1
Q
of vertebrae lumbar spine
A
5
2
Q
how do lumbar vertebrae differ
A
larger size
absence of costal facets
*Designed for load bearing upon the VB (anterior elements)
3
Q
Why may there be less / more lumbar vertebrae?
A
L5 can sacralize/ fuse with S1
can have an extra vertebrae
4
Q
Spinous Process of Lumbar Vertebrae
–shape
–orientation
–its job
A
large and rectangular
have bulbous tip
almost horizontal
extended posteriorly
provide attachment for fascia, muscles and ligaments
5
Q
What is key characteristic of a lumbar vertebrae:
- SP
- why important
A
wide and rectangular spinous processes:
important because of attachments of muscles, fascia, ligaments, WB, maintain lordosis
6
Q
What facet orientation would favor flexion /extension physiological movements?
A
sagittal plane
we would not be able to do rotation as easily, as rotate open facets on side to which we rotate
7
Q
Which ligament resists flexion of the lumbar spine?
A
PLL:
restrict flexion
(longest lever arm to resist flexion is the interspinous—skinny but longer lever arm than the supraspinous even though supraspinous is wider)
8
Q
What ligament goes slack as go into flexion?
A
ALL
9
Q
What segments will not add much to lumbar rotation and why?
A
orientation changes and L5 on S1 is more of a frontal plane,
L4-L5-S1 orientation-we have the lumbosacral ligaments to help support the area
10
Q
Peripheral annular bulge?
A
NR damage minimal because not pinching nerves
11
Q
Bony Architecture of the lumbar Spine
- # vertebra
- Differ because of their l____
- designed for load-bearing upon ____
- ___ can sacralize
- can have extra vertebrae
A
- Five vertebra
- Differ because of their larger size and absence of the costal facets
- designed for load-bearing upon the vertebral bodies (anterior elements)
- L5 can sacralize: fuse with S1
- can have extra vertebrae
12
Q
Lumbar Spinous processes
- Size and shape
- Orientation
- Role
A
- Large and rectangular, Have bulbous tip
- Extended posteriorly, Almost horizontal
- Provide attachment for fascia, muscles, and ligaments
13
Q
Lumbar TP
- Shape
- which one is the longest
- Which way does L1-L4 face?
- Which way does L5 face?
- what type of accessory process?
A
- Long and thin except for L5
- L3 is the longest (generally)
- L1-L4 pass laterally and backwards
- L5 passes laterally and then upwards and slightly backwards
- Small tough accessory process
14
Q
Lumbar TP:
Which one is not long and thin?
A
L5
15
Q
Lumbar TP:
Which one is longest?
A
L3
16
Q
Lumbar TP:
which way does L1-L4 pass?
A
LATERALLY and BACKWARDS
17
Q
Lumbar TP:
Which way does L5 face?
A
passes LATERALLY, then UPWARDS, then slightly BACKWARDS
18
Q
Lumbar TP
What type of accessory process?
A
small and tough
19
Q
Lumbar Articular Process
What type of joint?
what cartilage?
how many processes?
A
- DIARTHRODIAL JOINT with synovial membrane and capsule
- Joint surfaces are covered with hyaline cartilage
- Superior articular processes
- Inferior Articular processes
20
Q
Lumbar Articular Process
What is on the joint surfaces?
A
Hyaline Cartilage
21
Q
Lumbar Articular Process
What type of joint?
A
DIARTHRODIAL JOINT with synovial membrane and capsule
22
Q
The facet is a synovial joint and so it will have synovial lining, it is all encased around hylaine cartilage and then encased in the capsule.
sometimes that can fray or desiccate a little and get put into the joint interspace and cause abnormal mechanics so you may not have a movement issue or may due to pain.
may find hypomobility in stiff spine or hypermobility in lax spine.
if have a surgical see what messes up the mechanics of the joint and how to improve them.
A
The facet is a synovial joint and so it will have synovial lining, it is all encased around hylaine cartilage and then encased in the capsule.
sometimes that can fray or desiccate a little and get put into the joint interspace and cause abnormal mechanics so you may not have a movement issue or may due to pain.
may find hypomobility in stiff spine or hypermobility in lax spine.
if have a surgical see what messes up the mechanics of the joint and how to improve them.
23
Q
What happens if the facet joints are loaded more than the VB?
A
If facet joints loaded more than VB we need to restore lumbar lordosis to redistribute the weight to the VB
24
Q
What happens if ligamentum flavum becomes lax?
A
Ligamentum Flavum is more posterior and is elastic but overtime can become lax and fold into the spinal canal and cause compromise of the spinal canal
— degeneration of discs or facets can cause it to lose elasticity, can get into spinal canal and can cause NR dysfunction
25
Superior Articular Processes
1. Concave or convex?
2. Orientation:
3. Mammillary process
1. Slightly concave
2. Face medially and posteriorly
3. Posterior border has rough elevation called the mammillary process
26
Is superior Articular Process concave or convex?
slightly concave
27
orientation of superior articular process?
MEDIALLY and POSTERIORLY
28
Which articular process has the mamillary process? What is it?
Superior articular process
it is a rough elevation on the posterior border
29
Inferior Articular Process
1. Concave or convex?
2. Orientation:
1. Slightly Convex
| 2. Face laterally and anteriorly
30
Articular facets are reciprocally ____ superiorly and _____ inferiorly
Articular facets are reciprocally concave superiorly and convex inferiorly
31
Is inferior Articular Process concave or convex?
Convex
32
Orientation of inferior articular process?
LATERALLY and ANTERIORLY
33
Facet Joints: how does alignment change at lumbosacral joints?
Change from SAGITTAL orientation to more CORONAL (frontal) orientation at the lumbosacral joints
34
Lumbar: Vertebral body:
shape and size
is it wider or deeper
is it broader or higher
1. Large
2. Kidney shaped
3. Wider than deep
4. Broader than high
35
Shape of vertebral canal
shape of equilateral triangle
Larger than thoracic spine
Smaller than cervical spine
36
Where is the vertebral canal largest/smallest?
Thoracic --> Lumbar -->Cervical (largest)
37
Discs make up about ___% of total length of vertebral column
Discs make up about 20-25% of total length of vertebral column
38
Function of the IV Disc (3)
1. Binds together vertebral bodies
2. Permits movement within segment
3. Transmits loads from one vertebral body to the next
39
Disc Material: fluid nucleous propulsus
as sidebend to the right: where will pressure change be greater?
change of pressure will be greater to the left,
40
Disc Material: fluid nucleous propulsus
As go into flexion: where will pressure change be greater?
As go into flexion the change in pressure will be more posterior
41
Disc Material: fluid nucleous propulsus
As go into extension: where will pressure change be greater?
As go into extension he change in pressure will be more anterior
42
Disc Material: fluid nucleous propulsus
Rotation
With rotation get more compressive affect due to annulus criss cross fibers
43
Disc Material: fluid nucleous propulsus
as sidebend to the left: where will pressure change be greater?
change of pressure will be greater to the right
44
Role of ligaments (3)
1. Principle role is to prevent excessive movement
2. Principal tensile load bearing elements
3. Provide information about posture and movement
45
Which ligament has the longest lever arm?
longest lever arm is the:
SUPRASPINOUS LIGAMENT
then the interspinous
and then the PLL
46
Vertebral Motion (2)
1. The motion segment: two adjacent vertebrae and their intervening disc and associated ligaments
2. In normal motion segment: these three parts are anatomically linked and mechanically balanced
47
What is a motion segment for vertebrae? (3)
TWO adjacent VERTEBRAE and their intervening DISC and associated LIGAMENTS
In normal motion segment: these three parts are anatomically linked and mechanically balanced
48
Significance of TWO adjacent VERTEBRAE and their intervening DISC and associated LIGAMENTS
Motion segment
In normal motion segment: these three parts are anatomically linked and mechanically balanced
49
Motion Segment : what may occur with age?
With age, degeneration may affect motion segment
with age more difficulty ie excursion of bone in VB or facet or IV foramen can mess up mechanics as well—get a sense of whether there will be a movement issue involved —not changing the bony change but can relieve the stresses
50
Motion segment: how is motion named?
Motion is named by direction of SUPERIOR vertebrae
51
What can occur if there is dysfunction in one part of segment?
Dysfunction in one part of segment may lead to dysfunction elsewhere
52
Flexion: Forward Bending
1) How do the facets glide?
2) Is it roll/glide?
3) what occurs at the facet joint?
4) which ligaments on slack?
5) which ligaments on stretch?
6) where does the nuclear material go?
1. Inferior facet of superior vertebrae glides anteriorly and superiorly (upwardly) over superior facet of inferior vertebrae
2. Combination of anterior roll and anterior glide of superior vertebral body
3. creates an opening at facet joint as inferior facet of superior vertebrae moves superiorly
4. Slack: ALL
5. Stretch:
(1) PLL
(2) Ligamentum Flavum
(3) Interspinous Ligament
(4) Supraspinous Ligament
6. Nuclear material shifts posteriorly (pressure changes)
53
Flexion: Forward Bending
How do the facets glide?
Inferior facet of superior vertebrae glides anteriorly and superiorly (upwardly) over superior facet of inferior vertebrae
54
Flexion: Forward Bending
Is it roll/glide?
Combination of anterior roll and anterior glide of superior vertebral body
55
Flexion: Forward Bending
what occurs at the facet joint?
creates an opening at facet joint as inferior facet of superior vertebrae moves superiorly
56
Flexion: Forward Bending
which ligaments on slack?
Slack: ALL
57
Flexion: Forward Bending
which ligaments on stretch?
Stretch:
(1) PLL
(2) Ligamentum Flavum
(3) Interspinous Ligament
(4) Supraspinous Ligament
58
Flexion: Forward Bending
where does the nuclear material go?
Nuclear material shifts posteriorly (pressure changes)
59
Extension: Backwards bending
1. How do facets glide?
2. What happens at the facet? (open/close)
3. Creates
a) Slack:
b) Stretch:
4. Nuclear material shifts where?
1. Inferior facet of superior vertebrae glides inferiorly and posteriorly upon superior facet of inferior vertebrae
2. Creates “closing” at facet joint
3. Creates
Slack:
(1) PLL
(2) Ligamentum Flavum
Stretch:
(1) ALL
4. Nuclear material shifts anteriorly
60
Extension: Backwards bending
How do facets glide?
Inferior facet of superior vertebrae glides inferiorly and posteriorly upon superior facet of inferior vertebrae
61
Extension: Backwards bending
What happens at the facet? (open/close)
Creates “closing” at facet joint
62
Extension: Backwards bending
which ligaments on slack?
(1) PLL
| (2) Ligamentum Flavum
63
Extension: Backwards bending
which ligaments on stretch?
(1) ALL
64
Extension: Backwards bending
Where does the nuclear material shift?
Nuclear material shifts anteriorly
65
Sidebending:
1. what motion is coupled with sidebending?
2. What opens? Explain the slide
3. What closes? Explain the slide
4. Where does right side bending cause closing and opening?
5. Which side approximates?
6. Where is nuclear material displaced?
7. Which ligaments are stretched?
1. Coupled with rotation
2. Inferior facet of superior vertebrae slides upward on contralateral side causing “opening”
3. Inferior facet of superior vertebrae slides downward on ipsilateral side causing “closing”
4. Example: RSB causes closing, right facet pair and opening left facet pair
5. Interspace on ipsilateral side approximate
6. Nuclear material displaced toward contralateral side
7. Contralateral ligamentum flavum and Intertransverse Ligament are stretched
66
Sidebending:
what motion is coupled with sidebending?
Coupled with rotation
67
Sidebending:
What opens? Explain the slide:
Contralateral side opens
Inferior facet of superior vertebrae slides upward on contralateral side causing “opening”
68
Sidebending:
What closes? Explain the slide
Ipsilateral side closes
Inferior facet of superior vertebrae slides downward on ipsilateral side causing “closing”
69
Sidebending:
Where does right side bending cause closing and opening?
