Axial Exam 2 Content
Unilateral PAs are used for pts that have difficulty with side bending and rotation towards a certain direction. If a therapist performs a unilateral PA on the *left* articular process of C3, they are working on either improving ____________ of C2 on C3, or improving __________ of C3 on C4 a. Left rotation, right rotation b. Left rotation, left rotation c. Right rotation, left rotation d. Right rotation, right rotation
a (Left rotation, right rotation)
What is the positional dx? (Left posterior TP of L5 in neutral and in flexion, even TPs in extension) a. ERSR b. ERSL c. FRSR d. FRSL
b. ERSL
TP is posterior on the R at L5; You identify this in flexion, in extension the TPs appear even. What is the POSITIONAL DX? a. ERSL b. ERSR c. FRSL d. FRSR
b. ERSR (As they flexed, they rotated right--therefore they can extend and side bend right)
Name the dysfunction: Pt's TP is posterior on the *right* at L5 while they are in flexion. In extension the TPs appear to be even. What is the *movement restriction*? a. ERSR b. FRSR c. ERSL d. FRSL
d (FRSL) (positional Dx = ERSR, type II non-neutral dysfunction) (pt cannot flex properly or SB left)
Name the dysfunction: Pt's TPs are posterior on the *right* at 2 or more segments and remain posterior when the pt flexes, extends, and when their spine is in neutral. What is the *positional Dx*? What type of dysfunction is this? a. FRSR; Type II b. NRot Left; Type II c. ERSR; Type I d. NRot Right; Type I
d (NRot right, type I) (Type I neutral dysfunction since present in ALL positions)
Which of the following is not an appropriate treatment approach when treating joint hypomobility: - PAIVMs - Mobilization with Movement (MWM) - Manipulation - Muscle energy techniques (METs) - all of the above are appropriate options
e (all of the above are appropriate options)
The following are possible causes of which movement restriction? - Right extension hypomobility - Left flexor muscle tightness - Anterior capsular adhesions - Right subluxation - Right small disk protrusion
extension and right side bending
A pt presents to you with restriction in extension and left side-gliding in C spine movements with no other restrictions. The *movement restriction* is ERS-R and the *positional Dx* is FRS-L. To treat this, position the pt to the edge of their *(flexion/extension)* barrier and then engage in the *(left/right)* SB barrier by translating the head from *(left to right/right to left)*. Have the pt activate the muscle that performs the opposite movements by *using their eyes* to provide the directional movement. To increase SB, have the pt resist the pressure you are applying to their *(left/right)* temple and instruct the pt to not let you move their head in the *opposite direction*. Hold for 3-5 sec.
extension, right, right to left, left (•Have the patient take a deep breath and they decrease the isometric contraction and the tension decreased move them further into a left lateral glide. •Repeat and/or engage other barriers of extension and/or right rotation - use eyes) (Additional Rx & HEP: retraction with repeated motion in supine and sitting, SNAGs/self-SNAGs, correct posture & ergonomics, T spine mobz) (FAST principle = Flexibility, [muscle] Activation, Strength & stability, Training specific - to pt's activity needs/goals)
Capsular pattern of the cervical spine
extension, equal loss of rotation and SB (side bending) (flexion usually unaffected)
Name the *lumbar* spine condition based off the following history & PE - - Back pain that can be associated with groin or thigh pain (typically does *not* radiate below knee) - Paraspinal tenderness - Reproducible Sx with *extension and rotation* - Coughing does *not* exacerbate Sx
facet syndrome
_________ LBP is reported to cause __-___% of chronic LBP. It is a result of repetitive stress, cumulative trauma, and inflammation at the facet joint.
facetogenic 5-15% (Facet joint OA is common; lumbar rheumatoid, psoriatic and gouty arthritides are much less common)
T/F: evidence has shown MET is the best intervention to intervene with movement restrictions
false (no conclusive evidence...typically better results when combined with exercise)
When trying to differentiate between hip pain vs SIJ pain, if you put the pt's hip in FABER and they feel pain *anteriorly* this indicates (hip/SIJ), whereas if the pt's pain symptoms are *posterior* which indicates (hip/SIJ) dysfunction
hip (anterior), SIJ (posterior) (if pt reports posterior pain, you need to differentiate between SIJ and gluteal pain)
What are the 2 possible causes of complications associated with the use of general HVLA thrust techniques
incorrect pt selection (lacking a Dx or incorrect Dx; lack of awareness of possible complications; inadequate palpatory assessment; lack of pt consent), poor technique (excessive force, amplitude, leverage; inappropriate combo of leverage; incorrect plane of thrust; poor pt/operator positioning; lack of pt feedback)
Fryette's ____ Law/Rule: When the spine is in *neutral*, lateral flexion and rotation occur in *opposite* directions (neutral mechanics - facets are not engaged or locked) - only applies to L and T spine. Cervical facets are always engaged - *Type I Mechanics*
1st (Law 1 also know as Type I dysfunction - "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 vertebra") (SB and Rot occur in the same direction in typical C spine EXCEPT in C1/C2)
What are the 2 reasons to use lumbar manipulation:
increase motion, decrease pain expected to know the proposed mechanisms (Exact mechanism still being examined, but the current proposed reasons why Lumbar manips help LBP = Changes in ANS/sympathetic tone, & a neuroendocrine system response [decrease in cortisol release])
If you've cleared the L spine, a pt does not have issues with repeated movements, and LBP does not centralize or peripheralize, this (increases/decreases) the probability of an SIJ dysfunction being the pt's problem
increases
While palpating a pt's TPs, if one is more *posterior on the left* compared to the right, you would say that vertebral segment is rotated to the (left/right)
left
The following findings are indicative of a (right/left) compression pattern in the spine - - Flexion: asymptomatic - Extension: Left buttock pain - L sidebending: Left buttock pain - R sidebending: asymptomatic - L rotation: asymptomatic - R rotation: could be symptomatic - Flexion + L sidebending: asymptomatic or symptoms lessen - Extension to pain onset + L sidebending: *severe* left buttock pain
left (need to localize the source of Sx to a specific spinal segment and then determine if that spinal segment is hypomobile or hypermobile, then you can develop a Tx strategy)
MET Clinical Application: - Precisely controlled position/proper _________ - Specific direction - Distinctly executed ________________ - __________ not pounds - 3 reps of 6-8 seconds each, re-test - __ sets per treatment
localization, counterforce, ounces, 3
In the absence of aggravating factors and insidious onset, what should you be thinking?
