MSK III: Oral Exam

List the 4 (big 4) altered muscle states (that you are responsible for). Describe each of them including causes, presentation, and intervention)

Voluntary Involuntary Chemical holding Adaptive shortening Involuntary muscle holding Involuntary reflex Cause Injury Dysfunction Signs and symptoms Hypertonicity Protective muscle guarding - loss of "free" motion Elevated resting tone Abnormal elastic response to touch Intervention Treat the cause of impairment (or the trigger) I.e. facet capsular entrapment If the capsule is pinched in the joint, it will cause a reflex muscle contraction Pulling capsule out of joint with the multifidus isometric contraction will relieve the pain produced by the capsule thus relieving he reflex muscle guarding 3 important words to remember = TREAT THE CAUSE Chemical muscle holding Typically occurs several days after a sprain or strain to the spine Cause: Sustained involuntary guarding - acute phase The involuntary muscle contraction will cause an increase in chemical build up of waste products in the muscles Once the inflamm subsides and involuntary muscle guarding relaxed Mm remains tense and tight bc of buildup of chemical waste prifuces May possibly lead to a compartmental syndrome Signs and symptoms Doughy to touch Limited ROM Intervention Heat and massage (deep finger kneading) Once inflammation is gone you can heat via active exercise, deep thermal heat (US) Then massage to flush out the chemical irritants and increase circulation to the muscle Think compartmental syndrome - multifidus Voluntary muscle holding Could indicate a more sinister pathology such as an underlying fracture (especially in the cervical spine) Cause Pain or fear of pain Often follows involuntary and chemical states Signs and symptoms Slow and guarded motions Trunk moves as a whole Intervention One sure nothing serious (e.g. fracture) Ignore, give reassurance, help them relax \ Movement - repetitive motion, oscillatory movement NormalTone/Shortened Adaptive shortening Tight muscle Cause Chemical muscle holding Slouching posture - e.g. to subcranial extensors Signs and symptoms Normal tone Shortened length, loss of ROM Altered posture - increased lordosis secondary to psoas shortening Intervention Myofascia stretching

What is a myofascial (MF) pattern (in general) (describe/define it)?

When movement is restricted not by the capsules but by the muscles and fascia and it will present in a pattern of the clinic during AROM. The lumbar spine has a pattern but the cervical does not. Dr Grant: a pattern of AROM that is restricted in the muscles or the fascia

Describe the movement of an abnormal/unhealthy disc with forward and backward bending of the spine.

When there is an unhealthy disc protrusion BB will protrude it further and so will FB. The nucleus will always move toward and protrude at the tear.

Describe the position of the Atlas with forward head posture.

With forward head posture the upper cervical spine is actually in extension So the atlas would be be more posterior or backwards

Tell me everything you know about the transverse ligament of atlas?

Wrapping around posterior odontoid to the medial tubercles of the lateral masses of atlas Part of Cruciform ligament The most important ligament of entire body CANNOT LIVE WITHOUT THIS If this is ruptured, it exposes the odontoid process and all you would have to do is look down and forward nod your head before it causes the odontoid to move posterior into the brainstem of the spinal cord (which obliterates the cardiac and respiratory centers of life) Attaches to the medial tubercles of the lateral masses on the atlas and in doing so wraps around the odontoid process (does not actually attach to the odontoid though because it allows for that pivoting motion to occur with rotation) Holds odontoid forward anteriorly into the arch of atlas Almost serves like a strong seatbelt preventing the odontoid from coming posteriorly into the spinal cord Prevents flexion from occurring between C1/C2 LIMITS the motion at the OA/AA joints Posterior joint (synovial joint) - transverse ligament of atlas articulating with odontoid- pivot joint Unique because it starts out as a ligament and then it transitions into a hyaline cartilage synovial joint complex

Where does the transverse ligament attach?

Wrapping around posterior odontoid to the medial tubercles of the lateral masses of atlas Part of Cruciform ligament The most important ligament of entire body CANNOT LIVE WITHOUT THIS If this is ruptured, it exposes the odontoid process and all you would have to do is look down and forward nod your head before it causes the odontoid to move posterior into the brainstem of the spinal cord (which obliterates the cardiac and respiratory centers of life) Technically you COULD live without if if you were stabilized and taken to the hospital to have a fusion of C1 and C2 and were stabilized after surgery But not going to walk around without it like you would without an ACL Attaches to the medial tubercles of the lateral masses on the atlas and in doing so wraps around the odontoid process (does not actually attach to the odontoid though because it allows for that pivoting motion to occur with rotation) Holds odontoid forward anteriorly into the arch of atlas Almost serves like a strong seatbelt preventing the odontoid from coming posteriorly into the spinal cord Prevents flexion from occurring between C1/C2 LIMITS the motion at the OA/AA joints Posterior joint (synovial joint) - transverse ligament of atlas articulating with odontoid- pivot joint Unique because it starts out as a ligament and then it transitions into a hyaline cartilage synovial joint complex

What is the purpose of the passive lumbar extension test? Can you explain how it is performed?

for lumbar spinal instability

Explain how the multifidus isometric contraction works? What structures prevent the capsule from being pinched on a regular basis?

multifidus attaches to the capsule and the theory is it will pull the capsule out of the joint when it isometrically contracts Mammillary bodies 3 Structures preventing the structure from being pinched - ligamentum flavum and multifidus and meniscoids

Define manipulation according to the APTA.

"A manual therapy technique comprised of a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement." -APTA

List 5 biomechanical effects (specific) of manipulation.

"Snap out of it! Men are at fault for restricting my mobility." Restore Mobility and Range of Motion Restore Restricted Connective Tissue: Restore cross-link function in the capsule Restore fiber glide in the capsule Elongate crimp in the capsule Restore water and ground substance: GAG/PG's Stress/Strain Curve Stretch/Snap Capsular Adhesions: Release Capsular/Meniscoid Entrapment: Correction of a Positional Fault

List the Paris 0-6 PIVM scale by names of the grades. Explain the type of intervention that is appropriate for each grade of mobility.

0 Ankylosis Ignore no manips 1 Cons. Restriction hypo Non-thrust; The joint is very tight but still has mobility 2 Slight Restriction Hypo Nonthrust + thrust; The capsule has restriction but it is extensible and the tissues are mobile enough to sustain thrust in a healthy way Thrust isn't going to be the first intervention you do 3 Normal 4 Slight Increase hyper Stabilize--?; No external support needed Exercises, postural awareness 5 Considerable Increase hyper Stabilize; External support needed Ext stab exercises and postural support; Strengthening muscles like the transverse abdominis, internal oblique, multifidus to help increase corset effect to help stabilize the spine 6 Unstable Very mobile, loss of osteoligamentous AND neuromuscular control; Stabilize--fusion; Surgical intervention likely

What are the 8 clinical signs of instability?

