MS Exam III: SI/Cx

Biomechanics of rotation in cx spine

Inferior glide of facet on side of rotation Amount of rotation decreases as you descend (angle of facets changes) C1/C2 = 50% of rotation 70-90° total

Inflare/Outflare

Inflare - IR and ASIS get closer and PSIS further Outflare - ER and ASIS laterally displaced and PSIS medially

Describing what happens with left rotation of the neck/head

Lower cx spine = left lateral flexion and slight extension (to keep upright and head level AA in full left rotation AO is SB right and slightly flexed -Limited by ligs, annulus and facets

Relationship of Lumbar spine to Sacrum in non-neutral position

Lumbar spine follows sacrum - Sacrum R sidebend = Lumbar R sidebend -> L convexity

McKenzie: Dysfunction Syndrome - Treatment Progression for Exctensiondysfunction

Lying Lying prone on elbows Extension in ly (prone press-ups) Extension in standing

McKenzie: Dysfunction Syndrome - Treatment Progression for flexion dysfunction

Lying Sitting Step Standing Standing

Active movement testing for normal cx spine

MAKE SURE IN NEUTRAL POSTURE 1. Flexion - should be within 2 fingers of chest OVERPRESSURE - stabilize on sternum 2. Extension - forehead to horizontal (NO OVERPRESSURE!) 3. Lateral flexion - ear towards shoulder OVERPRESSURE - stabilize at opp. shoulder 4. Rotation - chin almost to shoulder OVERPRESSURE - Wrap around forehead and grab occiput and stabilize shoulder

Gold standard for dx of TMJ

MRI -Disc internal derangement -OA

Thoracic pain referred from elsewhere

Maigne: 70% from lower cx (C5-T1) Presents as localized tenderness lateral to T5/T6

Occlusal Position/Maximal Intercuspation

Median occlusal position - full occlusion - all teeth articulate Start position for TMJ

Costovertebral joint movement

Minimal glide and rotation occurs d/t strong ligament attachments

Temporomandibular Joint

Modified hinge joint - COMPLEX (has disc) Covered by fibrocartilage - STRONG 2 component parts: 1. Condyle of mandible with articular tubercle of temporal bone 2. Glenoid fossa of jaw (houses condyle but not articular component

Rib angle

Most posterior aspect of rib shaft -Attachment for iliocostalis muscle

Discal movement

Moves with condyle as it translates -Upper joint - Mouth opening = anterior in upper joint to maintain contact with articular eminence (disc pulled posteriorly via lateral pterygoid -Lower joint - Anterior movement of condyle relative to posterior movement of disk (disk and condyle glide as unit)

Coupled movements of tx spine

NEUTRAL - SB and rotation to opposite sides NON-NEUTRAL - SB and rotation to same side GREENMAN - depends which move happens first -If SB first, rotation to opposite side -If rotation first, SB to same side (might also depend above or below apex with above at T1-T4 SB and rotation to same side and T4-T8 opp)

PPIVM of TYPICAL Cx spine: Forward flexing in sitting

NEUTRAL POSTURE -Ask pt. to chin tuck to flatten cx One hand in hair at front PALPATE with middle finger of other hand Go segment by segment

Cx positions: neutral resting, close-packed, capsular pattern

NEUTRAL RESTING: Slightly extended (lordotic curve) CLOSE-PACKED: Complete extension CAPSULAR: W/ R facet issue = Problems L lateral bending, L rotation, forward bending deviates to R

What is unique about cx IV discs?

NO posterior annulus on disc = lots of cx arthritis (DJD/DDD) To make up for it, PLL is thicker in cx. and bony blocks stop lateral disc hernations (unco joints)

What grades should you use in C2-C7 PAIVM?

NOT big movement (No 2/3s) Use 1 for pain relief OR 4 for increased range OR Sustained hold

Special tests for thoracic outlet: Adson's Maneuver

Narrows scalene triangle -Monitor radial pulse -Extend and ER UE passively -Extend cx spine and rotate head toward side -Take deep breath INTENSITY not RATE Can do to opposite side as well

Dysfunction Syndrome: Adherent Nerve Root (ANR)

Occurs 6-10 weeks post derangement (trauma) -Nerve sheath has become adherent or scarred at site of injury - no free gliding AKA: Intermittent Sciatica

Tubercle of rib

On posterior surface between neck and body Divided into: -Medical articular portion - smooth convex facet articulates with same # TP -Lateral non-articular portion - rough non-articular area for lig attachments

Prone Knee bend test

One hand palpating L4 to cue and ask if they have pain here. Take ankle and slowly move through range Watch for: Point in flexion of knee buttock rises or rotation or resistance, or pain

Anterior/Posterior Innominate

One side moves with pelvic tilt while other side is stationary.

Superior/Inferior Pub

One side of pubic symphisis is higher or lower than other side.

Where does Quadratus lumborum attach?

Origin: Transverse processes of L1 - L4, the ilolumbar ligament, posterior third of the iliac crest Insertion: Inferior border of the 12th rib Action: Lateral flexion of vertebral column; Depression of thoracic rib cage, Elevation of the pelvis Blood Supply: Branches from the lumbar artery Innervation: Ventral primary rami of T12 - L3

Ausculatation of TMJ

Over TMJ and listen for: 1. Clicking 2. Crepitus

PPIVM of TYPICAL Cx spine: Rotation in sitting

PALPATE at lateral aspect of SPs Can do this full grasp with all 3 motions

Progression of exercise in cx patients

PHASE 1 - TMJ rotations, eye/tongue movements, grip work, shoulder isometrics, supine UE, chin tucks, aerobic work, stretches (don't start with stretching) PHASE 2 - Less table positions, minimal/no support, multi-directional movement, different types of contractions, add speed, add balance

McKenzie: Postural Syndrome treatment exercises

PIC she said she'd send ??

Thoracic: Structural exam

POSTURE Posterior view -Scoliosis -Rib symmetry -Winged/protracted scapula Lateral view -Kyphosis Anterior -Sternum (forward, downward?)

McKenzie abbreviations

PP = produces pain ↑P = increases pain ↓P = decreases pain A = Abolishes pain POSITIONS NE = No effect NB(AR) = No better (as a result) NW(AR) = No worse (as a result) W = Worse B = Better

Muscles of protrusion of TMJ

PRIME MOVER -Lateral pterygoid -Masseter (oblique fibers) -Medial pterygoid

Muscles of depression of TMJ

PRIME MOVER = gravity -Supra and infrahyoid -Lateral pterygoid for lower portion (pull disc forward) -Digastric

Treatment of ANR

PROGRESSION of FORCES IN FLEXION 1. Flexion in lying 2. Flexion in step standing (OPP leg on step) 3. Flexion in standing 4. Perform Rx after midday and ALWAYS follow with REIL or REIS

PAIVM Movement Testing C2-C7: P/A unilateral pressure

PRONE -Put thumbs over articular pillar -Push P-A Opens facet on the same side under finger (rest hands on pt - don't strangle)

Treating Anterior Torsion R on R

PRONE Push on R ILA (anteriorly and superiorly) Palpate L sacral base

Treating Posterior Torsion R on L

PRONE Push on R sacral base (with hypothenar eminence) Palpate L ILA

5. Sacral thrust/spring test

PRONE Slowly push through full range on sacrum

Soft tissue mobilization: Lifting neck muscles

PRONE Stabilize head with one hand Lift muscle bellies with thumb

PAIVM Movement Testing C2-C7: Posterior-Anterior (prone)

PRONE with head straight on contour (want straighter spine - less lordosis), -arms relaxed at side* -Thumbs together back to back on SP CEPHALIC = opening of level below CAUDAL = closing of level below (glide at 45° - facet orientation)

Main function of Uncovertebral joints

PROTECTS nerve root from being compressed by disc -Anterior wall of vertebral foramen -Supports dorsal and lateral annulus fibrosis (disc herniations more posterior instead of lateral

Greenman - First Rib Muscle Energy Technique (add pic??)

PT behind patient and props one arm on leg. -Side glide patient to uninvolved side -Put hand on first rib with thumb posteriorly -Move patient's head slightly towards hand to put scalenes on slack -Isometric resistance at head -Glide rib caudally -Hold for several breath cycles -Re-assess rib alignment

Typical pain patterns in SI joint

Pain over SI joint - BUT this can be L3 or S1 radiculopathy L3 much more often.

Sacrotuberous ligament

Palpate - find IT and drop medial and superior

Thoracic passive movement testing: Lateral flexion (SB)

Palpate for opening on opposite side or closing on same side

Thoracic passive movement testing: Rotation

Palpate for opening on same side or closing on opposite side

SI Joint assessment in supine (palpation)

Palpate: -Iliac crests -Pubs -Inguinal ligament (look for tenderness) -ASIS

SI assessment in prone

Palpate: -Sacral base -ILA - A/P dimension (depth) and superior/inferior -Leg length (eye ball) -Gluteal tone (assymetrical = chronic SI joint issue) -Ischial tuberosities -Sacrotuberal ligament (upslip = slack on one side)

Thoracic: Soft tissue mobilization

Patient sidelying - -Place one forearm on rib cage and other on iliac crest grab medial aspect of paraspinals and pull laterally ??