RSB:
causes closing, right facet pair
opening left facet pair
70
Sidebending:
Which side approximates?
Interspace on ipsilateral side approximate
71
Sidebending:
Where is nuclear material displaced?
Nuclear material displaced toward contralateral side
72
Sidebending:
Which ligaments are stretched? (2)
Contralateral
1. ligamentum flavum
2. Inter-transverse Ligament
73
Rotation
1. What slides in the vertebrae?
2. What limits ROM?
3. Is direction of rotation named according to upper or lower vertebrae?
4. Is rotation named according to VB or SP?
5. with what motion is rotation coupled?
6. Where is the gap? Compression?
1. Occurs when upper vertebrae slides over lower vertebrae
2. Shearing forces limit ROM
3. Direction of rotation is named according to upper vertebrae moving on lower vertebra
4. Named according to the direction of the body and not the spinous process
5. Coupled with Side-bending
6. Rotation causes a gap on the ipsilateral facet joint and compression on the contra-lateral facet joint
74
Rotation
What slides in the vertebrae?
Occurs when upper vertebrae slides over lower vertebrae
75
Rotation
What limits ROM?
Shearing forces limit ROM
76
Rotation
Is direction of rotation named according to upper or lower vertebrae?
Direction of rotation is named according to upper vertebrae moving on lower vertebra
77
Rotation
Is rotation named according to VB or SP?
Named according to the direction of the body and not the spinous process
78
Rotation
With what motion is rotation coupled?
Coupled with Side-bending
79
Rotation
Where is the gap? Compression?
Rotation causes a gap on the ipsilateral facet joint and compression on the contra-lateral facet joint
80
Right rotation of the superior vertebrae separates_______
Example: right rotation of the superior vertebrae separates its INFERIOR FACET from the SUPERIOR FACET of the inferior vertebrae
81
If VB turns right, where does SP turn?
Vertebral Body turns right and spinous process turns left
82
Does the disc move when the vertebrae move?
**disc not necessarily moving around because encapsulated by annulus but pressures are changing.
If there is damage to the annulus then the disc material can start to work its way out to the periphery.**
83
Combined Movements
normal to see with side bending and rotation.
but we do not expect to see in flexion and extension.
84
Coupled motion
1. where it occurs
2. is it the same throughout the lumbar spine?
a) Occurs throughout the entire spine
b) Lumbar spine—coupling varies with the level and position
c) Many opinions about the direction of coupling: ipsilateral or contralateral side (see next slide)
85
Non-coupled motion:
if person is flexing and also side bending we would need to explore this abnormality
86
Coupled Movements:
what is it?
one that gives the most ease and most ROM, soft end feel (due to configuration of the facet joints)
1. Movement combinations that result in most ease
2. Results in greatest ROM and softest end feel
3. involve one motion being accompanied by another
4. occurs due to configuration of zygopophyseal joint
87
What causes coupled motion to occur?
occurs due to configuration of zygopophyseal joint
88
What type of motion results in greatest ROM and softest end feel?
Coupled Movements:
89
What is neutral in Fryette's Law?
Neutral refers to any position where facet joints are not engaged (idling) and ligaments and capsules are not under tension
90
Fryette’s First Law: Neutral Mechanics or Type I Mechanics:
(1) assume normal standing posture with normal A/P curves
(2) When any part of the lumbar or thoracic spine is in NEUTRAL position:
SIDE-BENDING of a vertebra will be OPPOSITE to the side of the ROTATION of that vertebrae
--sidebend to the right with neutral spine lumbar: rotation will occur to the left
91
Which law: When any part of the lumbar or thoracic spine is in neutral position: sidebending of a vertebra will be opposite to the side of the rotation of that vertebrae
Fryette’s First Law: Neutral Mechanics or Type I Mechanics:
92
Fryette’s Second Law: Non-Neutral Mechanics or Type II Mechanics:
(1) Facets are ENGAGED (not idle) and ligaments are under tension due to physiological motion that has occurred
(2) SIDE-BENDING and ROTATION occur to the SAME SIDE!
(a) ie if flexed spine, and side bend: the rotation will go to the same side
(3) May be at more risk to injury when non-neutral mechanics are present
93
Fryette’s First Law: Neutral Mechanics or Type I Mechanics:
Neutral spine
SIDE-BENDING of a vertebra will be OPPOSITE to the side of the ROTATION of that vertebrae
94
Fryette’s Second Law: Non-Neutral Mechanics or Type II Mechanics:
Engaged facets (ligaments under tension)
SIDE-BENDING and ROTATION occur to the SAME SIDE!
95
Which mechanics put at most risk of injury?
May be at more risk to injury when non-neutral mechanics are present
96
Which law
Facets are ENGAGED (not idle) and ligaments are under tension due to physiological motion that has occurred
SIDE-BENDING and ROTATION occur to the SAME SIDE!
Fryette’s Second Law: Non-Neutral Mechanics or Type II Mechanics:
97
Which law ie if flexed spine, and side bend: the rotation will go to the same side
Fryette’s Second Law: Non-Neutral Mechanics or Type II Mechanics:
98
Which law -sidebend to the right with neutral spine lumbar: rotation will occur to the left
Fryette’s First Law: Neutral Mechanics or Type I Mechanics:
99
Fryette’s Third Law: Type III Mechanics
(1) If motion in one plane is introduced to the spine, motion in the other two planes is thereby restricted
----if i move a segment, any part of the spine, i will be limiting movements at other parts of the spine because it is so interconnected: if head is rotated to the left you can feel it in the lumbar spine
----segment to segment it is restricted as well, if you take up slack then less slack is available
100
Which law
If motion in one plane is introduced to the spine, motion in the other two planes is thereby restricted
Fryette’s Third Law: Type III Mechanics
101
Which law
if i move a segment, any part of the spine, i will be limiting movements at other parts of the spine because it is so interconnected: if head is rotated to the left you can feel it in the lumbar spine
Fryette’s Third Law: Type III Mechanics
102
What type of motion is fryettes laws related to?
physiological
103
In flexion and extension: what coupling?
Fryette
Katlenborn
Greenman
Fryette: in flexion and extension: coupling occurs to the same side
Katlenborn:
a) in Flexion: sidebending and rotation to the same side
b) but in extension: sidebending and rotation to the opposite side
Greenman: it depends on what part of the curve you are looking at
a) Coupling varies, dependent upon A/P curves (most relevant in thoracic spine)
b) Follows Fryette’s Law for the Lumbar Spine: flexion and extension: coupling occurs to the same side
104
Coupling: flexion/extension
Fryette
in flexion and extension: coupling occurs to the same side
105
Coupling: flexion/extension
Katlenborn
FLEXION: sidebending and rotation to the same side
EXTENSION: sidebending and rotation to the opposite side
106
Coupling: flexion/extension
Greenman
Greenman: it depends on what part of the curve you are looking at
a) Coupling varies, dependent upon A/P curves (most relevant in thoracic spine)
b) Follows Fryette’s Law for the LUMBAR SPINE: flexion and extension: coupling occurs to the same side
107
Who agrees with Fryette for Flexion/Extension in the lumbar spine?
Katlenborn only agrees that in FLEXION that sidebending and rotation occur to the same side
Greenman
- Follows Fryette’s Law for the LUMBAR SPINE:
- flexion and extension: coupling occurs to the same side
108
Who is different in their coupling rule for extension?
Katlenborn
FLEXION: sidebending and rotation to the same side
EXTENSION: sidebending and rotation to the opposite side
109
Non-Coupled Movements :
[go against normal mechanics—dont go as far, don't want to stay there-but a patient may have a facet or disc issue and be stuck in that and so have pain]
1. Movement combination that result in decreased or absent ease
- For example: stand in neutral alignment by sidebend and rotate to the same side / or flex lumbar spine and sidebend and rotate to opposite sides
3. Non coupled movements: results in least ROM and hardest end feel
4. Patients may be moving in non-coulee way as a result of pathology
110
Movement combination that result in decreased or absent ease
Non-coupled movements
111
Which types of movements result in least ROM and hardest end feel?
Non coupled movements: results in least ROM and hardest end feel
112
Stand in neutral alignment, Sidebend and Rotate to the same side actively:
noncoupled movement
113
Flex the lumbar spine and try to sidebend and rotate to the opposite side actively
noncoupled movement
114
Why might a patient be moving in a non-coupled way?
Due to a pathology
115
Disease States that affect the spine (8)
1. Ankylosing Spondylitis
2. Osteoarthritis
3. Paget’s Disease
4. Osteoporosis
5. Spondylosis
6. Scoliosis
7. Laminectomy/ Fusion / Chemonucleolysis
8. Degenerative Disc Disease
116
Structural changes in the spine (3)
1. Spinal Stenosis
2. Spondylolysis
3. Spondylolisthesis
117
Pathomechanics in spine (3)
1. Fracture
2. Narrowing of IV Foramen
--multiple causes
(degeneration, bone excursions blocking nerve exits)
3. Issues with Facet or IV Disc
118
Causes of fracture in spine (3)
a) Trauma
b) Osteoporosis
c) Fractures secondary to other conditions
119
1. Please review notes about pathologies and fractures of the spine from HSS course
2. Review for spine assessment
a) MMT
b) Goniometry
1. Please review notes about pathologies and fractures of the spine from HSS course
2. Review for spine assessment
a) MMT
b) Goniometry
120
What does bio-psychosocial analysis of LBP: Waddell address?
1. Addresses common, non-specific back pain
[injury causes fear to move leads to cascade: fear avoidance with non-specific back pain: ie had a fall and land on butt and have LBP, initially it will hurt and have muscle spasm and protective of movements and avoidance, get immobilization and disuse, causes muscle weakness joint stiffness and loss of cardiovascular fitness, leads to atrophy loss of coordination and musculoskeletal dysfunction]
121
Explain the cascade
Pain/Injury causes
fear to move leads to cascade:
fear avoidance with non-specific back pain: ie had a fall and land on butt and have LBP,
initially it will hurt and have muscle spasm and protective of movements and avoidance,
get immobilization and disuse,
causes muscle weakness joint stiffness and loss of cardiovascular fitness,
leads to atrophy loss of coordination and musculoskeletal dysfunction (physiological impairment)
122
Fear Avoidance Beliefs Questionnaire: FABQ
a) Does patient believe that physical activity and work will affect LBP?
b) Does this fear lead to avoidance of activities?
Waddell: musculoskeletal dysfunction has certain sx, we attend to the sx and label them and are influenced by how we were treated when we were young/how we are being treated to how magnified the pain is
123
8 Physical Findings Discriminate Patients with LBP from Normal Subjects (8)
Pt with LBP will have limitation in one or more of these clinical tests
Treat the cause: Acute disability proportional to number of objective clinical findings
Treat by disrupting the cycle: with chronic pain, disability is disproportional to the physical findings and it is self-sustaining
1. spinal tenderness
2. sit up
3. Pelvic Flexion
4. Total flexion
5. Total extension
6. Lateral flexion
7. SLR
8. Bilateral active SLR
124
Wedell
how to interpret 8 Physical Findings Discriminate Patients with LBP from Normal Subjects
Wedell says that patients with LBP with true organic cause, one or more of these tests will be positive.
If they have a lot of the tests being positive or pain is out of proportion for clinical findings then think about a biopsychosocial aspect to the pain.
1. spinal tenderness
2. sit up
3. Pelvic Flexion
4. Total flexion
5. Total extension
6. Lateral flexion
7. SLR
8. Bilateral active SLR
125
Wedell-we think malingerer, what do we do
Do not just say they are a malingerer, think about what the trigger is to get through that barrier (ie social influence at home, anger about accident, loss of work, may need to get a psychologist or social worker on the case) —we identify more than treat a psychological issue
with a malingerer we try to figure it out and get them to a higher level
126
Wedell: when do we treat cause/when do we disrupt the cycle?
