USA S1 Midterm
A state of hypermobility that is clearly unstable. The joint usually looses its normal opposition of articular surfaces, may rest in an abnormal position and demonstrates instability of active motion.
Instability and Luxation
• Disappears when adequately supported • Hypertonic but otherwise normal to touch • Limb feels 'heavier'
Involuntary muscle holding
The innermost portion of the intervertebral disc has irregular fiber direction and is ...
avascular, aneural.
• In 2005 the World Federation of Chiropractic unanimously agreed that chiropractors should be identified as ...
back-care specialists
Anterior to the posterior tubercle on on either side is the groove for the vertebral artery which is important to recognize because as the vertebral artery comes up the transverse foramen, from C6 all the way up to C1, once it crosses the transverse foramen of C1 it travels posteriorly they anastamose to form the ____ ____ in the foramen magnum.
basilar artery
Still, much of the legal difficulty in which physical therapists find themselves is due to giving up the right to use the term "manipulation." The Model Practice Act for Physical Therapy states the following: "Because of political sensitivities over the term "manipulation," it may occasionally be necessary to ...
find an acceptable alternative that still authorizes, and in no way limits, the use of manipulative therapy procedures by physical therapists."
If you are asked how many joint surfaces are on the sacrum, the answer is six, but if you are asked how many synovial joints are on the sacrum than the correct answer would be ...
five.
in functional side bending of the neck, the head ...
follows the neck to look in front of the shoulder.
What Principal Type of Technique is this? The progressive oscillation, a stretch which combines oscillations, has several advantages over the simple stretch. It allows for stretches in easy stages during which the clinician can note the tissue changes and decide to continue or to cease. Typically the first oscillation begins at the first stop, the second and third take the joint to the second stop, and the fourth and final oscillation, pushes the joint beyond the second stop (true barrier) to change its end feel.
Progressive Oscillation (Paris)
• He's a pain in the booty • She's a pain in the neck • Expressions that tell us stress gets to our spine
Psychosomatic stress
Kaltenborn changed the theoretical foundation of manipulation through his application of ...
arthrokinematic (intricate mechanics of joints) principles to manipulation.
Thus for instance, in cervical side bending right functionally the head follows the neck into side bending and rotating right - actually remaining relatively neutral on it. But when performing non-functional side bend right where the head chooses to remain facing the front despite the fact that the neck is side bending and rotating right - then there must be left rotation of the head on the neck. As you will learn in S3 most if not all that left rotation is ...
at A/A.
Because of the unique shape of these joints its in multiple planes of motion but you could think of it as being in the horizontal plane.
atlantooccipital joint. The same with C1/C2, the atlanoaxial joint.
both of those joints are in the coronal plane, and they are horizontal
atlantooccipital, atlantoaxial
C1/C2 is "biconvex". So its convex on convex. What keeps it stable is the...
ligaments around it.
a yellow ligament and it is attaching from lamina to lamina, all the way up and down the spine.
ligamentum flava
There is no ____ _____ between occiput and C1 and C1 and C2. Instead you have these membranes.
ligamentum flavum
between C2 and C3 is where the ____ _____ begins.
ligamentum flavum
Spastic torticollis is a correct use of the term, as is the spasm that may occur when a trigger point or sensitive structure is stimulated causing ...
nearby muscle fibers to twitch.
In lumbar spine Anterior to the facets is the vertebral arch, which is where the ...
nerve root exits the vertebrae.
Still, the theory that subluxations can cause disease and correction of subluxations can facilitate the cure of disease is the basic tenet of chiropractic; a tenet for which there is ...
no scientific proof.
• The direction of treatment planes, which according to Kaltenborn should ...
not just be tangential to the joint, but follow a line drawn across the surface of the concave joint member.
Summary of what to look forDuring EXAMINATION OF ACTIVE SPINAL MOTION
• Ease of performance • Smoothness of curve (symmetry) • Recruitment of vertebra o hitching o blocking o instability (juddering) o trick movements o range
. Myofascial Pattern of Lumbar Spine:
• FB limited • all other movements relatively free
Arthrokinematics of thoracic FB
• Facets are vertical and the ribs also play a role • Facets slide up and ribs rotate on their long axis
Arthrokinematics of lumbar FB
• Facets slide up and somewhat forwards especially at their lower levels
Forcible trauma is usually the cause - there will invariably be joint damage and forcible reduction will be required.
Dislocation
In lumbar sine Most posterior structure is the spinous process. Anteriorly to process, on either side is the ____
lamina.
'If a bone appears to be out, but has normal motion ...
leave it alone'
With right side bending, the ____ alar ligament becomes taut.
left
if you are going to rotate the subcranial spine to the right, then your ___ alar ligament is going to get taut.
left
Three aspects of pain
physical, rational, emotional
In the lumbar spine, Only four joints are synovial, the other ...
two (discs) are fibrocartilagenous.
Where joint surfaces have lost their normal relationship and are unable, actively or with gentle passive motion, to return to its neutral or rest position.
Dislocation
there are a total of ___ vertebrae in the spine.
33
Manipulation philosophies based on normalizing joint mobility: Emphasis is on restoration of normal 'joint play.' The techniques are specific for the extremities, less so on spine.
Mennell
How many joint surfaces on C1/Atlas? -
5 total - 2 are superior articular facets on either side, these are very broad and flat because they hold the occipital condyles - 2 inferior articular facets - 1 is the facet for the dens, located on the posterior aspect of the anterior tubercle.
This is a superior view of a cervical vertebrae. If you look posteriorly, you see that the spinous process is...
"bifid". It is a "Y" shaped spinous process. (unique to cervical spine.
Any time we talk about vertebrae in the spine, we are often discussing them in pairs, because we are concerned with the ____ ____
"motion segment".
the midpoint on the back of the posterior arch of the atlas.
"posterior tubercle".
Additionally, tender muscles we palpate may be in ____ _____ as a result of prolonged muscle guarding and are thus tender due to simple accumulation of metabolites.
'chemical holding'
It is not possible (except at one small every shifting point in range) to side bend the spine without it also rotating. Nor is it possible to rotate without it also side bending. Thus, these motions are ...
'coupled' or as some would say 'combined.'
A useful method of detecting tone or tension in the subcutaneous tissue is to use the technique known as _____or a more simple technique preferred by this author for its rapidity and ease of instruction called here _______
'skin rolling' /'20 degree skin rolling'.
Still proposed • Proposed the "law of the artery" What is that?
(health depends on adequate blood supply, diet and nutrition, exercise, and healthy living).
where the dens articulates with the anterior arch of the atlas.
(median atlantoaxial joint)
How many articular surfaces on a typical cervical spine vertebrae?
- 10 - two superior articular facets - two inferior articular facets - two intervertebral discs - two uncinate processes superiorly - two uncinate processes inferiorly
- If a step on standing or muscle tone, decreases upon lying
- Spinous processes frequently deviated • Not necessarily a positional fault
SB rules In the Subcranial Spine NON-FUNCTIONAL
- side bending causes rotation to the opposite side -Rotation produces side bending to the opposite side
. How many joint surfaces are on a typical lumbar spine vertebrae?
-6: 2 are the superior articular facets -2 inferior articular processes - 2 intervertebral discs on intervertebral bodies above and below.
Frequent sites of spinous process deviation
-Bifid upper lumbar spines are common -Recessed T11 is common
During EXAMINATION OF ACTIVE SPINAL MOTION- As a rule leave the shoes on. Why?
-More functional -Doing up laces and pulling on boots can injure the back, especially when more vulnerable following a relaxing examination and/or treatment
Where are the six joints of the sacrum?
-Two where the sacrum articulates with the innominate. -superior articular processes of the sacrum articulate with the processes of L5 to make up the L5/S1 facet joints. -Inferiorly, one comes from the sacrococcygeal joint and superiorly it integrates with the L5/S1 intervertebral disc.
So T7 articulates with the ...
7th rib above and then the 8th rib below.
