity, less force was produced

Increased activation of the superficial muscles may be a functional substitute for inadequate support by the deep
neck flexors
Although a decrease in muscle control may be initiated due to pain/injury, it sustains past acute pain and may contribute to
chronic pain.
EVIDENCE BASED IMPAIRMENTS
o
Cervical AROM deficits
o
Muscular system involvement
o


Cervical muscle function does not spontaneously recover with the reduction of pain
o

Impaired neuromuscular efficiency (NME) is demonstrated by an over-activity of the superficial mm in people with chronic neck
pain

Lack of activation of deep cranio-cervical flexors

Altered muscle contraction patterns of the cervical spine and shoulder girdle

Decreased neuromuscular efficiency

Decreased endurance/fatigue

Decreased strength
Postural control deficits

Lack of kinesthetic sense

Altered balance receptors

Altered eye-head coordination
THERAPEUTIC INTERVENTIONS
o
Activate the deep cranio-cervical flexors via low load exercise
o
Endurance training to cranio-cervical flexors and shoulder girdle mm
o
Co-contraction exercises for stabilization (cervical flexors/extensors)
o
Kinesthetic sense, balance strategy, eye-head coordination training
o
Re-train movement patterns for cervical spine muscle control
o
Task specificity
CRANIO-CERVICAL FLEXION TEST (C-CFT): A test that tests the pattern of activity in the deep and superficial neck flexor muscles in a staged
performance of increasing range of CC flexion.

Purpose of C-CFT: muscle activation patterns; proprioception sense; test mm endurance/strength
o

Test neural tension, joint mobility (PIVM) and muscle length before CCFT
PROCEDURE:
84
o
Put pt supine, in hook-lying position with towel under occiput to maintain neutral
o
Place the folded, non-inflated cuff under the upper cervical spine (C0, C1, C2)
o
Inflate cuff to 20 mmHg for baseline measurement and have pt nod down to 22 mmHg
o
Analyze the patient’s movement, train them for proper movement, and then test strength/endurance of deep flexors

o

Look for slow, controlled movement; relaxed global muscles; have pt perform flexion, not retraction; exercise should
be pain-free
Testing: Pt should be able to hold 22 mmHg for 10 seconds, 10 times

If they can, progress to the next level 24 mmHg, 26,  30 mmHg as the goal

For each level they should do 10 sec x10 reps

Normal pt should reach 26-28 mmHg; symptomatic will be between 20-26 mmHg
Can also employ scapular stabilization (serratus, mulifidus, rows) training, postural re-ed, balance training, eye gazing, stretching
LUMBAR STABILIZATION TRAINING: used to train the TA muscles for endurance/spinal stability

TA does not produce movement; it only compresses the abdominal cavity and creates stabilization

First step is to train pt how to fire TA; have pt lie supine and pull belly button in while breathing and maintaining still pelvis
o

Cuff should stay at 40 mmHg supine, or 70 mmHg prone
4 levels of progression, all with TA fired to induce abdominal bracing:
1.
Level 1: abdominal bracing; pelvic tilt; heel-slides; hip flexion; single leg lift; isometric counter rotations
2.
Level 2: prone multifidus isometric; prone multifidus hip extension; bridging; unilateral bridging; lateral bridging
-
Make sure core and gluts are tight; prevent lordosis
3.
Level 3: quadruped abdominal bracing; quad pelvic tilt (cat-cow); quad shoulder flexion; quad hip extension; plank
4.
Level 4: pelvic tilt on ball; hip flexion on ball; knee extension on ball; static balance
-
Can use hands, no hands, eyes closed
85