MSK 2: Thoracic spine & Lumbar spine

Innervation - What is anterior to the vertebral bodies? - What are you looking for when investigating pain in this area? - Where in the spine is the greatest amount of convergence?

*Sympathetic trunk anterior to vertebral bodies near the CVJ* Convergence of autonomic and somatic sensory information Somatovisceral and viscerosomatic complaints Greatest amount of convergence = C8-L2 Looking for pain patterns that aren't reproduced with positioning or movement

Posterior rib cage - How do ribs effect the t-spine? - Where do ribs 2-9 articulate? 1 and 10-12?

*Thoracic spine & rib mobility are interdependent* NEVER TREAT 1 W/O THE OTHER Ribs 2-9 articulate with two vertebral bodies Ribs 1 and 10-12 articulate with one vertebral body

Extension preference & lateral shifting

- Acute disc problem--> if initially correct shift & load the painful side of the disc it may be painful initially - Do repeated movements bc pain starts to dissipate - Addresses apprehensiion & fear avoidance

Manual Traction - Lumbar

- Looking for decrease in their pain - Can do both legs or one legs (compression unilaterally?)

Manual Traction with belt - Lumbar

- More intense. Wrap around ankle

Scoliosis management: - Infantile idiopathic: What age group is most likely to ? Prognosis? - Juvenile idiopathic: Which gender is at a higher risk? What age group? Prognosis? - Adolescent idiopathic: What percentage of cases does this account for?

1. Infantile idiopathic - younger than 3 years, 80-90% spontaneously resolve 2. Juvenile idiopathic - children 3-9 years, Girls > boys Generally at high risk for progression to more severe curves 3. Adolescent idiopathic - manifesting at or around the onset of puberty, Accounts for 80% of all cases of idiopathic scoliosis

Which technique is better?

3 techniques: Supine global lumbar rotation thrust as used in CPR development study, maximum of 2 attempts per side Side lying more specific lumbar rotation thrust sore side up, maximum of 2 attempts Prone central PA to L4 and L5, 2x60 seconds at each level, 30 seconds between each set Side lying and general technique both work in CPR

Etiology of Mechanical LBP - What is the MOST common cause of back pain?

60 asymptomatic volunteers, ages 20-59 1. Disc protrusion: 62-67% 2. Extrusion: 18% Sequestration: 0% 3. Early ZAJ arthrosis: 13-18% Nerve root deviations: 3-7%

How do the annulus and nucleus interact? - Where does the most rotation come from? - When is the load the greatest? - How does disc nutrition happen? Which kind of movements enhance disc hydration?

Annulus and nucleus maintain a symbiotic relationship when responding to compressive load Disc nutrition via diffusion at the end plate Pumping enhances anaerobic metabolism, which enhances healing Pumping = Dehydration and rehydration Most rotation at L5-S1 Load during sitting higher than standing Disc pathology likely

Lateral spinal stenosis

Degenerative changes causing narrowing of the intervertebral foramen A consequence of aging

Flexion/Extension - What is flexion limited by? Extension? - What does expiration and inspiration induce?

Flexion limited primarily by the disc and the ribs/sternum Extension limited by the spinous processes and facets Inspiration induces thoracic extension Expiration induces thoracic flexion

Motion tests in sitting for thoracic spine - What is the purpose? - What motions would you do? How would you rule in disc?

Flexion--> With Neck flexion, (+) disc Extension Side bending (L) and (R) Rotation (L) and (R)--> With neck flexion, (+) disc Active and passive (overpressure) 1D motion Purpose = Observe the quantity and quality of movement, Assess for pain provocation

Muscle response to tissue injury - Who is compensating for who? What can Tx this?

Global muscles try to compensate for lack of segmental stability (multifidi vs. erector spinae) & some spinal manipulation may help break this cycle - Local ms inhibition & manip may help

Maitland terminology

Go to the point of resistance & then give over pressure Mobilization = low velocity Manupulation= high velocity

Lumbar HVT L3-4 right rotation

Good body contact is critical Good PT posture and strong connection between upper and lower body (stabilise those abdominal!) PT's upper body should be over pt's pelvis PT's front leg close to plinth pt's top knee held between PT's thighs and plinth PT's back leg in line with long axis of pt's femur HVT is best delivered by weight shift from front leg to back leg