1. History or demonstration of tissue relaxation/creep Inability to sit still for long periods Discomfort increases as the day wears on, relieved by movement or rest 2.Increased muscle tone while standing 3.Presence of a "step" or rotation (spondylolisthesis, retrolisthesis, or spondylolysis) 4.Disappearance of muscle tone, step, or rotation on prone lying 5.Shaking, "juddering" while forward bending First 60*; >60* = glutes and hams 6.Difficulty coming up from forward bending May bend knees or put their hands on their knees 7.Grade 5 or 6 on passive motion palpation Hypermobile 8.Radiological evidence of motion studies of forward and backward bending showing both increased angulation between the vertebrae and more important still- excessive translation.

Describe the stress/strain curve including all of the aspects of it, and how its related to biological tissues and PT.

1. Toe Region - As the structure is lengthened there is settling of the collagen bundles into a more compact arrangement. In addition the inherent crimp in the collagen is straightened out. Both of these events contribute to the toe region of the stress-strain curve. 2. Elastic Region - The elastic region is the linear portion of the curve. It represents the elastic (reversible) lengthening of the structure. 3. Elastic Limit (Yield Point) - This is the limit of the stress and strain to which the structure can be exposed without causing plastic elongation. 4. Plastic Region - The plastic region begins gradually as microfailure begins to occur within the tissue. 5. Ultimate Stress - This point is where the maximum resistance is offered by the tissue. This is a critical point where the structure lengthens with decreasing resistance. Beyond this point microfailure occurs at a much greater rate. 6. Necking - Necking is where the slope of the curve becomes negative and the structure begins to give way to the load. Catastrophic failure of the structure is imminent once necking has begun. 7. Ultimate Failure - At the point of ultimate failure the structure becomes incompetent. The structure has completely failed at this point and there will remain little or no connection between the disrupted ends of the structure.

Tell me everything you know about the intervertebral disc?

23 discs- 1 in between each vertebrae Annulus fibrosis Orientation of fibers After first layer it goes the opposite way What is the point of disc Shock absorption Movement Nucleus pulposus Mostly water GAGs and proteoglycans And how it attracts the water CEP Sharpey's fibers Nutrition Nutrition via diffusion Imbibition Aneural/ Avascular OVERALL: Except for the outer 1 or 2 layers are neuro and vascular Aneural Avascular Innervation Outer Annulus Fibrosus (1 or 2 layers) (Very Sensitive Guys!!!) 1. Branches from Ventral Ramus: APR (anterior primary rami) 2. Sinuvertebral Nerve (Recurrent Nerve aka recurrent meningeal) 3. Gray Ramus Communicans- more anterior -from sympathetic Blood Supply: 2 Areas: Considered avascular but there is a little blood supply in the outer AF Extracellular Matrix - lateral side of photo Capillaries at the CEP exchange nutrition via diffusion Main blood supply from the segmental blood supply from the aorta and you can see that the capillaries send blood supply up through the subchondral bone through the cartilaginous endplate where the exchange of nutrition occurs Disc herniations Older people crab meat and it dried out There are less disc herniations in elderly due to this Younger people more watery Relate it to PT and if this is a common dx we see

What is a capsular pattern?

A pattern of restriction of AROM due to joint stiffness (capsular stiffness) We think there may be joint stiffness due to the AROM we are seeing General capsular pattern of the lumbar spine? Deviation to side of restriction with FWB Limited slide of restriction Limited SB to opposite side of restriction Primarily you will see a restriction in AROM when the joint that is stiff is required to upslide or gap in the lumbar spine General capsular pattern of the cervical spine? Deviation to side of restriction with FWB Limited SB and rotation to the opposite side

What is the clinical relationship of AROM to arthrokinematics? Why is it important for a physical therapist to understand this relationship?

AROM is going to show visibly the osteokinematics and once you examine the patient further you will confirm the arthrokinematics .

What's a myotome and a dermatome How would a LMN reflex present as hyperreflexive when there isn't an UMN problem?

Acute disc herniation due to the inflammatory response NOt systemic its just at the one nerve root Lasts only 24 hours

Tell me everything you know about the alar ligaments?

Alar means wing There is a R and L alar lig Originates: on posterior lateral aspect of odontoid Attaching: up to the medial aspects of the occipital condyles Function: to stabilize the occiput on c-spine (atlas and axis) When we rotate or side bend head to R, the opposite side of the ligament becomes tight To check range, move in the opposite rotation and opposite sidebending and the ligament will be tight So if you side bend to L or rotate to the L the R alar lig will become tight and restrict the motion

Describe how the atlas moves with FWB, BWB, SBR and SBL

Atlas moves in the same direction as the occiput (p. 17 S1) The occiput acts like a car and the atlas gets driven around as a passenger.

What is radiculopathy? What causes it? How do you treat it?

Can occur cervical or lumbar LFS and disc herniation may or may not cause radiculopathy Radiculopathy is a clinical condition which involves one or more nerves resulting in impaired function (a neuropathy). The site of injury in radiculopathy is at the level of the spinal nerve root. The result is pain (known as radicular pain), weakness in limbs, numbness/paresthesia, and difficulty in controlling specific muscles (physiopedia) Causes: LFS and/or disc herniation Tx: traction (LFS), positional distraction / bolster (cervical / lumbar disc herniation)

What is radiculopathy? Define it? What is the clinical presentation. What is the test item cluster you would use in the clinic to confirm cervical radiculopathy?

Cause Degenerative changes FHP OSteophytes from lateral interbody articulations (uncovertebral joints/ joints of vonlushka) Thickening of the ligamentum flava Arthrosis of the facet joints Contributing Factors U/T slouch and stiffness MC hypermobility and instability Disc/Radiculopathy S&S sensory and or motor dysfunction Neurogenic pain- deep radiating Pain distributed to neck, interscapular, arm FHP Cervical motions closing the involved foramen increase arm pain Reflex,sensation, motor signs, neural tension Distraction relieves arm sx Limited mid/upper thoracic mobility TEst Item CLuster - Lat FOraminal Stenosis Cervical rotation < 60deg Positive Spurling's Compression Test Manual distraction relieves sx UE neural tension 3 out of 4 findings (probability 65%) 4 out of 4 findings (probability 90%)

Tell me everything you know about ligamentous weakness of the lumbar spine. (Not sure if this was specific to lumbar spine?)

Cause Repeated minor strains Obesity, poor postural habits Prolonged exposure to vibration 😶 (truck drivers) S&S Pain on assuming a fixed position Pain relieved by changing position Relieved by "cracking" the back-increasing weakness Ligaments (supraspinous and S/I) sensitive to touch Rx Early stages Exercise-stabilization, posture/back school education Later stages - prediscal rest/controlled activity coset , braces, taping Instruction in first aid ie- BB if injury should occur This will approximate tear in AF and creates compression in the posterior disc to prevent ambition of fluid and prevent the NP from swelling out Pts advised to get into a corset ASAP to prevent an herniated NP Ligamentous weakness is a precursor to a disc problem. As pts weaken their lig they are also weakening the AF which is also has Type I collagen Once annulus becomes gradually weakened over the years, one event could potentially rupture the last few fibers and result in disc herniation Thoracolumbar Ligamentous laxity/ postural back pain Very common to have lig laxity in the spine Sitting for long periods putting the spine in more flexion stretching the posterior structures (facet capsules, PLL, supra and interspinous lig) can get overstretched causing instability How do we fix this? Dynamic stabilizers - multifidii perfectly aligned to control segmental motion in all plane As we FB we get ant shear of one vertebrae sliding on another and disc is primary static stabilizer of this but the mulltifidii can resist this dynamically Important to do exercises that recruit the multifidii ROM ex does nothing to increase strength

What is the clinical presentation for someone with a TMD dysfunction

Causes: Poor head posture Dental problems Anxiety, stress Trauma S&S Local pain and tenderness Painful movement Clicking jaw Headaches

What is the primary tissue that RA effects?