major problem
What nerve provides innervation to facet joints of the spine - the facet joint typically receives *dual innervation* from a *branch above* and one *at the same level* (makes it hard to pinpoint neural innervation issues)
medial branch of dorsal rami
Facet joints have a _________ sleeve that are extensions of the synovium. These sleeves can be found on the anterior, posterior, or both aspects of the facet joints and function in helping to guide to joints, keep the capsule from getting pinched, and increase the surface area of the facets (for attachment sites) - not present in everyone - most are fibrous in nature, some adipose, and some fibroadipose in nature
meniscoid (some people have them, some people don't--could be why some people have more neck pain than others)
What are the 4 M's that can help treat a compression pattern in the spine?
mobilization, movement, manipulation, muscle energy
Related to spinal dysfunction, this is *where we find the restriction*/what the vertebrae *cannot do* - the position the facets will NOT go - this is the direction in which we will get the segment to move with Tx - determined via movement exam and palpation skills (TPs)
movement restriction (opposite of positional Dx) (Ex: positional Dx = FRSL --> Movement restriction is ERSR)
(Multifidi/Longissimus) are active with *contralateral* spinal rotation, whereas (multifidi/longissimus) are active with *ipsilateral* spinal rotation - *Both* are active with ipsilateral sidebending and extension
multifidi, longissimus
The 'Movement Control' section of Treatment Based Classification chart involves flexibility of _________, __________ and __________ as well as the need to gain good motor control which happens through what 3 stages?
neural structures, joint, ST (soft tissue), (3 stages of motor control:) activation, acquisition, assimilation
Clinical Pearl: "The PE of the lumbar spine must include a thorough assessment of the ________________, _____________, and ______________ systems of the hip, LE, low back, and pelvic region."
neuromuscular, vascular, and orthopaedic
Case Study: - 77 y/o male - 1 month hx LBP - PMH: R inguinal hernia repair (2 months ago), asthma, chronic a-fib, long hx of multiple episode of LBP - meds: bronchodilator & warfarin - radiographs: slight decalcification, old compression fx of corpus L2&3, DJD - Tx: chiropractor--no improvement over 7 sessions Do you manip?
no (should see improvement quickly with manips) (following last tx, immediate increase in sx, radicular pain--turned out to be lumbar hematoma)
Substantive (reversible/non-reversible) lumbar complications: - Significant vertebral compression fx or disruption of spinal canal - Disc herniation-prolapse-extrusion - Persistent radiculopathy - Cauda equina
non-reversible
___________ = Sacral *base* flexion with inferior lateral angles (ILAs) moving posteriorly - makes sacrotuberous ligaments taut
nutation (sacral bases moving anterior and inferior)
Combined movements: if the initiating movement is side bending (latexion), the conjunct rotation of the joint is (same side/opposite)
opposite
In an *anterior* SIJ torsion dysfunctions, the *seated FF test* is positive on the (same/opposite) side of the diagnosed sacral torsion
opposite (Seated FF test is named according to the side that is stuck forward in nutation. The anterior torsion is named according to the direction the sacral base is turned E.g. If the right sacral base was STUCK forward into nutation the sacrum would be TURNED TO THE LEFT. The seated FF test would be positive on the RIGHT) (Seated FF test blocks out innominate movement so you really focus on sacral movement: whichever sacral base is caught on the innominate will flex forward and is unable to counternutate whichever sacral base goes forward, the axis is the opposite side; e.g. if the right sacral base was stuck in nutation the axis would be the left axis)
This is *how we name a dysfunction* and is based off of what the vertebrae *can do*/the position it is stuck in - basically a directional preference - Type I example: Neutral SB left rotate right - Type II example: Flexed rotated SB (FRS) right, Extended rotated SB (ERS) left - determined via movement exam and palpation skills (TPs)
positional Dx (opposite of movement restriction)
Kyphosis in the T spine increases with age, especially between the 5th and 6th decade. Exercises that target and strengthen the (anterior/posterior) thoracic musculature can delay the progression of kyphosis
posterior (exercise examples: horizontal GH ABD TB pull aparts, TB resisted bilateral GH flexion, bird dog, anything really OH; foam roll T spine; Cat-cow, thread the needle, child's pose)
A good way to differentiate between a costotransverse joint issue vs a facet joint issue is by _________ the ribs
springing (palpate TP and then spring the rib; if this reproduces pt's Sx = likely a costotransverse joint issue and not a facet joint issue)
This test is believed to be an indicator of pelvic girdle function in cases characterized by SIJ pain. - ability of the pelvis to maintain stability during load transfer between the spine and lower limbs is key - if the PSIS on the same side of the stance limb moves cephalad relative to the sacrum, the test is positive (motion occurs b/c the anteriorly rotated pelvis is not locked in place) - if the PSIS has no motion relative to the sacrum on the stance limb, the test is negative
stork test
As you bend forward (flexing your spine), you are (stretching/compressing) the posterior components of the spinal capsule (facets)
stretching
As you rotate to the *left*, you are - (stretching/compressing) the Left facet joints in the L spine + T11-T12 - (stretching/compressing) the Right facet joints in the L spine + T11-T12
stretching, compressing
As you rotate to the *right*, you are - (stretching/compressing) the Left facet joints in the C and T spine - (stretching/compressing) the Right facet joints in the C and T spine
stretching, compressing
As you side bend to the *right*, you are - (stretching/compressing) the Left facet joint - (stretching/compressing) the Right facet joint
stretching, compressing
The following are recommendations for treatment of neck pain with mobility deficits in the (acute/subacute/chronic) - Cervical mobilization or manipulation - Thoracic manipulation - Cervicoscapulothoracic endurance exercise
subacute
There are 3 categories for approaches to exam of the SIJ, what are they
symptom provocation tests (higher reliability), tests of static position of bony landmarks, position testing during movement, monitoring bony landmarks
T/F: A "type 1 dysfunction" will present with asymmetry in neutral, flexion and extension.