Mobilization techniques - Grades 1-2 - Grades 3-4

Grade I and II - small and large amplitude mobilizations at the beginning of the range Oscillatory Pain modulation Grade III and IV - large and small amplitude mobilizations up to the end of the range (into the tissue resistance) Oscillatory or sustained hold Mobility

Subjective Hx

Health History Red Flags? Yellow Flags? Consider Who, What, When, Where, Why and to What Extent? Clusters of symptoms Aggravating and relieving factors Activity, Rest, Position, Cough/sneeze/strain, Time of day *Direction Does the pain centralize or peripheralize with repeated or sustained movements? Flexion Extension Side bending

T4 Syndrome - History: Common cause, duration of Sx, functional difficulties? - Clinical exam findings:

History Whiplash, trauma Can be insidious after vigorous upper body activity Duration - 1-6 years Difficulty sleeping supine Clinical examination Full supraclavicular fossa or convex upper trap contour Hypomobility of one or more segments T2-T7 Hypomobile ribs (+) Roos Vasomotor changes in the UE's

Subacute or Chornic LBP with Movement Coordination Impairment - Lumbar Instability - Subjective findings

History: recurrent, catching, locking back pain, with repeated unprovoked episodes of feeling unstable or giving way Inconsistent symptomatology; worse with sitting, prolonged standing and semi-flexed postures Most common aggravating mvmts- forward bending and return from forward bend, lifting and sneezing Clicking or clunking noises Pain with ROM

Examination: To what extent is the pain? - What other questions do you want to ask yourself when assessing their pain/dysfunction?

How long? Severity? How is the patient's daily life affected? Is the patient sensitized? Chronicity?

Acute & Subacute LBP with mobility deficits: Muscle strain

How would these patients present? What are your intervention goals? How would you intervene? *Resisted Isometrics*

PAVIM

Lumbar spine Cranial PA (glide along the plane of the facets)--promotes extension

Contraindications to neural mobilization

Malignancies of nervous system Acute inflammatory infections Instability in the area Spinal cord injuries Worsening neurological signs and symptoms Cauda equina symptoms CNS disorders Suspected disc lesions Dizziness related to CAD Extreme pain

Outcomes: Reducing shoulder pain - Manipulation vs. traditional PT group

Manipulation Group Manipulation to the thoracic spine and ribs, cervical spine and GHJ 70% of patients reported feeling "cured" at 5 weeks post-randomization Traditional PT Group Therapeutic ex, massage, physical agents 10% of patients reported feeling "cured" at 5 weeks post-randomization

Outcomes: Improving shoulder motion - Standard care compared to manipulation group

Manipulation compared to Standard Care (PT, NSAIDS, up to 3 corticosteroid injections) Reports of being "fully recovered", Manip group vs Standard Care group At 12 weeks - 43% vs 21% At 52 weeks - 52% vs 35%

Manual vs Positional Traction

Manual traction Controlled by the therapist Can isolate specific region Positional traction Can be isolated to a specific intervertebral segment or facet joint Patient can assume positions at home

Terminology in manual PT

Mobilisation, Manipulation and Manual Therapy Historically used interchangeably as synonyms (which they are not), and therefore grouped together in analysis of methodology and results "If we do not clearly define and clarify these terms, then we frankly will hinder our professional growth." "Lack of precision in terminology not only prevents us from accurately interpreting and applying research results in clinical practice, it sends confusing messages to referral sources and patients."

CTJ: WB accessory mobilization for spine - What to do if spinous process is painful?

Mobilization can be performed bilaterally over articular pillar if spinous process is painful Especially useful in upper thoracic spine Cranial hand stabilizes the head Caudal hand provides a PA glide

LBP examination: Who - Which patient age groups are most susceptible to particular types of pathology? - Once you have a disc pathology, what is likely to happen?

Non-specific LBP 12-35 y.o. Acute disc disorder 25-45 y.o. Central protrusion/prolapse >40-45 y.o. Posterolateral protrusion/prolapse 18-45 y.o. Recurrent (discogenic vs facet) >55-60 y.o. Once you have a disc pathology, you are going to have some issues stabilizing those segments--multifidi (hypermobility)

TOS Clinical Exam - What might the clinical presentation be for TOS?