What happens to the spinal canal during
-it is narrowed and shortened -the disc and ligamentum flava bulge into the spinal canal on full backward bending
How many joint surfaces on your typical thoracic vert.? 12 total:
-on each side there are three surfaces that articulate with ribs -superior and inferior costal facets, costal facets on transverse processes -the superior and inferior costal facets are the "costovertebral facets" where the vertebrae articulates with the rib (the costotransverse joint) -the superior and inferior costal facets articulate with two separate ribs. The costal facets on the transverse processes articulate with the same rib as the superior costal facets. -superior and inferior facets B add another 4. -the last two are from the intervertebral discs above and below -12 total surfaces, 10 are synovial
Chiropractic medicine was founded by ...
Daniel David Palmer in 1895; 20 years after the foundation of osteopathy.
A muscle having less than the normal response is termed hypotonic. This could be due to ...
-reflex inhibition, such as in the quadriceps when the hamstrings are on stretch, - in the lumbar spine due to nerve root involvement.
Six results of restricted motion
1. Disuse atrophy of supporting musculature 2. Degeneration of synovium ... Pannus like in-growth of synovium 3. Contraction, binding and proliferation of collagen 4. Nutrition of the disc reduced due to restricted osmosis and filtration 5. Generalized loss of segmental flexibility and function 6. Liability to further injury
The spinous process BELOW the slipped vertebra forms a step and the slippage is felt AT THE LEVEL of spondylolisthesis
Degenerative Spondylollisthesis
The core of chiropractic teachings has been called the Law of the Nerve, which can be described as follows:
1 A vertebra may become sublimed 2 This may cause impingement of nerves 3 Which interferes with the vital nerve force and causes disease 4 The cure lies in adjusting the vertebrae.
Clinical Signs of Instability
1 History or demonstration of tissue relaxation/creep: 2 discomfort increase as the day wears on, relieved by movement or rest 3Increased muscle tone while standing 4 Presence of a 'step' or rotation (spondylolisthesis, retrolisthesis or spondylolysis) while standing 5 Disappearance of muscle tone, step or rotation on prone lying 6 Shaking (juddering) while forward bending 7 grade five or six on passive motion palpation 8 radiological evidence of motion studies of forward and backward bending showing both increased angulation between the vertebra and more important still - excessive translation
Five categories of spine tx
1 Manipulation 2 Exercises 3 Posture 4 Modalities 5 Back school
four contributions of Paris
1 appreciation of multiple spinal syndromes rather than a single cause 2 role of instability in spinal pain 3positional distraction as an alternative to mechanical traction 4de-emphasis on thrust techniques.
Tissue Palpation Consists of the Following:
1. Condition 2. Position 3. Mobility
Posture can be disturbed as a result of decrease in muscular strength or coordination, as a result of pain or disturbed vestibular function. [4] , [5] , [6] Postural abnormalities are associated with numerous dysfunctions. For example, the following dysfunctions have been associated with forward head position: (7)
1. Increased kypholordosis at lower levels 2. Stiff upper back and "hump" 3. Subcranial restrictions (atlas stuck posteriorly) 4. Dental malocclusion (jaw recedes) 5. Possibly decreased blood supply to brain) 6. Thoracic outlet syndrome, due to adaptive myofascial shortening and lowering of the clavicles 7. Shoulder dysfunction; decreased abduction and external rotation as well as harder end feels.
Dysfunction is reversible by
1. Manipulation for joint stiffness 2.Posture correction 3. Exercise to support joint instabilities 4. Myofascial stretching for adaptive shortening 5. Heat, massage and exercises for muscle tone and condition 6. Back school for prevention of recurrence
Five distinguishing features of our eval
1. We listen to the patient 2. Our hands are placed on the patient 3. We seek to find and reproduce the patient's 'pain' 4. We are not afraid to explain our findings 5. We alleviate their fears for now they know they have come to someone who understands their complaint
14 steps of a spinal eval
1. pain assessment 2. initial observation 3. history and interview 4. structural inspection 5. active movements 6. neurovascular assessment 7. palpation for condition 8. palpation for position 9. palpation for mobility 10. upper and or lower quarter assessment 11. radiologic and other medical data 12. summary of findings (assessment) 13. treatment plan 14. explanation and prognosis
in the lower thoracic and in the entire lumbar spine, the nucleus pulposis is typically positioned ...
2/3 of the way posterior. So that's why lumbar herniations are more frequent, compared to cervical herniations.
So we have 33 total vertebrae and __ intervertebral discs.
23
Seven vertebrae in the cervical spine, plus 12 thoracic, 5 in the lumbar spine, five fused vertebrae that make up the sacrum, and then ___ vertebrae that make up the coccyx gives you and avg. of 33 (unusally 4).
3-4
Implications of Terminology While in the minds of most, manipulation refers to thrust manipulation (accompanied by an audible "pop") the Guide to Physical Practice defines manipulation in the following manner: "Therapist Mobilization/manipulation: ...
A manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissue that are applied at varying speeds and amplitudes, including a small-amplitude/ high- velocity therapeutic movement."
The author prefers the progressive stretch as it combines the best of the traditional with Maitland. Why?
A stretch is necessary to increase range restricted by a 'tight' capsule but by adding the oscillations and presumably firing more mechanoreceptors (Type I and II) and thus closing the 'gate' to nociception, the technique is more comfortable to the patient.
1 Normal tone 2 Limited range of motion
Adaptive shortening
Another important influence on physical therapy manipulation. • A physician and an osteopath • Taught both Kaltenborn and Paris • Made many important contributions to techniques and theory • Emphasized the role of the sacroiliac joints, facet joints, ligaments, and muscles in spinal pain at a time when most focused on the disc • Introduced traditional osteopathic techniques to physical therapists • Emphasized skill in locking and hand placement • De-emphasized force
Alan stoddard
runs down the entire anterior portion of the spine. It is a very thick and supportive ligament.
Anterior longitudinal ligament
• Mani with movements • Promotes natural apophyseal (facet) glides by assisting the motion being performed by the patient usually in a weight bearing position.
Brian Mulligan
The facts that the surfaces are both convex and more or less in the horizontal plane, lend to increased motion for rotation at this segment. So, 50% of your rotation is going to occur at ...
C1/C2.
. Typically _____ spinous processes are bifid.
C2-C6
Most cephalic intervertebral disc is ___
C2/C3
The ligamentum flava runs from the---
C2/C3 segment, lamina to lamina, all the way down to L5/S1.
Define Mid Cervical region of the spine : C2/C3-C7/T1
C2/C3-C7/T1
gray area bw mid cervical and upper thoracic
C7/T1
Define Upper Thoracic region of the spine
C7/T1-T3/T4
• Remains even when supported • Doughy to touch • Limited range of motion, i.e., extensibility
Chemical muscle holding
• In 1976 ___ ____ and three other chiropractors sued the AMA, American Hospital Association, and American Radiological Association on grounds of restraint of trade; claiming that these three associations denied them, among other, hospital privileges. Wilk won his case and the Committee on Quackery was disbanded.
Chester Wilk
_____ perform the majority of manipulations in the United States; 94% of manipulations covered by insurance are performed by them.
Chiropractors
_____ began stabilization exercises in the 1970's and _____ published on the physical examination for instability in Spine in 1984.
Evjenth/Paris
• Given that no one has ever biopsied a fibrositic nodule then this condition does not exist
Fibrositis
A non entity.
Fibrositis:
These motions are termed 'pure' in that they exist without causing either side bending or rotation which always work in combination and are thus termed 'combined' or 'coupled.'
Forward and Backward Bending (Extension and Flexion)
"No one physical therapist has done more than _____ ______to upgrade the art and science of joint manipulation. His studies with the likes of James Mennell, Stoddard, Cyriax and McConnail resulted in a thorough grounding and understanding not just of techniques and patient management but also of the basic science of arthrokinematics and how such science influenced the practice of manipulation."
Freddy Kaltenborn
Describes those motions we normally perform in the course of a day, e.g., forward and backward bending, trunk rotation.
Functional (physiologic)
Syria • Advocated and taught manipulation to physical therapists. Some of the most influential physical therapists in the field of manipulation were among his students in the 1950s:
Geoffrey Maitland Freddy Kaltenborn Stanley V. Paris . these were at the forefront when manipulation was re-introduced into physical therapy.
-Started in the late 1950's to teach a system of orthopedic examination and manipulation. -Treatment consisted of graded oscillations and the occasional thrust -Aimed at reducing reproducible signs and symptoms.