Mobility Testing of TMJ: Distraction/Longitudinal Glide

Patient sitting Stabilize head with one hand Thumb on superior aspect of molars Index finger on exterior surface of mandible Push inferior/anterior ONLY end of range and sustained

8. Squish Test

Patient supine Place hands on ASIS Apply downward and slightly medial force Feel for difference R vs. L

Costotransverse joint movement

Rotation at 6/7 Glide 7-10

SI joint: Fxs

Rule out fractures! Palpate sacrum and SI joints (use moderately deep pressure) + = Localized, point tenderness

Treating Hypermobile SIJ

SI belt -> Prolotherapy -> Surgery (fixation/fusion)

Anterior torsion - Right on Right

SI dysfunction + L SEATED flexion test** -Base of sacrum anterior L -ILA posterior R -ILA motion R increased on FB (around axis of L ILA) -Medal malleolus shorter on R in prone -Lumbar scoliosis convex on L -Lumbar lordosis increased

R unilateral flexed sacrum / INFERIOR SHEAR (sacrum tips down on right)

SI dysfunction + R SEATED flexion test -Base of sacrum anterior on R side -ILA inferior on R side -Medial malleolus longer in prone on R (related to position of sacrum) -Lumbar scoliosis convex R -Lumbar lordosis - normal to increased

Posterior torsion - Right on Left

SI dysfunction + R SEATED flexion test -Base of sacrum posterior on R -ILA anterior on L -ILA motion - R increased on extension -Medial malleolus short on R in prone -Lumbar scoliosis convex to the L -Lumbar lordosis reduced

R unilateral extended sacrum / superior shear

SI dysfunction + R SEATED flexion test -Base of sacrum posterior on R side -ILA superior on R side -Medial malleolus shorter in prone on R -Lumbar scoliosis convex L -Lumbar lordosis - decreased (stiff spring test)

Bilateral flexed sacrum

SI dysfunction + SEATED flexion test bilaterally Lordosis increased

Bilateral extended sacrum

SI dysfunction + SEATED flexion test bilaterally Reduced lumbar lordosis

What information do mobility tests give you?

SIDE but not direction of dysfunction

Soft tissue mobilization: Cervical Thoracic Junction

SITTING or PRONE Hold upper trapezius and levator Both thumbs dorsally, fingers ventrally Press vertically with thumbs and then pull dorsally END TREATMENT SESSION - Patient's love this

SLR Test

SLR - Sciatic nerve SLR + Ankle DF + Everson = Tibial nerve SLR + Ankle PF + INV = Superficial fibular nerve S:F + Ankle DF + INV = Sural nerve Add passive neck flex/ext Add cerv Sidebend

Palpate anterior aspect of TMJ

SOFT TISSUE -Temporalis (above ear and clench) -Lateral and medial pterygoid -Masseter (at cheek under fingers) -Scalene -Suprahyoid

Scoliosis rotation (and effects on ribs)

SP rotate toward concavity and vertebral bodies rotate toward convexity -Ribs on convex side separate and move posteriorly producing rib hump -RIbs on concave side approximate and move anteriorly, producing rib flattening

Stages of TMJ Disc Dysfunction

STAGE 1 - Slightly anterior and medial disc on mandibular condyle - inconsistent click, mild or no pain STAGE 2 - Anterior and medial, reciprocal click in early opening and late closing - severe constant pain STAGE 3 - Reciprocal consistent click present later in opening and earlier in closing (disc further forward) - more painful (on retrodiscal material) STAGE 4 - Click rare, no pain - disc no longer relocates - can scar over and form pseudo disc TREAT WITH DISTRACTION

Starting exercise for cx patients

START in gravity eliminated position -Stable positions -Use short lever arms -Cardinal planes (not dynamic) -Keep UEs below 90°

Structural vs. Non-structural scoliosis

STRUCTURAL - Fixed lateral curve with rotation NON-STRUCTURAL - Reversible lateral curve without rotation

Cx nerve root foramen borders

SUPERIOR: Inferior pedicle above INFERIOR: Superior pedicle below ANTERIOR: Uncovertebral joints POSTERIOR: Facet joint

4. Thigh thrust

SUPINE 90° hip flexion on one side (stand on this side), put hand under sacrum. Hug femur and compress

PAIVM Movement Testing C2-C7: P/A unilateral pressure

SUPINE Creates rotation (nice because you can watch patient)

Manual Cx traction

SUPINE Hands under occiput - pull towards you

PAIVM of TYPICAL Cx spine: Side gliding

SUPINE MCP jt of index fingers squeezing articular pillar Shift right and left and feel give Gliding Right = L sidebend = R facets opening

Mobility Testing of TMJ: Lateral glide of mandible

SUPINE Mouth slightly open Thumb inside on medial aspect of mandible Push laterally ONLY end of range and sustained

Soft tissue mobilization: Superficial neck muscles

SUPINE Stabilize forehead Pull transversely along long muscles of erector spinae

Soft tissue mobilization: Deep neck muscles

SUPINE Use 2, 3, 4 fingers with eminences on occiput Pull in cranial direction

PPIVM Cx Rotation for Treatment

SUPINE - head on plinth Cradle neck and occiput (does the work) One hand on chin, forearm along face (just guiding) -Rotate away from side of pain to open IV foramen (can do grade III for this, make sure movement in unison) GENERAL - for relaxation

Diseases affecting Cx (systemic and other) - hyper vs. hypomobile

SYSTEMIC/HYPERMOBILE 1. Downs 2. RA -High rate of DJF/DDD = hypomobile

SI Joint Ligaments

Sacrospinous forms greater sciatic foramen Sacrotuberous is compressive force keeping joint together Posterior SI Lig has 3 layers 1. Short interosseus lig 2. Intermediate 3. Long posterior SI lig

LQ Exam: Myotomes

T12, L1-L3 = Iliopsoas (don't let me push knee down) L2-L4 = quadriceps(dont let me bend knee) L4 = anterior tibialis (don't let me push foot down) L5 - Extensor hallucis longus (don't let me pull down toe) S1 - FIbularis longus/brevis S1-S2 = Gastroc/soleus (don't let me pull you up) S2-S4 = bladder/foot intrinsics (test by asking about bladder) 5 seconds

Typical Tx vertebrae

T2-T8 -Transverse and A/P diameters about symmetrical -Kyphosis d/t back of vertebral bodies being higher than front as it goes down -Small vertebral foramen -Lamina - short, thick, broad and overlap each other

Transverse processes of typical thoracic vertebrae

TPs point laterally and slightly posteriorly TPs have bulbous tip (muscle attachments) Have oval facets for articulation with tubercles of corresponding ribs

Cx IV Discs (innervation)

-35% height of cx spine -Gives lordotic shape -Outer 1/3 innervated by vertebral and sinuvertebral nerves WIDE distribution of nociceptors (results in diffuse and different presentations)

Ligaments around ribs (55:40)

-Anterior longitudinal ligament -Radiate ligament -Interarticular ligament -Superior Costotransverse ligament - rib to TP -Intertransverse lig (between TPs)

Dentate ligaments

-Apical lig - from odontoid to basiocciput -Alar lig - posterior lateral odontoid to occipital condyles (centers dens - relaxes in SB)

Medial Branch of Posterior Division of Spinal Nerve innervates...

-Articular capsule -Posterior ligamentum flavum -Interspinous lig -Supraspinous lig -Lateral branch innervates skin and deep back muscles

T10

-Articulates only with 10th pair of ribs -Does not anchor rib 11

Body of sternum

-Articulates with manubrium at sternal angle (2nd rib attaches here) -Articulates with 2-6 ribs via costal cartilage -Has small facet for articulation with 7th costal cartilage

PPIVM of TYPICAL Cx spine: Sidebending in sitting

-Ask pt. to chin tuck to flatten cx One hand in hair at front PALPATE with middle finger LATERAL to SP (either ipsilateral and feel closing or contralateral and feel opening)

History: Issue resulting from repetitive position/movement

-Asymmetry in sitting/standing posture -Asymmetry in sleeping

General Cx info

-Bears less weight than Tx or Lx -More mobile than other sections -Need stability in AO and AA to support head and protect SC and vertebral arteries

Anatomy of Axis (C2)

-Bifurcated SP -TP for vertebral artery -Odontoid in center - pivot for AA

Attachment of TMJ Disc

-Collateral discal ligs - Permits A/P roll of condyle (medial and lateral = MDL/LDL) Lateral pterygoid helps to pull the disc forward = Lower part of lateral pterygoid -Fibroelastic tissue on posterior aspect prevents disc from going too far back

Contraindications to McKenzie

-Doesn't show directional preference -Can't change sxs -Inflammatory disorders -Structural anomalies -Referred from elsewhere -Neurological disorders

Thoracic: Special Questions

-Effect on breathing/coughing -Effect of pushing/pulling -Tightness in chest -Digestive problems

McKenzie: Postural Syndrome Sx Behavior

-End range stress of NORMAL structures -Frequenty sedentary positions -Usually <30 yo in frequent sedentary positions -Often complains of both thoracic and cervical pain -NO change in intensity and/or location -*NO change in pain with repeated motions* -No loss of movement, signs of pathology