Observation - posture Long neck "Droopy shoulders" Protracted head and shoulders "Swelling" - 1st rib elevation or fullness in the supraclavicular fossa Hands --> Sweating, temperature/Trophic changes

Contraindications to high velocity thrust technique

Osteoporosis Pregnancy Fracture Active infection in the area Ligamentous laxity Malignancy

Thoracic extension

Passive extension PT supports the patient under the arms Can add overpressure for pain provocation

Cyriax Release Test- alternative

Patient positioned with elbows at 90° with towels sufficient to elevate the shoulder girdles Forearms and wrists neutral Position held until symptoms are produced Up to 30', to patient tolerance Looking for symptom intensity to decrease

Passive Lumbar Extension test

Patient prone Therapist lifts the legs about 30 cm off the plinthe (+) test = c/o strong pain, heavy feeling or apprehension in the low back

Thoracic flexion - What could you do to confirm disc pathology?

Patient seated on the corner of the table Verbal cues: "Flex through the trunk" "Bring your shoulders to your waist" Add neck flexion - (+) disc Add breathing: Increased pain with expiration = disc

Cyriax Release Test - What is a positive test? What is this actually doing?

Patient shrugs and leans back against PT, then relaxes Unloading the brachial plexus looking for release Hold up to 3' (Up to 30', to patient tolerance Looking for symptom intensity to decrease?)

PPIVM Lumbar spine flexion

Patient: side lying, lumbar spine neutral (use prop under waist if necessary) Therapist facing patient thread cranial arm through patient's upper arm at elbow caudal arm on pelvis palpate adjacent spinous processes or interspinous spaces Procedure to rotate from above: Use cranial arm on patient's thorax as lever to rotate upper spinous process towards plinth Stabilise lower spinous process and pelvis Procedure to rotate from below: Use caudal hand on pelvis to rotate lower spinous process "up" away from plinth Stabilise upper spinous process and thorax Indications Assess intersegmental rotation Treat intersegmental rotation loss Notes Left side lying rotate from above or below yields right rotation

General screening for LBP - What is the first step? What to recommend for/against imaging? - What are the options for patient's who don't respond to initial treatment?

Patients who do not improve, consider non-pharmocological 1. acute LBP - spinal manipulation 2. chronic or subacute LBP= interdisciplinary (rehab including PT) -exercise therapy, acupuncture, massage therapy, yoga, spinal manipulation, CBT

Clinical bottom line - How quickly has the research showed improvements in cervical spine pain following the CPR?

Patients with cervical spine pain and 3 or more of the above findings are likely to experience moderate perceived global improvement from thoracic spine manipulation and cervical ROM exercise within 2 treatment sessions (4-8 days) 2010 f/u study did not support the CPR but DID demonstrate significantly greater improvements in disability at short- and long-term f/u for patients who received manip+ther ex vs. ex alone

Prognostic indicators of people with mechanical neck pain most likely to respond to thoracic manipulation - 6 factors

Patients with mechanical neck pain most likely to respond positively to thoracic manipulation Six prognostic indicators 1. Duration of symptoms < 30 days 2. No symptoms distal to the shoulder 3. Looking up does not aggravate symptoms 4. FABQPA score of < 12 5. Diminished upper thoracic spine (T3-5) kyphosis 6. Cervical extension ROM of < 30° (inclinometer)

Clinical reasoning of manual therapy - What are the 5 prognostic indicators of ppl most likely to respond to cervicothoracic manipulation with shoulder pain?

Patients with shoulder pain most likely to respond positively to cervicothoracic manipulation Five prognostic indicators 1. Painfree shoulder flexion < 125° 2. Shoulder IR < 50° 3. (-) Neer test 4. Patient not taking meds for pain 5. Duration of symptoms < 3 months If 3 of the 5 indicators were positive, the chance of treatment resulting in a successful outcome increased from 61% to 89%

Prone instability tests

Perform PA on a painful segment Ms are dynamically supporting hypermobility

Quadrant test

Position Patient stands with feet shoulder width apart Therapist stands behind the patient, grasping the patient's shoulders Action Patient extends as far as possible, then sidebends, then rotates toward the affected side Therapist provides OP through the shoulders A positive test is reproduction of symptoms. If pain is local, unilateral - high sensitivity for facet joint dysfunction.

Why do spinal manipulations make our patient feel better?