Geoffrey Maitland of Australia
the father of ________, the founder of British Orthopedics, was a bone setter
Hugh Owen Thomas
An increase in range from the expected normal in that subject. In athletes especially gymnasts this may be the normal situation.
Hyper mobility
But, when it comes to advocacy for physical therapy manipulation, possibly the most influential figure was James H. Cyriax
James Cyriax
studied the phenomenon of manipulation scientifically; including with the use of radiographs. He wrote: "There is no magic about joint manipulation. When cure of symptoms occurs, it must be in accordance with the laws of anatomy, physiology and psychology. If existing knowledge of the laws does not cover proven facts they must be extended."
James Mennell
James Cyriax followed...
James Mennell at St. Thomas's
followed suit and advised his colleagues to "learn then to imitate what is good and avoid what is bad in the practice of bonesetters
James Paget
a staunch advocate of physical therapy manipulation in the United States. He published on manipulation in Physical Therapy.
John Mennell (James Mennell's son)
_____ ________ is now an integral part of the practice of physical therapy and serves as part of the management of most spinal and extremity joint conditions.
Joint manipulation
may increase with repetition if the muscles are weak, or decrease if the muscles are strong and are learning through repetition to adapt.
Juddering (shaking)
• Emphasis on convex-concave relationships of joint surfaces; an idea developed from the work of Marlin; central to modern physical therapy manipulation.
Kaltenborn
The Grading System for Intersegmental Mobility [PIVM that we use is based on that of _____ and ____ (1959) who were the first to place numbers on the range of passive intervertebral motion. Both used a different system.
Kaltenborn/Stoddard
Manipulation philosophies based on normalizing joint mobility: Emphasis is on arthrokinematics, particularly convex-concave relationships. Techniques are very specific and somewhat eclectic.
Kaltenborne
It is very important to recognize that the spinal cord ends around ...
L1
Define Lumbar Spine region :
L1/L2- L5/S1
Most caudal disc is at ____
L5/S1
all of the joints of the sacrum are synovial, except the...
L5/S1 intervertebral disc articulating with the sacrum which is a fibrocartilagenous joint
More noticeable in the thoracic region is the condition where the patient has small areas no larger than a silver dollar and ever so slightly raised. These areas feel 'doughy or spongy', and pressure of more than a second or two upon them may result in leaving behind the examiner's fingerprints marked clearly into the skin to such a degree that the fine details of the fingerprints may be noticed.
Localized Swellings:
The spinous process of slipped vertebra forms a step and the slippage is felt ABOVE THE LEVEL of spondylolisthesis
Lytic spondylolisthesis
Manipulation philosophies based on relieving pain: The manipulations performed must produce 'no pain,' and the direction of manipulation is 'contrary' to the direction of greatest hypomobility (least direction of restriction). Maigne techniques are derived from osteopathic joint techniques, and they are specific.
Maigne
Manipulation philosophies based on relieving pain:Oscillations are used to eliminate reproducible signs. The techniques are specific.
Maitland
The skilled passive movement to a joint
Manipulation
Physical therapists should only mobilize, not manipulate?
Manipulation and mobilization is synonymous, according to the Guide to Physical Therapy Practice.
What Principal Type of Technique is this? There are a number of techniques, which while they are traditionally performed passively on the patient, may be assisted in restoring active movement if indeed the patient moves with the clinician. It is a 'natural' movement that the clinician gives over pressure. Mulligan terms this a MWM, i.e., a mobilization with movement. In this text a number of techniques lend themselves to this additional emphasis and shall be so indicated with MWM.
Manipulation with Active Movement (Mulligan)
Manipulation philosophies based on relieving pain: Repetitive motion is used for centralization of pain.
McKenzie
THORACIC AND CERVICAL PIVM Techniques Covered
Mid-Thoracic • Spring Test o prone lying P.A. over spinous process for tilt o prone lying P.A. over transverse process for glide o prone lying P.A. over adjacent trans. proc. for rot. Upper Thoracic in Sitting • Forward Bending • Side Bending • Rotation Mid-Cervical • SB; supine lying
This is perhaps the most difficult of all passive mobility tests for the novice to perform correctly and to illicit the necessary information as to mobility.
Mid-cervical side bending
occasionally crystalline like deposits can be felt along the scapula crest. Also, in the area of the sacroiliac fibro fatty nodules can be felt and dissected. These are entities that have been explored and demonstrated.
Muscle Deposits
an entity and is related to the rheumatic group
Myalgia
This technique rarely needs performing and should be avoided in the elderly. It gives very little information and may on occasion prematurely test the vertebral artery resulting in an accident.
Neck BB
Describes those motions which are not normally performed, e.g., neck or trunk side bending while facing forwards, i.e., in a frontal plane.
Non-functional, (non-physiologic)
Define Upper Cervical (aka sub cranial) region of the spine :
O/C1/C2
What Principal Type of Technique is this? These have value for the reduction of pain (Grade I and II) or for gentle prodding of the barrier (Grade IV). Grade IV may be delivered in a series of short bursts against the barrier. They are gentle, have the advantage of oscillations and hence firing mechanoreceptors that lessen discomfort and hence muscle guarding.
Oscillations (Maitland)
Manipulation philosophies based on normalizing joint mobility : Joints and body structures are mobilized for increased motion. The techniques are specific.
Osteopathy
• Founded in 1874 by physician Andrew Taylor Still following a divine revelation
Osteopathy
Here we shall feel for abnormal amounts of fat, tissue fluid tension, localized swelling, nodules and a sense of a lack of 'health' - indicating poor diet, alcoholism, etc.
Palpation of subcutaneous tissues
Manipulation philosophies based on normalizing joint mobility: Emphasis is on restoration of normal arthrokinematics, especially component and joint play motions. Pain is de-emphasized. Techniques are specific and eclectic.
Paris
Tissue Fluid tension In the male it is frequently present in individuals suffering from ___ ____
Peter's Principle
Summary of Indications for Manipulation
Relief of discomfort • By oscillations and repetitive motions to gate discomfort • By mechanically increasing ROM which in turn • enables gating of discomfort • hasten repair of tissues Restore more normal motion • By mechanical methods of stretch and progressive stretch which in turn o helps gate pain o increase tolerance to insult
• Repetitive motion is used for centralization of pain which many interpret as centralizing the disc.
Robin McKenzie
LUMBAR TECHNIQUES
Rotation o lumbosacral gap - ligamentous tension lock - using straight leg o lumbar rotation using progressive oscillations via the transverse processes o Mid-lumbar rotation in side lying - ligamentous tension locking • Side Bending o lumbar side bending - prone lying - abducting leg - thumb or finger block o lumbar side bending - side lying raising legs • Myofascia o lumbar multifidus isometric to the facet capsule o stretch to myofascia in supine lying Upper Lumbar • Upper lumbar rotation in side lying - ligamentous tension locking adaptation of mid-lumbar rotation Other • Distraction o positional distraction
Defined as an uncontrolled involuntary twitch
Spasm
Denotes a facilitated segment
Spasm
• Studied with Cyriax, Stoddard, and Kaltenborn, as well as with osteopathic and chiropractic schools and practices. • Appointed lecturer in spinal treatments at the New Zealand School of Physiotherapy.
Stanley V. Paris of New Zealand
Instability was first spoken of by _____ in the 1950's and part of his PIVM (passive inter vertebral motion) testing.
Stoddard
What Principal Type of Technique is this? Is a force applied at the barrier with the intent of moving through the elastic to the plastic area and thus creating deformation and hence increased length? The deformation results in heat and this may be used from four to eight seconds later to apply a second stretch against what is then a softer and more pliable barrier.
Stretch (traditional)
Mechanical Effects of Manipulation
Stretch restrictions within the capsule • Restore fiber glide • Restore ability to crimp • Stretch or snap adhesions between the capsule and bone ends
Our definition is again of a hypermobile/unstable joint to the degree that the normal anatomical relationship has been lost - such as in a flaccid hemiparesis. But, and here is the key, the joint can be manually returned to its normal or rest position. Used in this sense the cause is usually neurological.
Subluxation
• _______became the field of specialized practitioners (barber surgeons, physicians)
Surgery
another gray area bw upper and mid thoracic.
T3/T4
Define Mid Thoracic region of the spine :
T3/T4- T12/L1
the first step in preparing to deliver a manipulation force.
Taking 'up the slack'
Physical therapists are not required to learn manipulation?