true
T/F: In the study comparing normal healthy people's SIJ motion vs people with degenerative lumbar spinal disorders (DLSD), the people with DLSD had *more* SIJ movement
true
T/F: studies have shown that cervical thrust manipulations and non-thrust manipulations are *equally* effective with *no difference* between their outcomes
true (Thoracic spine manipulation + exercise is MORE EFFECTIVE compared to exercise ALONE)
T/F: the sacrum does the opposite motion as the spine
true (lumbar flexion = sacral extension = counternutation)
T/F: Studies have shown a potential effect of performing PAIVMs is decreasing a pt's pain perception / increasing their mechanical pain threshold
true (harder to activate pain via mechanoreceptors)
T/F: when treating a spinal compression Dx, it is best to start the patient in a painless position to perform PAs, and gradually progress them into their painful direction
true (need to start in direction of preference to eliminate pain and prevent muscle guarding)
TPs are posterior on the right at 2 or more segments. TPs are posterior on the right in flexion, neutral, and extension. - Type I or II dysfunction? - Nomenclature? N-Rot or FRS/ERS? - Positional dx? - Which Fryette's Rule? - Movement restriction?
type 1, N-Rot, N-Rot R, 1, unable to rotate L and SB R
SIJ torsion/rotational dysfunctions are named first according to the (axis being moved on/direction sacral base is turned), *then* according to the (axis being moved on/direction sacral base is turned)
(FIRST:) direction sacral base is turned, (SECOND:) axis being moved on
If someone has both type 1 and type 2 dysfunctions, which should you treat first?
(recommended to treat) type 2
What is the capsular pattern of the thoracic spine
(symmetric limitation of...) rotation, SB, extension (least loss of flexion --> makes sense due to most of the population being kyphotic)
General Rules for Mulligan Techniques: - visualize __________ ____________ - movement must not produce ________ - mobilization technique applied in the direction of ___________________ motion - active or passive overpressure @ ____ ______
- joint plane - pain - osteokinematic - end range
what are the indications to perform a reverse NAG?
- unsuccessful NAGs - cervical & upper thoracic dysfunction - stiff thoracic spines - end range lower cervical rotation dysfunction
Approx how long could your patients experience some transient effects following a HVLA manip?
24-72 hours
Fryette's ____ Law/Rule: if spinal segments are fully engaged in *flexion or extension* (non-neutral spine), then lateral flexion and rotation occur in the *same* direction (controversial). - always applies to C spine - *Type II Mechanics*
2nd (•Law 2 also know as Type II non-neutral dysfunction - "When any part of the spine is in a position of hyperextension or hyperflexion, the side bending of the vertebra will be to the same side as the rotation of that vertebra." •This motion always occurs in C2-T3)
Fryette's ____ Law/Rule: if motion is reduced in one plane, the motion in the other planes are reduced
3rd (•Fryette's third "law" tells us that if motion in one plane is introduced to the spine, any motion occurring in another direction is thereby restricted.)
When selecting MET as an intervention tool, what 3 things should you look for (to ID the problem as a MSK somatic / mechanical dysfunction)? (*ART*)
Asymmetry (of position), Restriction (in ROM), Tissue (texture changes)
Special test: while in supine one hip flexes and the other is extended, apply an overpressure - named according to the side with the hip being flexed (posterior innominate)
Gaenslen's or pelvic torsion
A ______ refers to any *mobilization* that involves the voluntary use of the pt's muscles. Used in clinical practice to *restore mobility of a motion segment*, retrain global movement patterns, reduce tissue edema, stretch fibrotic tissue, and retrain the stabilizing function of the intersegmental muscles - Use when/with: endfeel = muscular, to relax the pt (in general or prior to manip), pts opposed to traditional manual therapy (manips/mobz), to lengthen a muscle in spasm, to *mobilize* restriction joint motion - Performed in ~3 sets of 6-8 seconds each, pt is moved further into limited motion during relaxation period between each set - *Two techniques*: Reflex inhibition & Contract-Relax
MET (muscle energy technique) (Basically take joint to its barrier, instruct pt to hold against GENTLE therapist resistance; resistance may be applied either into or away from the restriction) (Hypertonicity of a muscle in the lumbar spine can restrict osteokinematic function of that segment. --> in plain words: Really small spinal mm - if they're tight or spasming they may prevent proper facet motion; going to utilize antagonist muscles in order to relax)
This method of spinal mobilization was first coined by Mulligan. It is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient. Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier. This treatment should *never cause pain* and should *quickly* result in pt symptom changes. - Two basic techniques: SNAGs & NAGs - Successful glide-mobilization is applied approx. 10 times before reassessing the joint motion
MWM (mobilization with movement) (SNAGs = Sustained natural apophyseal glides; can be applied to spinal joints, rib cage, and SIJ; therapist applies appropriate zygagophyseal glide while pt performs symptomatic movement; This must result in PAIN FREE movement; most successful when Sx are provoked by a movement and are not multilevel; usually performed in WB positions NAGs = Netural apophyseal glides; Basically an oscillatory glide; often used for C and upper T spine; mid-end range facet joint mobz applied antero-superiorly along treatment planes of joint selected; useful for grossly restricted spine movement; Tx of choice in highly irritable conditions)
If someone has a loss of FB (C5 on C6) which nag do you perform? loss of BB (C5 on C6)?