Goals of cx stabilization

-Exercise for every neck patient (prevent, control, eliminate sxs while exercising) -Facilitate more functional posture and movement patterns -Find position of comfort

Difference between male and female pelvis

-Female is broader, open outwardly with larger pelvic brim -Male is higher and narrower

Mobility Tests for SI Joint

-Forward flexion -Backward bending -Stork (marching) test -WB provocation -Lumbar movement (clear or implicate Lx)

General anatomy of Tx vertebrae

-Get bigger as you go down -Costal facets on bodies that hold rib heads -Facet on TP that helps articulate with rib tubercle

Cauda Equina Syndrome (cause/sx)

-Immediate referral for MRI or CT -*Surgical Emergency - immediate surgical consult needed* CAUSE: Compression of multiple lumbosacral nerve roots below conus medullaris. Symptoms: -LB pain - Sciatica (unilateral or bilateral) -Saddle sensory disturbances -Bladder and bowel dysfunction -Variable lower extremity motor and sensory loss

Typical rib attachments (rib 3)

-Inferior demifacet of rib 3 attaches to 3rd thoracic vertebra -Superior demifacet of rib 3 attaches to 2nd thoracic vertebra -Crest of rib 3 attaches to disc between 2nd/3rd tx vertebra

When NOT to exercise for cx patients

-Irritable - acute cx radiculopathy -Unstable

Common complaints of TMD

-Jaw impairments -Facial pain -HA -Tinnitus -Clicking -Locking

McKenzie: Dysfunction Syndrome - Objective

-Loss of movement in predictable directions (d/t adaptive shortening) -Happens over long time (usually) -Pain before full end range -Repeated movement may not increase or decrease ROM immediately (slowly resolving condition) -Pain no worse with repetition

Atypical ribs: Rib 1

-Most curved -Broadest - scalene muscles, protect arteries -Shortest -Single facet which articulates with body of tx1 -No angle -No costal groove

McKenzie: Derangement Syndrome - Objective

-Neuro signs may be present -Directional preference likely -Centralization/Peripheralization occurs (ONLY in derangement) -Can disturb sleep

Flexibility Testing on SI examination

1. Hamstrings - SLR 2. Hip flexors - Thomas Test 3. Rectus femoris - Ely's 4. TFL - Ober's test 5. Piriformis -Supine - hip to 90°, adduct and IR (normal is 20/20) -Prone - knee flexed to 90°, bilateral IR

Slump Test

1. Hands behind back 2. Slump 3. Neck protrusion (flex lower and extend upper) 4. Neck flexion 5. Straighten leg 6. Overpressure (grab from heel)

Symptoms of over treatment

1. Increased muscle guarding 2. Loss of energy 3. Increased pain >1 hour after treatment 4. Increased edema and/or erythema 5. Increased stiffness after rest 6. Loss of ROM the following day

Compartments of TMJ (and accompanying movement)

1. Inferior - hinge joint -Underneath disc and articulates with condyle. Attached to m/l of poles. Condyle allowed to rotate and move on disc - small movement 2. Superior - gliding joint - between temporol bone and meniscus (above disc) -Larger and looser attachments allowing for gliding

Why don't we touch TPs in cervical spine for mobilization?

1. Weak 2. Uncomfortable 3. Little - difficult to grasp them

Thoracic outlet sites of compression

1. interscalene triangle - anterior scalene, middle scalene and 1st rib 2. Costoclavicular space (between clavicle and 1st rib) 3. Neurovascular bundle passing beneath coracoid process and tendon of pec minor 4. OTHER - faulty posture, presence of cervical rib, edema, muscle spasms, trauma, stress

3 Degrees of freedom

1. opening/closing (x axis) 2. Protrusion and retrusion (y axis) 3. Lateral movement (z axis)

TMD Disability Index

10 Qs - 5 answers to each -Talking -Brushing/flossing -Eating -Musical instruments (wind - right mouth piece) -Sexual activities -Sleep

Active movement testing of TMJ - Lateral deviation

10-15mm (Magee) Central incisor of maxillary tooth to central incisor of mandible

Cx Special Tests: Shoulder Abduction

Abduct arm and place palm on head - relieves symptom Indicates extradural compression (often at C4-C5)

McKenzie: Pain with sit to stand is a sign of....

Active (symptomatic) disc bulge Kyphosis -> lordosis with obstruction

Relationship of Lumbar spine to Sacrum w/ movement in neutral position

Adaptive spine sidebends to opposite side of SI joint (if non-adaptive you need to treat this first) EXAMPLE: Sacrum sidebends to R and rotates to the L -> Lumbar sidebends L -> Lumbar scoliosis with convexity to the Right

Beginning to treat cervical spine

Address pelvis first - lumbar angulation can change alignment (get them in proper posture first) -Education (ergonomics etc.) -Strengthen retractors

What often causes thoracic outlet syndrome?

Aggravated by carrying or doing overhead work

Mandibular measurement

Angle of jaw to mental protuberance on each side

Anterior/Posterior Joint Capsule in Cx Spine

Anterior = strong but lax in neutral and extension Posterior = thin - can lead to stability issues

Baer's Point

Anterior part of SI along joint line -2" lateral from umbilicus -1/3 of way from umbilicus to ASIS

Effect of flexion/extension on torsions

Anterior torsions improve with extension, made worse with flexion (Opposite sacral base goes anteriorly and gets closer to even compared to other sacral base) Posterior torsions improve with flexion, made worse with extension (Opposite sacral base goes posteriorly and gets closer to even compared to other sacral base)

TMJ - Reciprocal click

Anteriorly dislocated disc - condyle pops past disc and back onto disc with closing -Audible click on opening -Second click on closing (usually)

AO (Atlanto-Occipital) Joint

C0-C1 2 symmetrical joints - superior articular facets of lateral masses and occiptal condyles 3 deg of freedom: axial rotation (little), flex/ext, lat flexion

What level do you start at with PAIVM in Cx spine

C3 - move C3 on C2

Anatomy of Typical Vertebrae

C3-C6 -Vertebral body wider than high -Uncinate processes -Uncovertebral joints (Von Luschka)

UQ Exam: Neuro Tests - dermatomes

Compare side to side on skin - "does it feel the same or different?" C2 - occiput *(under ear) C3 - jaw line/neck C4 - Supraclavicular fossa C5 - Lateral brachium C6 - Lateral base of thumb C7 - Distal phalanx digit #3 C8 - Ulnar border of 5th digit T1 - medial border of forearm

Special tests for thoracic outlet: Hyperabduction maneuver

Compresses neurovascular bundle against rib cage using pec minor Abduct arm 140° - move it around and see if pulse changes -Extension and rotation of head to opposite side may increase sxs

Special tests for thoracic outlet: Costoclavicular maneuver

Compresses neurovascular bundle between 1st rib and clavicle -Retract shoulders, depress and puff out chest -Check pulse on both arms

SI Mobility Test in supine: SI Provocation Test

Compression - Cross hands and push out on iliacs Distraction - Push iliacs together (can relieve sxs but can also cause pain d/t ligament tension)

Mandibular movements: Protrusion

Condyle and disc translate anteriorly and inferiorly together upper joint because it's gliding motion

Thoracic treatment: Rib mobilization

Contour web space around rib - reinforce with wrist -Press in on exhalation -STAY pressed in through inhale and exhale -Release on inhalation

Measuring FHP

Craniovertebral angle - Tragus of ear to posterior aspect of C7 54° = normal (smaller = more FHP)

Anatomy of Ilium

Crescent shaped, concave posterosuperiorly, very irregular crest lying between 2 furrows Lined with fibrocartilage (SI joint has 2 types)

Ligaments of C0-C2

Cruciform lig -transverse portion keeps dens in place -Vertical portion Dentate ligaments -Apical lig - from odontoid to basiocciput -Alar lig - posterior lateral odontoid to occipital condyles (centers dens - relaxes in SB) Tectorial membrane - support Ligamentum nuchae - inter/supraspinous lig

Using respiration to aid mobilization

Exhalation moves sacral base anteriorly Inhalation moves sacral base posteriorly

Most typical limited movements in thoracic spine (hypomobility)

Extension and rotation

Using position to change mobilization

Extension moves sacral base anteriorly -USE FOR: Unilateral sacral shear, counter-nutated sacrum, posterior torsion Flexion moves sacral base posteriorly (tougher - child's pose)

McKenzie abbreviations for resisted movement

FIL - Flexion in lying (start here - unloaded) RFIL - Repeated... (10x - unless sx earlier) EIL - Extension in lying (reverse anything provoked from FIL) REIL - Repeated... If loading isn't an issue you can start in standing FIS - flexion in standing RFIS - Repeated ... EIS - Extension in standing REIS: - Repeated... SGIS - Side glide in standing RSGIS - Repeated...