Cervical spine instability can be due to rheumatoid arthritis Due to synovial joint degradation -primary tissue that RA effects Most affected region: upper cervical and C4/5

Define joint play and component motion. What are examples in the spine of both? What is the clinical relevance?

Component motions are the motions that take place at a joint surface in order to facilitate a particular movement. They are under voluntary control and SPECIFIC to a particular classical motion and thus follow the convex concave rule as was learned in biomechanics. PTs can restore component motions through our manipulations Component motions can be facilitated by an isometric contraction. With an isometric contraction there is no classical motion occurring, however there is some arthrokinematic motion happening. This is the theory behind muscle energy techniques. Component motions are used to detect joint dysfunctions that may be interfering with active range of motion. Examples of component motions are glides. Example in the spine: rolls, glides, upslide, downslide, tilt, gapping Joint Play Motions are not under voluntary control. This means that they need an outside force in order to occur. They do NOT follow the concave convex rule. Joint play motions are used to detect the joint's ability to relieve and absorb extrinsic forces. Having joint play allows the joint to absorb outside forces, such as ground reaction forces, and thus decrease the risk of injury to the joint. One of the primary reasons for development of degenerative joint disease and osteoarthritis is the loss of joint play and therefore the inability to absorb extrinsic forces on the joint. Examples of joint plays are distractions and tilts. Example in the spine: distractions, All manipulations will be either a component motion or joint play From MSK I notes - E1 manual Glide improve movement in one direction Joint play stretch the whole capsule If you are not stretching the jt itself you will cause other problems

Define manipulation according to Dr. Paris and the APTA. Why is it important that PTs fight for the right to use that term as well as to perform manipulations?

Definition = "the skilled passive movement to a joint..." Mobilization/Manipulation "A manual therapy technique comprised of a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement." -APTA "The skilled passive movement of a joint with a therapeutic intent" -Paris There is strong evidence to support manipulation in PT, both thrust and non thrust

Define thoracic outlet syndrome. What is the clinical presentation? What is your clinical approach for managing these patients?

Definition: Compromise of the neurovascular structures of the upper extremity-typically between scalenes, 1st rib and pec minor Causes Functional: Hypertrophy or adaptive shortening of the anterior scalene muscle Elevation of the first rib Hypertrophy of subclavius Adaptive shortening of the pectorals minor muscle Congenital Causes: Broad insertion or two-banded insertion of anterior scalene muscle Fibrous slip running from anterior scalene to mid-scalene muscle Presence of a cervical rib or fibrous band from C7 Other Bony exostosis of the first rib - old fracture Tight pectoral fascia Symptoms: Pain and paresthesia in upper extremity At times deep aching ill-defined Typically medial forearm and arm in ulnar n distribution Intermittent claudication-arm pain with activity Raynaud's phenomenon Intermittent edema, venous engorgement, cyanoses Dorsal scapular pain Treatment: Depends on what was found may include... Manipulation of restricted joints including the first rib also other ribs Myofascial manipulation for tight muscles- pecs, UT, scalenes, levator scap Postural re-education -attention to head & scapular position Instruction in diaphragmatic breathing so pt does not over utilize scalenes Home program of self-stretching & mobilizing Special treatment for release phenomenon Pts wake with burning paresthesia in UE Before they go to bed if they can unweight the arms to release pressure on the thoracic outlet often notice paresthesia in UE If pt waits until tingling sensation goes away they can typically sleep through the night

How does the clinical presentation differ for someone with a disc herniation vs. lateral foraminal stenosis? Consider both cervical and lumbar involvement.

Disc herniation(spinal nerve): follows dermatomal/myotomal pattern herniated disc can present with symptoms including sensory and motor abnormalities limited to specific myotome Lateral foraminal stenosis: presses on the nerve roots Both may or may not cause radicular symptoms It may show on imaging but it means nothing Radiculopathy would mean nerve root injury In general - disc injury is younger Pt (under 50), stenosis is older Provocative movements are going to be polar opposites Stenosis usually older person standing straight is going to be difficult- gets worse Prefer to sit cause they can lean forward BB does not help cause foramen is already too small Tx: opening braces flexion exercise; listen to what pt says helps- flexion based ex, traction Disc -usu younger person Symptom provocation in sitting, walking feels better BB may help with disc herniation Tx: maybe flexion exercise once tear heals, work in pain free ranges, optimize healing Neuro findings - dermatome, myotome, neural tension, reflexes L4/5 foramen - L4 stenosis, L5 disc stenosis/disc DIsc herniation Post lateral Feels better when leans to the L (away) with R herniation Actually pulls the nerve root away from the herniation Post medial Feels better when leaning to the (towards) R cause slackening nerve root The painful side will go down for distraction WHen can we start BB exercises ? If its not painful~ 3-4 wks (initial annular healin) post herniation eval= rep extension and rep flexion exercise and see what relieves their sx Hands on their butt, Standing against the counter and BB In the case of a newer herniation BB does not put the nucleus in but there are several other reasons it may make them feel better The part of nucleus that sticks out will dry up overtime and macrophages will eat it up (jelly donut and ants ) this can take months and months Seated rotation and picking up something is usu MOI

Why is a female more susceptible to SI joint dysfunction as opposed to males?

F articular surface is smaller and smoother predisposing it to instability CoG is behind the hip jt whereas in M it is down the center causing more torsioning on the so with SLS activities there is more torsion on the hip jt so there would be an anterior movement on the sacrum with a posterior torque F childbirth and pregnancy laxity in ligaments More hormonal influence on the SI due to the menstrual cycle Females tend to have unilateral stressors to the SI due to childcare

Describe the movement of a normal/healthy disc with forward and backward bending in the spine.

FB Nucleus moves posterior and the annulus bulges anteriorly and flattens posteriorly BB Nucleus moves anterior and the annulus bulges posterior and flattens anterior

What effects does FHP have on the TMJ?

FPH causes depression of the mandible In order to keep jaw closed, muscles are activated to close jaw (masseter and temporalis) and tension is placed on the muscles Places tension on the ligaments

What is first aid for a newly herniated disc?

First you want to educate the patient about what they might feel if they have herniated a disc Its a sharp pain, quick pain you want to approximate the tear So immediately have them BB so the nucleus does not have the capability of swelling Lay flat, force BB you can even use taping and bracing, not allowing swelling and allowing healing to begin Compressive abdominal corset, antiinflammatory they will feel better because inflammation in the neural sheath is gone Significant changes in neural tension right away

Can cartilage heal?