Treat the cause: Acute disability proportional to number of objective clinical findings
Treat by disrupting the cycle: with chronic pain, disability is disproportional to the physical findings and it is self-sustaining
127
Wedell acute disability
Patients with true LBP will have limitations in one or more of these clinical tests. Acute disability will be proportional to the number of objective clinical findings-treat the cause
128
Wedell chronic pain
With chronic pain the disability is disproportional to the physical findings and is self-sustaining-treat by disrupting the cycle
129
Clinical Prediction Rule and Spinal Manipulation
Which variables for spinal manipulation to work?
4/5 variables spinal manipulation likely to work
(1) symtoms DURATION
(2) FEAR AVOIDANCE beliefs
(3) lumbar HYPOMOBILITY
(4) HIP IR ROM
(5) NO SYMPTOMS DISTAL to the knee
130
Sources of Pain from Facets:
1. OVERLOAD of BONY TRABECULAE
(stand in lordosis, support with a lot of extension)
2. Joint INFLAMMATION and HYPERTROPHY
3. MICROFRACTURE
4. DYSFUNCTION
5. VASCULAR disturbance of bone or soft tissue (nourishments of facets/disc)
6. DEGENERATIVE process
- ----Degenerative Joint Disease
- ----Meniscoid synovial folds (get in the way)
- ----Normal adaptation to stress
- ----Subluxation (slipping of one facet on the other, can be accompanied by loss of disc height or loss of the movement get stuck in a particular position)
131
Pain from Facets
DEGENERATIVE process (4)
1-----Degenerative Joint Disease
2-----Meniscoid synovial folds (get in the way)
3-----Normal adaptation to stress
4-----Subluxation (slipping of one facet on the other, can be accompanied by loss of disc height or loss of the movement get stuck in a particular position)
132
Why is pain hard to localize when
Innervation to disc, medial aspect of posterior ramus innervations structures as well as the sinovertebral nerve innervating the disc
Innervation to disc, medial aspect of posterior ramus innervations structures as well as the sinovertebral nerve innervating the disc—this pain is diffuse and hard to localize because fibers run up a level or down a level—hard to say pain is in one spot
133
Facet Joint Dysfunction:
Dysfunctional position of facets
---facets can become maligned and create abnormal stress on tissues (capsule, ligament, disc) and abnormal mechanics of motion
Premise of treatment - re-align facets to restore normal mechanics
134
How is a facet joint dysfunction named?
Name by the direction they cannot complete or the one which is symptomatic
eg flexion dysfunction: cannot complete flexion without discomfort or abnormal movement pattern
named by the movement the patient cannot do: if pain with extension it is an extension dysfunction
We need to restore L2 on L3 into flexion or into extension for our mobilizations: realign the facets and make it a more stable system to decrease the stress to decrease the sx
135
Premise of treatment in facet joint dysfunction
re-align facets to restore normal mechanics
136
Facet Joint Instability:
Instability: hypermobility of motion segment
Premise of treatment: restore balance of the motion segment, teach stabilization techniques
—make sure alignment is proper and then go to stabilization exercises
137
Premise of treatment for facet joint instability
restore balance of the motion segment, teach stabilization techniques
—make sure alignment is proper and then go to stabilization exercises
138
What are the three things in Macnabs classification?
1. Disc Protrusion
2. Disc Herniation or Prolapse
3. Intraspongy Nuclear Herniation (nuclear material goes up into the endplate)
139
Type 1 Disc Protrusion: Peripheral Annular Bulge
annulus fibrosis protrudes CIRCUMFERENTIALLY beyond the peripheral rims of the vertebral bodies but there is no serious nerve root compromise
NO serious NR compromise
140
Type 2 Disc Protrusion: Localized Annular Bulge
annulus fibrosis bulges and causes clinical signs-----usually UNILATERAL
Touches a nerve or messes up the mechanics enough to cause the patient some PAIN
141
Type 1: Prolapsed IV Disc:
Displaced material is confined to only a few strands of the annulus fibrosis
Disc is CONTAINED inside ANNULUS
142
Type 2: Extruded IV Disc
Displaced nucleus goes THROUGH ANNULUS annulus and PUSHES the PLL
comes through annulus and pushes into PLL
143
Type 3: Sequestered IV Disc
Extruded material LIES FREE IN THE SPINAL CANAL where it can:
(1) Remain trapped between the NR and the disc
(2) Migrates and lie behind the vertebral body in the NR
(3) Migrates to the IV foramen
(4) Migrates to midline, just anterior to the dural sac
144
Type 1 Disc Protrusion:
Peripheral Annular Bulge
annulus fibrosis protrudes CIRCUMFERENTIALLY beyond the peripheral rims of the vertebral bodies but there is no serious nerve root compromise
NO serious NR compromise
145
Type 2 Disc Protrusion:
Localized Annular Bulge
annulus fibrosis bulges and causes clinical signs-----usually UNILATERAL
Touches a nerve or messes up the mechanics enough to cause the patient some PAIN
146
Disc Herniation or Prolapse: Type 1
Type 1: Prolapsed IV Disc:
displaced material is confined to only a few strands of the annulus fibrosis
Disc is contained inside annulus
147
Disc Herniation or Prolapse: Type 2
Type 2: Extruded IV Disc
Displaced nucleus goes through annulus and pushes the PLL
comes through annulus and pushes into PLL
148
Disc Herniation or Prolapse: Type 3
Type 3: Sequestered IV Disc
Extruded material lies free in the spinal canal where it can:
(1) Remain trapped between the NR and the disc
(2) Migrates and lie behind the vertebral body in the NR
(3) Migrates to the IV foramen
(4) Migrates to midline, just anterior to the dural sac
149
What can a sequestered disc material do when it is free in the spinal canal? (4)
(1) Remain TRAPPED between the NR and the DISC
(2) Migrates and lie behind the VERTEBRAL BODY in the NR
(3) Migrates to the IV FORAMEN
(4) Migrates to midline, just ANTERIOR to the DURAL SAC
150
Intra-Spongy Nuclear Herniation:
Schmorl’s Nodes: herniation of the nucleus pulposus into the vertebral body
151
Schmorl’s Nodes:
herniation of the nucleus pulposus into the vertebral body
152
Premise of Treatment:
Protrusion:
manage current symptoms and prevent further degeneration (don't want to get prolapse)
153
Premise of Treatment:
Prolapse
centralize the nuclear material: many schools of thought
can do mechanical things to bring nuclear material back to the center location such as extension to fix posterior protrusion
154
Premise of Treatment:
Sequestration
encourage movements that don't cause sx, may need surgery based on MRI
155
General Management for disc herniation/prolapse
what should intervention design be based on
1. Design intervention based on signs and symptoms and known precautions
2. Manage the pain then the movement problem while respecting the pain and the physiological state of the tissues/person
156
Disc herniation/protrusion/prolapse: should pain or movement problem be managed first?
Manage the pain then the movement problem while respecting the pain and the physiological state of the tissues/person
157
Disc issue: Sources of Pain
LOCAL
difficult to localize: pain transmitting nerves innervate multiple levels
a) Disc
b) Facet
c) Ligament
d) Muscle
158
Disc issue: Sources of Pain
RADICULAR
Radiate from nerve-follow dermatomal pattern
a) Rule out local peripheral nerve involvement
b) Radicular vs Non Radicular Issue
c) Nerve Root vs Peripheral Nerve issues
159
Disc issue: Sources of Pain
REFERRED
from like-innervated structures
| especially thoracic spine and shoulder girdle area, or visceral refer to lumbo-pelvic region
160
TREATMENT Schools of Thought
1. Facet school:
2. Cyriax School:
3. McKenzie School:
4. Osteopathic Approach:
1. Facet school: treat the facet
2. Cyriax School: treat the disc primarily
3. McKenzie School: looks at disc and also movement dysfunction as well as postural syndromes—extension, disc, postural, true dysfunction, disc derangement
4. Osteopathic Approach: muscle energy techniques, mobilizations, manipulations to get the patient back into alignment
161
TREATMENT Schools of Thought
Facet school:
treat the DACET
162
TREATMENT Schools of Thought
Cyriax School:
treat the DISC primarily
163
TREATMENT Schools of Thought
McKenzie School:
looks at DISC and also MOVEMENT DYSFUNCTION as well as POSTURAL SYNDROMES—extension, disc, postural, true dysfunction, disc derangement
164
TREATMENT Schools of Thought
Osteopathic Approach:
muscle energy techniques,
mobilizations,
manipulations
to get the patient back into alignment
165
Neurodynamic Treatment: David Butler'
--what is the issue
NEUROLOGICAL component and dura is stuck and not GLIDING as it should
166
Functional Orthopaedics: IPA
--what is it
FUNCTIONAL MOVEMENT ASSESSMENT and assess whether normal and restore normal PHYSIOLOGY
167
Movement System Balance Theory, Movement System Impairment (Sahrmann)
--what is it
STRETCH tight structures, STRENGTHEN weak structures
Evaluate and treat to get back to total body better physiological state
168
Interventions Integrated with Primary Schools of Thought:
| 6
1. Neurodynamic Treatment: David Butler
2. Functional Orthopaedics: IPA
3. Movement System Balance Theory, Movement System Impairment (Sahrmann)
4. Back School
5. Spinal Stabilization
6. Traction
169
Treatment-Based Classification Groups for Acute LBP:
we can classify patients as to what treatment would make them better-certain signs and symptoms where a certain treatment is preferred over another treatment—research based
(4)
1. SPECIFIC EXERCISES
- -Extension syndrome
- -Flexion Syndrome
- -Lateral Shift Syndrome
2. MOBILIZATION
- -Lumbar
- -SI
3. Immobilization
- -Immobilization Syndrome
4. TRACTION
- -Traction Syndrome
- -Lateral Shift Syndrome
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Treatment-Based Classification Groups for Acute LBP:
SPECIFIC EXERCISES
- -Extension syndrome
- -Flexion Syndrome
- -Lateral Shift Syndrome
171
Treatment-Based Classification Groups for Acute LBP:
MOBILIZATION
- -Lumbar
| - -SI
172
Treatment-Based Classification Groups for Acute LBP:
Immobilization
--Immobilization Syndrome
173
Treatment-Based Classification Groups for Acute LBP:
TRACTION
- -Traction Syndrome
| - -Lateral Shift Syndrome
174
Movement System Balance Theory: Shirley Sahrmann
what is it?
Movement System Impairment Classification
175
Movement System Balance Theory: Shirley Sahrmann
What does this standardized examination include?
2. Standardized examination that includes test movements of low back and lower extremities
--Active movements looking for substitutions
--Flexibility tests for muscles related to posture
--Strength/coordination tests for postural control
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Movement System Balance Theory: Shirley Sahrmann
what are the 5 categories ?
5 Categories:
(1) Lumbar Flexion
(2) Lumbar Extension
(3) Lumbar Rotation
(4) Lumbar Rotation with Flexion
(5) Lumbar Rotation with Extension
[she categorizes lumbar pain based on MOVEMENT TENDENCIES- evaluate you during tasks,
- is there a bias i.e. a flexion bias
- this allows her to create a program to counteract those tendencies and strengthen and stretch as needed for normal movement pattern
- exercise based interventions: stabilization and stretching]
177
Movement System Balance Theory: Shirley Sahrmann
What is classification based on?
Classify based on consistent pattern
178
Movement System Balance Theory: Shirley Sahrmann
What is the goal?
Goal: alter MOVEMENT and POSTURE of patients that produce inordinate STRESS ON TISSUE CAUSING SYMPTOMS
179
Movement System Balance Theory: Shirley Sahrmann
1. which exercises are selected?