McKenzie: Derangement Syndrome response to movements

FLEX: Usually - deviation away from painful side (unless have sciatic nerve root entrapment) EXTEND: Deviation away from side of pain SIDE GLIDING: Lateral shift + unilateral side gliding issues REPEATED MOVEMENTS: Peripheralization with movements that worsen disc impairment -Centralization with opp. movement

LLD

FUNCTIONAL vs. ANATOMICAL 1. Check ASIS's and scan for compensations 2. Check GT (eliminates pelvis) 3. Have patient bridge and then pull legs (change way of lying) 4. Measure GT-> Medial malleolous (careful for muscle mass difference)

Mobility Test for SI: Backwards Bending

Fingers on sacral base - = Thumbs dip anteriorly to same depth + = One side doesn't move as much Testing for SI dysfunction

Sharp Purser (add this from practical slides)??

Flex first

Thoracic resisted testing

Flexion - hand on sternum Extension - T1/T2 area SB - shoulder Rotation - scapulas

Cx ROM

Flexion/extension: 150-160° (Extension = 70°, F = 80-90°) Lower cx = 100-110, suboccipital = 20-30, AO = 15° Lateral flexion = 45° Suboccipital = 8° Rotation = 80-90° 50% at AA

Thoracic active movement testing: Ranges

Forward bending: 20-45° Backward bending: 20-45° Sidebending: 20-40° Rotation: 35-50° Sometimes better to measure these with landmarks of C7-T12 Then add overpressure

Freeway space, Overbite, Overjet

Freeway (2-4mm) - Palpate in ear, condyles touch finger pads OR separate lips and see if there is space Overbite - Overlap of max teeth over mandibular Overjet - max teeth protruded anteriorly (thumb sucking/pacifiers/tongue thrusters)

Cx exam: Provocation tests

GET IN NEUTRAL ALIGNMENT 1. Cx compression 2. Cx distraction - could have pain with adherent nerve root or stretched ligament

Mobility Test for IS: Standing Forward Flexion Test

Get eye level with PSIS and place thumbs UNDER. Pt. flexes forward - = Both move cranially and anteriorly in symmetry + = One side moves first and further cranially Testing for Ilioscaral (IS) Dysfunction (innominate moving on sacrum) Gold standard to determine side of dysfunction (looking for difference

Gliding vs. Hinge movements

Gliding of protrusion and retrusion take place in superior compartment Hinge movements of depression and elevation take place in inferior compartment

SI Mobility Test in supine: Leg Length

Have patient bridge and then bring legs flat. Grab both legs under malleoli and check length. Have patient come into long sitting - = Difference stays the same. + = A change in leg length. (if disparity increases, then leg that got longer = posterior innominate) Should correlate to findings of FB test and stork test ISSUES: 1. weak abs 2. tight hamstrings

Thoracic passive movement testing: Extension

Have patient cross arms and hold across as bring them backward

Thoracic passive movement testing: Flexion

Have patient cross arms and hold across as bring them forward

McKenzie: Correcting Lateral Shift

Have patient placing weight on AFFECTED leg and shift hip into wall (for lateral lesion, leg will be further away)

Stretching alternative: Upper trapezius and SCM (PICS)

Head in flexion, L SB and R rotation R arm over head L arm on chair Lean body to left HOLD for 7 sec

Stretching alternative: Levator scapulae (PICS)

Head in neutral - into flexion, L SB and L rotation L hand over head R hand holds base of chair and lean trunk away and keep head in same position HOLD for 7 sec

6. Faber (Patrick) Test

Hip if pain getting into position SI if pain on pressure

UQ Exam: Neuro Tests - myotomes

Testing for FATIGUE weakness 1. Hold for 5 seconds 2. OR 5 repetitions C1 = Neck rotation or flexion (side of forehead) C2-4 = Levator scap (shrug and hold - reps) C4 = Diaphragm/levator scap (under ribs) C5-6 = Shoulder abduction/elbow flexion (90°) C6 = wrist extension C7 = elbow extension, wrist flexion C8 = Thumb extension (fonzie), finger flexion (3rd DIP) T1 = finger abduction (palm down) POSITIVE = nerve problem somewhere in path

What is unique about movement at SI Joint?

There is no prime mover that allows it to move in half of pelvis. It responds to passive movement.

Body/shaft of rib

Thin, flat, long and curved -5-6cm beyond tubercle, body swings sharply forward -Point of greatest change in curvature is angle of rib -Costal groove on internal surface near inferior border - protects intercostal vessels/nerves

Atypical ribs: Rib 2

Thinner and double length of 1 -Attachments: SA, SP, Scalenes, Intercostals Articulates with 2 demifacets w/ first and second tx vertebra -No or slight rib angle

Cx Special Tests: Spurling Test (Quadrant test)

Vertebral artery test in sitting Add compression = impinge nerve root + = radicular complaints in nerve pathway Add distraction - should relieve sxs

Mobility Test for SI: WBing Provocation

WS side to side. Make sure spine stays aligned and not laterally bending

McKenzie: Treating unilateral Stenosis

Want to OPEN that side up Pain NOT from space occupying lesion but lack of space on that side.

Thoracic treatment: Progressive oscillation

With any treatment, you can time with breathing and then go to the next grade.

McKenzie: Derangement Syndrome Sxs based on movement

Worse in sitting, sit to stand, bending Better walking and lying

Sternocostal joint

between costal cartilage and sternum -First pair directly united to manubirum by synchondrosis -2-7 articulate as synovial joints with lateral border of sternum

Tx spine: Lateral flexion

facets open contralateral side Close ipsilateral side COUPLED with rotation

To achieve full end range of UCC flexion

flexion and nod

Video of stages of TMJ Disc Dysfunction

https://www.youtube.com/watch?v=mB468Jh9aAY

Sternum

inclined downwards and slightly forward -Slightly convex anteriorly, concave posteriorly

Movement of 11/12 ribs with respiration

inhalation = posterior and lateral exhalation - anterior and medial

Innervation of costovertebral joints and costotransverse joints 57:30

innervated by dorsal rami of adjacent spinal nerve

Anatomy of sacrum

lined with hyaline cartilage

Mandibular movements: Lateral deviation

one condyle spins around vertical axis, and other translates forward R deviation = Spin on R, translation on L

Thorax

osseo-cartilaginous framework that houses and protects organs of respiration and circulation

One thing to do with all cx patients

postural education

To achieve full end range of UCC extension

protrusion

To achieve full end range of LCC extension

retraction and extension

PAIVM Movement Testing C2-C7: Posterior-Anterior (prone) w/ caudal direction

rotate around so facing that direction (Caudal - closing level below)

Passive movement testing of cx

tested in sitting HAND PLACEMENT - one on occiput, one on forehead 1. Flexion - ligament or bony end feel 2. Extension - muscle tightness or bone 3. SB/Rotation - soft tissue stretch

Anatomy of Mandible

Largest bone of the face

Pterygoid

Lateral pterygoid - Needs to relax to elevate (close) jaw To access LP - put finger pad lateral to molar and up by cheek and feel it as you protract and retract jaw Medial pterygoid - Palpate under angle of jaw with closing

Mandibular movements: Retrusion

Limited by TM ligaments becoming taut (retrodiscal material occupy space)

Interchondral joints

Located between ribs and cartilages of 6-8 (sometimes 9-10) -May become fibrous or fuse later in life

Teeth numbering

#1 = R maxillary moler (1-16 = maxillary) Mandibular L to R = 17-32

Treating Counter-nutated sacrum

(extended) Push on top of sacrum (sacral base) Palpate at apex - should pop into your hand

Mobility Test for SI: Sitting Forward Flexion

(first check static) Innominate bones blocked via ITs - = Cranial and symmetrical movement + = 1 side moves first and further Testing for SI dysfunction

Treating Nutated sacrum

(flexed) Push on bottom half of sacrum (apex) Palpate at sacral base (should pop into your hand)

Facets of typical thoracic vertebrae

-2 Superior Costal facets - Rib above sitting on this (larger - carry weight of rib) -2 Inferior Costal facets (demi facets)- helps anchor head of rib below -Superior intervertebral facet (part of posterior elements) - situated at level higher than body -Inferior articular facet - at level of body -TP facet (articulates with rib tubercle

Sinuvertebral Nerve Innervates...