For a full thickness tear, inflammation thus bleeding, you need to have a full thickness tear for this blood to flow to the area and create healing Without a full thickness tear you are not going to get a healing response Severity of injury Cellular process of how this heals

Describe how you would effectively stretch a muscle that is presenting with decreased length. (Example: hip flexors). Explain different methods of stretching (static, contract relax, etc)

For a muscle to gain length to be stretched the stretch must elongate (deform) the CT elements of the muscle Once the CT is elongated sarcomeres will regrow back to the individuals genetically predetermined number pg 148 S1 Sustained Stretch Fatigues the stretch reflex Must be in excess of 15 min PNF Employs contract/relax to stretch the collagen of the muscle when it is momentarily relaxed Inhibitive Distraction Uses pressure over the origin or insertion of the muscle to stimulate the GTOs and thus cause the muscle to relax prior to the therapeutic stretch Overpower the muscle This can rarely be achieved -an exception would be the hemiparetic pt where the muscle has lost tone (flaccid and cannot resist, child acute torticollis) From VOPPT: Static? 30s duration of stretch was more effective than 60s Hold the stretch longer (60s) in older patients (65-85yo) Contract-relax stretching is effective but not likely due to stimulation of the GTO, but more likely due to increased tolerance to stretching and viscoelastic properties For contracture of muscles that have adaptively shortened and lost sarcomeres, prolonged static stretching will stimulate myofibrillogenesis and increase the number of sarcomeres

What is the pop or crack you may hear with manipulation?

Gas, principally nitrogen is released from the synovial fluid and remains intracapsular Gas distends the joint and stretches it Distended capsule fires Type III- relaxes muscle relieving tension Gas can be seen on standard X-ray Benefits Continue stretch of capsule Firing of the type III and GTO of attaching muscles (multifidus) relaxing inhibition of m tone in neighbor muscles Negatives If already hypermobile→ may become more hypermobile Increased stress on disc "Dependency" brought on by the feeling of immediate relief and perhaps release of endogenous hormones Muscle inhibition

What are the cluster of findings to suggest clinical instability.

History or demonstration of tissue relaxation/creep Inability to sit still for long periods Discomfort increases as the day wears on, relieved by movement or rest Increased muscle tone while standing Presence of a "step" or rotation (spondylolisthesis, retrolisthesis, or spondylolysis) Disappearance of muscle tone, step, or rotation on prone lying Shaking, "juddering" while forward bending First 60*; >60* = glutes and hams Difficulty coming up from forward bending May bend knees or put their hands on their knees Grade 5 or 6 on passive motion palpation Hypermobile Radiological evidence of motion studies of forward and backward bending showing both increased angulation between the vertebrae and more important still- excessive translation.

What is the facet capsular pattern for the lumbar spine if a facet on the Right is stiff?

If a R facet is limited in the lumbar spine: FB= deviation to the R (to the tight side) BB= deviation to the L but 2x more upslide than downslide so more evident in FB SBR= free RL= free SBL=limited RR=limited (cannot gap on the R) If a L facet is limited in the lumbar spine: FB= deviation to the L (to the tight side) BB= deviation to the R but 2x more upslide than downslide so more evident in FB SBR= limited RL= limited (cannot gap on the L) SBL=free RR=free

What is myelopathy? Define it. What is the clinical presentation? What is the test item cluster you would use in the clinic to confirm myelopathy.

It is due to degenerative changes impacting on the cervical spinal cord causing myelopathy of the cord Myelopathy- damage or disease to the cord due to pressure upon it Cause Congenital narrowing of cervical spinal canal Hypermobility/ instability Resultant bosses and bars into the spinal canal Infolding of ligamentum flavum Contributing Factors Poor posture-forward head Cervical stress, strain, sports, MVA Compensatory hypermobility due to UT kyphosis/ stiffness (increases osteophytes) Instability can occur mostly at C2/C3 and C5/C6 S&S BIL UE sx- think central Vague, transient neuro signs arms and legs UMN signs (hyper reactive reflexes) Babinski and clonus Gait deviation and poor balance Clustered Clinical Findings for Diagnosis (Spinal Stenosis Lecture) Over age 45 Gait deviation Positive Babinski Reverse Supinator Sign Positive Hoffman's Sign (last 3 all hyperreactive reflexes)

Tell me everything you know about the ligamentum flavum?

Ligamentum flavum starts at C2/C3 (SAME AS MULTIFIDI) Thicker and more yellow ligament starting at C2/C3 and goes down to L5/S1 joint segment Yellow ligament (has more elastin and elastic properties to it) attaches lamina to lamina intersegmentally on both sides and supports posterolateral spinal canal Helps prevent hyperflexion injuries and helps to return to an upright position from a flexed position can contribute to central spinal stenosis in lumbar b/c when you bend backwards the ligament has potential of buckling inwards toward central canal and spinal cord

What is the myofascial pattern for the lumbar spine? What additional clinical presentations do you see with someone with a MF pattern? Explain how you know the MF is the problem in a patient with this presentation not the joint.

Like a shirt in the lumbar spine it is the direction off the fascia in the lumbar spine FB limited; all other movements relatively free Normal FB= nice rounding of spine (lumbar lordosis will reverse) Abnormal FB= remaining flat in lumbar region Investigate Quality and Quantity If pt can side bend normally this means the jts can independently upslide and they it is likely a myofascial restriction indicating muscle and fascia are limiting the movement

How would someone present structurally with stiffness? (those with capsular patterns)

Limited ROM but still be able to function Posture would there be a deviation? PT intervention for the aboves? Capsular entrapment-Multifidus isometric multifidus contraction to pull the capsule outside of the facet joint cause it is pinched inside the facet joint Stiffness- manipulation for mechanical effects

Define spinal instability.

Loss of both osteoligamentous and neuromuscular control Must have both to be unstable P. 153 in S1

What is a facet capsular pattern (in general) (describe/define it)?

Means there is joint stiffness and with stiffness you will get limitation of movement depending on the plane

Why do we (at USAHS) believe backward bending can relieve/centralize leg pain in the case of a disc herniation? (hint... its not because the herniation is going back in)

Mnemonic= "Good (gate) ladies(loses proteo) fear(fear) nerds (neural) with(water) mobile (mobilize) penis'(promotes)" Gate Control Theory Firing of large proprioceptors block onward transmission of nociception (pain) that will reduce and centralize pain Elevates the water content of the disc Repetitive motion has been shown on T2 MRI to increase the water content and thus lesson the irritability of the disc to its peripheral and perhaps invading nociceptors Mobilizes the facet joints Backwards bending stretches the facets more so than forward bending Promotes Circulation Generally relieving irritability Help relieves the fear of movement Thus promotes functional recovery Neural tension is reduced Due to slackening of the cauda equina when a lordosis is achieved and maintained Loses proteoglycans Over time this occurs and so does its ability to attract water so it begins to shrink.

What do each of the upper cervical spine clinical instability tests test (each one specifically)?

Modified Sharp Purser Test To Detect Atlanto-Axial Instability: Transverse Ligament Anterior shear test transverse lig Evaluate the stability of the upper cervical spine ligaments and membranes for signs of instability or reproduction of symptoms: Transverse Ligament Alar-odontoid integrity test paris approach To Identify an Odontoid Fracture or Laxity/Rupture of the Alar Ligaments Alar ligament stress test supine (could do in sitting - more difficult) To Determine the Stability of the Alar Ligaments

What would someones AROM look like in a newly herniated disc?