2. when is stabilization used?
3. what is done to tight structures?
Intervention via exercise
1) Select exercises by those movements which reduce LBP during clinical examination
2) Stabilization exercises as needed
3) Increase extensibility of tight structures that IMPEDE MOVEMENT in certain directions during clinical examination
180
Movement System Balance Theory: Shirley Sahrmann
how is patient education used?
Patient education about postures to avoid
181
Examination
SUBJECTIVE
1. Present History
2. Area: Location of symptoms
3. Onset
4. Nature: pain description: pain scales (numerical rating scale, mcgill pain scale)
- --note if there is a mismatch with findings
- --oswestery questionnaire
- -track patient as they go through therapy
5. Behavior: of symptoms
- --SIN: severity, irritability, and nature
6. Precipitating/alleviating factors
7. Effect of rest on symptoms
8. Particular questions related to
- --Type of mattress, pillow
- --Position of sleep
- -Effect of prolonged sitting
- -Effect of coughing or sneezing—intra-abdominal pressure relates to the intra-discal pressure
9. Refer to use of standardized indices and disability questionnaires to quantify and track patients perception of the problem
- --Oswestry Low Back Pain Questionnaire
- --Quebec Task Fore Questionnaire
10. Special Questions (look out for caudal equine syndrome)
- --Trouble with bowel or bladder
- --Numbness in groin area or down leg
- --Recent unexplained weight loss
- --Medications
11. General Health
12. Tests- x-rays, MRI, CT scan, bone scan
13. Past history
14. Social history
15. Family history
16. Level of activity (what is their sport, recurrent sport)
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Oswestry Low Back Pain Disability Questionnaire
onine: The Oswestry Disability Index (also known as the Oswestry Low Back Pain Disability Questionnaire) is an
extremely important tool that researchers and disability evaluators use to measure a patient's permanent
functional disability. The test is considered the ‘gold standard’ of low back functional outcome tools [1].
183
RA
24 hour clock
worse at night or worse with activity or constant throughout the day
184
arthritis
24 hour clock
in which case pain pattern will be stiff in morning better as day goes on and better with movement
185
ankylosis spondylitis
24 hour clock
When is it better?
186
facet issue
24 hour clock
certain activity or movement
187
disc issue
24 hour clock
certain activity or movement such as sitting in flexion pushes the disc back and causes pain)
188
ROM for left side bending provides what data?
willingness to move-and watch face, mechanics i.e. side bending and neutral spine rotation will be opposite but if rotation to same spine in neutral lumbar spine may have a non coupled movement, always ask where is the pain
189
posture : what to include in exam?
what should we be sure to include exam? ability to correct the posture and also the UE and LE flexibility tests because we can help her and lengthen hip flexors etc them if they are tight so that stresses are in the proper part of the spine and not the improper parts of the spine. posture is a teaching moment-give education on posture to patient-like overtime you get a text i want you to fix your posture
there is a yarmulke two inches above your head, keep it in there
bend at your hips
190
Why is SYSTEMS REVIEW so important?
REVIEW OF SYSTEMS: always remember that systemic or visceral disease can mimic musculoskeletal disorders.
Do a thorough review.
191
Purpose of Lower Quarter Screen?
Clear the Hip and SI Joints
Review last semester: muscle tests, reflexes, sensation, provocative testing hip, compression and distraction for SI joint.
192
Initial Observation:
| 6
1) Observe moment
2) Check gait
3) Observe body type
4) Observe posture
5) Facial Expressions (associated with movement and at rest)
6) Noticeable Deformities, atrophy or swelling
193
Structural Examination
a) Do a complete POSTURAL inspection : sitting, standing etc.
b) Observe patient from POSTERIOR, LATERAL, and ANTERIOR view
c) Check SYMMETRY of bony landmarks
194
Do a complete postural inspection : sitting, standing etc.
(1) what these postures do for their pain: typical and corrected
(2) postural inspection:
head orientation,
scapula and acromion for shoulder height levels, and inferior angles,
heights of pelvis both sides,
knee recurvatum flexion,
feet pronation supination turn in turn out,
look are segments rotated when look from above at birds eye view,
side curves cervical thoracic and lumbar,
lateral shift (something happening pt is trying to get away from vs a scoliosis where there is a compensation along the spine):
195
What would a lateral shift look like?
see the block of the scapula shifted over the block of the pelvis/body:
shifting without much of a compensation (in a scoliosis head and pelvis still aligned with compensation curves along the spine—the scoliotic curves have rotation and rib deformities)
196
Palpation
| 4
a) Condition of SKIN, subcutaneous tissue and MUSCLES
- -skin rolling
- -histamine reaction scratch test [can give a hint as to location of the problem]
b) Check SKIN for TENDERNESS, MOISTURE, TEXTURE, faun’s beard, cafe au lait spots
c) Check subcutaneous tissues for NODULES
d) Check muscles for TENDERNESS, TIGHTNESS, and MSUCLE SPASMS (trigger points)
197
**MUST: study the anatomy of the spine and the muscles
flexibility tests, reflexes,
**MUST: study the anatomy of the spine and the muscles '
flexibility tests, reflexes,
198
tenderness along inguinal ligament
may be a refer of LBP
199
Landmarks to find body of L4
Body of L4 level of Iliac Crests
--a superficial landmark is the SP is directly behind the body
body of L4 is big
--from here we can count up and count down: there will be an interspace, then a wide SP, then an interspace …note if the patient is flexed or extended the interspace will change
200
Landmarks to find SP of L5
Spinous Process of L5 is superior-medial to PSIS at 30 degree angle
---L5 is less rectangular and a little more pointy
201
Landmark to find T12 SP
T12: follow 12th rib and count down
T12 SP has less downward slope and more horizontal orientation
202
How to find number of Lumbar Vertebra:
1) Check by counting up and down
2) if discrepancy confirm with X-ray
3) Lumbarization of S1—results in 6th lumbar vertebra
4) Sacralization: L5 is fused to sacrum
203
How to get 6th lumbar vertebrae
Lumbarization of S1—results in 6th lumbar vertebra
204
How to get 4 lumbar vertebrae
Sacralization: L5 is fused to sacrum
205
Active Movement Testing
purpose (3)
1. quality of movement
2. willingness to move
3. quantity of movement
206
Quality of movement
(a) can be smooth and easygoing, can be that they swing around and then go into flexion due to structural barrier or may jutter a bit, may go down smoothly and then a bunch of segments go at once.
(b) If smooth movement then we apply the overpressure and see if it will provoke the systems
(c) since we are interested in lumbar spine the overpressure will be in the lower thoracic region
207
Quantity of movement
(a) Goniometry: note placement
(b) Bubble goniometer
(c) Measure hand to floor
(d) they make a cervical range of motion device
(e) must report it as an ARC OF MOTION AS A RANGE and not just a single number
(f) Documentation:
Movement Diagram
(1) Forward Bending:
(2) Side bend Left: all the way no pain
(3) back bend: a little bit and then pain
(4) Side bend Right: halfway and experienced pain
(5) Left rotation: where in the arc they have their limitations
(6) Right Rotation:
208
ACTIVE MOVEMENT TESTING
| 5 things
1. Active ROM
2. Overpressure
3. Sustained
4. Repetitive
5. Combined
209
What we look for in sustained AROM
Does this position bring pain back to a central position if it was radiating,
is it local, does it create more radiation i.e. if the disc is moved and it peripheralize the pain
if posterior lateral extrusion or protrusion then it may peripheralize ,
if it was peripheral pain and stay in the position may centralize the pain if an anterior protruded disc because it brings the disc more central—
McKenzie: pain centralize, prelipheralize, stay the same
210
What we look for in repetitive AROM
go to end range and come back away from it over and over and see what happens to the pain-did it get worse/better/peripheral/central/stay the same—it can help, it can make it worse
APPLICATION to McKenzie Examination, Sahrmann , Treatment Based Classification
- --what happens to the pain if you are repeating the task
- --McKenzie: understand if it is a postural syndrome, it is a dysfunction, a derangement
- --Sahrmann: if there is a lumbar flexion or extension bias
- --Treatment based classification: if repeated extension helps, if repeated flexion helps
- --McKenzie: flexion, extension, and side-glide in standing and lying
*side gliding in McKenzie instead of sidebending (stabilize thorax against wall and bring pelvis under thorax repeatedly and what happens to the symptoms)
211
Application of repetitive AROM to McKenzie Examination, Sahrmann:
APPLICATION to McKenzie Examination, Sahrmann , Treatment Based Classification
---what happens to the pain if you are repeating the task
- --McKenzie: understand if it is a postural syndrome, it is a dysfunction, a derangement
- --McKenzie: flexion, extension, and side-glide in standing and lying
- --Sahrmann: if there is a lumbar flexion or extension bias
- --Treatment based classification: if repeated extension helps, if repeated flexion helps
*side gliding in McKenzie instead of sidebending (stabilize thorax against wall and bring pelvis under thorax repeatedly and what happens to the symptoms)
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What we look for in combined AROM?
Application to Osteopathic Approach:
---what happens with combined movements
---put spine into MAXIMAL OPENING or CLOSING
ie close many lumbar segments physiological extension and sidebending to one side
and rotation away from that side for opening /
max closure with combined movement or the quadrant position and find out if it reproduces the pain may mean a facet issue and not a disc issue /
or some sort of a joint issue - can be systemic or localized problem
use combined movements to maximally open or close the intervertebral foramen
213
LUMBAR SPINE AROM
Flexion
0-40/60
214
LUMBAR SPINE AROM
Extension
0-20/35
215
LUMBAR SPINE AROM
Lateral Flexion
0-15/20
216
LUMBAR SPINE AROM
Rotation
0-15 (really it is 0-3/18)
217
Lumbar Spine Trend:
Flexion-Extension
.Lumbar --> cervical --> thoracic???
218
Lumbar Spine Trend:
Lateral Flexion
.?
219
Lumbar Spine Trend:
Rotation
cervical --> thoracic --> lumbar ?
Lumbar Spine – B(M) (backward)
so most limited in rotation
flexion/extension & side bending are most available
L5 is the exception
Lumbar Spine: 90 degrees in horizontal plane, and point 45 degrees medially: degree of motion most restricted is rotation (most restricted, it is furthest from plane of motion needed for rotation) but we have flexion, extension, lateral flexion
L5 is a transitional vertebrae is an exception to this rule
220
Demo for Active Movement testing: need to be able to visualize the area, try to be at eye level
Flexion:
“bend forward at the waist, come back up” stabilize the pelvis because only want lumbar spine to move: hands at ASIS and forearms at the back of the pelvis so movement in lumbar spine. If want cervical do a chin tuck and roll down. You are behind the patients so show them first. Note ROM and quality: i.e. ROM WNL or jutter into flexion (jutter indicates instability so think about stabilization exercises) when you do flexion or try to stabilize the pelvis forearm in contact with buttock and fingers anterior to ASIS
overpressure: stabilize the pelvis and use lower thoracic for the overpressure
221
Demo for Active Movement testing: need to be able to visualize the area, try to be at eye level
Extension:
“Put your hands flat on the back of the buttocks, arch your back backwards, any pain? come back to neutral” note where most of the movement is coming from. Look for the pivot point. Where does he initiate from. [Extension can be done in prone and only use arms to push up into extension and can be sustained or repeated and ask what this does to the pain—if hard for patient to do in standing or want more of a McKenzie approach]
not overpressure extension
222
Demo for Active Movement testing: need to be able to visualize the area, try to be at eye level
Side bending:
“Hands at your side, tilt to the right, come back, tilt the left, come back” Note the arc of movement and the pivot points. Note symmetry. Note if hyper or hypomobility and what region. Side bending to the right was
overpressure: press
223
Demo for Active Movement testing: need to be able to visualize the area, try to be at eye level
Rotation:
“criss cross your arms and rotate” stabilize pelvis bump my hip against the side and my hand anterior, or just do ASIS. -compare sides, note quality,
overpressure: get on the lower ribs/T spine (not scapula) and rotate extra
224
Demonstrate AROM for the patient:
what you will say
Bend forward at the waist, come back with your hands on your pelvis.