-Outer annulus -Tissues in SC -PLL -Dura mater -Vertebral disc -Innervates branches above and below level

Observation in TMJ

-Posture (FHP creates issues with breathing, swallowing, nervous system) -Facial symmetry -Resting position of jaw - clenching - freeway space -Ease of opening/closing - watch as talking -Alignment of teeth and how many teeth -Position of the tongue - ask -Swallowing -Soft tissue examination - CA - connection between HPV and uterine/cx/mouth

McKenzie: Assessment - Lateral Shift Types

-Primary (or Relevant) = d/t disk material relative to spinal nerve in intervertebral space EXAMPLES: Kyphosis, Scoliosis -Secondary - Result of condition NOT cause of it ?? OR it's there but not affecting condition??- Dysfunctional facet joints - Usually >30 yo. Should be treated as dysfunctions (everything else)

Subjective in TMJ

-Radicular complaints (ear, tooth -Position of sleep, pillows - prone sleeper an issue -Trauma -Opening/closing pain -Clicking with movement - indicates disc problem -Crepitus - indicates arthritic changes -Locking -Dental work -Appliances - bite plates (retainer)

Typical rib

-Rib head - 2 articular facets separated by ridge (crest of head) -Crest articulates with IV disc by intra-articular lig. -Inferior facet articulates with numerically corresponding vertebra -Superior facet articulates with vertebra above

Cartilage in SI joint

-Sacrum lined with hyaline cartilage -Ilium lined with fibrocartilage

Contraindications to McKenzie: Structural Anomalies

-Spina bifida -Lumbar sacralization -Spondylosis -Spondylolysis -Spondylolisthesis

Cx Special Tests

-Spurling Test (quadrants) -Lhermitte's sign -Shoulder abduction -Valsalva

McKenzie: Dysfunction Syndrome - Treatment (details)

-Stretch shortened tissues in direction of dysfunction (into pain) - 10x every 2 hours for 4-6 wks and then decrease -Must produce localized pain which should subside in 10-20 min -Posture correction as needed - strengthen and stretch to ease restoration of alignment

Treatment of TOS

-Stretch soft tissues -Strengthen postural muscles -Mobilize 1st and 2nd ribs -Mobilize/stretch tx spine -Appropriate neural tension

TPs of typical vertebrae

-TPs have gutter like shape to protect nerve root -Nerve goes out directly lateral

Muscles of elevation of TMJ

-Temporalis -Masseter -Medial pterygoid -Medial portion of lateral pterygoid

Anatomy of Atlas (C1)

-Transverse diameter > AP diameter -2 lateral masses biconcave superior articular surface (hands holding up globe) -Small articular facet on anterior arch for odontoid (articulates odontoid on C1) -TPs have foramen for vertebral arteries MOTION: ROTATION

History: Pregnancy/child birth

-Type of delivery -Length -Position -C-section scars

Movement of ribs with respiration

-Upper ribs have more pump handle (anterior part of rib moves superiorly) -Lower ribs have more bucket handle (lateral aspect moves superiorly) Axis is more transverse in upper and more A/P in lower

Special cx subjective questions

-Work, leisure (dentists) -Glasses - progressive lenses can cause issues -Issues swallowing (anterior disc herniation can impinge on esophagus) -Mouth breather? - jaw and head come forward (TMJ/neck issues) -Sleeping position? (multiple pillows, prone etc.) -Type of pillows? (FHP) -Headaches? (change in HAs?)

Thoracic PAIVM: Rotation

1. Unilateral TP 2. Dummy hand on above TP and below TP 3. Horizontal pressure to SP

TMJ Disc

Biconcave - 2 compartments - upper and lower Avascular and aneural -2mm anteriorly, 3mm posteriorly Fibrocartilaginous

Cruciform ligaments

-transverse portion keeps dens in place (arches across ring of atlas) -Vertical portion (body of the axis to the foramen magnum)

Yellow/Red Flag Cx Questions

1. Dizziness, vertigo, drop attacks (just falls to floor = arrhythmias) 2. History of RA, other inflammatory arthritis, treatment of steroids 3. Neurological involvement of LEs (balance, ataxia, drop foot)

Defining Scheuermann's Disease

1. Excessive thoracic kyphosis with wedging >5° OR 2. At least 3 adjacent segments with end plate irregularities

Mobility Test: for SI Stork (Marching) Test

1 thumb on sacral base, other under PSIS on lifting leg side. - = Innominate drops (PSIS) and sacrum stays put + = PSIS moves superiorly (hikes up) Testing for IS dysfunction

Ribs

1-7 = True - articulate directly to sternum through costal cartilage 8-10 = False - articulate with sternum through costal cartilage of ribs above 11/12 = Floating - no articulation Intercostal spaces larger anteriorly and in upper ribs

Special tests for thoracic outlet

1. Adson's maneuver 2. Costoclavicular maneuver 3. Hyperabduction maneuver

Thoracic disc herniation sxs

1. Anterior chest pain 2. Interscapular, epigastric and LE pain 3. Pain with deep breathing/coughing 4. Muscle spasms, weakness or decrease ROM 5. Dural stretch may be + -Can have neuro sxs if cord compressed

SIJ Special Tests

1. Anterior gapping test (provocation test) 2. Posterior distraction test (provocation test) 3. Gaenslen's test 4. Thigh thrust 5. Sacral thrust/spring test 3/5 = sensitivity .91, specificity = .78 6. FABER/Patrick Test 7. Prone knee bending 8. Squish Test

UQ Exam: Pathological reflexes

1. Babinski sign (drag up and medial - should curl towards) 2. Clonus 3. Hoffman Sign (scrape dorsal 3rd digit and clawing is positive sign in 4th/5th digit)

Thoracic outlet anatomical anomalies

1. Cervical rib - partial or full?? (pg. 315) 2. First rib attaches to 2nd rib

Cx Neurological Exam

1. Dermatomes 2. Myotomes 3. Reflexes 4. Pathological reflexes

Muscles surrounding SI Joint

1. Flexors/Extensors 2. Hip Abductors/Adductors 3. Hip ER/IR 4. Stabilizers - Abs, diaphragm, pelvic floor, multifidus, erector spinae

Active movement testing cx for AO and AA joint

1. Jut and nod for AO joint -use nose and midline as reference -check for lateral deviation to side with nodding (one side doesn't move and pulls nose towards it) 2. AA joint - fully flex neck to lock cx and then rotate -Should be 35-45°

Medication for TMJ pain

1. NSAID's 2 Steroids 3. Opiates Trigger point injections Occlusal therapy - bite guard Psychotherapy

General ways to treat Sacral dysfunctions

1. NSAID's 2. Stabilizing SI belt 3. Restore proper joint alignment 4. Restore muscle length 5. Regain muscle strength 6. Stabilization exercise program 7. Insure proper biomechanics

McKenzie: Dysfunction Syndrome - Treatment Progression

1. Patient generated forces 2. Patient generated overpressure 3. Therapist overpressure 4. Therapist mobilization 5. Therapist manipulation

Sternum orientations

1. Pectus Excavatum - funnel chest (posterior) 2. Pectus Carinatum - pigeon chest (forward and downward) 3. Barrel chest (forward and up)

Order of treatment of SI joint

1. Pelvis upslip/downslip 2. Pubs 3. L5 (non-adaptive) 4. Sacrum 5. Ilium

3 types of syndromes

1. Posture - time dependent 2. Derangement 3. Dysfunction

McKenzie: Postural Syndrome treatment

1. Posture correction via patient education (body mechanics, posture, ADL) -Dynamic disc 2. Instruction on prevention and exercise -Stretch tight structures -Strengthen weak muscles -HEP

Harold Gelb - 3 part model for TMJ

1. Predisposition - nervous, clenchers, high anxiety 2. Tissue alteration - congenital deviations, fibrotic changes, inflammatory response 3. Psychological dependence - difficult to treat

Anatomical accommodations for LLD

1. Pronate at ankle 2. Flex knee 3. Posteriorly rotate innominate DON'T USE SHOE LIFT until you can see if you can make postural change

Treating muscle spasm

1. RELAX! 2. Ice massage 3. Soft tissue techniques 4. E-stim 5. Biofeedback on masseter 6. Identify stressors - incessant chewing, hypermobile - limit opening 7. Reposition structures - mobilize 8. Cx strengthening 9. Posture

McKenzie: Derangement Syndrome Treatment

1. Reduction of derangement 2. Maintain reduction (72 hours) 3. Recovery of function 4. Prevention of recurrence/prophylaxis - move on from McKenzie to core stabilization etc.

Rules of movement in AO Joint

1. Rotation and sidebending ALWAYS in opposite directions 2. Flexion/extension are non-coupled movements (doesn't change way it rotates/sidebends)

Rules of movement in C2-C7 Spine

1. Rotation and sidebending ALWAYS in same direction 2. Flexion/extension are non-coupled movements

Treating Posterior Innominate

1. SIDELYING - Top leg EXTENDED R hand on iliac crest, L hand on IT Rotate ilium forward 2. PRONE - Lift distal femur up, other hand pushes ilium down (can ask patient to bring knee down - engage rectus and then move after contraction stops) 3. SUPINE - One side off side of table. -Straddle leg and can have them pulling up -pull up on ilium

Treating Anterior Innominate

1. SIDELYING - Top leg FLEXED One hand on IC, other on IT Rotate ilium dorsally (push down) 2. PRONE - over side of table with LE between knees (can have patient lift leg up and engage hamstrings isometrically. Push on IT, pull on IC

Cx Traction: Determinations

1. Severity of sxs - neurological evaluation 2. How they respond to it 3. Radiological evaluation

Order of SI examination

1. Standing structural assessment and mobility testing 2. Supine - looking at pubic symphysis -Treat to correct PS if necessary 3. Prone - sacral dysfunction -Treat sacrum 4. Supine - innominate dysfunction -Treat innominate

TMJ Special Questions

1. Sucking on pacifier or thumb? (what age) 2. Mouth breather - sleep apnea 3. Difficulty swallowing (trigeminal nerve) 4. Earaches, HAs, dizziness (FHP, subcranial muscles)

Quick Functional Tests for cx spine

1. Swallowing (tests lips, jaw, pharynx, larynx, suprahyoid, infrahyoid 2. Look up at ceiling (full ROM extension) 3. Look at shoes (full ROM flexion) 4. Check over each shoulder (facets same as SBing so just rotation necessary) 5. Tuck chin in (upper cx flexion, lower extension) - reduces lordosis 6. Jut chin out (upper cx extension, lower flexion)

Common area for disc herniation in thoracic

1. T7-T8 2. T6-T7 3. T8-T9

Order of ligaments becoming taut

1. Temporomandibular 2. Sphenomandibular 3. Stylomandibular

2 types of TMJ patients

1. Traumatic 2. Psychological overlay - clenchers - VERY tough to treat

Atlanto-Odontoid Joint

Biconvex (convex on convex) -Can see meniscoids here.