Motion very guarded in every single direction What if its 1-2wks? Neuro sx down their R leg- BB would reproduce sx depending on if PM or PL they will have sx leaning one side Leaning Rot away will likely produce neuro sx it will be closing the space producing neuro sx Limited in backward bending PL= lean left and a little forward - lean away from site of herniation Because it pulls the nerve away from the herniation PM= lean toward the site of herniation Because it pulls the nerve away from the herniation p.156

What is the purpose of the MaLT test? Can you explain how it is performed?

Multifidus Lift Test (MLT): Dr. Rot's opinion: Consider calling it the "MaLT" Test due to "Muscle Length Test: MLT" Preliminary evidence supporting the reliability and validity of the MLT to assess lumbar multifidus function at the L4-L5 spinal level.

Define whiplash associated disorder. What is the clinical presentation? What is your clinical approach for managing these patients? (New injury > 2 week vs. old injury 2 months)

Muscle guarding Generalized non specific pain Vague visual, hearing, swallowing issues Fatigue Sensorimotor and proprioceptive disturbances may possibly cause sx such as dizziness, unsteadiness, visual disturbances Altered postural stability, reduced cervical position sense and decreased control of head and eye movements WAD Alterations noted in cervical m including atrophy, and fatty replacement of cervical extensor m's Most notable in multifidus and suboccipital m's, also semispinals cervices Magnitude of fatty infiltrates greatest in chronic WAD patients Tendon/Ligament Repair Days 2-4: Cellular Stage Clot forms Infiltration of macrophages and fibroblasts Weak and unstable type III collagen produced Connection is basically cellular and very fragile Days 5-21: Fibroplasia Increase in collagen production Collagen remodeling Gentle motion directs collagen fiber direction, increases strength, rate and completeness of healing Days 21-60: Consolidation Well organized collagen, more fibrous than cellular Increase in the strength of the connection Increase in number of stable bonds (cross links) Days 60-360: Maturation Large type I collagen predominant Connection is mainly collagen Stable connection Quebec Task Force: Classification Grade 0 - No complaints of neck p! With no physical signs Grade I - complaints of neck pain, stiffness or tenderness w/ no physical signs Grade II - complaints of neck pain and physical signs including decreased ROM and point tenderness (most patients) Quebec Task Force: Classification Recommendations Maintain normal activity Early intervention/Avoid poor posture Exercises to address AROM and motor impairments as tolerated Manual therapy in conjunction with exercise and advice if measures indicate continued benefit Thrust techniques in the thoracic spine may help Do not wear collar, but if collar helps OK, wean off gradually, if not take off Address sensory/proprioceptive loss (controlled head movements with laser to targets and with eyes open/closed) Educate on pain neurophysiology Decrease reliance on medication Psychological support if needed Neck specific exercises including motor control and muscle endurance training were found to provide benefits over general activity, suggesting the important of neck muscle activation Evaluation Findings Postural muscle imbalance Limited and guarded AROM Muscle weakness as well as decreased endurance and motor control M tightness Limited joint mobility Tenderness and increased m tone Intervention Early m strength training, re-education for coordination and endurance to prevent atrophy and fatty infiltration Manual Physical Therapy to address restricted joints and tight musculature Balance and coordination exercises for patients with dizziness and proprioceptive issues

Differentiate myelopathy from radiculopathy. How do you differentially diagnosis these two diagnoses?

Myelopathy occurs when there's damage to the cord Central spine stenosis can cause myelopathy Below L1-L2 causes cauda equina syndrome Central disc herniation can cause radiculopathy Central spine stenosis BiIL sx radiculopathy Central canal stenosis positive UMN reflexes Lateral foraminal positive LMN or suppressed reflexes Can myelopathy be from a disc central herniation or central stenosis? Both myelopathy=damage or disease to the cord and can be caused by a disc herniation Think of it as an incomplete SC injury WILL BE BILATERAL Pos UMN signs Will have gross motor weakness and gross sensation loss WILL NOT FOLLOW A SPECIFIC DERMATOME OR MYOTOME PATTERN This is because it is not nerve root involvement Dermatomes and myotomes are a specific change associated with a specific nerve root

List the 4 mechanoreceptors by type. Tell me everything you know about each of them.

Name Type Location Fired By Grade Type 1 Postural Capsule Oscillations, graded or progressive All, decreases pain Type II Dynamic Capsule Oscillations, graded or progressive All, decreases pain Type III Inhibitive Capsule, Ligaments Stretch or sustained pressure; Thrust At least grade III Type IV Nociceptive Most tissues (not in brain, SC, nerves, hyaline cartilage) Injury and Inflammation N/A

What is the myofascial pattern for the cervical spine?

No consistent pattern due to the layering of the musculature in the cervical spine Depends on the muscles involved Due to the orientation of the m and fascia NO AROM pattern Support the pts arms and have them side bend. If they can side bend fully or further than before it would indicate a myofascial pattern is present due to the joints being able to move independently with arms supported If you unweight arms and improves SOME but not full it could be both but you would need more specific testing to determine this before treating *never can base treatment off of AROM only

What are the clinical characteristics of normal and abnormal AROM of the spine?

Normal "FAT PiMP" Full ROM according to body type Adequate relaxation of antagonists Takes place smoothly regardless of speed Pain free Muscles are normal strength Passive range is greater than active Abnormal "PULPIT" Pain during or at end range Unwillingness to move Limited range Painful arc Signs of instability Compensatory or "trick" movement

Tell me everything you know about the quadratus lumborum?

Origin: Iliac crest Insertion: inferior border of 12th rib & transverse processes of T12 + L1-4 Action: Lateral side bend & elevation of pelvis (reverse action), eccentric control of contralateral side bending Innervation: Ventral rami L1-L4 Iliolumbar ligament Attaches from the lumbar L4/L5 transverse processes to the iliac crest This ligament did not exist in any of us in the first 10 years of our life Develops AFTER the first decade of life and forms from the quadratus lumborum WOAH! QL goes from transverse processes of T12-L5 and 12th rib and comes down into the iliac crest The inferior portion of this muscle goes through a metaplasia phase after the first decade of life Metaplasia = muscle tissue transforms into a connective tissue Iliolumbar lig= Provides significant stability at L4/L5 segment and L5/S1 segment to improve stability in the lower lumbar spine and sacroiliac area Other sacroiliac ligs as you can see but we will dive deeper into those when we get to the SI section of this course

Tell me everything you know about the levator scapulae.

Origin:Transverse processes of vertebrae C1-C4 Insertion: Medial border of scapula (from superior angle to root of spine of scapula Action: Scapulothoracic joint: Draws scapula superomedially, rotates glenoid cavity inferiorly;Cervical joints: Lateral flexion of neck (ipsilateral), extension of the neck Innervation: Anterior rami of the nerves C3 and C4, dorsal scapular nerve (branch of the C5)

Define osteokinematic movement and arthrokinematic movement. What are examples of them in the spine? What is the clinical relevance of a physical therapists understanding of osteokinematic and arthrokinematic movement?