The Commission on Accreditation in Physical Therapy Education (CAPTE) requires the teaching of mobilization/manipulation.
Manipulation philosophies based on relieving nerve root pressure Chiropractic (traditional)
The purpose is to move vertebra to relieve nerve root pressure. These techniques are specific.
Manipulation philosophies based on relieving nerve root pressure Bonesetters
The purpose of this technique is to click bones back into place. These techniques are specific.
Manipulation philosophies based on relieving nerve root pressure Cyriax
The spinal techniques are designed to move the disc, and thus relieve nerve root pressure. Cyriax techniques are non-specific.
Normal motion on rotation for RR:
The spinous process swings left, then curls slightly upwards toward end of range
Only Chiropractors can safely manipulate?
There is no evidence of harm to patients when manipulation is done by physical therapists. Physical Therapists are authorized, qualified, and competent to manipulate.
Common in the upper thoracic areas, particularly of women at middle life but occurring in both sexes, it appears also to accompany nervous tension and anxiety states.
Tissue Fluid Tension:
For palpation in standing, Any findings that warrant attention may now be palpated Examples:
Tone of muscles • Reversal of a curve, i.e., reversed thoracic kyphosis • Presence of a step suggesting spondylolisthesis
• Goes when supported • Voluntary movements restrained • No doughiness
Voluntary muscle holding
• Muscle lacks bulk • Does not demonstrate normal elastic tone to touch • May feel 'stringy'
Wasting and fibrosis
a British physician who had learnt manipulations from a local bonesetter, a book on manipulation in 1870. He advised his colleagues to seek to understand the reasons for the successes of manipulation
Wharton Hood
Physical therapists do not have a history in manipulation?
Wrong! Physical therapists were manipulating in Sweden and the Netherlands before the establishment of chiropractic.
how the disc gets its nutrition.
a cartilaginous end plate
When palpating for moisture, Any dry, smooth, shiny skin is indicative of ...
a chronic condition,
In a triple response of Lewis On occasion the redness will fail to show more than a slight trace and in such instances we would suspect...
a chronic involvement of the sympathetic nervous system at that level;
Although many chiropractors are starting to question the subluxation theory, the original postulates are alive and well: The definition adopted by the Association of Chiropractic Colleges in 1996, describes subluxation as ...
a complex of articular changes that compromise neural integrity, adversely influencing the function of organ systems and general health. [vii]
What we are palpating for is best termed as a 'difference,' that is, ...
a difference from the normal or expected.
Palpation • Cannot be performed by two persons on the same spot at the same time, such as experiencing sound, taste or a view. There is a Need for validation studies and improved psychomotor learning models. Some studies, conducted by experienced clinicians, show ...
a high intra rater reliability and methods need be developed to improve training that would enhance inter rater reliability.
The scratch test will evoke the triple response of Lewis, that is, ...
a histamine reaction which results firstly in a blanching followed by a reddening and later, perhaps, a wheal.
The upright orientation of facets in the lumbar spine , allows for ...
a lot more forward bending.
In a spinal eval we will find a good number of false positives, i.e., physical findings that do not bear on the patient's condition, e.g., :
a raised shoulder in a low back patient
Surely there is a better word than 'out.' What we are really observing is that a vertebra is 'stuck' at some point in its range, usually at end range, and is either unable or unwilling to return to neutral. It is simply caught by, say, ...
a roughness between the articular surfaces, by the impaction of a synovial meniscus, or by having stiffened up in a position in which it was held following some injury.
At the second stop the barrier is engaged and the type of manipulation may be considered - namely ...
a stretch or stretches, or a progressive oscillation.
fluid travels from the vertebral body, ...
across the cartilaginous disc, into the disc.
Use finger tip 'proprioceptive' stimuli to help facilitate the patient localizing these movements. Do not use the fingers to feel during...
active motion observation.
the orientation of the facet joints dictates our ...
active mov't or our function.
Palmer did not want to use the word "manipulation," probably in order to avoid that his treatment would not be confused with osteopathy, which he had studied extensively. 'Believing that all bodily functions are controlled by the flow of nerve vibrations from the brain to the spinal cord and out through openings between the vertebrae, Palmer claimed that ...
adjusting the vertebrae to remove interference with this flow of nerve energy would allow the body to heal most diseases.'
10 Chiropractors have claimed hegemony on the term manipulation; equating manipulation with ...
adjustments or simply with chiropractic [all of which is a stretch].
• The threat to the chiropractic profession is that other professions can manipulate; professions that are ...
aligned with mainstream medicine and adhere to evidence-based practice
For palpation of temperature, Contact is made at the neck and then slowly drawn down the paravertebral region, first on one side and then on the other. It will be noted that the upper thoracic area is usually the warmest and that the temperature decreases gradually until there is a somewhat sharp drop in temperature at the level of the iliac crest as the palpation passes over the gluteal muscles - an area that usually contains a higher percentage of body fat. Any change in this pattern from one level to the next, such as a suddenly warm area - may indicate...
an acute condition, or conversely a cool area a chronic condition
a slight rise in moisture is more indicative of ...
an acute condition.
made up of type 1 collagen which resists tension.
annulus fibrosis
The transverse processes in the cervicle spine have an ....
anterior and posterior tubercle.
relatively weak compared to others around the sacroiliac joint.
anterior sacroiliac ligaments, (oftentimes prone to dysfunction and injury)
But a fibrositic nodule there is not. The phenomenon of the nodules that we can feel in most thoracic erector spinae is nothing but muscle fibers contracting in response to the palpating finger to protect the underlying muscle spindles. If the finger is now rolled over these contracting muscles a 'nodule' like entity will be felt and depending on the muscle state will demonstrate a degree of discomfort. These same 'nodules' cannot be found in cadavers yet are universally present in the living. The only possible conclusion is that they ...
are a physiological response to the touch.
Iliolumbar ligament is a vry important stabilizer in the lower lumbar spine, attaching the lumbar spine to the pelvis. But it is also prone to dysfunction. It has a very specific pain referral pattern ...
around the posterior aspect of the iliac crest and then anteriorly into the groin.
There are in fact very few when one considers how gentle, as gentle as a breath, that a Grade I oscillation may be. On the other hand, there are numerous contraindications to strong stretching techniques. But again, many contraindications are relative to the therapist's skill and experience and so, like most items in life, it ...
becomes relative.
How many layers does the intervertebral disc have?
between ten and twelve layers.
Note the pars interarticularis, located ...
between the superior and inferior articular processes
• Manipulation remained in the domain of folk medicine, transmitted from father to son, as exemplified by the ______
bonesetters
• In order to survive, chiropractors will have to adapt a more scientific approach and it could be argued that many of them are doing that by ...
borrowing ideas from physical therapy.
We did not conclude that craniosacral motion does not exist, but based on our data, we ...
cannot conclude that it does either.
attaches the vertebral body to the intervertebral disc.
cartilaginous endplate
Everything in the vertebral foramen, below L1, is all...
cauda equina.
Directly posterior to that is the sacral canal which is where the ...
cauda equine is housed.
in the upper and middle thoracic, the joint plane is ...
closer to 60 degrees.
The vertebral arteries start at C6 and ...
come all the way up to C1, where they join in the foramen magnum.
Type II collagen resists _____
compression.
in non-functional side bending of the neck the head ...
continues to face forwards while the neck is being side bent - not something we normally do.
in the cervical spine, the joint plane is ...
coronal and about 45 deg. from horizontal
USA #7 That since dysfunction is the cause of pain, the primary goal of physical therapy should be to ...
correct the dysfunction rather than the pain. When, however, the nature of the pain interferes with correcting the dysfunction, the pain will need to be addressed as part of the treatment program.
So you have the costal facet of the transverse process, articulating then with the ...
costal tubercle on the rib.
lateral to the costovertebral joint, you will see where the rib again articulates with the thoracic spine vertebrae at the ...
costotransverse joint.
where the head of the rib articulates with the vertebral body of the thoracic vertebrae.
costovertebral joint
During the last two decades chiropractors have mounted an organized attempt to restrict physical therapy practice, by removing spinal manipulation from physical therapy state practice acts. From 1993-2004, at least 30 physical therapy state chapters have had to ...
defend the right of physical therapists to practice manual therapy.
