Axial Exam 2 Content

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

___________ = Sacral *base* flexion with inferior lateral angles (ILAs) moving posteriorly - makes sacrotuberous ligaments taut

nutation (sacral bases moving anterior and inferior)

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)

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)

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

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)

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)

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 you are *shaking* your head (no) this motion occurs at what joint

AA (atlanto-axial, C1-C2) (the ANTERIOR portion of this joint is CONVEX on CONVEX = same direction of roll and glide)

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)

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

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)

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)

When you are *nodding* your head (yes) this motion occurs at what joint - 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)

OA (Atlanto-occipital) (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])

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)

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)

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) (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 or extended* position, side bending and rotation occur to *opposite* sides

Type I

(Type I/Type II) movement - - When lumbar spine is in a *flexed or extending* position, side bending and rotation occur to *same* side

Type II

Unilateral PAs are used for pts that have difficulty 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)

Which of the following is *not* essential for differential Dx and indicative of a referral to a different medical practitioner: a. Pt has pain that is reproducible by specific motions and/or positions b. Pt's clinical findings are suggestive of serious medical or psychological pathology c. Reported limitations or impairments are inconsistent with Dx/classification scheme d. 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: a. X (flexion/extension), Y (rotation), Z (side bending) b. X (flexion/extension), Y (right torsion), Z (left torsion) c. X (nutation/counternutation), Y (longitudinal), Z (oblique) d. 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* an appropriate intervention technique for cervical headaches and/or extension dysfunctions a. neck collar for stabilization b. head nods c. chin retractions d. posture correction e. ergonomic improvements

a (neck collar for stabilization)

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 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? a. Left on Left anterior/forward dysfunction b. Left on Right posterior/backward dysfunction c. Right on Right anterior/forward dysfunction d. 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)

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)

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: a. tests of static position (palpation of bony landmarks) b. movement testing monitoring bony landmarks c. symptom provocation tests d. 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 (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.)

The 3 lumbar PAIVM techniques

central PA (over SP), unilateral PA (over articular process), transverse (glide) (on lateral side of SP)

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)

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* 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. A non-capsular pattern of motion loss at the hip b. Failure to improve after a week of conservative therapy c. Insidious onset of symptoms d. 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: a. Bone pathology resulting in weakening b. Neurological presentation (cord or nerve root compression) c. Vascular deficits d. pain and hypomobility e. Lack of Dx f. 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): a. obesity, inactivity, HTN b. osteoporosis, prolonged sitting, malnourishment c. smoking, repetitive lumbar flexion, arthritis d. 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)

The atlanto-axial (C1-C2) is an odd little joint. Which of the following describe the motion(s) that are allowed at this joint? a. only rotation b. flexion, extension, & sidebending c. only rotation and sidebending d. rotation, flexion, & extension

d (rotation, flexion, & extension) (35-47 deg rotation each direction, ~5 deg extension, ~10 deg flexion)

What would be true of the following if the sacrum is unilaterally nutated anteriorly (flexed) on the *left* : a. The left sacral base is more posterior/backward compared to the right side b. The left ILA is more anterior/forward compared to the right c. the seated FF test would be positive on the right d. 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)

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

Which of the following is not an appropriate treatment approach when treating joint hypomobility: a. PAIVMs b. Mobilization with Movement (MWM) c. Manipulation d. Muscle energy techniques (METs) e. all of the above are appropriate options

e (all of the above are appropriate options)

Capsular pattern of the cervical spine

extension, equal loss of rotation and SB (side bending) (flexion usually unaffected)

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)

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 5-15% of chronic LBP. It is a result of repetitive stress, cumulative trauma, and inflammation at the facet joint.

facetogenic

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: 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)

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)

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)

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

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)

What are the 2 reasons to use lumbar manipulation:

increase motion, decrease pain (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])

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)

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

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

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)

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

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)

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)

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

T/F: Approximately half of patients experience some transient effects (e.g. stiffness, HA, fatigue, discomfort) following a spinal manipulation and these effects may last 24-72 hours

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: 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)

(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)

(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)