Arch backwards then come back
Touch the right knee then the left knee
Criss cross arms and turn right and then turn left
225
In what plane is L5-S1
frontal plane
| not 60 degree thoracic where rotation is facilitated, here it is 60-90 relative to horizontal
226
Pain on Left side facet when sidebend to the left
Closing left and opening right.
Pain on the side to which they side bend:
- -the source of the pain can be the facet itself when close the facet and add compressive forces
- - can also be some disc involvement whereas that is pinching down on herniated disc --at least inflammatory tissue to you close intervertebral foramen,
227
Pain on Right side facet when sidebend to the left
if patient had pain when sideband L the pain is on the right problem can be
--muscular because stretching irritated muscles,
--facet can be painful because stretch the capsule on that side,
--if there was a posterior lateral disc i am putting more pressure on that disc side.
228
Sidebend left and there is pain on the left:
- -joint
| - -disc herniation-if the disc is lateral to the NR it is pinching down on it
229
Herniation is lateral to the NR:
What is the postural deviation you will see in that patient?
Patient bends AWAY from the the herniation because leaning to the same side would elicit pain
230
Herniation is lateral to the NR:
What is the painful side?
Disc herniation is lateral to NR as leaves intervertebral foramen —when sideband to the left pinch the NR and create pain
231
Herniation is lateral to the NR:
How does patient compensate??
Compensate by shifting away from the NR
232
Herniation is lateral to the NR:
Postural deviation
away from the painful side
233
Herniation is medial to the NR:
What postural deviation will you see?
patient posture lean TOWARDS the side of the herniation because tilting away would irritate the root and cause pain
234
Herniation is medial to the NR:
How will the patient appear?
Patient bends towards the herniation
235
Herniation is medial to the NR:
Will the patient feel pain when lean towards or away from the NR?
When patient shifts away from the NR drag the NR and the dura which comes out of the IV foramen with the nerve, over the irritable area, that dragging creates the pain
236
Herniation is medial to the NR:
How will patient compensate for pain? Why?
Patient will compensate and shift towards the painful side for some slack so the medial herniation does not so much press on the nerve
237
Herniation is medial to the NR:
Postural Deviation
Postural deviation towards the painful side
238
Where is the LESION if patient side flexes TOWARD the painful side and symptoms increase?
1. Articular
| 2. Disc Herniation LATERAL to the nerve root
239
Where is the LESION if patient side flexes AWAY the painful side and symptoms increase?
1. Articular
2. Muscular
3. Disc Herniation MEDIAL to nerve root
240
If herniation is lateral to nerve root postural deviation is _____
If herniation is lateral to nerve root postural deviation is to the opposite side
241
If herniation is medial to the NR, the postural deviation is ______
If herniation is medial to the NR, the postural deviation is to the same side
242
Resisted Movements: what is the goal?
Goal is to see if muscular contraction reproduces the pain
— do not want to allow any movement, only isometric contractions, not grading the strength: it is selective tissue tension testing to see if the muscle is involved. Should be done in an ideal posture, as good as possible
243
Resisted Movement Testing:
Flexion
Extension
Lateral Flexion
Rotation
FLEXION: sternum and ask them to bend forward
EXTENSION: patient seated, resist at lower rib cage for lumbar level, ramp up resistance and ramp off mid back
LATERAL FLEXION: i have forward backwards stance and my hands are on lateral shoulder
ROTATION: one hand anterior and one posterior shoulders to fulcrum
244
What should you do if resisted movement testing results in weak and painless?
do MMT because this is not where we grade muscle strength
245
MMT lumbar extension:
prone and hands in 3 are sides, 4 are behind head, 5 forward -sternum needs to clear the mat to give the grade
246
Passive Movements:
we do something different with the spine, what is it?
Normally through physiological range-but here we want to know what happens at the segments = one segment on the other:
passive physiological interververtebral movement testing (PPIVM)
247
Purpose of PPIVM
To see what happens to the symptoms at segmental level: joint, facet, and surrounding soft tissues capsule and ligaments.
[We want to see segment by segment at each facet pair]
In the lumbar spine, these physiological movements are difficult to perform due to the weight of the body
May give you a sense of multi-segmental problems
248
PPIVM: Forward Bending
Option 1: Sidelying two legs
Pt
PT
Action
Patient Position
- -Sidelie
- -Neutral spine
- -Hips and knees in 90-90
Physical therapist:
- -anterior pelvis to hold patient knees
- -grasp near ankle
- -WS to create the movement
PT action
--find PSIS, base of sacrum, L5-S1 interspace: then i can side-shift
249
PPIVM: Forward Bending
Option 2: Sidelying one leg
Pt
PT
Action
Patient Position
Sidelie
Neutral spine:
Hips and knees in 90-90
Physical therapist:
- Use my body anterior pelvis to hold patient knees
- my arm under the top leg and grasp near the ankle
- WS to create the movement
PT action
find PSIS, base of sacrum, L5-S1 interspace: then i can side-shift (
palpate interspace L5-S1
250
PPIVM: Backwards Bending:
Sidlying using leg
patient close to edge of treatment table
palpate L5-S1 interspace glide leg posteriorly to sense closing of each segment
251
What to palpate in PPIVM
Where to put monitoring finger
--palpate interspace L5-S1 and Sense opening and back to neutral, open and back to neutral, at interspace and move to next interspace
--monitoring finger at interspace above which you do not want to have open yet
252
PPIVM: Backward Bending
Prone press-up
(it has to be passive)
patient prone, hands on plinth, aligned with patient shoulders
palpate T12-L1 interspace
Pt slowly raises up into extension as PT palpates segmentally down to L5/S1
253
PPIVM: Sidebending
Sidelying using pelvis
--Get on brim of ilium
--palpate interspinous space or on right lateral aspect of the two spinous processes or on the left lateral aspect of the two spinous processes —pull towards me sideband left, push and create right sidebending
--Rock pelvis cranially, side bend same direction
--Rock pelvis caudally, sidebend opposite direction
254
PPIVM: Sidebending
Sidelying using both legs
patient postion
PT
direction
---patient position: sidelying, hip and knees in 90-90
- -PT:
- grasp both lower legs, pivot patients knees on my thigh crank legs (abduct) to ceiling or to floor which will bring pelvis towards the rib cage :
--Direction:
=Raise patients feet to ceiling, SB to same direction as feet
=Lower feet to floor: SB opposite direction
**do not want to stretch on rectus femoris
255
PPIVM: Sidebending
Prone
patient prone (can have a pillow under), spine neutral
PT supports patient leg (knee flexed for comfort, resting tibia on my forearm)
Palpate interspace L5/S1 and slowly abduct leg to sense (palpate intersperse on top or either side)
256
PPIVM: Sidebending
Sitting
position as with flexion and extension, patient seated near top of plinth
PT can squat to create SB toward PT
257
PPIVM: Rotation: how is it named?
named by segment above: L3 left rotation on L4
remember: name by superior vertebra of motion segment, even if inducing rotation from lower vertebra
258
PPIVM: Rotation
Prone : Using Iliac Crest
patient position
PT
patient prone
PT: hands on iliac crests
(stand with a forward backwards stance and rock forward and back to create the rotation: return to neutral for that segment and go up the chain to the next segment)
(if using right pelvis i sand on left side of the patient for better leverage):
start at L5-S1 interspace, reach around to brim of ilium and ASIS region, palpated, take forward backward diagonal stance, rock myself backwards to bring pelvis with me to get the rotation and maintain that rotation and then i rotate a little bit more and then go to the next segment.
Don’t shift the pelvis left or right, only rock it left and right to feel close on one side and open on the other, back to neutral on that segment etc and work way up the chain.
Lift up RIGHT crest, rotation to LEFT follows up the chain
- -Rotate body of sacrum right: L5-S1 left rotation. Then keep rotating right: L4-L5 left rotation.
- -Opening occurs on the same side as the named rotation: left rotation L3 on L4 the opening is on the left and closing is on the right
259
PPIVM: Rotation
Prone using Legs: longer lever
Patient knees at 90
Rotate legs to the RIGHT : this creates left rotation of the sacrum etc: you get a relative right rotation of L5 on S1 etc in direction of ankles
- --grab the outer leg and tuck in or grab between the two legs
- --turn feet to her left so sacrum is going right and L5-S1 going left (Left rotation of L5 on S1)
- --Go back to neutral
- --Go up to the next segment
- --Don’t shift the legs or the pelvis, want a pure rotation as go up the chain
so the direction of the rotation is the direction of the legs — but easier to think of it as where did the sacrum go and work form there
260
What is Passive Accessory Intervertebral Movements?
Intervertebral motions we cannot make voluntarily-we do this to assess joint motion (because ligaments will not be at maximum tension).
They are named by the direction of the movement
261
Why we do What is Passive Accessory Intervertebral Movements?
we do this to assess joint motion (because ligaments will not be at maximum tension).
262
PAIVM
| P/A Techniques: from a posterior to an anterior position (aka an anterior glide)
1. General Spring Test
2. Specific P/A pressure on Spinous Process:
3. P/A pressure on bilateral Transverse Processes:
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PAIVM
General spring test
1) Purpose:
2) what does it assess
3) Patient Position
4) PT
5) What we are looking for
1. for an overall sense of how the spine is moving from one segment to another *sense overall relative mobility of all motion segments
2. Assess the degree of play: press down on SP and a little on body of sacrum to get an idea of the relative degree of play as we move up the spine
—we will not say it is definitely 4-5 but we can say when i spring on 4-5 i get a reactive muscle spasm and patient reports pain, or 4-5 is more mobile than 3-4.
Later we will do specific PA, this is just a big picture.
3. Position patient prone in neutral spine
4. heel of hand on the SP (thenar, hypothenar, or in between, and reinforce with one hand over the other)
and push SP towards floor with vertical force with a gentle lean of my body.
For sacrum my fingers pointed towards their feet, my heel of hand over base of sacrum, my shoulders over that preparation, and just a gentle spring.
5. Look for excessive play vs normal play
This gives an idea of how much play we have.