Now we are looking down on the superior aspect of C2/axis. The most anterior portion is the____
dens/odontoid.
Palpation for tenderness or hyperalgesia is performed by the fingertips, drawn lightly over the surface of the skin in the ...
dermatome expected to be affected by the previously observed pathology.
When testing for mobility, • Start away from the restricted area so as to ...
develop an appreciation of what is normal for the patient • Also, respecting the painful area is less likely to provoke discomfort and thus the patient will remain relaxed and know what to expect when the testing procedure reaches the sensitive area.
Physician's Role
differential diagnosis & treatment of disease
Physical Therapist's Role
differential evaluation and treatment of dysfunction
. That's why they are often referred to as "U joints". You can also see how they sort of protect the intervertebral disk. This is one of the reasons why ...
disc herniations are less frequent in the cervical spine
Contraindications To Stretches, Progressive Stretches, Grades III and IV, and Thrust: ...
disease and likelihood of causing osseous and ligamentous damage
Physiology of the pop- The distraction creates a negative pressure which is countered by an explosion (pop) of fluid into a gaseous state. This obeys accepted fluid mechanics. The gas is most probably nitrogen. As a result the joint is now ...
distended since the gas occupies more space than the fluid.
• In 1963, the American Medical Association (AMA) formed its Committee on Quackery to address the chiropractic problem. This committee ...
distributed propaganda against chiropractic and worked to exclude payment for chiropractic services from federally supported health programs.
We don't think of the nucleus as a shock absorber, it is more ...
distributing forces in the lumbar spine.
the attachment of the cartilaginous endplate to the disc is _____ and it's a strong attachment. B
fibrocartilage
USA philosophy #1 That joint injury, including such conditions referred to as osteoarthrosis, instability and the after effects of sprains and strains are ...
dysfunctions rather than diseases.
Hypermobile segments will/may sublux into a faulty position... .
e.g., spondylolisthesis
means that all techniques are considered and practice takes a little from more than one group. A practitioner who merely follows one style is a limited practitioner.
eclectic
It should be evident that the Institute has attempted to instruct in an eclectic approach in recognition that our knowledge has come from many sources, that while no one school of thought has emerged supreme many can offer information and experience. Thus the Institute feels that while it certainly has its preferences and biases, it nonetheless has the responsibility to attempt to incorporate a little from every reputable source. Hence the ...
eclectic approach.
nodules are most prevalent in
ectomorphic females
Muscle tone It is an ____ ____ which we call normal.
elastic response
there is a little bit of a yellow discoloration to ligamentum flavum, it is sometimes referred to as the yellow ligament. It is unique because the tissue contains ...
elastin.
Medially, the supraspinous ligament turns into ...
erector spinae fascia around L3/L4.
the supraspinous ligament does not go below L3 or L4, depending on the individual. After that, it is mostly taken up by ...
erector spinae fascia.
USA #6 That the physical therapist's primary role is in the ...
evaluation and treatment of dysfunction, whereas that of the physician is the diagnosis and treatment of disease. These are two separate but complementary roles in health care.
How do we relieve physical causes of pain?
examine for and list the dysfunctions
How do we relieve rational causes of pain?
explain the physical findings and reproduce 'find' the patient's pain
also in the horizontal plane, but now it is downwardly sloping a little more to its actually at a 45deg. angle from the horizontal in the coronal plane.
facet joints of cervical spine
Additionally, the patient may report tenderness, particularly if we request them to inform us of anything that feels different. Again, by observing and palpating the operator may notice on touching a tender area a reflex spasm of muscle fibers, indicating a ...
facilitated segment.
So if your transverse ligament isn't present, then you are going to have the odontoid approximate into the spinal cord, upon ...
forward flexion of the neck and head.
• If a spasm is instant and consistent it is a ...
genuine response
] Chiropractors are coming to see the subluxation as a liability [v] and "perhaps the...
greatest single barrier to professional development for chiropractors."
The pop is not a goal of manipulation. When it occurs at a stiff joint then the effects can be very beneficial. When, however, it occurs at a hypermobile joint, which is usually the case with self manipulation, then the effects are often ...
harmful in a long term sense.
Uniquely, the outer annulus ...
has a blood supply and is innervated.
if a patient is restricted in non-functional side bending to the right but can perform it quite simply when doing it functionally it might just mean that...
his restriction is not a side bending right restriction but rather a rotation left of atlas on axis.
Lateral to the uncinate process, you can see the nerve root gutter, where that is going to...
house the nerve exiting the cervical spine.
Radiological studies are apt to be the least reliable since they show total range rather then movement within range and thus may confuse hypermobility for instability. These are distinct entities. Ex: Gymnasts may be ...
hypermobile but at least initially are unlikely to be unstable. •
A muscle that has a higher resting tone or a higher than expected response we term___
hypertonic.
• Muscles on occasion display an increase in bulk overweight is expected • Weight training • Instability
hypertrophy
The most common sight for fatty cysts (or subcutaneous nodules) is over the_____ _____about one to two inches from the midline. These are normally a little tender but can become acutely tender when there is other pathology in the segment.
iliac crest
, L4 is medial to the
iliac crest.
runs from the L4 transverse process in the L5 transverse process over to the innominate.
iliolumbar ligament
In lumbar spine, Note the____ ___ ____ which makes up the superior aspect of the intervertebral foramen (where the nerve root exits.).
inferior vertebral notch
The most important factor differentiating between the groups that practice joint manipulation is the...
intended purpose of the treatment.
typically stronger than the anterior sacroiliac ligaments.
interosseous sacroiliac ligaments
where the vertebral bodies are articulating with the intervertebral disc.
intervertebral joint
Denslow, an osteopath, wrote that with few exceptions (such as at the lateral side of the neck where the cervical nerves emerge), the tissues of the body framework are non-tender to moderate, non-traumatic forces. Abnormal tenderness is associated with an abnormality in the tension or 'tone' in the involved tissues and because, as will be discussed shortly; ...
irritation of hyperalgesia areas initiates certain patterns of neuromuscular reflex activity.
the reddening that occurs in a triple response of lewis can be very rapid and considerably intense - indicating...
irritation of the sympathetic nervous system at that level.
The multiple manipulative techniques have more in common than not in common. The principal differences are three:
is the manipulation principally to correct specific movement dysfunction (e.g., Paris); or is it to relieve pain by either gating it with oscillations (e.g., Maitland); or gating it with endorphins and the relaxation response (e.g., chiropractic).
If a vertebra appears to be out of alignment yet has normal PIVM then ...
it is not stuck and should be left alone.
What happens to the spinal canal in mid cervical FB?
it lengthens and also narrows, but volume remains about constant
'.. a state of altered mechanics, either an increase or decrease from the expected normal, or the presence of an aberrant motion.'
joint dysfunction
USA philosophy #5 the primary cause of degenerative joint disease is ...
joint dysfunction. Therefore it may be concluded that its presence is due to the failure or lack of accessibility to physical therapy.
the ligamentum flavum attaches to each...
lamina in the spine.
: Fatty tissue is usually evenly distributed, being firmer in the short, stocky type and often mistaken for musculature due to the increase in connective tissue present. Localized areas of fat are quite possibly ...
localized areas of tissue fluid tension.
in a lateral view of a facet from the thoracic spine, the spinous process is ...
long and downwardly sloping. That is a major difference bw facets from lumbar v thoracic.
Skin blemishes, moles and nodules that raise the level of the skin should be palpated, and particularly when of large size. If any of these ...
make a recent onset or appear to be attached to deeper structures, the patient should be referred to their physician.
In lumbar spine, Posterior lateral on the superior articular processes you find the _____ ______
mammillary processes.
USA philosophy #3 That where the dysfunction is detected as limited motion (hypomobility), the treatment of choice is ...
manipulation to joint structures, stretching to muscles and fascia and the promotion of activities that encourage a full range of movement.
Posterior to the sacral canal is the ...
median sacral crest.
Grade I and II oscillations have been used in the presence of ____ ________, and quite effectively for the relief of pain.
metastatic disorders
• Treatment with herbs developed into ...
modern pharmacotherapy
The same procedures as palpation for temperature now are carried out to detect ...
moisture changes.
As you move toward innermost layers of the intervertebral disc, fiber direction becomes...
more irregular.