Osteokinematics: deals primarily with overall movement of bones, with little reference to their related joints. The study of the gross motions of limbs or other body parts relative to one another and to body and environmental references. Examples: flexion, extension, abduction, adduction, supination, pronation Arthrokinematics: concerned with more intimate mechanics of the joints. The study of relative motions that take place between articular surfaces and related joint structures within a joint. Examples: translation (glide, slide), rotation coupled with translation (curvilinear) From (Biomech Study Guide Exam 1) What is osteokinematics vs arthrokinematics relative to the Spine? Osteo - One long bone moving on another yes the spine is considered a long bone Arthro -movements of joint surfaces Facets should always be in our answer Component motion and joint play = arthrokinematics Examples in the Spine: Facet joints sliding, =arthrokinematics Spine itself FWB and BB, etc=osteokinematics By observing osteokinematics with AROM we can correlate with the PROM and PROM accessory for arthrokinematics in order to direct treatments Is rotation an osteokinematic and arthrokinematic movement OR just osteokinematics? arthrokinematics= Glide, tilts, gaps, compression, rolling Rotation is never arthrokinematic term

Explain the difference and clinical relevance between functional and non-functional SB in the cervical and lumbar spine.

PG 16 FROM S1 Functional: those motions which we normally perform in the course of the day. (FB, BB, trunk rotation) In functional side bending of the neck, the head follows the neck to look in front of the shoulder This occurs on a diagonal Non-functional: those motions which are not normally performed (neck or trunk SB while facing forward In the non-functional SB of the neck the head continues to face forward while the neck is being side bent, clearly a non functional movement. This occurs on the coronal plane Cervical Spine Functional SB: Rotation to same side in mid cervical (C23-C7/8) and subcranial spine (O/A and A/A)- due to facet planes Non-functional SB: Rotation to the same side - in M/C spine but rotation to the opposite direction in the S/C spine S/C A/A= with side bending R→ rotation L Lumbar and thoracic Functional SB: Rotation to the same side (the facet slide): Down and back on concavity Up and forward on convexity Non-functional SB: Rotation to the opposite sides- due to crowding of ribs and the lordosis which is from approximately T6 to S3 increasing the lordosis and thus the rotation to the opposite side

Describe the anatomical changes that happen to the spine at all regions (Subcranial, Mid-cervical, upper-thoracic, mid-thoracic, and lumbar) (besides arthrokinematics) in all directions (FWB, BWB, SBR, SBL, Rot R, Rot L).

PINE MOTION COMPARISONS: Facet Joint Orientation Mid-Thoracic Frontal plane orientation Increased side-bending Limits Flexion/Extension (due to frontal plane orientation) Rotation limited by rib cage Lumbar: Sagittal plane orientation Increased Flexion/Extension Limited Rotation/side-bending (due to vertical orientation) Some limit of side bending LUMBO-SACRAL FACETS L5/S1 Spine Segment FACETS: Planar/Synovial Joints 90° to the Transverse Plane (basically vertical) In the frontal plane Motion: Flexion (more motion) Extension (more motion)

What does PIVM and PAIVM stand for?

PIVM=passive intervertebral motion PAIVM= passive accessory intervertebral motion-like the spring test!

What muscles would you expect to be imbalanced in a patient with forward head posture? How can physical therapy intervention help correct FHP? What are 5 cervical spine musculoskeletal impairments?

Pectoralis major/minor tight Levator scapulae and interscapular muscles are loose (lengthened) Longus colli weak/loose Multifidus and semispinalis (posterior neck extensors) impairments Involuntary muscle guarding Facet capsular entrapment Facet joint stiffness

Tell me everything you know about longus coli and longus capitus.

Posterior Neck extensors, stability- semispinalis and multifidus Anterior neck flexors and stability- longus coli and longus capitis, Motor control impairments tend to occur in the neck flexors in patients with chronic neck pain and after whiplash injuries with overactivation of the superficial muscles (anterior scalene and sternocleidomastoid) and underactivation of the deep neck flexors (longus coli and longus capitis). Neuromuscular control exercises enhance the function of the active subsystem. The cervical multifidus may provide stability via segmental attachments to cervical vertebrae, and the longus coli and longus capitis may provide anterior stability as a result of the position of the muscle anterior to the cervical vertebral bodies. Strengthening the stabilizing muscles of the cervical spine enables these muscles to improve the quality and control of movement that occurs within the neutral zone. identified muscle synergy impairments between the superficial and deep anterior cervical spine muscles in patients with both insidious onset and whiplash neck pain disorders. Retraining of the deep neck flexor and extensor muscles is an important component of rehabilitation of many of the cervical spine disorders treated by physical therapists Origin:Superior part: Anterior tubercles of transverse processes of vertebrae C3-C5; Intermediate part: Anterior surface of bodies of vertebrae C5-T3; Inferior part: Anterior surface of bodies of vertebrae T1-T3 Insertion: Superior part: Anterior tubercle of vertebra C1; Intermediate part: Anterior surface of bodies of vertebrae C2-C4; Inferior part: Anterior tubercles of transverse processes of vertebrae C5-C6 Action: Bilateral contraction: Neck flexion; Unilateral contraction: Neck contralateral rotation, neck lateral flexion (ipsilateral) Innervation: Anterior rami of spinal nerves C2-C6 Longus Capitis Origin:Anterior tubercles of transverse processes of C3-C6 Insertion: Basilar part of occipital bone Action: Bilateral contraction - head flexion; Unilateral contraction - head rotation (ipsilateral) Innervation: Anterior rami of spinal nerves C1-C3 The longus colli and capitus provide anterior stability. (CCFT) Strengthening the stabilizing muscles may enable those muscles to improve the quality and control of movement occurring within the neutral zone. Every component-ant, lat, post, diagonal

What are the precautions and contraindications for manipulation?

Precautions Instabilities Fractures Tumors All diseases, likelihood of causing osseous and ligamentous damage Rotation techniques Presence of ligamentous (annular disc) weakness

Define a painful entrapment (capsular) pattern.

Presentation of limited AROM due to pain cause the capsule is getting pinched with movement Caused by awkward eccentric movement What does this presentation look like? Pain with SB, rotation to same side, BB, limited due to the bone coming closer together and pinching your capsule Anytime there is a downslide that movement is limited because it hurts cause the joint capsule is swollen and pissed If you were to put the skin of your finger in a door jam and the someone shut the door the skin would now swell. If someone shut the door again, it would hurt even more Leaning away takes away some pain because that capsule is pinched and swollen and in some people it even hurts to be upright so they may present tipped away What can painful entrapment turn into as it heals? Synovitis Then can heal and turn into stiffness- comes full circle SO capsular pattern=stiffness Capsular entrapment= painful pinched capsule limited in downslide Would you expect to see neuro presentation with these with AROM? NO

What are the different type of headaches? What is the clinical presentation of each? How would treat each of them

Principal indicators that we may be able to help (MSK not medical) Pain begins in the cervical or thoracic spine and radiates to the head Headache can be affected by a change in posture or movement A hx of trauma to the neck preceded the headaches Physical or emotional stress brings on the headache Red Flags! A very short hx A new headache that they have not had before A headache that is worse than ever before Behavioral and mood changes Treatment Approaches Medical Causes: diet, allergy, disease, hypoglycemia, HBP, or hormonal They are typically congenital or have a family hx Treat: medications and diet Psychological Causes: stress Treat: counseling, biofeedback Musculoskeletal: Causes: mechanical including postural, muscular, and joint dysfunctions that trigger the headache Treat: manipulation of joints and soft tissue Treatment to musculoskeletal triggers Ergonomic factors of posture, stress, lifting, etc. Patient education Inhibitive distraction Medical Headaches (no MSK presentation) Migraine with Aura Migraine without Aura- several hrs Cluster Headache- mostly M Vascular Disorder-aneurysms, venous congestion Intracranial Neoplasm

What is the purpose of the prone instability test? Can you explain how it is performed?