NAG C5 into flexion on C6; NAG C6 into extension on C5
This MWM technique is basically performing oscillatory mobilizations/glides. It is often used in mid-end range for C spine and T spine joints. - Useful for grossly restricted spine movement - Done in WB - Tx of choice in highly irritable conditions
NAGs (natural apophyseal glides) (similar to PAIVMs) (finesse techniques: traction & vary amount of flexion)
When you are *nodding* your head (yes) this motion occurs at what joint - Roll and glide are in (opposite/same) directions at this joint - the joint has ____ deg flexion and ____ deg extension; very minimal rotation occurs at this joint - (convex/concave) on (convex/concave) joint surface (same/opposite direction)
OA (Atlanto-occipital) - Roll and glide are in *opposite* directions at this joint - the joint has ~10 deg flexion and ~15 deg extension; very minimal rotation occurs at this joint - convex on concave joint surface (opposite direction) (SB and Rot to opposite directions If L SB is restricted at this joint found in extension the movement restriction = E SB [L] Rot [R] positional Dx = F SB [R] Rot [L])
what are the 4 primary directions for PAIVMs (prone) in the cervical spine?
PA central glide on spinous process, PA on auricular pillar/transverse process (unilateral or bilateral), transversely on the lateral side of the spinous process, AP on articular pillar or vertebrae
glides / accessory intervertebral movements; assesses joint glides - Helps determine the presence of articular involvement - If joint glide is restricted, the restriction cause is articular (joint surface or capsule). If joint glide is normal, the restriction must be caused by extra-articular structure (muscle or periarticular structure) - falls into 'Movement Control' section of Treatment Based Classification chart
PAIVM (passive accessory intervertebral movements) (•End-Feels •If articular restraints are irritable, range may be normal but spasm end-fee •Reflex muscle contraction can also prevent motion cause pain •If end-feel is softer than expected capsular one, suggests compromise of structure. •Hard, capsular end-feel indicates a pericapsular hypomobility, •Jammed end-feel indicates a pathomechanical hypomobility.) (this can be used to treat joint hypomobility)
PROM at a particular joint; assesses the ability of each segment to move through its normal physiological ROM. Physiological movements repeated in a WB/gravity-eliminated position that can tell us if joint motion is normal, hypomobile (reduced), or hypermobile (excessive). - Helps determine the presence of articular involvement - Characterize as normal, excessive, or reduced compared with neighboring segment - falls into 'Movement Control' section of Treatment Based Classification chart - *Indications*: abnormal movement, abnormal joint position
PPIVM (passive physiological intervertebral movements) (Hypomobility: if painful, may be acute sprain of a structure; if painless, may have contracture or adhesion - use PAIVM to determine if restriction is articular or extra-articular)
What are some of the methods used to increase ROM?
PPIVMs, PAVIMs, Mulligan, Thrust, mobilization devices, rotation
This joint is very stable and functions in distributing and dissipating forces coming from the ground up the LE and as well as forces coming from the top of our bodies down the spine. The wedge-shaped bone articulates with the wings of the pelvic innominates
SIJ (sacroiliac joint) (innominate = bone without name; made up of the ischium, iliac, and pubic bone)
This MWM technique is a prolonged PAIVM while the pt moves through their ROM. It is useful in the spine and extremities and should be *safe & painless* - Most successful when Sx are provoked by a movement and are not multilevel - Done in WB positions
SNAGs (Sustained natural apophyseal glides) (therapist applies appropriate zygagophyseal glide while pt performs symptomatic movement; This must result in PAIN FREE movement)
Favorable responses to SNAG with acute lumbar flexion ROM - _______ after several successful SNAGs - tape into _________ - may add McKenzie approach (repeated extension) - Mulligan however would avoid extension if it were *___________*
STOP, extension, painful
Facet joint referral patterns: C2-3: C3-4: C4-5: C5-6: C6-7:
See pic
What are the *5 variables* that seem to be correlated with having a successful prognostic effect with the use of regional SI/Lumbar *manipulation*
Sx < 16 days, One hip > 35 deg IR, Lumbar hypomobility, No Sx below knee, FABQ (work) score < 19 (the more variables present in a pt, the higher probability of successful outcome with spinal manipulation [5 variables = 99%]) (Study suggested that looking at the variables in general may be more predictive for which pts will improve with their LBP Sx, regardless of intervention applied [manips, mckenzie, etc])
When trying to identify a treatable somatic lesion (body issue), what does the acronym START stand for
Sx reproduction, Tissue tenderness (TTP), Asymmetry (alignment or movement), ROM, Tissue texture change
(Type I/Type II) movement - - When lumbar spine is in a *neutral* position, side bending and rotation occur to *opposite* sides
Type I (to lock, side bend & rotation to the same side)
(Type I/Type II) movement - - When lumbar spine is in a *flexed or extended* position, side bending and rotation occur to *same* side
Type II (to lock, side bend & rotation to the opposite side)
TPs are posterior on the right at L5. Identified in flexion. TPs appear even in Extension. - Type I or II dysfunction? - Nomenclature? N-Rot or FRS/ERS? - Positional dx? - Which Fryette's Rule? - Movement restriction?
Type II, ERS or FRS, ERSR, 2, FRSL..unable to FLEX rotate L and SB L
__________ is how we name the dysfunction, this is the position the facets can move into and they are "stuck" there a. positional diagnosis b. movement restriction
a. positional diagnosis
Does the pt have a directional preference? If yes--treatment? If no--now what?