In a spinal eval, we will collect info...
more quickly than we can assimilate it
. But in the spine an acute 'catch' often produces ...
motor shock or fear that causes the subject to go rigid and thus help maintain the dysfunction.
The mammillary process is where the ...
multifidus attaches
James Cyria created a system of
musculoskeletal diagnosis by selective tissue tension
Those who speak of fibrositis have not been able to show the fibrositic nodule nor to agree on clinical findings. It would be better to use the term __________which is probably in a chemical muscle state (see below) from fatigue or overuse.
myalgia (painful muscles)
is a canal through which blood supply can reach the vertebral body
natrium foramen
USA philosophy #4 That when the dysfunction is manifest as increased movement (hypermobility), laxity or instability, the treatment of the joint in question is ...
not manipulation, but stabilization by instruction of correct posture, stabilization exercises and the correction of any limitations of movement in neighboring joints that may be contributing to the hypermobility.
___ ____ sits between the spinous processes and the supraspinous ligament. So, it is posterior in the neck.
nuchal ligament
made up of type II collagen and water.
nucleus pulposis
• Beneficial effects of "the pop"
o a continuing stretch on the capsule o firing of the type III articular mechanoreceptors and GTOs of attaching musculature (multifidus) o thus reflex inhibition of muscle tone in the neighboring muscles
Arthrokinematics of BB in the lumbar spine
o facets slide down o facets fulcrum on the lamina o facet joints open up cephalically
Arthrokinematics of thoracic spines in BB
o facets slide down o ribs rotate
Arthrokinematics of midcerival BB
o facets slide down and back on the more caudal member o caudal facet meets the pedicle above and cephalid vertebra slides back on this contact result is that the superior part of the facet joint opens up (see X-Ray) o lateral interbody joints have slid backwards
Negative effects of "the pop"
o if already a hypermobile joint, then it will be more hypermobile o a stress on a disc which if hypermobile will become more so o a 'dependency' brought on by the feeling of immediate relief and perhaps by the release of endogenous hormones o for a short period of time, until the muscles regain their tone and the gas is re-absorbed back into fluid, the joint is at increased risk for injury since being swollen it is unstable and the muscles formerly protecting it have been relaxed
Arthrokinematics of sub cranial BB
o occiput rolls onto posterior atlas condyles o atlas slides posterior under occiput o atlas slides back on axis
Rules for FUNCTIONAL SB in lumbar and thoracic spine
o side bending causes rotation to the same side o i.e., the facets slide- down and back on concavity - up and forward on the convexity
In midcervical BB, Mid-cervical • The vertebra slide upwards and forwards on the vertebra below • This motion takes place in: (3)
o the facets, which slope up and forwards o lateral interbody articulations o intervertebral discs
How do we relieve emotional causes of pain?
o touch and caring, above all listening o explanation in positive and realistic terms o avoiding fearful expression (degeneration, arthritis, etc.) o give a prognosis and reassurance
Palpation of differences are _____ findings
objective
the outer annulus actually has an _______ orientation and the fibers cross each other. So this is why rotation can often be damaging to the disc, because we think of, if somebody rotates in one direction, you only have ____ of the fibers resisting that force.
oblique/50%
the alar ligaments attach the posterolateral portion of the dens, up into the ...
occiput, medial to the condyles.
In the Scratch Test, The dorsum of the thumbnail is now drawn down the patient's back from _____ to the ____ ____ _____ on a line about ____ ___ ____ to the spine.
occiput/5th sacral vertebra/1 1/2 inches lateral
Kaltenborn emphasized • Treat joint mechanics, not pain; on the assumption that ...
pain will be eliminated once function is improved. This position has been followed since by most physical therapy practitioners of manipulation.
• Sensitive 'nodules' are created by the _____ _____
palpating finger
This is a common site of fractures in the lumbar spine, especially lower lumbar.
pars interarticularis
Without great and awkward effort, rotation can only be ...
performed functionally
Physical therapists got involved early on. In Sweden, in the early 1800s, the forerunners of physical therapists - more aligned with physical education than with medicine - were...
performing manipulations, traction, and massage.
Manipulation in the US was reintroduced by foreign trained practitioners in the 1960s and 1970s, over the protests of the APTA and AMA (audio below); since then ...
physical therapists have lead in the development of manipulation.
Manipulation philosophies based on normalizing joint mobility: places the emphasis on mobilizing by combing manual overpressures with active range of motion, thus facilitating the active movement. There is some emphasis on arthrokinematics - Kaltenborn background.
places the emphasis on mobilizing by combing manual overpressures with active range of motion, thus facilitating the active movement. There is some emphasis on arthrokinematics - Kaltenborn background.
While muscles may initiate the motion and certainly control the posture throughout motion, it is the ...
plane of the facet joints that dictate the motion that will take place. ligaments play a restraining role towards the end range of motion.
runsalong that posterior arch of the atlas on up into the occiput.
posterior atlanto occipital membrane
Between the atlas and the occiput, you have the ____-______ membrane. That's a very thin membrane.
posterior atlantooccipital
You have the the _____ _____ membranes superiorly, then below that with the green circle, that's the _____ _____membrane.
posterior atlantooccipital/posterior atlantoaxial
runs up and down the entire spine, on the back side of the vertebral bodies and disc.
posterior longitudinal ligament
The alar ligaments attach the odontoid to the ...
posterolateral portion of the dens.
. After 1980, when physical therapists declared that the terms physiotherapy and physical therapy were synonymous, chiropractors in Florida are able to ...
practice "physical therapy" - they just cannot say they are physical therapists!
Contrary to what chiropractors claim, chiropractic has increasingly encroached on physical therapy territory. Most chiropractic schools teach physical therapy modalities [ii] and chiropractors have lately expanded of the definition of subluxation to include constructs, such as hypermobility and "aberrant motion" [iii] that were a part of the physical therapy vocabulary as early 1965. [iv] Furthermore, most chiropractic state practice acts include terminology that allows them to ...
practice "physiotherapy" or "physical therapy" and chiropractors can advertise physiotherapy.
• In other parts of the world, osteopathy is still ...
practiced as a manual therapy
We should see a lordosis in the cervical spine and lumbar spine, kyphosis in thoracic, lumbar and sacrum/coccyx. If these curves aren't present, then the spine is more ...
predisposed to dysfunction.
Contraindications to Rotation Techniques:
presence of ligamentous (annular disc) weakness
Instability is a term which has come into vogue over the past decade. What is "vogue"
prevailing fashion or style at a particular time.
The transverse ligament of the atlas usually gets the most attention because it's such an important ligament in that it ...
prevents the atlas and occiput from moving forward on C2. Or it prevents a relative, posterior displacement of the odontoid.
AScientific Difficulty with Palpation is that it is Subjective, not objective. It is also Entirely _____ - thus presenting difficulty in presentation
private
If a vertebra appears to be out of alignment and the site is accompanied by swelling and or tenderness, then it ...
probably is stuck and in need of manipulative correction. If in doubt, and in the absence of contraindications, it is not unwise to try manipulation.
Contraindications • To Grade I Oscillations:
probably none
As a general rule manipulations cause no pain. But some pains 'feel good' and the patient will say so, and others are necessary to make a change. Some are unavoidable, such as when superficial tissues are tender. If a pain 'feels good' then ...
proceed with care and reassess the next day. If none the worse or better, then proceed as necessary using perhaps even more force.
11 After guidelines on the treatment of low back pain, containing a favorable evaluation of manipulation, were published by the RAND Corporation [ii] chiropractors claimed this as victory for chiropractic. This is a blatant mis-representation, because the guidelines supported manipulation; not adjustments or chiropractic. Such chiropractic publicity following the publication of the RAND guidelines forced the authors to ...
publish a correction
Syria (when describing release phenomenon) He was referring to the thoracic outlet but equally it applies to that experience we have all had when after sitting back on our heels and then changing our posture we get painful numbness and tingling. In this later case it is easy to recognize that it is a 'release' of pressure that causes the symptoms. Perhaps it is a ...
re-vascularization of the nerves.
Physical therapists have mounted NO similar attacks on the sovereignty of chiropractors over their field of practice or their name; physical therapists are only guilty of ...
reclaiming manipulation as a part of their practice.