Bilaminar retrodiscal pad

2 component parts: - superior lamina which is elastic - as disc goes forward, elasticity gives and allowed to go forward. Contracts when closing mouth to pull it back) -Inferior lamina not elastic - tether. If disc goes all the way forward, this is last ditch effort to keep it from dislocating. Rich in blood and neural supply. Sits behind disc = prone to be irritated and inflamed.

Synovial Membrane of TMJ

2 parts (2 joints in one): Superior synovial membrane - lines fibrous capsule superior to articular disc Inferior synovial membrane - Lines capsule inferior to articular disc

Temporomandibular ligament (lateral ligament)

2 parts: Inner oblique - attaches to lateral pole of condyle and posterior disc with postglenoid tubercle acting to prevent POSTERIOR dislocation Outer oblique - attaches to neck of condyle, strengthens LATERALLY

Sternocostal movement

2-7 - small amount of glide to assist in respiration

AA Joint

3 linked joints - Atlanto-Odontoid and 2 AA joints ONLY ROTATES - Trochoid joint (between odontoid, anterior arch of C1 and lateral mass) - odontoid stays in place and osteoligamentous ring turns C1 pivots on C2

Active movement testing of TMJ - Protrusion

3-6mm Jut jaw and see how far inferior go in relation to superior

McKenzie: Derangement 1-7

40:00 - EVEN #s have deformities - correct deformity FIRST 1: Low back (central and symmetrical) 2: LB with kyphosis 3: Unilateral or asymmetrical as far down as into knee 4: Same as 3 but with deformity - Lateral/kyphosis/LS 5: Into calf to foot (generally not bilateral) 6: Same as 6 but with deformity (TOUGHEST) 7: Anterior sway - pregnant women - femoral nerve involvement

TMJ: Rocobado's Protocol

6 reps 6x/day -Place tongue in resting position -Controlled opening (tongue stays on top - moderate opening) -Rhythmic stabilization (opening/closing) -Stabilized head flexion (deep cx flexors) -Axial neck flexion -Shoulder retraction

General facet joint orientation in Tx spine

60° relative to horizontal and 20° from frontal -SHOULD allow greatest movement in rotation but limited d/t ribs

HEP for chronic neck pain

??

Differentiating between LBP and SI Joint

A study by Dreyfuss et al states that "patients with confirmed SIJ pain rarely identify concurrent pain at or above L5. -Combine this with Laslett's cluster of 5 tests Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bog- duk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21 (22):2594-2 602.

Advantages/Disadvantages of Manual Cx Traction

ADVANTAGES -Greater control over neck -Can directly feel the forces DISADVANTAGES -Labor intensitve -Time consuming

Upslip/Downslip

AKA superior ilial shear Downslip is VERY RARE - someone hung upside down.

Differential Dx for Adherent Nerve Root (ANR) and Entrapment

ANR -Intermittent -Onset >6 weeks -May compromise gait -NB/NW -Extension has NO EFFECT -Reduced ROM into flexion -No change with repeated motions (change over time) -SLOW gains in ROM ENTRAPMENT -Intermittent -Onset >12 weeks -May compromise gait -B with RFIL/S -Can PP with EXTENSION -Repeated flexion ↑ROM (nerve figures out better path) -QUICK gains in ROM

Lateral view of Cx ligaments

AO/AA membrane continuation of ALL Posterior AO membrane continuation of PLL

Pelvic examination

ART -Asymmetry -ROM abnormality -Tissue texture alteration -USE DOMINANT EYE (L for me) -Careful with lines of clothing - can deceive

Sacral Base/Sulcus/Hiatus/ILA

BASE - Find PSIS and drop off medially Sulcus - depth from drop off Hiatus - Indentation where SPs would be ILA - just lateral to hiatus

Palpate posterior aspect TMJ

BONY -Mastroid process -TP of C1 SOFT TISSUE -Trapezius -Suboccipital muscles -Semispinalis cervicis and capitus -Ligamentum nuchae -Levator scapulae

Treating pubic symphysis dysfunction

Beauty is you treat bilaterally (regardless of what type of pubic dysfunction) SHOT GUN TECHNIQUE -Patient in hook lying -Resist abduction (hold at sides of knees) -Resist adduction (put one hand on knee and triceps on other knee) Hold for 7 second contraction 2-3x

Sciatic Nerve

Between greater trochanter and ischial tuberosity.

Palpation: Hyoid, Thyroid, cricoid, articular pillars, posterior triangle

Between mastoid process and Inferior angle = TPs of C1 Hyoid = C3 Thyroid = C4/C5 Cricoid = C6 Articular pillars = stack of facet joints Posterior triangle = Anterior SCM, Posterior trapezius, inferior clavicle

Costochondral joints

Between ribs and costal cartilage -No ligaments

UQ Exam: Reflexes

Biceps: C5-C6 Brachioradialis: C6 Triceps: C7 Jendrassik maneuver - w/ distraction

Greatest degree of flexion/extension in Cx (and related issues)

C5-C6 Highest incidence of Tetraplegia because it's the apex of the lordotic curve -Also highest incidence of DJD and nerve root issues

McKenzie: Dysfunction Syndrome

CAUSE: Mechanical DEFORMATION of soft tissues d/t ADAPTIVE SHORTENING. via poor posture, trauma, derangement. Dysfunction named by direction of limitation (Flexion dysfunction = cannot flex) -Pain before full end range when structures stretched (leads to adaptive shortening) -Can produce SECONDARY LATERAL SHIFTS -Intermittent pain (based on directional movement) -Loss of movement or function

McKenzie: Postural Syndrome

CAUSE: Mechanical deformation of soft tissue d/t postural stresses (bending finger and holding it) -Prolonged loading - *STATIC postures* -*Time dependent* -*Intermittent pain* -Pain reproduced via prolonged position -Relief by some position -Not referred

McKenzie: Derangement Syndrome

CAUSE: Mechanical deformation of soft tissues d/t INTERNAL DERANGEMENT OF DISC - tend to reoccur -Motion segment mechanics altered because of this deformation. -Usually constant pain -Pain can change in intensity and location with repeated movements (often worse with further flexion) -ROM can change with repeated movements or sustained postures -Pain may refer -Commonly 20-55 yo -Males>females

Treatment of Entrapment

CLOSE side of entrapment and OPEN contralateral side. Want to move structure back into place and allow it to go into opening. Lumbar spine push AWAY. ALWAYS start with this

Dysfunction Syndrome: Entrapment

Caused by sequestered nuclear material Occurs later than ANR because fibrocity increases and sequestration takes time

McKenzie: Dysfunction Syndrome - Management Considerations

Change is SLOW therefore: -Compliance is difficult -PT must emphasize small improvements-HEP should have quick, small progressions

Manubrium

Clavicular notch on each side - articulated with sternal end of clavicle -Below notch, costal cartilage of first rib forms a synchondrosis with lateral margin of manubrium -Also articulates with part of second costal cartilage

Clenching vs. Grinding

Clenching = tightening of muscles Grinding - teeth together (Bruxism)

Anatomy of Pelvis (bones/joints)

Closed osteoarticular ring with 3 bony parts and 3 joints: -2 innominate bones -sacrum -2 sacroiliac joints -Pubic symphisis

Mandibular movements: Depression (opening)

Combo of rotation and translaton -Anterior rotation (spin) of condyle on disc (lower joint - beginning) -Translation (gliding) anteriorly and inferiorly (upper joint)

Thoracic facet dysfunction

Common, associated with rib dysfunction -Movement impaired -Decreased joint play at facet and rib -Sx with respiraton, pain in anterior chest wall

Typical ROM in TMJ

DEPRESSION 40-50mm - 11-25mm come from rotation (18-25mm needed for normal mastication) PROTRUSION 6-9mm (need depression to protrude) LATERAL DEVIATION 8mm

McKenzie: Dysfunction Syndrome response to movements

DIRECTIONALITY TO IT FLEX: With adherent sciatic nerve root - deviation toward side of root irritation (shorten nerve) EXTEND: Usually not a significant deviation due to facet apposition in extension SIDE GLIDING: May show limited side gliding but not necessarily lateral shift REPEATED MOVEMENTS: If stretches shortened structures will produce pain BUT won't make patient worse.