Yes: direction-specific exercises No: do they meet 4 criteria? (no symptoms distal to the knee, low FABQW <19, >1 hypomobile segment, hip IR >35) ^^if yes to these, manip
The position the person is "stuck" in, which is also the direction of movement they can move into is known as the? a. positional diagnosis b. movement restriction
a. positional diagnosis
Which of the following is *not* essential for differential Dx and indicative of a referral to a different medical practitioner: - Pt has pain that is reproducible by specific motions and/or positions - Pt's clinical findings are suggestive of serious medical or psychological pathology - Reported limitations or impairments are inconsistent with Dx/classification scheme - Pt's Sx are not resolving with applied conservative interventions
a (Pt has pain that is reproducible by specific motions and/or positions)
While some sources claim the SIJ moves around SEVEN axes of motion, Lepak suspects this is incorrect and was not a fan. Instead, he preferred the 3 axes from a study mentioned in the ppt. These three axes were: - X (flexion/extension), Y (rotation), Z (side bending) - X (flexion/extension), Y (right torsion), Z (left torsion) - X (nutation/counternutation), Y (longitudinal), Z (oblique) - X (latitudinal), Y (longitudinal), Z (nutational)
a (X -flexion/extension-, Y -rotation-, Z -side bending)
The key to performing a thrust in the thoracic region is: a. finding that balance point where it feels like you are pivoting them at the spot that requires the thrust b. using as much force as you can generate to ensure you get a cavitation c. using an "ape" hand (PIP and DIP flexed while MCP in neutral) vs an open hand position (hand is flat with fingers in neutral) when trying to manipulate the person in the supine position d. using the extension gliding technique over the flexion guiding techniques when trying to alleviate cervical headaches and facilitate good posture
a (finding that balance point where it feels like you are pivoting them at the spot that requires the thrust)
What is the main muscle that attaches to the *sacral base*: a. multifidi b. piriformis c. iliopsoas d. transverse abdominis
a (multifidi) (erector spinae also attach to the sacral base via their attachment to the lumbosacral fascia)
Which of the following is *NOT* a common characteristic/clinical presentation for a pt with neck pain with mobility deficits: a. Older age (>50 y/o) b. Acute neck pain (< 12 wks) c. Restricted cervical ROM d. Segmental hypomobility of the C and T spine (found during PPIVMs and PAIVMs) e. Sx isolated to the neck (referred pain may be present)
a (older age > 50 y/o) (Characteristics/Clinical Presentation: 1. Younger age < 50 years 2. Acute Neck Pain < 12 weeks 3. Restricted Cervical ROM 4. Segmental hypomobility of the cervical and thoracic spine. - found during PPIVMs and PAIVMs - 5. Symptoms Isolated to the Neck -referred pain may be present)
A "type II dysfunction" may present with asymmetry in? - flexion and neutral - extension and neutral - only in flexion - only in extension - flexion, extension, and neutral
a, b, c, or d (trick question)
If someone is stuck in FLEXION (their positional dx) they are able to Flex. They cannot Extend (movement restriction). I will notice this asymmetry when they try to _______. a. extend b. flex
a. extend
The following are recommendations for treatment of neck pain with mobility deficits in the (acute/subacute/chronic) - Cx-Tx mob or manip - Cx ROM, stretching, and isometrics - Advice to stay active plus home cervical ROM and isometrics - Supervised exercise, including; cervicoscapulothoracic and UE stretching, strengthening, and endurance training - General fitness training (stay active)
acute
In a/an (anteriorly/posteriorly) rotated innominate, the ASIS on the involved side will be *inferior* compared to the uninvolved side with palpation. During the long sitting test, the involved side will appear *longer in supine* and will shorten or become neutral as pt comes up into long sitting - Positive standing FF test on involved side - In prone, involved side PSIS is superior compared to contralateral side
anteriorly (MET for anteriorly rotated innominate: use hamstrings and glutes to pull innominate backward/posteriorly rotated)
passively shrugging your patients shoulders helps to differientiate a myogenic restriction (scapulocervical or thoracocervical musculature) vs _____________ restriction in the cervical spine?
athrogenic
The facet joints of T1-T2 are typically innervated by the medial branches from: a. only T1 b. C8 and T1 c. T1 and T2 d. T2 and T3
b (C8 and T1)
A pt presents to you with LBP that you suspect is sacral in origin. You perform a series of tests and the results were - - Seated FF test: positive on the left - Spring test: positive - Palpation: Left sacral base is more posterior/superficial What is the most likely Dx? - Left on Left anterior/forward dysfunction - Left on Right posterior/backward dysfunction - Right on Right anterior/forward dysfunction - Right on Left posterior/backward dysfunction
b (Left on Right posterior/backward dysfunction) (A positive seated FF test indicates there is an anterior or posterior SIJ dysfunction; The axis of the dysfunction is always opposite of the positive side - with this question the positive side was on the Left so the axis = right axis A positive Spring test indicates a posterior/backward SIJ dysfunction This + the Left sacral base being more posterior/superficial with palpation suggests that the sacrum is rotated left along the Right axis)