264
PAIVM POSTERIOR/ANTERIOR
Specific P/A pressure on Spinous Process
Use pisiform area contact, reinforce wrist as needed
```
find brim of ilium, come across and find L4, pisiform on L4, reinforce my wrist, bring my shoulders over, gentle lean down and back up.
get pisiform (cushy area) on the segment
reinforce
```
downward pressure
glide and assess the play (evaluate the slide in the facet at that level)
go to next segment, SP L3, press down, and back up
P/A movement of the vertebrae on upon the other—feel the body glide anteriorly bring the facets down towards the floor
my shoulder is over the preparation for a pure P/A force, do not want to incorporate rotation into it —lock my arms and use my body for a gentle force so that I can perceive the motion
265
PAIVM POSTERIOR/ANTERIOR
P/A pressure on bilateral Transverse Processes
note that this method will bow the vertebrae forward
Place middle and index fingers over respective Transverse Processes, use ulnar border other hand to press anteriorly symmetrically
TP tend to stay to the upper half of the vertebrae, fingers on the TP, create a forward tilt in addition to the P/A
As I press on the vertebrae, the vertebrae bows forward, this gives a flexion as well as a P/A—it is a rock forward at the facets (not just an up down), a different kind of play
- ----Find the TP, approach brim of ilium and come across to estimate location of L4, the TP is on the upper half so come lateral towards upper half of SP and work my way out above the muscle mass and around and in into where TP would be. Consider persons proportions. Come from outside to inside to find the TP. You feel it as a density, not the same as feeling the SP due to all the tissue around it and it is deeper. Come around a muscle mass and go in towards the VB to find the TP. Find one then go to the other side and find the other
- ----A finger on each TP, rest my hand flat
- ----Ulnar border of other hand on my fingers
- ----A nice downward glide and come back up
Take index and middle fingers and place them passively on the persons back as passive cushions, whole hand flat, the other hand ulnar border on our fingers to create the force towards the floor for the P/A of the transverse processes, bring shoulder over ulnar border hand and glide towards the floor and stay with it as it glides back—sometimes feel the play better on its way back then on its way down
P/A of L3 on L4
266
PAIVM ROTATION
Rotation
-purpose?
gives a sense of opening on one side and closing on the other side
267
PAIVM ROTATION
Rotation against spinous process:
1. direct laterally: lateral force
2. Forearms parallel to floor for direct rotation, do not want to also be getting P/A, just pure rotation
3. Press on the lateral side of the SP: push SP away from me so body will turn towards me: press outer side of SP, forearms level to the mat, push away, create a rotation : SP to left, VB to the right
---Find brim of ilium, come across. Push soft tissue out of the way-push it down and forward or push it up and out of the way and get skin out of the way to get thumb against SP, forearms level to the bed, and direct it away from yourself: gentle pressure and recoil it back. Then go up to the next segment.
268
PAIVM ROTATION
Unilateral P/A on a transverse process:
ie press on right TP of L3, create left rotation of L3 on L4
(to get L5 TP press on PSIS/iliac crest to press on TP of L5 to rotate L5 on S1 to the degree that it is going to happen)
P/A pressure on one transverse process to induce rotation
Put pisiform area on TP and P/A to the floor to create a rotation
Rotate L5 by springing iliac crest
Find TP, put heel of hand on TP, shoulder over, gentle downward pressure, and come back up, to create the rotation.
269
PAIVM: ROTATION
Rotation with “high-low fingers” on TPs
Hand placement as with P/A on TP but span one motion segment
ie still use the fingers of one hand and ulnar border of the other hand to reinforce: create a counterrotation by placing one finger on left L3 TP and right L4 TP so create a rotation at that motion segment. It is a counter-rotation left L3 TP will rotate L3 right, and L4 do a relative left rotation if on the right side TP, to create more of the rotation of L3 on L4 to the right.
On left and right and do dummy hand technique, press to the floor, create a counter-rotation at the motion segment of interest
Finger on TP of vertebrae and on opposite TP of vertebrae below, hand is flat, ulnar border of other hand on top of my fingers, be as vertical as possible, push down to the floor and feel a rotation: top vertebrae away from me, and bottom vertebrae towards me (depends on which side TP she was on)
270
Lumbar Compression
What to do
Purpose
1. Patient seated on treatment table
Patient is anchored on table, back to me
2. Compress through the scapula and then load towards the ischial tuberosities from the acromion process
3. Can also produce downward pressure through the first rib
4. Keep my elbows low dropping down / r i can be on table and press down from above
5. Assess how reactive the tissue is, assess if the loading creates a problem or does the loading pick up an instability
271
Lumbar Distraction:
1. Grab hold of the patient’s wrists, my elbows on their lower ribs (only want lumbar spine)
Squeeze and go backwards and as I lean backwards I am creating the distraction. I lower back down to the table and then back up.
My anchor is against her lower ribs pushing in, hands are just there, have her up against my chest and I lean backwards to create the distraction.
272
Does lumbar spine have a lot of rotation?
Take away is c-spine rotation most, l-spine has least (b/c orientation of facets)
273
Blue flag:
workers compensation case, and if they are not motivated to return to job there is a barrier for their full recovery
274
Black flags
barriers that related to financial constraints or transportation: ie high co-pay or deductable that will limit their access to PT
275
Red flag
Signs of serious pathology
276
Yellow flag
Pain behaviour (including pain and coping strategies
Emotional response
Beliefs, appraisals and judgements
277
Assess why?
extension + side bending + rotation
this will pick up FACET issues
can be facet issue: hypertrophic, inflamed,
can be NERVE IMPINGED
278
Assess why?
flexion + side bending + rotation
bring hand down thigh
this will pick up DISC issue
if do combo to left and pain at right side: facets are opening and the disc is being posterior laterally
posterior – lateral bulge is most common
279
Worse in the morning pain can be:
Arthritis
Bulging disc
Mattress
280
L2
hip flexion
281
L3
Knee extension
282
L4
DF
283
L5
big toe extension (if weak gluteus mediaus also can be sued for L5)
284
S1
PF (peroneous longus and brevis)
285
S1-S2
gastroc/soleus
286
S2, S3, S4
bladder (ask bowel and bowel questions)
foot intrinsics
287
Myotomes
Illiopsoas
T12
| L1, L2, L3
288
Myotomes
Quads
L2, L3, L4
289
Myotomes
Anterior Tibialis
L4
290
Myotomes
Extensory Hallucis Longus
L5
291
Myotomes
Peroneous longus and bevis
S1
292
Myotomes
Gastroc / Soleus
S1, S2
293
Myotomes
Bowel and Bladder
S2, S3, S4
294
Myotomes
Foot intrinsics
S2, S3, S4
295
Myotomes
Gluteus medius
L5
296
Dermatomes
L1
inguinal line
Disc herniations are rare for upper lumbar so not usually tested unless Hx indicated
297
Dermatomes
L2
anterior prox thigh
Disc herniations are rare for upper lumbar so not usually tested unless Hx indicated
298
Dermatomes
L3
anterior medial thigh-medial knee
299
Dermatomes
L4
medial leg
300
Dermatomes
L5
lateral leg
301
Dermatomes
S1
lateral foot/calcaneus
302
DTR
S1
Achilles Tendon
303
DTR
L4
Patellar Tendon
304
DTR
Achilles Tendon
S1
305
DTR
Patellar Tendon
L4
306
Note Asia that L2 is medial upper thigh and L3 medial knee, medial malleolus L4, L5 is between first and second big toe on dorsum foot, S1 is lateral posterior calcaneus
Note Asia that L2 is medial upper thigh and L3 medial knee, medial malleolus L4, L5 is between first and second big toe on dorsum foot, S1 is lateral posterior calcaneus
307
What do Babinski, Clonus indicate?
UMN Lesion
308
Grading DTR
```
0 = absent
1+ = decreased/ hyporeflexive
2+ = normal
3+ = hyperactive
4+ = hyperreflexive
```
*jendrassik
309
Lateral Thigh
Lateral cutanous nerve of the thigh
--numb with tight jeans, tight belt compressing the nerve
peripheral vs dermatome:
-dermatomal nerve spirals
310
Medial Thigh
Obterator nerve
Dermatome: different levels that innevrate the medial thigh
311
Lateral Calf
Peripheral:
proximal: common peroneal nerve
Distal: superficial peroneal nerve
Between the toes: Deep peroneal nerve
L5: down between toes but use other distribution parts to help
312
Posterior calf
Sural nerve
S1/S2 lateral foot border and go up calf
313
Peripheral nerve vs. dermatome
Lateral thigh = lateral cutaneous nerve of thigh/ multiple dermatomes
```
Prox- medial thigh = obturator vs. multiple dermatomes
lateral calf
proximal = common peroneal nerve
distal = superficial peroneal nerve
deep peroneal nerve btwn toes (L5)
```
Sural nerve – posterior-lateral calf- more distinct boundaries vs. S1-S2
Peripheral nerve vs. dermatome
Lateral thigh = lateral cutaneous nerve of thigh/ multiple dermatomes
```
Prox- medial thigh = obturator vs. multiple dermatomes
lateral calf
--proximal = common peroneal nerve
--distal = superficial peroneal nerve
--deep peroneal nerve btwn toes (L5)
```
Sural nerve – posterior-lateral calf- more distinct boundaries vs. S1-S2
314
Prone knee flexion bend if upper lumbar lesion compressing nerve root, dermatomal pattern, use DTR, cluster exams to localize distribution
Prone knee flexion bend if upper lumbar lesion compressing nerve root, dermatomal pattern, use DTR, cluster exams to localize distribution
315
Dural Testing
Sciatic Nerve: L5, S1, S2
1. Straight Leg Raise
2. Laseque Sign
3. Well Leg Straight Leg Raise
4. Kering Sign: Passive Flexion
316
Dural Testing
Femoral Nerve: L3, L4
1. Prone knee bend
317
Straight Leg Raise:
What does it test?
How is it set up?
Pain at 30?
Pain at 90?
Sciatic Nerve: L5, S1, S2
Point is that you have a working hypothesis = something is happening with the nerves
This pulls on the sciatic nerve
Demonstration
- -Supine
- -Straight leg, bring it up passively stabilize the knee and hold from under the ankle
-->They would say it hurts at a certain ROM
(asterik vs tight hamstring and gastroc)
Pain:
- --Sciatic Nerve: L5, S1, S2
- --If it is a disc problem = usually pain around 30 degree range
- --If state pain when up to 90 – probably not dura because after 90 mechanically there is less stretch on the nerve
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Last year version
pSLR Test
pSLR (Passive SLR)/ Lasegue:
Disc bulge,
limited mobility/neurotension of sciatic nerve
I lift his leg into a SLR: if increase of symptoms before 70 : then lift head up and see if that changes symptoms: increases with cervical flexion (+), otherwise if it doesn’t increase the pain it may just be hamstrings
This test can be used to measure improvements objectively
add DF to get nerve tensions = Braggards Tests
319
pSLR: where in the range would it hurt if it is a disc problem?
30 degrees
320
pSLR Test
| rosen
Stretch sciatic nerve proximally.
L5:
Herniated disc at L4–L5 or L5–S1: pressure on the L5 or S1 nerve roots, stretching the sciatic nerve cause worsening of the lower-extremity pain or paresthesias or both.
Pt lie supine
With the patient’s knee extended, take the patient’s foot by the heel and elevate the entire leg 35–70 degrees from the examining table.
As the leg is raised beyond approximately 70 degrees, the sciatic nerve is being completely stretched and causes stress on the lumbar spine.
(+) increased LE pain/paresthesias on the side that is being examined.
(+ cross response) pain down the opposite leg, significant for a herniated disc.