Differential Dx for typical Dysfunction vs. ANR Dysfunction

DYSFUNCTION -Pain not referred -No neuro signs -Pain at end of available ROM ANR -Referred along nerve -Can have neuro signs -Pain occurs at predictable point in repeated movements

T4 Syndrome

Decreased mobility of upper T segments (esp. T4) ONSET: Insidious or new activity involving flexion Sxs: Glove parasthesia -hot/cold or swelling hands (vascular issues) -Non-dermatomal patterns in UE (SNS involvement) -Neck, upper T pain, HA in cap of head -+ Neuro tests -Sx in AM and get worse TREATMENT: Mobilize affected segment, posture, movement re-education

Scheuermann's Disease

Degeneration of bone resulting in excessive kyphosis in thoracic spine Occurs during growth spurt (12-16 yo) ASSOCIATED with lumbar lordosis, scoliosis or tight hamstrings

Anatomy of C7 Vertebrae

Different from C3-C6 because of long SP (Prominens) Transitional vertebrae

Shape of disc and temporal articulation

Disc is biconcave Articulation is convex on convex

Pseudo sciatica

Distal compression related to piriformis

Floating rib attachments to Tx

Don't have inferior facet to guide it.

Piriformis

ER - Palpate between greater trochanter and anterior/inferior sacrum (won't feel unless spasms) Inferolateral aspect of sacrum to GT

What movement to avoid in Spondylolisthesis

EXTENSION no good for Spondylolisthesis

R Inferior Shear (Downslip)

EXTREMELY RARE (walking usually corrects it) + R Standing forward flexion test -R ASIS inferior, R PSIS inferior, IT inferior -Medial malleolus longer on R -Sacrotuberous ligament tight R

PPIVM of TYPICAL Cx spine: Rotation in supine

Easier because don't have weight of head

SI lumbar/sacrum evaluation/testing in prone

Evaluate: -Lumbar curve Test: -Spring sacrum - only true accessory movement test -Spring lumbar - if L curve is flat it will be stiffer and less movement

Thoracic active movement: Ribs

Excursion at 3 different points: 1. Under axilla for upper chest 2. Nipple line for mid 3. 10th rib for lower

SI Joint during gait cycle

ILIOSACRAL MOVEMENT: Innominate rotates anteriorly and posteriorly during ambulation. SACRAL MOVEMENT: Axis of rotation originates on side of WBing leg -L on L, return to neutral, then R on R, return to neutral

Orientation of typical thoracic vertebrae inferior/superior articular processes

INFERIOR articular processes project downward and directed anteriorly, medially and slightly inferiorly -slightly concave SUPERIOR articular processes project upward and face posteriorly, slightly lateral and superiorly -slightly convex

L Inferior Pubic Dysfunction

IS dysfunction + L Standing forward flexion test L Inferior pubic tubercle L tender inguinal ligament

Right Outflared Innominate

IS dysfunction + R Standing forward flexion test ASIS lateral on R PSIS medial on R Sacral sulcus medial and shallower on R

Right Inflared Innominate

IS dysfunction + R Standing forward flexion test ASIS medial on R PSIS lateral on R Sacral sulcus lateral and deeper on R

Right Anterior Innominate

IS dysfunction + R Standing forward flexion test Inferior R ASIS, Superior PSIS Longer medial malleolus on R Sacral sulcus prone - shallow R (rotates towards sacrum)

R Superior Pubic Dysfunction

IS dysfunction + R Standing forward flexion test R Superior pubic tubercle R tender inguinal ligament

Right Posterior Innominate

IS dysfunction + R Standing forward flexion test Superior R ASIS, Inferior PSIS Shorter medial malleolus on R Sacral sulcus prone - deeper R (rotates away from sacrum)

7. Prone Knee Bending

If pain in anterior thigh before full range = rectus If pain in lumbar spine or radicular pattern - L3 (femoral nerve)

Algorithm for management of cx radiculopathy (36:00)

If progressive neuro sxs - DON'T TREAT If non-op for 2 weeks and no change -> back to doctor. -If no improvement and questioning dx = EMG -Non-op do for 6 weeks and re-assess. -If no improvement at 6 wks - MRI (if didn't get one earlier) If then negative on MRI - think systemic - rheumatologist.

Relationship of combined movements in SI Joint

If sidebend to one direction, ALWAYS rotate in opposite direction

Position and respiration best to mobilize sacral base anteriorly

If you want to move the sacral base anteriorly - do it on exhalation and extension

Test for Spondylolisthesis

In standing - one hand over sacrum and one hand on abdomen. Squeeze hands together PAIN worsens = discal pain Sx relief = Spondylolisthesis

Difference between movement in supine and prone

In supine the innominates can rotate In prone sacrum can move and innominates stable

T1 Vertebrae

Instead of 2 costal facets, only has one. Articulates with facet of 1st rib. Longest TP in Tx Inferior facets face down and forward

Universal pattern for SI joint

L = upshear, superior pub, L on L, sacral flexion, posterior innominate -L upshear/R downshear -Right inferior pubs/ L superior pubs -L on L / L on R -Left sacral flexion -R anterior innominate / L posterior innominate **If not one of these, they will have more pain and dysfunction

LQ Exam: Dermatomes

L1 = inguinal line L2 = Anterior proximal thigh L3 = Anterior medial knee L4 = Medial leg L5 = lateral leg S1 = lateral foot/calcaneus S2 = behind knee S3 = gluteal fold

Ankylosing spondylitis

LB and Tx pain -Not relieved with lying in supine -Worse with rest, better with activity -AM stuffness -Hx of collagen disease in family ONSET: <40 yo

Sacral flexion/Extension

No true axis Unilateral motions that are not normal SF = sliding motion of 1 side on the other (slip sacrum on iliac). Posterior and inferior movement of ILA (inferolateral angle)

Nutation/Counternutation

Nutation = pelvic brim decreased and pelvic outlet increased

Active movement testing of TMJ - opening

OPENING - palpate with pinkie in ear facing forward - feel condyle move away (35-50mm) Measure - align ruler with inferior part of maxillary teeth and superior part of mandibular teeth (quick check - 3 knuckles between opening - of own patient)

Thoracic PAIVM Testing: Spring Test

Oblique angle of forearm but force is PA with other arm Arm gets more vertical as you go down Compresses below and gaps above (??)

Order of Assessment for SI joint

Observation Subjective 1. Standing - ASIS/PSIS, GT -Mobility testing 2. Supine - Pubic symphisis - palpate PS, Inguinal, IC?, 3. Prone - SI joint - Sacral base, PSIS, ILA, apex, IT, Sacrotuberous lig, gluteal tone 4. Supine - Ilium - iliac crests, LLD?

Cx Nerve roots and sites of compression

Occupies about 25% of foramen and surrounded by dural sleeve COMPRESSION 1. Osteophytes at uncovertebral joints 2. Swelling of facet capsule 3. Venous congestion in dural sleeve (inflammation) 4. Nerve root ischemia

3. Gaenslen's test

Patient with one leg off table (max hip extension) and other in full hip flexion Want pelvic rotation - so symptomatic side is down + = pain - indicates SI, pubic, hip, L4 nerve, femoral nerve

Pseudo trochanteric bursitis

Piriformis spasm (attached to GT)

Cervical facet joints

Posterior arch has superior and inferior articular facet Filled with meniscoid - fatty and highly innervated -As you age, meniscoid atrophies and causes decreased stability.

McKenzie: Assessment - Lateral Shift

Postural shift of upper torso along lower torso (named by direction of shoulders) MUST CORRECT LATERAL SHIFT BEFORE STRAIGHT PLANE MOVEMENTS (always follow lateral shift with extension/flexion - whichever you're treating)

Cx Special Tests: Valsalva

Probably get this info in subjective - Pain with coughing, sneezing or bearing down? Indicates: 1. Neoplasm 2. Herniated disc

Best exercise to start with for acute and chronic cervical conditions

Proprioceptive and therapeutic exercises

Maximal movement of extension for upper cervical area

Protrusion

Movement of disc in protrusion and retrusion

Protrusion - drop down and forward Retrusion - back and up

To achieve full end range of LCC flexion

Protrusion and flexion

Temporomandibular Capsule

Provides proprioception -Capsular ligament -Articular capsule is thing and loose anteriorly, medially and posteriorly (subluxes/dislocates anteriorly) -Strong laterally Fibrous capsule attachments: -Margin of articular area of temporal bone -Neck of mandible

Iliopsoas

Proximal attachment to TPs of T12-L5 Distal attachment to lesser trochanter

Uncovertebral Joints

Pseudo-synovial jt -Uncinate processes have cartilage lined vertebral surfaces facing medially and superiorly -Capsule continuous with annulus fibrosis of disc -Limits lateral flexion (bony block) AGING - as IV space narrow becomes WBing joint -Matures at ages 10-20

Alar Ligament Stress Test (pt 1)

Pt. sitting in neutral -Stabilize C2 (SP and vertebral arch of axis with thumb and index finger. -Passively rotate to each side SHOULD BE 20-30° rotation + = reproduction of sxs

Alar Ligament Stress Test (pt 2)