Case Study: A 45 y/o male with a chief complaint of Left LBP with paresthesias (tingling) along the Left posterior thigh and anterolateral aspect of the left LE. Pt's occupation = quality control manager. His pain is intermittent and variable, being the most intense in the evening and at night making it sometimes difficult to fall asleep. Occasionally the pt is awakened by his pain, but is able to fall asleep after repositioning. Pt's pain is increased with L SB, Extension, PSLR on L side, prolonged walking and sitting as well as with coughing and sneezing. The pt has no Hx of cancer or other general health concerns. Upon PE of the left hip: passive ADD was limited and reproduced L posterior thigh pain, while passive hip flexion, IR and ER were equal bilaterally (noncapsular pattern). Of all this information, what is *not consistent* with MSK pain? a. pain being intermittent, passive ADD reproducing Sx, pain increasing with coughing & sneezing b. Night pain, passive ADD reproducing Sx, pain increasing with coughing and sneezing c. tingling along thigh, pain increasing with side bending and extension, pain being intermittent d. none of the above are correct
b (Night pain, passive ADD reproducing Sx, pain increasing with coughing and sneezing) (pain increasing with coughing & sneezing may be discal in nature or potentially visceral) (Pt was not making progress, pt got X-ray and other medical imaging while continuing with PT, this pt had small cell carcinoma of the lung that had metastasized to hip Red flag/warning signs: Not getting better with PT, hip pain that doesn't follow capsular pattern, >50yrs, pain lasting more than a month)
During a spinal examination, if *more* ROM is present when the scapulo-cervical muscles are *relaxed*, this indicates the origin of the pt's pain Sx are likely due to a a. joint/articular issue b. muscular issue c. visceral referral issue d. none of the above are correct
b (muscular issue) (e.g. perform a passive shoulder shrug on a pt. Ask them to SB their head to the L and R; If ROM is limited equally it might be more joint/articular related; If ROM improves, more likely to be muscular issue)
What is the main muscle that attaches to the *anterior portion* of the sacrum? a. quadratus lumborum b. piriformis c. iliopsoas d. transverse abdominis
b (piriformis)
Name the dysfunction: Pt's TPs are posterior on the *right* at 2 or more segments and remain posterior when the pt flexes, extends, and when their spine is in neutral. What is the *movement restriction*? a. Left SB, Right rotation b. Right SB, Left rotation c. Left SB, Left rotation d. Right SB, Right rotation
b (right SB, left rotation) (positional Dx: NRot right; Type I neutral dysfunction)
The transverse processes are posterior on the right at 2 or more segments. The asymmetry is notices in neutral, flexion, and extension. This positional diagnosis is? a. N-Rot left b. N-Rot Right
b. N-Rot Right
A person with a FRS positional diagnosis (means they are "stuck" in Flexion, Rotation, and Sidebent) and means they cannot extend. The asymmetry when palpating would be found when they? a. flex b. extend
b. extend
what are the absolute contraindications to spinal manipulations?
bone (any pathology leading to bone weakening), neurological, vascular, lack of diagnosis, lack of pt consent, pt positioning cannot be achieved due to pain/resistance
A pt asks about the potential harm that could occur with a lumbar manipulation. Your best response in this situation is to tell them: a. "It is about the same risk as taking NSAIDs on a regular basis" b. "It is really anyone's guess" c. "Severe complications from lumbar spinal manipulations seem to be rare, about 1 in several million manipulations" d. "The overall serious complications of lumbar spinal manipulation include death, disc herniation, and lumbar fracture"
c ("Severe complications from lumbar spinal manipulations seem to be rare, about 1 in several million manipulations")
Name the dysfunction: Pt's TP is posterior on the *right* at L5 while they are in flexion. In extension the TPs appear to be even. What is the *positional Dx*? What type of dysfunction is this? a. FRSR; Type II b. NRot Left; Type I c. ERSR; Type II d. NRot Right; Type I
c (ERSR; type II) (type II non-neutral dysfunction since ONLY seen in flexion) (pt is able to extend normally thus that is their positional Dx, flexion would be their movement restriction since they can't do that properly without spine rotating)
The *ventral* rami of ______ is thought to primarily supply the ventral (anterior) portion of the SIJ a. L3 b. L4 c. L5 d. S1
c (L5) (Ventral rami of S2 supplies lower portion)
Lumbar manipulation, according to the Treatment-Based classification system, is used for: a. movement control b. functional optimization c. symptom modulation
c (symptom modulation) (Clinical findings: disability = high, Sx status = volatile, Pain = high to moderate Tx: directional preference exercises, manip/mobz, traction, active rest) (look for directional preference & utilize if pt has one; usually use a manipulation if pt is NOT responding or doesn't have a directional preference)
Of the following SIJ tests, which one has the highest reliability and potentially most useful: - tests of static position (palpation of bony landmarks) - movement testing monitoring bony landmarks - symptom provocation tests - all of the above are equally reliable and useful for diagnosing SIJ dysfunction
c (symptom provocation tests)
Match the section of the thoracic spine with their likely transverse process' location: a. T1-T4, T9 b. T5-T8 c. T9-T11 -___: TPs at the base of the SPs -___: TPs up 1 interspinous space -___: TPs up 2 interspinous spaces
c, a, b (these don't work that well...but people have used them for a long time) (picture info doesn't agree with Lepak's slides, but it looks quite official so :] ) (Generally the TRANSVERSE process is at the level of the Spinous process of the vertebra 1 level above in the thoracic spine. T11 & 12 are more difficult to predict due to the variability in position.)
What is the movement restriction? (Left posterior TP of L5 in neutral and in flexion, even TPs in extension) a. ERSR b. ERSL c. FRSR d. FRSL
c. FRSR
The 3 lumbar PAIVM techniques
central PA (over SP), unilateral PA (over articular process) (checks rotation), transverse (glide) (on lateral side of SP) (also for rotation)
If someone has a loss of rotation equally left to right, which nag do you perform? loss of unilateral rotation or SB?