Laseque Sign:
Tight hamstrings or is of a neurogenic:
1. raising the leg up to the point pain, and then lowering the leg slightly (should reduce pain)
2. Passively DF to increase the stretch on the sciatic nerve. PAIN = NEUROGENIC, no pain = tight hamstrings
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Laseque Sign
If they say it is the pain that they get (ex: on their in step): lower leg slightly add dorsiflexion
1. You would lower the leg down (presumably taking the stretch off the nerve),
2. Ask the patient if the pain went away
3. Then put the stretch on it again, but in a different way: take the foot into DF and ask if there is pain
PAIN: sciatic, nerve root, or dura:
the pain would be reproduced in the in step because took the stretch off the hip and applied it again at the ankle
=positive SLR test and a positive Laseque sign
322
Well Leg SLR
= a SLR of the non-affected leg
POSITIVE: contralateral nerve root irritation sits MEDIAL to nerve root
If symptoms are RELEIVED: contralateral irritation sits LATERAL to nerve root
------------
This pulls the dura from the other side—want to see if symptoms are still reproduced on the bad leg
Notes: If you pull on an irritated dura on anywhere else, you may produce the symptoms--Dura is like stockings – all connected--Do the SLR on the other test – they would feel it on the opposite side and in the same spot they have pain--This tells you they have serious inflammation
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Kering Sign: Passive Neck Flexion
Really highly irritated – pull on the dura and get pain from anywhere else
Pull from above: pull from spinal cord level level – passively and gently pull neck into flexion gently
If pain in bad leg this confirms a hot irritable area, when we pull from anywhere
324
Prone Knee Bend
Femoral Nerve stretch: L3, L4
```
Prone
Stabilize Lumbar Spine
Hip in neutral
Bend knee
A point in the ROM where she identifies pain: is it a quad stretch or is it a reproduction of the pain
```
Positive: reproduction of the pain
325
Prone reflex tests
Hamstrings
Gastroc/Soleus
326
Adverse Neural Tension
nerves are reacting abnormally based on stretch
Defined by Butler: “abnormal physiological and mechanical responses produced from nervous tissue structures when their normal range of movement and stretch capabilities are tested”
327
Neurodynamic testing
“an analysis of the lengthening (stretching) and sliding (gliding) abilities of neural structures”and an analysis of the “ability of the nervous system to cater to changes in interfacing structures”
There is slack which is needed for us to bend and reach: the system evaluates the play by palpations where the interfaces are
- --sciatic nerve popping out from between bellies of hamstring muscles
- --peroneal nerve back and around medial malleolus
- --nerve to dorsum of foot under extensor retinaculum
328
Butler feels that nervous system never forgets an injury:
Not the normal sliding and gliding
Patients with adverse tension syndromes give history which involves injury to nervous system – MVA or fall
These injuries increase tension in nervous system
Symptoms are usually worse with tension – increasing maneuvers
- -->Resting in bed in the long sitting position: telling you the nerve under tension is reactive and by taking off tension – relieves pain
- -->Getting into a car
Pain could be described as anything – burning, tingling, stab: depends on hotness of the nerve and what the original injury is
329
“an analysis of the lengthening (stretching) and sliding (gliding) abilities of neural structures”and an analysis of the “ability of the nervous system to cater to changes in interfacing structures”
Neurodynamic testing
330
"abnormal physiological and mechanical responses produced from nervous tissue structures when their normal range of movement and stretch capabilities are tested”
Adverse Neural Tension
331
Neurodynamic testing
Sx include
```
Pain
Burning
Weakness
Paralysis
Paraesthesia
```
332
Abnormal postures are often related to patient’s attempts to relieve adverse neural tension: adaptations to having stress on the nerve:
give 4 examples
Raised shoulder girdle
Hip externally rotated in stance
Forward head posture: puts plexus on slack
Flattened thoracic spine
333
Butler finds adverse tension syndromes are related to ____ of disorder
why
Butler finds adverse tension syndromes are related to chronicity of disorder
System has had time to allow adaptive measures to occur
But, the nervous system has not been treated sufficiently
334
Why Butler finds adverse tension syndromes are related to chronicity of disorder?
Butler finds adverse tension syndromes are related to chronicity of disorder: System has had time to allow adaptive measures to occur
But, the nervous system has not been treated sufficiently
Therefore, testing will provoke the symptoms when the right tissues are elongated
We elongate the tissues in a selective systematic way to figure out where there is a problem
335
Why will neurodynamic testing provoke symptoms?
Butler finds adverse tension syndromes are related to chronicity of disorder:
System has had time to allow adaptive measures to occur
But, the nervous system has not been treated sufficiently
Therefore, testing will provoke the symptoms when the right tissues are elongated
We elongate the tissues in a selective systematic way to figure out where there is a problem
336
Is neural tissue flexible?
Neural tissue is inherently flexible
| Assess flexibility, assess the play
337
Pathological mechanisms in injured/diseased tissues may ____ mobility of the nervous tissue
Pathological mechanisms in injured/diseased tissues may cause decreased mobility of the nervous tissue
Can be evaluated by neuro-dynamic tests of flexibility: pull on one get symptoms in another
338
What is the first step of neurodynamic testing after observation?
perform a series of base tests
Check mobility of selected portions of nervous system to isolate a site where mobility is impaired
(Patient history, observe postures/adaptations to postures, observe selective movement,)
339
page 28
page 28
340
Tension Testing Precautions (9)
1. Screen for “red flags” indicated need for immediate attention for trauma, neoplasm, infection and inflammation
2. Tension tests are complex and involve many components. Be careful not to aggravate other structures
3. Irritability related to the nervous system
Worsening disorders
4. Presence of neurological signs
Be very cautious, don’t want to pull on a nerve that is not functioning well, not conducting well, can perform the test with caution
5. Poor general health
6. Compromise of the spinal cord, e.g., spinal
stenosis
7. Acute and unstable neurological signs
8. Cauda Equina lesions
9. Injury to spinal cord
341
Tension Testing precautions
Ex: night sweats, night pain, pain out of proportion (may not be mechanical, may be a tumor, infection, inflammation)
Screen for “red flags” indicated need for immediate attention for trauma, neoplasm, infection and inflammation
342
Tension Testing Precautions
Ex: get a positive SLR – don’t irritate the nervous system more once we already have the data we need
Tension tests are complex and involve many components. Be careful not to aggravate other structures
Ex: get a positive SLR – don’t irritate the nervous system more once we already have the data we need
343
Tension Testing Precautions
Irritability related to the nervous system
Irritability related to the nervous system
344
Tension Testing Precautions
Ex: getting medication and its getting worse, red flag
Worsening disorders
345
Tension Testing Precautions
Presence of neurological signs
Be very cautious, don’t want to pull on a nerve that is not functioning well, not conducting well, can perform the test with caution
346
Tension Testing Precautions
ex: flu, diabetes is not under control
Not a time to stress the nervous system
Poor general health
347
Tension Testing Precautions
spinal stenosis
Compromise of the spinal cord, e.g., spinal stenosis
Or if they have bowel and bladder issues, do not do the test
348
Tension Testing Precautions
Acute and unstable neurological signs
ACUTE and UNSTABLE neurological signs
If they just started, or if they’re getting worse: acute neuro signs that are documentable -would not test
Sometimes good, sometimes bad – unstable
349
Tension Testing Precautions
Cauda Equina lesions
Cauda Equina lesions
350
Tension Testing Precautions
Injury to spinal cord
Injury to spinal cord
351
Tension Testing Precautions
Warning:
There are inherent dangers in mobilizing the nervous system
You must do a thorough neurological exam assessing for _______ and _____
Warning:
There are inherent dangers in mobilizing the nervous system
You must do a thorough neurological exam assessing for abnormal findings and abnormal reflexes
If getting a headache or getting nauseous then stop the test
Both nerve roots are intertwined with the SNS– don’t want to provoke
352
Tension Testing
The symptoms response:
(4 things)
1. At what point in ROM do symptoms begin? (Ex: 40 degrees in SLR begin to have sx)
2. What are symptoms? (Tingling,numbness, burning)
3. What are symptoms at limit of range? (Specific symptoms)
4. Are symptoms equivalent to the chief complaint?
353
Tension Testing
When is resistance to stretch first encountered?
- -what does this mean
- -why we care
Helps understand where the barrier might be – what did I put on stretch to create this resistance and when I stretch it a little more and get the symptom from the patient
Maybe they can go little further but have resistance at 30 and an absolute stop at 40 in the SLR, where the resistance helps to understand where the barrier may be
Muscular resistance will feel different: This is almost like an EMPTY END FEEL – they want to pull back from your resistance, They tense up, Slowing down your speed
354
Tension Testing
2 questions to ask about resistance
1. when is stretch first encountered?
| 2. What behavior is this resistance?
355
Tension Testing
Assessment of what 2 things must be made after each component of the test is added or taken away?
1. Symptom Response
| 2. Resistance
356
Tension Tests
BASE TESTS
(5)
1. PASSIVE NECK FLEXION: pons, cord, meninges
2. STRAIGHT LEG RAISE; tibial, peroneal, sciatic tracts, lumbar sympathetic trunk, lower lumbar roots
3. PRONE KNEE BEND: femoral tracts, mid upper lumbar roots, meninges, cord
4. SLUMP: pons, cord, meninges, sciatic tract
5. UPPER LIMB TENSION TESTS: individual nerves
357
Tension Test
PASSIVE NECK FLEXION:
what it tests:
1. pons
2. Cord
3. meninges
358
Tension Test
STRAIGHT LEG RAISE
what it tests: (5)
1. tibial tract
2. peroneal tract
3. sciatic tract
4. lumbar sympathetic trunk
5. lower lumbar roots
359
Tension Test
PRONE KNEE BEND:
what it tests: (4)
1. femoral tracts
2. mid upper lumbar roots
3. meninges
4. cord
360
Tension Test
SLUMP:
what it tests: (4)
1. pons
2. cord
3. meninges
4. sciatic tract
361
Tension Test
UPPER LIMB TENSION TESTS:
what it tests: (1)
individual nerves
362
Tension Tests
When performing test:
Starting position should be ___
Test ___ between sides
Start with ___ side
Starting position should be consistent each time
Test symmetry between both sides (start with the good side)
Start with unaffected side
363
Tension Tests
What to look for
1. Feel for barriers to movement
2. Note onset of RESISTANCE, PAIN or other SYMPTOMS
3. Assess QUALITY of movement
4. Watch for antalgic postures during tests
5. Test symmetry between both sides (start with the good side)
364
Tension Tests
Which side do first?
Tension Tests
365
Slump Test:
1. Patient position
2. Name the next 4 steps
3. Is the other leg done?
4. When is response assessed?
5. Normal Response
6. Indication for slump test
is a neural tension test which is indicated when the patient complains of spinal symptoms.
```
1. Patient seated,
knees together,
Hands Linked behind back,
Cervical Spine neutral,
Patient slumps
```
2.
Maintaining flexed position, bend neck toward chest and overpressure (one finger)
Actively extend knee
Dorsiflex ankle
Slowly release neck flexion
3. Repeat other leg
You can then ask patient to extend both legs together
4. Response assessed at each step
5. Normal Response:
pain area of T8-T9,
pain behind extended knee and hamstring area
6. Indications: spinal symptoms, to ensure that nervous system moves and stretches properly
366
Slump Test:
set up
4 steps
```
SET UP
Patient seated,
knees together,
Hands Linked behind back,
Cervical Spine neutral,
Patient slumps
```
4 STEPS
1. Maintaining flexed position, bend neck toward chest and overpressure (one finger)
2. Actively extend knee
3. Dorsiflex ankle
4. Slowly release neck flexion
REPEAT OTHER LEG
You can then ask patient to extend both legs together
367
Slump Test: normal response
pain area of T8-T9,
pain behind extended knee and hamstring area
368
Slump Test Indications
1. patient complains of spinal symptoms.
| 2. To ensure the nervous system moves and stretched properly
369
Slump Test Positive
Worsening of neurological symptoms can be indicative of pathology secondary to tension in the nervous system.
370
Slump Test
| rosen
The slump test (Figure 6.61) is a neural tension test which is indicated when the patient complains of spinal symptoms. The test is conducted as follows:
r Patient’s position: The patient is sitting with both lower extremities supported with the upper extremities behind the back and the hands clasped.
r Instruct the patient to “sag.” Overpressure can be added to increase the degree of flexion. Maintain flexion and then ask the patient to bend the neck toward the chest. Overpressure can be added and the symptoms are reassessed. While maintaining the position, instruct the patient to extend one knee and reassess. Then ask the patient to dorsiflex the ankle and reassess. Release neck flexion and reassess. Ask the patient to flex the neck again and repeat the process on the other leg. Finally, both legs can be extended simultaneously.
The test is terminated when the symptoms are produced.
Normal responses can include pain at T8–T9 in
approximately 50% of patients, pain on the posterior aspect of the extended knee, decreased ROM in dorsiflexion, and a release of symptoms and an increase in range when neck flexion is released (Butler, 1991). Worsening of neurological symptoms can be indicative of pathology secondary to tension in the nervous system.