Pt. sitting in neutral -Stabilize C2 (SP and vertebral arch of axis with thumb and index finger. -Passively sidebend R/L SHOULD BE little movement (little SB C0-C1, NONE in C1-C2) -Repeat test in flexion/extension (follow with SBing) CAN DO EACH IN SUPINE (tougher)

Rib torsion w/ Tx spine

Right rotation = posterior aspect of right rib turns externally (anterior margin appears flattened) -posterior aspect of left ribs turn internally (anterior margin appears accentuated)

PAIVM Movement Testing C2-C7: Transverse pressure on SP

Push SP laterally Create rotation - same as in lumbar spine Pushing R = L rotation = R facet opening (Same as unilateral pressure on articular pillars)

Treating R Superior Shear (unilateral sacral extension)

Push down on R side of sacrum (near sacral base - use hypothenar to get into it) Palpate ILA on R side

Treating R Inferior Shear (unilateral sacral flexion)

Push up on R ILA Palpate sacral base on R side

Biomechanics of sidebending in cx spine

R SB Sliding motion, not opening -Right facet closes, left opens -Coupled with R rotation <C2 20-45°

Stretching alternative: Scalene (PICS)

R SCALENES Right hand over medial end of clavicle and first rib Extend, SB and rotate away

R on R / R on L

R on R - Right ROTATION around right oblique axis = anterior rotation around ROA -> Anterior torsion = normal movement R on R means L sacral base moving forward (L ILA moves posterior) L on R is NOT normal movement = L rotation of R axis causing (R sacral base moves back and L ILA moves forward) https://www.youtube.com/watch?v=cs9QUIeHqko

Why is a R on R Anterior torsion positive for L Seated flexion test?

R on R is around R axis, so it's the L base that is moving as R is on the axis.

R Superior Shear (Upslip)

RARE Won't see it in standing - compensate with trunk + R Standing forward flexion test -R ASIS superior, R PSIS superior, IT superior -Medial malleolus shorter on R -Sacrotuberous ligament lax R

Mobility Testing of TMJ: Medial glide of mandible

RARELY DO SIDELYING Thumbs on lateral aspect of mandibular condyle (outside mouth) Push in

McKenzie guide for treatment (red, yellow, green light)

RED Derangement 1. peripheralization = direction is incorrect 2. Movement too rapid - use mid-range Dysfunction 1. Movements too forceful - creating microtrauma YELLOW (progress further) Derangement 1. ?? Dysfunction 1. NW /NE after a few days of HEP GREEN Derangement - P ↓ or abolished Dysfunction - PP at end range

Arthrokinematics: Mandibular patterns (Rest position, occlusal position, hinge position)

REST - Tongue on palate behind maxillary teeth OCCLUSAL (bite) - Teeth closed and together HINGE - Slightly open (more than resting) - space in between is FREEWAY space - allows tongue to be in right spot

Resting Position, Zero Position, Closed-Packed, Capsular pattern

RESTING - Teeth slightly apart ZERO - Mouth closed CLOSED - many different theories CAPSULAR - Deviation to affected side, loss of functional opening

Jaw Jerk Reflex

Relaxed jaw -Index and middle finger on chin and tap RESPONSE: Closure ABNORMAL: UMNL

Sympathetic chain ganglia tx (31:40)

Rib in very close proximity to sympathetic system

Cx Special Tests: Lhermitte's Sign

Same as slump test but more awkward!

Dominick's Traction for cx (PICS)

Seated Stabilize forehead Other hand at lower cx spine and slide up until occiput HOLD for 3-4 seconds = approx. 25 lbs pressure EASE off Releases soft tissue GREAT for HAs

Pubic Symphisis (type of joint, ligaments)

Secondary cartilaginous joint - amphiarthrosis (little movement) Interosseus ligament - fibrocartilaginous disc LIGS: Anterior/Posterior and Superior/Inferior

Atypical ribs: Rib2 11-12

Short -Single facet on head -No neck or tubercle -Articulate only with bodies of 11/12 tx vertebra and not TPs

X-Ray of Atlanto-Odontoid/AA Joint

Should see no opening between joints - kept together by transverse ligament -Look for alar ligament and odontoid fx.

Atypical ribs: Rib 10

Single articular facet on head articulating with 10th tx vertebra

Observing patient with SI joint issue

Sitting posture - often asymmetrical - will have legs crossed. Sit to stand - challenging. Requires rotation of hemipelvis Gait - HS challenging because force goes up to SI.

Sciatica (causes, treatment)*

Specific type of Radiculopathy where pain is caused by impingement/irritation of one of the three lowest lumbar nerve roots (L4, L5 & S1) Treatment is often nonsurgical unless concurrent cauda equina symptoms present or not responding to conservative therapy *CAUSES* -Disc herniation -Annular tear

Sphenomandibular ligament

Spine of sphenoid to lingula in mandible -Allows mandible to hinge open -Responsible for pain after prolonged opening (takes over after Temporomandibular ligament)

Architectural dysfunctions

Spondylitis - inflammation of vertebral body Spondylosis - catch all fpr degenerative conditions Spondylolysis - stress fracture in the pars interarticularis Spondylolisthesis - forward displacement of vertebra

Treatment of cervicogenic HA

Stabilize head and place radius under occiput and rotate arm.

Stretching alternative to forceful neck stretching

Stretch comes from hand

Stylomandibular ligament

Styloid process to angle of mandible (between masseter and pterygoid) -Keeps joint together -Pulls disc back for closing -Stop gap from extreme extension (opening) - tight at end range

Iliolumbar Ligament

Superior band: L4 TP -> IC Inferior band: L5 TP -> IC Present only in adults (children: fibers from QL) Palpate through erector spinae

Swallowing and tongue position

Swallow with tongue in normal position

Costotransverse joints

Synovial joints -Located between tubercle of ribs and reciprocal facets on TPs of vertebrae of same #

ATYPICAL THORACIC VERTEBRAE (20:40)

T1 - costal facet on body and little vestigial demi facet for rib 2. TRANSITIONAL VERTEBRAE 1. Superior costal facet - big on body 9-12 and migrates down. - ANTERIOR 2. Inferior facet gets smaller and by 10 - no longer has one - ANTERIOR 3. Inferior articular facets at 12 - looks to side to accept L1s facet - MIDDLE 4. SPs become more horizontal and less overlapping - POSTERIOR

Thoracic Rules of 3

T1-T3 = TPs at same level as SP T4-6 = TPs 1/2 level above SP T7-9 = TPs 1 level above SP T10 = TPs whole level above SP T11 = TPs half level above SP T12 = TPs at same level as SP

Biomechanics of cx flexion

Top vertebral body tilts and slides anteriorly -Nucleus moves posteriorly -Stretches posterior annulus -Limited by PLL and Nuchae, lig flavum -Facets barely engaged -Unstable position 80-90° (limited by sternum)

Biomechanics of cx spine extension

Top vertebral body tilts and slides posteriorly -IV space compresses -Ant fibers of annulus widen -Limited by ALL and posterior arches -Joint surfaces maximally congruent = CLOSED-PACKED POSITION 70° (15 at AO joint)

What is traction reaction?

Traction reaction - happens in middle age males with thick necks with limited ROM and hx of cardiac arrhythmia Sxs: Nausea, dizziness, hyperventilation Take off traction and can get tingling in hands and fingers, arrythmia tinnitus, blurring of vision WHY? - Cardiac nerves are irritated - stimulating SNS What to do: Use manual traction to see how they react OR monitor with mechanical traction

T12

Transition -Superior articular facet very thoracic -Inferior looks lumbar -Body become more WBing -TPs become shorter

McKenzie treats what type of issues?

Treats MECHANICAL issues If neurological or systemic - other type of treatment

Innervation of joint

Trigeminal nerve

T9

Typical EXCEPT - has no direct articulation with costovertebral joints of 10th ribs (means demifacets on body are absent)

What to do before specific neck exam?

UQ exam - look over this...

Hyoid muscles

Underneath chin Attach to hyoid bone Balancing muscles for muscles above

Cx Resisted movement testing

Use 2 fingers "Don't let me move you" Looking for spasm/asymmetry 1. Flexion 2. Extension 3. Lateral flexion 4. Rotation

PAIVM Movement Testing C2-C7: Posterior-Anterior (supine)

Use index or middle. Harder to do cephalic/caudal (nice because you can watch patient)

What happens to alignment when a R on R anterior torsion does prone prop?

Usually - R sacral base moves posteriorly With prone prop, sacral base drops forward on R side thus alignment should be better.

History: Usual cause of SI joint pain

Usually unexpected heel strike or MVA. Force directed superiorly

Cx exam: Vertebral artery test

VBI - vertebral basilar insufficiency = reduction of blood flow through vertebrobasilar arterial system. Supplies posterior brain FULL TEST: 1. Sitting - AROM rotation (hold 10 sec) 2. Sitting - AROM - look over shoulder (hold 10 sec) 3. Supine - PROM (2 hand hold - forehead and occiput) - extend, sidebend and rotate and hold 15-30 sec. -Back to neutral -Other side 15-30 sec POSITIVE: blurring vision, vertigo, nystagmus, dizziness, HA, pain, tinnitus If positive = NO CX MANIPULATION!

Thoracic discs

thin 1:5 ratio