• Cyriax was perhaps first to describe the _____ ______. We may now describe this as the painful paresthesia that occurs when pressure is removed from a neurovascular complex.
release phenomenon
USA philosophy #2That dysfunctions are manifest as either increases or decreases of motion from the expected normal or by the presence of aberrant movements. Thus, dysfunctions are
represented by abnormal movement.
In nearly all cases manipulations are performed with goals of relieving nerve root pressure, directly relieving pain, or for ...
restoring motion to a joint.
upright orientation of facetslimits us in our ability to _____ in our lumbar spine, but it gives us more _____ _____
rotate/forward bending.
the alar ligaments check ...
rotation in side bending.
the direction of the fibers of the interspinous ligaments.
runs up and back or superior/posterior type direction. That allows for forward bending.
Most authorities are in agreement as to what happens in spinal motion. The exception would be the _____ where not enough is known in order for agreement to be reached. It is the terminology that confuses between one speaker and the next.
sacroiliac
You can see that the facet joints in the lumbar spine are in the ____ plane. and they are also ____ degrees from the horizontal.
sagittal, 90
• Some non noxious deposits do exist especially around the _____
scapula
The slack takes us to the end of the end feel, to what may be called the _______
second stop.
USA #9 That it is the patient's responsibility to restore, maintain and enhance their health. In this context the role of the physical therapist is to ...
serve as an educator, to be an example to the patient and to reinforce a healthy and productive life style.
Bonesetters not only practiced manipulation but also...
set fractures and treated joint strains
When we look at the lateral view of the spine, the first thing we want to recognize is the curves. The curves are very important because they provide ...
shock absorption to the spine.
Side Bending Rules In the Mid-cervical Spine • FUNCTIONAL
side bending causes rotation to the same side
Side Bending Rules In the Mid-cervical Spine • NON FUNCTIONAL
side bending causes rotation to the same side (same as for functional) It is the head that is in a different position between functional and non-functional as in the latter the head must rotate to the opposite side.
Rules for NONFUNCTIONAL SB in lumbar and thoracic spine
side bending produces rotation to the opposite side (observe the posture of scoliosis)
There are a total of ____ joints on the sacrum.
six
In Method of Detection by Bony Landmarks in the Thoracic Spine and Lumbar Spine we are looking for
space between spinous processes • FB and BB 'pinch' spinous processes for rotation
an uncontrolled involuntary jerk of muscles.
spasm
The vertebral foramen is aka the ...
spinal canal or central canal.
T3 is often adjacent to the
spine of the scapula.
In lumbar, The lamina is the structure that is between the ...
spinous process and the articular processes.
. The multifidus is a very important muscle and it also attaches to the ...
spinous process.
What is the job of the alar ligaments?
stabilize C2 on the head.
The reddening in a triple response of lewis is measured by its (4) ______________, which we then compare from one level to the next and from one side to the other.
strength, rapidity of onset, duration and eventual disappearance
Also appreciate that a joint, such as the glenohumeral, may initially dislocate but due to damage on the labrum may be the subject of ___ _____
subsequent subluxation.
the erector spinae fascia, these tendons going out at a ...
superior to lateral direction. That allows for forward bending.
Medicine for disease, physical therapy for function, ...
surgery for our failures
The curves are important components for shock absorption and distribution of force. The other thing that provides shock absorption is the ...
surrounding musculature.
Paris in 1965 adapted both (Kaltenborn/Stoddard) systemsto a system which had '3' as normal and an equal number of gradations on each side of three. This gave the system _________ and allowed a slight increase of motion which is normal in some athletes, to be distinguished from hypermobility that requires some correction and unstable which is now considered to be pathological.
symmetry
This definition leaves no doubt that mobilization and manipulation are _____ ____, spanning a continuum of techniques, which can be applied to both joints and soft tissues.
synonymous terms
Modern manipulation has its roots in medicine and was advanced by physicians, who ...
taught physical therapists.
posterior longitudinal ligament in the upper cervical spine is referred to as ______ _______
tectorial membrane.
Our touch by pressing on muscle spindles causes the surrounding fibers to contract and thus we feel this increasing recruitment of fibers as an _____ _____, i.e., the firmer we press the more fibers are recruited and thus the firmer the tone feels.
telastic response
The skin shall be palpated for ...
tenderness (hyperalgesia), temperature, moisture, texture and response to the scratch (triple response of Lewis viz. blanching, redness and swelling).
Looking at a superior view of C1. Posteriorly we have no spinous process but ...
the "posterior tubercle".
T12 can be found by locating
the 12th (lowest) rib
The base of the sacrum is where ...
the L5/S1 intervertebral disc articulates with the sacrum.
For palpation of temperature, The practiced examiner will use the pads and tips of the two middle fingers - but the student may use ...
the anterior aspect of the forearm to detect temperature changes - or even the back of the hand.
runs down the anterior portion of all the vertebral bodies.
the anterior longitudinal ligament,
where the atlas articulates with the occiput.
the atlantooccipital joint,
The subcranial region is very different in design and hence mechanics that is the rest of the spine. Its movements are quite predictable and are fully explained in the course S3. For this course all we really need to know is that atlas will always move in the direction that occiput moves in. Thus on FB of occiput ...
the atlas slides forward.
There is also a superior vertebral notch, which is on the superior aspect of the vertebrae and that is what makes up ...
the bottom half of the intervertebral foramen.
Generally, the patient will be considered to be in the prone position for the palpation of the spine for condition although ...
the cervical region is often best managed with the subject supine.
The atlantooccipital joint has the occipital condyles which are convex, then it has ....
the concave superior articular facets of C1.
We examine both functional and non-functional motion because...
the difference between them may tell us a great deal.
the most medial of all the ribs. It is a very broad, flat rib compared to the rest.
the first rib
Manipulation has probably been used by healing professions since the earliest the days of humanity. The _________ described manipulation and traction, which even in his day was an old art.
the greek physician Hippocrates
The most important thing here is that the zygoepophyseal joints in the thoracic spine beginning in the upper thoracic, increase their slope from ...
the horizontal to about 60 degrees.
. T7 can be found adjacent to...
the inferior angles of the scapula.
Here we are looking down on a thoracic spine vertebrae. The pedicle is the bony process that joins the vertebral body to ...
the lamina, transverse process, all the posterior structures.
The cruciate ligament consists of ...
the longitudinal portion, and then the transverse ligament of the atlas.
Palpation for tenderness, while part of any examination, can also be quite misleading. Tender muscles in the lumbar spine, for instance, do not necessarily mean that the muscles are the source of the dysfunction. Discomfort can be provoked because ...
the muscles are part of the affected segment in which the threshold for eliciting discomfort/pain is greatly reduced.
Looking at a lateral view of the lumbar spine, you can see that the inferior vertebral notch from the vertebrae above, and the superior vertebral notch from the vertebrae below makes up the intervertebral foramen. That's where ...
the nerve root exits the spinal column.
runs from the posterior processes back to the supraspinous ligament.
the nuchal ligament
For a first occurrence we treat principally that which we decide are the immediate causes of the pain. We should inform the patient of the other findings that have not been corrected but which may cause a recurrence and which would then need to be taken care of. This might also be communicated to the referral source for the same reason. In this manner should symptoms occur ...
the patient/physician will not think you have 'failed' and try elsewhere; they will come back to you.
In S1 overpressure techniques are not instructed due to ...
the possibility of unwittingly aggravating the patient's condition.
When we palpate a muscle at rest the tone we feel is not that which was there but rather ...
the response of the muscle to our touch.
If a vertebra appears to be out of alignment yet it moves freely then the bony landmarks which you palpated and which lead you to think that it was not in the right place were simply anomalous - or ...
the segment is hypermobile.
How many surfaces articulate with C2? -
the two superior articular facets that articulate w C1. - the two inferior articular facets - The "anterior articular facet", where the dens articulates with the Atlas - On the back of the dens, the transverse ligament articulates so that could be considered a joint surface. It is known to be synovial. - Inferiorly it articulates with the C2/C3 INTERVERTEBRAL DISC - 2 uncovertebral joints - a total of nine joint surfaces on C2
In the middle of the transverse process of the cervical spine is the tranverse foramen, which is where ...
the vertebral arteries travel.