Prognostic for benefiting from a lumbar spine stabilization program NOT for identifying Spinal Instability

How would you manage a patient with positive cervical instability tests?

Provide reassurance and education 3 Call the primary care M.D. or specialist for further dx studies. Diagnostic imaging indicated Document all details of the + tests Consider driving patient to proper MD.

Tell me everything you know about the multifidus?

Proximal Attachment: Transverse Processes of C2 to C7, T1 to T12, L1 to L5, posterior sacrum S3/4 area Distal Attachment: Spinous processes of vertebrae above origin; Attaches from C2 to around S3 in the Sacrum and then attaches to all transverse processes, spinous processes and mammillary processes (lumbar spine) in the posterior aspect of the spine- from chat with Dr Grant "ATM" articular process/capsule, transverse process- thoracic spine, mamillary body-lumbar spine and sacrum" - ATM cause we are SO POOR "SP- spinous process" There is good evidence for the multifidus attaching to the facet capsule Action: Aids in spinal extension, side-bending, and rotation, aids in stabilization of the spine and stiffens the spinal segments when it contracts Innervation: Dorsal Rami Spinal Nerves Mammillary Process-lumbar vertebrae only!!! Posterior aspect of articular facet joint Bump sticking out to serve as attachment site of multifidus lumborum m Multifidus M LBP, m can be weak and inhibited If we don't strengthen it, then the likelihood of LBP goes UP Multifidis attaches to the mamillary process (post aspect of facet) so the multifidus CAN contract and has the potential to pull the capsule out of the joint if there is facet capsular entrapment - whether in the lumbar spine or cervical. We can use the contractile element of the multifidus to remove the entrapment on a pt

What are the 4 effects of manipulation? Tell me everything you know about each of them.

Psychological Touch- caring and intelligent hands Applied with care/compassion/communication - patient feedback. Reproduce chief complaint symptoms - relief for patient. Induced Movement (IN PRESENCE OF FEAR) Systematic Review: show Inducing skilled motion with therapeutic intent can help decrease a patient's fear of motion. Pop/Snap the beneficial effects of manipulation do not appear to be dependent on the production of the audible sound of a joint. Clinically, sometimes experiencing the "pop" is the patient's preference and expectation. Placebo and Nocebo effects The effect of touch and reassurance from a medical professional can have powerful effects on decreasing the patient's fear and anxiety which can reduce pain and disability. It has been demonstrated that a negative effect can be produced in some patients by suggesting that the intervention tends to have a negative effect on pain. Patient's Expectations: Patient's expectations for success of PT interventions have a strong influence on outcomes. Believing that manipulation would help and not receiving manipulation lowered the odds of success compared to believing manipulation would help and receiving manipulation. THERAPEUTIC ALLIANCE Many studies indicate that the therapeutic alliance is the best predictor of treatment outcome. Neurophysiological Gate Control theory spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain. Biopsychosocial theory of pain Physical, Mental, Social, Emotional, Spiritual (soul), etc Bio-Psycho-Social-Soul = entire essence of the human being. Centralization of pain The process where the pain experience moves from a peripheral location to a more central location. This is considered a favorable therapeutic effect. McKenzie method based on this Muscle inhibition-Type III Inhibitive, located in the capsular ligaments and ligaments around the joints Fired by stretching, sustained pressure and thrust manipulation because the joint and capsule will be distended and the capsule will put pressure to stimulate those type III Fired by the joint pop/stretched capsule, very slowly to adapt Movement and hence nutrition Spine manipulation moves the articular capsules. =Helps to secrete synovial fluid which is needed for the nutrition of the joints. Spine manipulation moves articular surfaces. Spine manipulation improves ROM Biomechanical Restore Mobility and Range of Motion Restore Restricted Connective Tissue: (Cross links, fiber glide and crimp are the 3 things needed for good biomechanics of CT) Restore cross-link function in the capsule Cross links= where the collagen matrix lies down on one another and cross each other, the contact points Which gives more substance to the CT and less mobility Restore fiber glide Fiber glide=the mobility in between collagen fibers) in the capsule Elongate crimp Crimp= slack in the collagen matrix and individual collagen fibers) in the capsule Restore water and ground substance: GAG/PG's Stress/Strain Curve These last 3 effects don't have much research but they might happen...: Stretch/Snap Capsular Adhesions: Release Capsular/Meniscoid Entrapment: Correction of a Positional Fault Chemical Probable release of endorphins Act as pain killers Above may explain why multiple thrusts to non-involved joints may give the best temporary relief-not advocated! They are all likely affected by spine manipulation but the one that is more supported in research is Neurophysiological and Psychological Effects More scrutiny and criticism on the biomechanical effects and model due to inconsistency, less research and less reliability about what is happening during manual therapy and the actual biomechanical effects taking place in CT. 3 main things we know about manipulation Manipulation decreases pain Manipulation increases ROM Manipulation improves function- research really supports this!

What are the differences between a male and female pelvis?

S1 p. 88 Females Smaller jt surface-occupies 2 sacral vertebra (male occupies 3) Flatter, smoother articular surface where M is rougher, more pronounced convexities and concavities on its surface Has the hip further away from it thus a greater leverage laced upon it (BT) Located further behind the hip than in the male so in standing has a greater backward torsion placed upon it Is subject to the stresses of childbirth Has more stress placed on it during sexual intercourse especially if the hips are tight Hormonal changes- throughout life Habitual one leg standing esp when had baby and holding baby on 1 hip

Why is a female more at risk for SIJ dysfunctions than males?