central nag @ appropriate level; unilateral nag over facet (try involved side 1st)
The following should be included in a POC for what condition? - Education in proper posture and body mechanics - Soft tissue techniques - Segmental mobilization techniques to improve range of motion - Improve deep neck flexor endurance - Scapular stabilization training - HEP to maintain gains achieved during physical therapy - Likely will need a few treatments over several weeks (Dr. Lepak reminder: Don't forget promoting moderate activities and the *thoracic* spine mobilization)
cervical hypomobility
The following are recommendations for treatment of neck pain with mobility deficits in the (acute/subacute/chronic) - Previous activities - Additional measures may included: pulsed or high-power US, intermittent mechanical traction, repetitive brain stimulation, TENS, electrical muscle stimulation
chronic (modalities are typically not indicated unless chronic)
As you bend backward (extending your spine), you are (stretching/compressing) the posterior components of the spinal capsule (facets)
compressing
As you rotate to the *left*, you are - (stretching/compressing) the Left facet joints in the C and T spine - (stretching/compressing) the Right facet joints in the C and T spine
compressing, stretching
As you rotate to the *right*, you are - (stretching/compressing) the Left facet joints in the L spine + T11-T12 - (stretching/compressing) the Right facet joints in the L spine + T11-T12
compressing, stretching
As you side bend to the *left*, you are - (stretching/compressing) the Left facet joint - (stretching/compressing) the Right facet joint
compressing, stretching
This MET technique works through the principle of *autogenous inhibition* (a sudden relaxation of muscle in response to tension which is an inhibitory negative feedback lengthening reaction that protects muscles against tearing) - Characterized by *contracting the hypertonic muscle* from its lengthened position, having the pt relax, and then further stretching/lengthening the muscle into the direction that has been limited - e.g. contracting the hamstrings, relaxing, stretching the hammies more, repeat - Movement = *Towards restriction barrier* (more often used in L spine or if pain level is low) - Need: accurate localization, low intensity isometric contractions
contract-relax
_________ = Sacral *base* extension with inferior lateral angles (ILAs) moving anteriorly - relaxes sacrotuberous ligaments
counternutation (sacral bases moving posterior and superior)
Which of the following is *NOT* a reason to use PAs: a. treating pain through a range b. treating EROM pain or stiffness c. treating muscle spasm d. all of the above are reasons to use PAs
d (all of the above are reasons to use PAs) (treating pain through a range - •large amplitudes into discomfort •increase speed of oscillation as pain decreases treating EROM pain or stiffness - •small-amplitude movements at the limit of the range •apply to dysfunctional segment, then above and below, repeat procedure several times treating muscle spasm - sustained at first before pain is reached then slowly progress to where pain is felt, then wait and sustain. When pain/spasm decreases move to the next barrier, waiting time may be as long as a minute.)
You are examining a 50 y/o male with complaints of left LBP for several months, left posterior thigh paresthesia, and paresthesia along the left anterolateral thigh and leg. Your mechanical examination was inconclusive. Which of the following symptoms should cause the *greatest* concern and signal the need for further examination by their physician? - A non-capsular pattern of motion loss at the hip - Failure to improve after a week of conservative therapy - Insidious onset of symptoms - No relief of symptoms with bed rest
d (no relief of symptoms with bed rest) (If pt cannot get relief with bed rest, something more serious cannot be ruled out If pt does find relief with bed rest then can be more certain their condition is not more sinister/serious)
Which of the following is *NOT* an absolute contraindication for the use of spinal manipulation in a pt's treatment: - Bone pathology resulting in weakening - Neurological presentation (cord or nerve root compression) - Vascular deficits - pain and hypomobility - Lack of Dx - Lack of pt consent
d (pain and hypomobility) (Bone pathology resulting in weakness = tumor, infection, metabolic [ostomalacia], congentical [dysplasia], Iatrogenic [long-term steroid use, osteoporosis], inflammatory [severe RA], trauma [fx]) (Neurological = cord compression, cervical myelopathy, cauda equina, nerve root compression with increasing deficits) (Vascular = VBI, Carotid, hemophilia) (RELATIVE Contraindications of manipulation = adverse rxn to previous manual therapy, disc herniation, inflammatory arthritis, pregnancy, spondylosis/spondylolisthesis, osteoporosis, anticoagulants - bleed easier, advanced DJD/DDD, vertigo, lax ligs, arterial calcification)
While there are a multitude of risk factors for SI joint pain, which of the following encompasses the 3 most important (in Lepak's eyes): - obesity, inactivity, HTN - osteoporosis, prolonged sitting, malnourishment - smoking, repetitive lumbar flexion, arthritis - pregnancy, MVA, trauma (falling onto buttocks)
d (pregnancy - ligament laxity, MVA, trauma - falling onto buttocks) (Other risk factors for SIJ pain: leg length discrepancy, prolonged vigorous exercise, lumbar surgery, torsional strains, infection, arthritis)
What would be true of the following if the sacrum is unilaterally nutated anteriorly (flexed) on the *left* : - The left sacral base is more posterior/backward compared to the right side - The left ILA is more anterior/forward compared to the right - the seated FF test would be positive on the right - the seated FF test would be positive on the left
d (the seated FF test would be positive on the left) (Lepak thinks a left unilateral nutation would basically look and feel the same during palpation as a right unilateral counternutation - so how do you tell the difference? It'll be based on the seated FF test)
TP is posterior on the R at L5; You identified this is extension, the TPs appear even in Flexion. What is the *positional dx*? a. ERSL b. ERSR c. FRSL d. FRSR
d. FRSR
What are the 6 tests in the Laslett's Algorithm to help rule in/out SI joint?