Nodules palpated beneath the skin are usually within the muscle, but occasionally a fatty nodule may lie above the muscle and may be distinguished from it when the muscle underneath is put into a state of contraction where it will be observed that the nodule remains on top of the contracted muscle and can be moved independently from it. These subcutaneous nodules seem to be of little significance and although frequently tender, ...
they are usually asymptomatic when the neighboring lesion is treated.
Use ____ to examine rotation in upper thoracic (one thumb on say C7 and the other on say T3)
thumbs
USA #10 Autonomy: Our body of knowledge is sufficiently unique and is of sufficient volume that ...
to depend of referral for patients is no longer morally defensible.
In Lumbar and Thoracic Spine, Rotation and side bending occur ...
to the opposite side
In the Cervical Spine, Rotation and side bending always occur ...
to the same side
the state at rest of a muscle.
tone
• The osteopathic profession in the USA has equal rights to physicians, but have abandoned their ...
traditional manual skills
In lumbar spine The most lateral structures are the
transverse processes on either side.
The uncinate process makes up the ...
uncovertebral joints/joints of Von Lushka/"U" joints/lateral interbody joints.
In addition to the 2/3 posterior position of the nucleus in lower thoracic and entire lumbar spine, what are two other reasons lumbar herniations are more frequent than cervical?
uncovertebral processes As well as, in the cervical spine, the disc dries out a little quicker.
USA #8 That the key to understanding dysfunction, and thus being able to evaluate and treat it, is ...
understanding anatomy and biomechanics. It therefore behooves us in physical therapy to develop our knowledge and skills in these areas, so that we may safely assume leadership in the non-operative management of neuromusculoskeletal disorders.
Interestingly the classification of '________ was incorporated first in the Paris system (Grading System for Intersegmental Mobility [PIVM)and before it became of clinical interest beginning in the 1980's. The system has been researched and an article published on some of the early research won the best scientific paper of the year award from Physical Therapy, Journal of the American Physical Therapy Association (1982).
unstable'
The lamina and pedicle are both part of the ...
vertebral arch.
where the cartilaginous endplate attaches to the ____ _____ is with hyaline cartilage so it is a weaker attachment and it is more susceptible to injury.
vertebral body
In the lumbar spine, The most medial structure, directly center, is the
vertebral foramen.
In a spinal eval we will • Need to decide ...
what we need to treat if the condition is a first occurrence and • What we need to treat if the condition is a recurrence or an exacerbation of a chronic condition
Many methods have been developed for measuring posture with CROM instruments [1] , photographic measurements [2] and electrogonimeters. [3] However it is doubtful if such measurements find their way into the clinical shop- floor as physical therapists mainly rely on observation of posture. This is a regular part of patient examination that ...
yields valuable information regarding the patient's condition.
the ______ joint, which is another name for the facet joint.
zygapophyseal
the facet joint capsule that surrounds all of the ...
zygoepophaseal joints.
The description of subluxation , which is central to chiropractic theory, and their mode of diagnosis, has since undergone modifications
• First subluxation represented static single-segment displacements of vertebrae • Later multi-level subluxations with patterns of distortions (structural approach) • Now chiropractors have an all-inclusive definition, including, hypomobility, hypermobility and "aberrant motion" • Subluxations are now palpated by way of motion palpation instead of just palpation for position.
Lumbar and thoracic active motions to assess
• Forward Bending 3x o view from the side o view from the back o view from the back with eyes closed • Backward Bending • Side bending - left and right • Rotation - left and right
List the techniques for Lumbar PIVM
• Forward and backward bending o Side lying double leg flexion • Side bending o Side lying raising legs o Prone lying raising pelvis o Prone lying impulse over trans. proc.
Mid Cervical and Upper Thoracic Motions to Examine
• Forward bending • Side bending both ways o with arms by the sides o with the weight of arms supported • Rotation both ways • No backward bending
Tissue fluid tension it places a considerable tightness and congestion on the underlying connective tissue and muscles, thus restricting motion in the area resulting then in
• Hypomobility in the upper thoracic and frequently compensating • Hypermobility in the low cervical spine, particularly at cervical C5/6. • Localized areas of increased fluid tension may occur throughout the spine, accompanying as they do the spinal lesion.
The most common sites Vertebra may be stuck (locked, fixed, held) in
• L4/5 • Mid-thoracic • Upper thoracic • Upper cervical
methods for restoration of function
• Lessen the input of noxious stimuli • Ensuring cerebral disregard • Increase input of inhibiting stimuli • Surgery to afferent pathways
When palpating for symmetry in standing.. As a rule, palpate from behind the patient List the six things you are to palpate from behind
• Level of iliac crests • Level of the PSIS • Level of greater trochanters • Level of the gluteal fold • Level of fibula head - or knee joint • Level of medial malleolus
When palpating for symmetry in standing, what is the only structure you need to palpate from the front?
• Level of the ASIS
5 Characteristics of Abnormal Motion
• Limited range • Unwillingness to move • Pain during or at end range • Painful arc • Compensatory or 'trick' movement
Neurophysiological Effects of Manipulation
• Movement and hence nutrition • Centralization of pain
Myofascial pattern of Cervical Spine
• No consistent pattern • Depends on muscles involved
Arthrokinematics of sub cranial FB
• Occiput rolls onto anterior atlas condyles • Atlas slides forward under occiput • Atlas slides forward on axis • Axis slides up and forward on C3
Four Primary Effects of Manipulation
• Psychological • Neurophysiological • Biomechanical • Chemical
When palpating the skin, what are you observing?
• Raised or lowered temperature • Moisture or dryness • Scars, ulcers • Scratch test for the triple response of Lewis
Chemical Effects of Manipulation
• Release of endorphins following multiple level thrust manipulations o these act as pain killers o the muscle reflexively relax from Type III mechanorecptor or GTO response o this approach is more representative of traditional chiropractic
When surgeons operate on the back they usually do so to: (3)
• Remove pressure from a nerve • Make space for neurovascular tissue • Provide for stability
Vertebra may be stuck (locked, fixed, held) in
• Rotation • Forward bending • Backward bending • Side bending • Or any combination of the above
Forward bending usually yields the most useful information in the lumbar and thoracic spines. Look in particular for
• Smooth transition of motion • Increase of the thoracic kyphosis • Loss or reversal of lumbar lordosis • Role of the hip • Any signs of instability
In the Cervical Spine, we shall combine evaluation for both condition and position. Why?
• Spinous processes are bifid and irregular • Transverse processes are too small and usually tender • Transverse process of atlas irregular
This same (release) phenomenon may occur during lumbar or cervical traction. The natural instinct is to stop the treatment but in point of fact the treatment might be just what the patient needs. Consider following this routine:
• Stop the treatment and explain the phenomenon • Next day should the symptoms recur encourage the patient to continue for, say, five minutes • Next day evaluate the results - if no worse continue for say, twenty minutes and on the third day forty minutes.
In Palpation for Condition and Tenderness of Ligaments, what are you looking for?
• Swelling • Loss of normal volume • Tenderness
During PFC, what are you looking for in terms of ligaments?
• Swollen or wasted • Tenderness
Key Points in Stretch Techniques
• Take up the slack and pause • This is to the second stop - the real barrier • Decide on the technique given the nature of the stop • If slightly restricted (grade II) perhaps a stretch • If very restricted (grade I) perhaps a progressive oscillation • If uncomfortable, back off a little and give Maitland Grade II
Six Characteristics of normal motion
• Takes place smoothly regardless of speed • Adequate relaxation of antagonists • Range is full - according to body type • Pain free • Muscles are of normal strength • Passive range is greater than active range
Psychological Effects of Manipulation
• Touch - caring and intelligent hands • Induced movement • Pop or snap
What is different about how we palpate for condition and position in the lumbar spine?
• Use articular columns and facets • Palpate with the subject in supine lying:
Practice of osteopathy included: (2)
• Visceral and peripheral massage • Spinal and extremity manipulation.
In the case of progressive spondylolisthesis the need to fuse is evident. But when else should a patient be fused? Some surgeons fuse regularly whenever they do low back surgery while others do not. The criteria are rather weak and are quite likely to be:(3)
• Young persons more than elderly • Males more than females • Heavy workers more than sedentary workers
3 Subcranial Active Movements to Examine
• forward nodding - view from the side • backward nodding - view from the side and front • side bending - view from the front or back