S1 p. 88 M- line of gravity passes though the hip joint F-line of gravity passes behind thus setting up a rotary movement - backward torsion Greater posterior torsion leverage on the SIJ due to the COG placed differently Female = acetabulum sits in front of the sacrum When F single leg stance and pressure goes superior from the acetabulum in front of the sacrum it will make the innominate roll into posterior rotation/torsion Male= acetabulum sits in line with the sacrum Men in line with COG no post torsion- force is equal and opposite Center of Gravity vs. Axis of Support in Males and Females Line of gravity passes behind the axis of support in females, where in males, the line of gravity and axis of support are in line with one another. As a result, females present with an increased posterior rotary moment (aka backward torsion of the innominate on the sacrum) with standing activities

What muscles may be tight (decreased length) if your patient demonstrates increased mid-cervical SB with the UEs supported, as opposed to when the UEs are not supported? (during your AROM examination)

SCOM, levator, scalenes, upper trapezius

List the 3 different SIJ dysfunctions and differentially diagnose them (hx, S&S and tx)

Sacroiliac Syndromes - 3 most common seen clinically Strain/Sprain One time event Common event from slips, falls and intercourse S&S: Pain, well localized over sacroiliac joint unilateral , doesn't spread far Hypermobility/Instability Result of persistent strain/sprain Maybe postpartum Multiple injuries S&S: Dull ache with prolonged positioning, ESPECIALLY on backward torsion - such as during standing on one leg or sloppy sacral sitting-increase sx(acetabulum in reference to the CoG in F (backward torsion in this position vs M) Reference possibly posterior thigh/ leg for pain into buttock but does not go below the knee - stays ipsilateral Lowered iliac crest on standing cause too "loosey goosey" Hypermobile symphysis pubis Positive spring test if SI - excessive movement and sx Displacement Can result from hypermobility/instability/hypomobility Can be extreme - MVA and pubic symphysis and SI may be really separated May be a tiny displacement- jt surfaces jammed on one another and jt not moving very well S&S: Constant or nearly constant low grade pain - even at bed rest More severe the displacement, more severe their sx Raised or lowered iliac crest Restricted passive motion - usually lower Cause joint surfaces stuck and wedged together Positive supine to sit test Looks at how pelvis is stuck in position and how it moves or doesn't move

List the 3 SIJ dysfunctions. and tell me everything you know about each of them. (Hx/MOI, S&S, and Tx); or differentiate between 2 of them.

Sprain/Strain Managed like in any other joint Hypermobility/ Instability Mostly in females Displacement Alterations in the bony landmarks treated with manip and then stabilization

How does someones presentation differ between lumbar stenosis and disc herniation?

Stenosis usu older person Standing straight the worse it gets Relief in sitting cause they can lean forward BB does not help cause foramen is already too small Tx: listen to what pt says helps- flexion based ex, traction Disc herniation usu younger person Prefer to walk Sx in sitting BB may help Tx: let it heal then work in pain free ranges Stenosis: Prefer forward bending and sitting Cannot stand for long periods of time Backward bending increases symptoms Older individuals Insidious onset - no mechanism of injury - occurs gradually Disc Herniation: Sitting increases symptoms Prefer to walk to alleviate symptoms Younger individuals Usually occurs due to hyperextension Bending lifting and twisting?

Define stress and strain.

Stress (Y Am I sO StresSED axis) My stress is through the ROOF! UP (Y axis)- The resistance of a tissue to deformation. Stress is a reaction force created in a structure, and occurs in the presence of an applied load Internal resistance of a tissue to an applied external force Tension, compression, shear Strain (X axis) - Deformation that occurs in a tissue or structure as a result of an applied load Tension (elongation), compression (pressure), shear (stress in the opposite direction, cutting, tearing), bending (elongation on one side, compression on the other), torsion (twisting, rotational shear)

Describe the arthrokinematics for all regions of the spine (Subcranial, Mid-cervical, upper-thoracic, mid-thoracic, and lumbar) in all directions (FWB, BWB, SBR, SBL, Rot R, Rot L).

Subcranial Mid-cervical Upper thoracic Midthoracic Lumbar

List the 5 facet dysfunctions (in order), and then tell me everything you know about each of them. (Hx/MOI, S&S, and Tx); or differentiate between 2 of them.

Synovitis/Hemarthrosis (Strain) Cause: Trauma/ Overstretch Awkward movement of catch S&S Guarded Movement Involuntary and voluntary muscle holding Rx Lumbar: rest, soft corset, careful movement Cervical: reast, soft collar careful movement- circular, consider interferential for swelling No stretching or strengthening in the acute stage Gentle circling similar to Codman's ex for the shoulder to help reduce m guarding and decrease pain Be very careful not to increase muscle guarding Stiffness Cause: Resolved Synovitis Hemarthrosis not symptomatic S&S Limited arthrokinematic ROM at the facet joints which then limits osteokinematic movement in a capsular pattern Lowered tolerance to insult hence strain and associated pain if from Current strain of the joint Neighboring hypermobile joint may become symptomatic - unstable in an attempt to compensate for lack of movement in a tight joint Rx Manipulation Painful Entrapment Cause: The facet joint capsule or a synovial fold in the joint capsule can get pinched within the facet joint Awkward movement in eccentric range and the patient experiences sudden pain When sleeping in an awkward position Because the facet joint capsule is caught within the facet joint is unable to slide down inferiorly because it further encroaches the capsule causing pain S&S Cervical: SB and rotation, extension to painful side = ↑ sx Head held away from painful side to unweight the facet capsule which is pinched in the joint Lumbar: SB and ext to painful side = ↑ sx May shift their weight to the opposite side to unweight facet joint capsule Unable to slide inferior inferior articular process down No neurological signs Rx Cervical: Multifidus isometric manipulation Lumbar: Multifidus isometric manipulation Rotational manipulation over a bolster Mechanical Block Cause: Idiopathic Loose Body of cartilage caught in joint Impaction of two rough joint surface S&S Sudden onset Block to motion Relatively pain free Rx Cervical: Strong manual traction with side bending away and rotation to the blocked side Lumbar: Rotational manipulation over a bolster to further open up the affected side Chronic Facet Arthrosis Cause: Poor posture Trauma Over use Wear and tear S&S Dull ache Local pain Stiffness Rx Decompress- exercise in the pool Posture/ Education Mobilize joints if stiff,neighboring joints if hypermobile Address muscular impairments

What is the purpose of the vertebral artery test?

Tests for Potential Vertebral-Basilar Insufficiency (VBI) A positive test would be any type of myelopathic (VBI) symptoms

What is the purpose of the Interspinous gap change during lumbar flexion-extension motion test? Can you explain how it is performed?

The low midline sill sign and interspinous gap change tests are effective for the detection of LS (Lumbar Spondylolisthesis) and LI (Lumbar Instability), and can be performed easily in an outpatient setting.

What is the purpose of the low midline sill sign test? Can you explain how it is performed?

The low midline sill sign and interspinous gap change tests are effective for the detection of LS (Lumbar Spondylolisthesis) and LI (Lumbar Instability), and can be performed easily in an outpatient setting.

Tell me the biomechanics/arthokinematics of the neck with SBR non-functionally (or any other direction) starting at the upper cervical spine and going to the upper thoracic spine. (be sure to discuss the combined/coupled motion)

Upper cervical OA- min motion AA- rotation to the L Midcervical Coupled motion- R facet moves down and back, L facet moves up and forward Causes rotation to the same side in the M/C spine but rotation to the opposite direction in the S/C spine Upper thoracic Spine same

What is the facet capsular pattern for the cervical spine if a facet in the Left is stiff?

Upslide more limited than downslide If a L facet is limited in the cervical spine: FB= possible deviation to L BB= deviation away from the L SBR= restricted RR= most restricted SBL= relatively free RL= relatively free If a R facet is limited in the cervical spine: FB= possible deviation to R BB= deviation away from the R SBR= relatively free RR= relatively free SBL= restricted RL= most restricted