371
Neural Tension Test
SLUMP TEST IN LONG SITTING
why is it diffetenet
Done as an assessment and treatment
Position offers slump from the *LEs and legs first*
Clinically, the response can be different
372
Neural Tension Test
Straight Leg Raise
1. PATIENT POSITION
2. STEPS
3. WHAT TO LOOK FOR
4. INDICATIONS
1. PATIENT POSITION:
Patient supine: (can put on my acromion) one hand above the knee,
the other hand above/proximal to the malleoli from underneath,
2. STEPS: if you stand facing the patient, walk up the table: where in the range are symptoms reproduced and is there resistance noted
Place one hand under achilles tendon and other anterior/proximal to knee
Lift leg until perpendicular to bed
3. WHAT TO LOOK FOR
- Symptom responses
- ROM
- resistance noted
COMPARE OPPOSITE LEG
4. INDICATIONS
Key tension test
Routine for all spinal and leg symptoms
373
SLR:
| Rosen
Stretch sciatic nerve/ Herniated disc L4-L5 or L5-S1
pt supine, knee extended, grasp the foot by the heel and elevate the entire leg 35–70 degrees from the examining table.
70 degrees: the sciatic nerve completely stretched = stress on the lumbar spine:
(+) increased LE pain or paresthesias on the side that is being examined.
cross + = pain down the opposite leg = herniated disc
Tight hamstrings = pain posterior part of the thigh, which is due to tightness of the hamstrings: determine with lowering the leg slightly and this will reduce the pain, then passive DF to increase the stretch on the sciatic nerve [Pain = neurogenic and not hamstring]
374
NEURAL TENSION TESTING
SLR:
PF and Inversion:
PERONEAL nerve (FIBULAR nerve)
1. Hands: Keep a hand under malleoli with a forearm resting on the shank to maintain the extension
and the other hand to bring the foot into PF and inversion
2. Squat then lift up and walk up table
3. Grab calcaneous and bring to inversion letting metacarpals turn, other hand does the PF
375
NEURAL TENSION TESTING
SLR:
Ankle DF
further tension to TIBIAL Nerve
rest forarm on shank to maintain knee extension
grab calcaneous for eversion, and DF
pSLR
376
NEURAL TENSION TESTING
SLR:
Ankle DF and eversion
Dorsiflexion/eversion: more tension along tibial tract: TIBIAL Nerve
rest forarm on shank to maintain knee extension
grab calcaneous for eversion, and DF
pSLR
377
NEURAL TENSION TESTING
SLR:
Ankle DF and inversion
tension along SURAL Nerve
rest forarm on shank to maintain knee extension
grab calcaneous for inversion, and DF
pSLR
(The small cutaneous branch arises as the common fibular nerve travels towards the fibular head. The nerve then continues down the leg on the posterior-lateral side, then posterior to the lateral malleolus where it runs deep to the fibularis tendon sheath and reaches the lateral tuberosity of the fifth toe, where it ramifies.[1])
378
NEURAL TENSION TESTING
SLR:
Plantar flexion/inversion
Plantar flexion/inversion: tension along COMMON PERONEAL TRACT
one hand on the proximal
Distal position at foot
Come up
379
NEURAL TENSION TESTING
SLR:
Hip Adduction
tension proximal SCIATIC tract
380
NEURAL TENSION TESTING
SLR:
Hip IR
further sensitize proximal SCIATIC tract
381
Passive Neck Flexion
1. Patient position
2. Test Steps
3. Symptom Response
4. Normal Response
5. Indications
1. PATIENT POSITION: Supine position with arms at side, legs together
2. TEST STEPS:
Do upper cervical spine then the lower cervical spine:
--->Upper cervical flexion: PT passively flexes the neck to a ‘chin tuck’ position
--->Lower cervical flexion: PT passively flexes the lower cervical spine
One hand stabilizes chest, or both hands hold neck/head
3. SYMPTOM RESPONSE: ROM and resistance encountered is noted
4. NORMAL RESPONSE pulling at cervicothoracic junction
5. INDICATIONS:
- -All spinal disorders: often positive in patients that have LBP
- -Headache symptoms
- -Arm and leg pain of spinal origin
382
Passive Neck Flexion
Patient position
Supine position with arms at side, legs together
TEST STEPS:
Do upper cervical spine then the lower cervical spine:
--->Upper cervical flexion: PT passively flexes the neck to a ‘chin tuck’ position
--->Lower cervical flexion: PT passively flexes the lower cervical spine
One hand stabilizes chest, or both hands hold neck/head
383
Passive Neck Flexion
Test steps
TEST STEPS:
Do upper cervical spine then the lower cervical spine:
--->Upper cervical flexion: PT passively flexes the neck to a ‘chin tuck’ position
--->Lower cervical flexion: PT passively flexes the lower cervical spine
One hand stabilizes chest, or both hands hold neck/head
384
Passive Neck Flexion
Symptom Response
SYMPTOM RESPONSE: ROM and resistance encountered is noted
385
Passive Neck Flexion
Normal Response
NORMAL RESPONSE pulling at cervicothoracic junction
386
Passive Neck Flexion
Indications
INDICATIONS:
--All spinal disorders: often positive in patients that have LBP
--Headache symptoms
--Arm and leg pain of spinal origin
387
SLR Test
TIBIAL NERVE
The tibial nerve can be stretched by first DF the ankle and EVERT the foot, and then performing a straight-leg-raise test.
The test is abnormal if the patient complains of pain or numbness in the plantar aspect of the foot that is relieved by returning the foot to the neutral position.
388
SLR Test
PERONEAL NERVE
The peroneal nerve can be stretched by first
PF the ankle and INVERT the foot, and then performing a straight-leg-raise test.
The test is abnormal if the patient complains of pain or numbness on the dorsum of the foot that is relieved by returning the foot to the neutral position.
(peroneal = fibular)
389
Butler believes that _______ will sensitize COMMON PERONEAL division more than tibial division of sciatic nerve
in the SLR tetst
Butler believes that hip medial rotation will sensitize COMMON PERONEAL division more than tibial division of sciatic nerve
390
Femoral Nerve Stretch Test
[rosen]
Herniated disc in the L2– L4 region.
The purpose of the test is to stretch the femoral nerve and the L2–L4 nerve roots.
The patient is lying on the side, with the test side up. The test can also be performed with the patient lying prone.
Support the patient’s lower extremity with your arm, cradling the knee and leg.
The test leg is extended at the hip and flexed at the knee.
If this maneuver causes increased pain or paresthesias in the anterior medial part of the thigh or medial part of the leg, it is likely that the patient has a compressive lesion of the L2, L3, or L4 nerve roots, such as an L2–L3, L3–L4, or L4–L5 herniated disc.
You can determine whether the pain is caused by tight rectus femoris or of neurogenic origin by releasing some of the knee flexion and then extending the hip.
If the pain increases with hip extension, it is neurogenic in origin.
391
PRONE KNEE BEND
1. patient position
2. action of the test
3. sx response
4. compare with opposite leg
1. Patient Prone
2. Grasp Lower Leg and Flex Knee
3. Symptom Response and resistance through movement noted
4. Compare with Opposite Leg
392
Prone Knee Bend
1. PATIENT POSITION
2. Test
3. What to look for
1. Patient prone:
hand under the knee
Then bring him back slowly into hip extension and monitor what they feel
IF they feel something they can lift their head a little bit
Grasp lower leg and flex knee
2. Symptom response and resistance through movement noted
Compare with opposite leg
393
Which Femoral Nerve Test is more sensitive?
Femoral Nerve becomes saphenous nerve which is slackened in prone knee bend.
More sensitive test to do in side lying position
394
Knee Bend in Side-lying
1. pt position
2. Test
3. What to do if symptom
4. Normal Response
5. Indications
1. PATIENT POSITION: Side-lying with the affected leg uppermost
Patient grasps the knee of the lower leg and flexes the neck (creating spinal flexion)
2. Therapist flexes the knee and extends the hip
3. If Sx: pt to lift their chin (releasing the tension from the spinal flexion)
=>if symptoms decrease confirm a neurogenic origin to the symptom
4. Normal response: pulling or pain in area of quadriceps muscle
5. Indications: used for patients with knee, anterior thigh, hip and upper lumbar symptoms
395
What is knee bend in side lying?
We tuck the patients head down
Patient tucks their knee up to their chest
Reach under the knee and support the leg with forearm
Bring hip into hip extension
If they feel something they can lift their head a little bit
Tell us if it is neurogenic origin to the symptom—confirm the hypothesis of nerve being stretched
396
Knee Bend in Sidelying
how to perform the test
1. PATIENT POSITION: Side-lying with the affected leg uppermost
Patient grasps the knee of the lower leg and flexes the neck (creating spinal flexion)
2. Therapist flexes the knee and extends the hip
3. If Sx: pt to lift their chin (releasing the tension from the spinal flexion)
=>if symptoms decrease confirm a neurogenic origin to the symptom
397
Knee Bend in Side lying
Indications (4)
Indications: sx in
1. knee,
2. anterior thigh,
3. hip and
4. upper lumbar symptoms
398
Knee Bend in side lying
normal response
Normal response: pulling or pain in area of quadriceps muscle
399
Butlers Two Treatment Concepts
1. Tensioner
| 2. Slider
400
Butler
Tensioner
Put the nerve under tension at both ends at the same time
401
Butler
Slider
Put the nerve under tension at one end at a time (in two step process)
Tension and one end and slack on the other end
402
When to do tensioner vs slider
Rhythmical,, steady, consistent, not forceful (like a grade 2, steady and consistent)
Might opt to do sliders first especially in cases where you don’t know how reactive that nerve will be
Then do tensioner when you’re in a more chronic state and want to get more progressive
Can throw someone off if you’re too aggressive with your neural tensions
403
Order of testing
```
Active movement tests
Repeated and sustained active movement test
Resisted
Passive mobility test
Passive accessory test
Neuro test
Neuro dynamic test
```
```
Active movement tests
Repeated and sustained active movement test
Resisted
Passive mobility test
Passive accessory test
Neuro test
Neuro dynamic test
```
404
Case study – stiffness with active movements, did not get worse with repeated, did not have relief with opposite movements, decreased play at a specific segment
Maybe facets probably not moving on each other the way they are supposed to be moving
Concept of: opening and closing
– maneuvers
Open – flexion, sidebending away, rotation toward
Closing – extension, sidebending same side, rotation away
405
Action to open facets
flexion, sidebending away, rotation toward
406
Action to close facets
Closing – extension, sidebending same side, rotation away
407
Patient’s L3/L4 segment is stiff when side-bend to the right:
Sidelying
Abduct the leg, Stabilize the SP with thumb, put legs in 90-90, block the SP of the vertebrae above,
rotate the legs to the floor or to the ceiling
Stabilize the SP and rock the pelvis to the head or to the feet in a side-lying position
408
4 positions to mobilize stiff L3/L4 when sidebend right
PRONE – abduct leg – manually stabilize SP with thumb
Stabilize L3 strongly
Do a grade 3 or 4 oscillation or sustained stretch at that end ROM and get pathological limit closer to the normal limit
SIDE LYING
Lumbar SB in side-lying
Legs at 90/90, block the SP above the level to be stretched
Rotate legs to the ceiling
SIDE LYING -PELVIS
Side-Lying using pelvis – stabilize level above
Rock pelvis cranially/caudally
SITTING:
use thumb as fulcrum against SP and SB trunk – perhaps for lower T- segments
For a lower thoracic or upper lumbar issue: can stabilize the SP and side-bend over the thumb in a sitting position—hard to make this passive, it would be active or active assistive
409
Eight tests successfully discriminated patients with low back pain from normal subjects and were significantly related to self-report disability in activities of daily living:
1. pelvic flexion,
2. total flexion,
3. total extension,
4. lateral flexion,
5. straight leg raising,
6. spinal tenderness,
7. bilateral active straight leg raising,
8. and sit-up.
גב
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