distraction, thigh thrust compression, sacral thrust, Gaenslen's (both sides)
T/F: A therapist can isolate a PA glide to one vertebral segment
false (Most, 3°- 4°, of the motion occurs at the segment of the central PA application, but this motion is also propagated both cranially and caudally) (In general a central PA causes extension throughout the lumbar spine except when it is applied to the upper two segments. At that point it still causes extension in the upper segments, but some flexion can be seen in the lower segments - a central PA on L1 will cause flexion at L4-L5)
T/F: The SIJ is a very mobile and unstable joint that is the source of majority of LBP
false (SIJ generally has LESS THAN 1mm of movement & SIJ has only been reported as the cause of LBP in ~10-13% of cases) (SIJ is primarily designed for stability; movement does occur here but it is very minimal)
T/F: costotransverse joints typically refer to a larger area than facet joints
false (costotransverse are typically more local)
T/F: Intense pain in both tuber & fortin areas is more likely amenable to SI injections
false (less likely)
T/F: there is a one single test that is highly reliable to diagnose SIJ disfunction
false (no single test, need to cluster tests) (positive cluster = 35% probability of SIJ, negative cluster = 92% certainty SIJ is unlikely)
T/F: Overall serious or severe complications of lumbar spinal manipulations seem to be common
false (they seem to be RARE) (minor complications such as stiffness/soreness are common but usually last less than 24 hrs--up to 72)
T/F: When performing a spinal manipulation, if you do not get an audible pop upon the thrust technique, and you choose to try again, you need to add force/amplitude to your thrust
false (you need to reposition pt precisely and add ONLY QUICKNESS to your next attempt) (-the main reason to do a thrust is to "jostle the joint" to relieve a slight, remaining restriction - the real work of restoring mobility and function is usually done via non-thrust -a cavitation, or "audible pop", is mainly a sign that the joint can move)
T/F: level 1 and/or level 2 RCT state that for acute/chronic low back pain you should NOT use thrust or non-thrust joint mobs
false (you should use them)
Non-neutral dysfunctions: If you are stuck in ext. what can't you do?
flex
The following are possible causes of which movement restriction? - left flexion hypomobility - left extensor muscle tightness - left posterior capsular adhesions - left subluxation
flexion and right side bending
The side to be manipulated (SI) was determined with the following algorithm: - first, the side of the positive standing ________ test; - if this test was negative, the side of tenderness during ________ sulcus palpation was manipulated. - If neither side was tender, the side reported by the patient to be _______ symptomatic was manipulated. - If the patient was unable to identify a more symptomatic side, the therapist _________ __ _____ to determine the side.
flexion, sacral, more, flipped a coin
What is the capsular pattern of the hip
flexion, ABD, IR
This area is located just below the PSIS and is a common pain referral area for pts that have true SIJ pain
fortin (area)
Once a hypomobile segment is identified, we must engage the barrier with our grade of treatment. What grade is necessary at these joints?
grade 3 or 4
What 4 criteria/variables are looked at that have a predictive favor that stabilization exercises would produce successful outcomes when treating LBP (as opposed to using lumbar manipulation) - having at least 3 of these 4 indicates the use of stabilization exercises for intervention
greater general flexibility (avg SLR ROM > 91 deg, postpartum, or high BLLS), positive prone instability test, positive aberrant movements, age < 40 y/o
In a/an (anteriorly/posteriorly) rotated innominate, the ASIS on the involved side will be *superior* compared to the uninvolved side with palpation. During the long sitting test, the involved side will appear *shorter in supine* and will lengthen or become neutral as pt comes up into long sitting - Positive standing FF test on involved side - In prone, involved side PSIS is inferior compared to contralateral side
posteriorly (MET for posteriorly rotated innominate: use rectus femoris and iliacus to pull innominate forward/more anteriorly rotated)
This MET technique is characterized by contracting a hypertonic muscle's *agonist* - e.g. contracting the quads in hopes to relax the hamstrings - Movement = *Away from restriction barrier* (more often used in C spine of in irritable cases) - too forceful of a contraction will be counter productive (increases synergistic activity) - When an agonist muscle contracts and shortens, its antagonist must relax and lengthen so that motion can occur in the agonist muscle. The contraction of the agonist reciprocally inhibits antagonist so that smooth motion may occur. A simple example of this is that one cannot flex the elbow unless the extensors relax.
reflex inhibition
Substantive (reversible/non-reversible) lumbar complications: - Minor vertebral compression fx - Disc herniation-prolapse - Nerve root compression - Adjoining or Regional strain
reversible
In a *posterior* SIJ torsion dysfunctions, the *seated FF test* is positive on the (same/opposite) side of the diagnosed sacral torsion
same (e.g. if a pt had a Right on left posterior torsion, their sacrum is TURNED TO THE RIGHT, and the RIGHT sacral base is STUCK leading to the positive seated FF test)
Combined movements: if the initiating movement is rotation (rotexion), the conjunct lateral flexion is (same side/opposite)
same side
(Type I/Type II) dysfunction - Asymmetrical presentation in neutral, flexion *and* extension (found in all 3) - Multi-segmental - May be adaptive or compensatory to a lesion above or below
type I (neutral dysfunction) (-Neutral dysfunction •Type I: letter "N" is used for neutral, NSLRR •Coupled to opposite sides - SB and Rot •Multiple segments - 3 or more, scoliosis •Compensatory •Present in all three positions; flex., ext. and worst in neutral •Treat last)
In neutral, we observe the TP of L5 is posterior. We flex them and still see a posterior TP. In extension, the TPs appear even. Is this a Type I or Type II dysfunction?
type II
(Type I/Type II) dysfunction - Dysfunction/asymmetry is present in *either* flexion *or* extension but NOT both - single spinal segment - trauma is common - It is recommended to treat this type of dysfunction *first* - Nomenclature for this type: FRS right, FRS left, ERS right, or ERS left
type II (non-neutral dysfunction) (ERS will be FOUND in flexion FRS will be FOUND in extension Neutral: TPs should look okay) (•Type II - ERS or FRS; right or left •Coupled to same side •Single segment •Traumatic •Major restriction present in neutral and either flex. or ext. •Treat first)
TP is posterior on the right at L5. Identified in extension. TPs appear even in flexion. - Type I or II dysfunction? - Nomenclature? N-Rot or FRS/ERS? - Positional dx? - Which Fryette's Rule? - Movement restriction?
type II, ERS or FRS, FRSR, 2, ERSL--unable to extend, rotate L and SB L
The following movement restriction can be caused by what? - side bending in neutral, flexion and extension
uncovertebral hypomobility or anomaly