Possibly Psychological Freeing trapped mensicoid or disc fragment Mechanical disruption of intra-articular adhesions Correction of a joint positional fault Neurophysiological effect: ascending and descending pain inhibition Reflexogenic effect: muscle relaxation Temporary hypermobility of the joint that restores normal joint play HVT may result in 'cavitations' (sudden release of synovial gas) Takes time (20-30 mins) for the synovial joint to reabsorb the gas ... hence the 'latent period' when joints can not be 're-popped'

Ribs: Primary purpose

Protect vital organs Contribute to stiffness Provides support for bipedal gait Facilitate respiration

Lumbar disc HNP (herniated nucleus pulpous)

Protrusion or extrusion of disc material causing neural impingement

Where to start with management?

Pt education? Avoiding sustained postures Encouraging movement Gentle vs aggressive? How to progress?

Joint mobilization with motion - Sustained lumbar glide with prone extension

Pt position: prone Therapist position: hypothenar eminence on spinous process other hand on pts anterior thorax at level of mobilizing hand. Mobilization: apply a cranial glide and lift while pt performs active extension in lying

Self sustained lumbar joint mobilization with motion extension or flexion

Pt position: standing using belt or strap under spinous process to be mobilized. Apply an anterior and cranial glide. Keep elbows flexed throughout the movement

Self lumbar SNAP (extension or flexion)

Pt position: standing using belt or strap under spinous process to be mobilized. Apply an anterior and cranial glide. Keep elbows flexed throughout the movement Facilitating superior & anterior glide of facets

Clinical Exam - Special tests

Quadrant test Slump test Prone Instability test Passive Lumbar Extension test Segmental mobility testing

Review

Quantity/Quality of movement Did the patient have a motion limit? Capsular pattern (CP) or Non-capsular pattern (NCP)? CP = Extension > equal limitations of SB and rot (painful) small flexion limit Which motions provoked their pain?

Spinal stenosis - Differential Dx

The pathophysiology is thought to be ischemia of the lumbosacral nerve roots secondary to compression from surrounding structures, hypertrophied facets, ligamentum flavum, bone spurs, scar tissue, and bulging or herniated discs

How can manual therapy help with cortical reorganization?

The thrust joint manipulation was associated with hypoalgesia, as well as a significant reduction in activity in the sensory-motor cortices S1, S2, anterior cingulate cortex, cerebellum, an insular cortices, with reduction of cortical activity correlated to decrease pain perception."

Sural nerve pathway - How do you sensitize?

emerges to the surface approximately 16 cm proximal to the lateral malleolus by piercing through the fascia (a potential site of entrapment), enters the foot posterior to the lateral malleolus, Locations for Sural nerve entrapment: compression (piercing fascia as exits posterior compartment) posterior to lateral malleolus anywhere along the lateral aspect of the achilles tendon and the foot where it lies against bone and tendon Sural Nerve Sensitization position of the foot and ankle is: Dorsiflexion and inversion

Regional Interdependence - Biomechanical and Neuropsychological

"Not dropping off your body for 45 minutes"

Nerve Mobs

"gradual progressive neuromobilization therapy" treatment to improve nerve tissue tolerance to tensile loading and elongation Tensioner neuromobilization 3 x 15 oscillations of combined* ankle DF, knee extension and femur adduction in right sidelying some hip flexion 3 x 15 oscillations of combined* ankle DF, knee extension in Slump position *Sensitization components were added/combined sequentially from distal to proximal from visit 8-10 as tolerated by the patient

Lumbar Instability - What are common objective findings?

(+) apprehension with movement lots of guarding Hypermobility/pain with spring test, Hypomobile adjacent segments Increased muscle guarding/spasm Postural deviations including lateral shift and changes in lordosis Creasing or spinal angulation with ROM Inability to recover normally from full ROM (return to stance with abnormal lumbopelvic rhythm) - Gower's sign Excessive AROM Aberrant quality of movement- hitching or catching motions No neural findings High levels of pain and functional deficits What is your intervention priority???

Ribs - What motion do they limit? Which plane of motion is this in? - Where do they attach?

*Clinically, limits side bending* Attach to vertebral bodies at the costovertebral and the costotransverse joints (CVJ & CTJ) Primary constraint to movement in the frontal plane

Intervertebral disc - What are they designed for? - What is the difference in nuclear material (internal & external) compared to Csp & Lsp? - What motion does the disc limit? - If there is a SB limitation, where should you look? Rotation limitation? Think of which tests you would use to confirm your hypothesis.

*Designed to contribute to overall stiffness & increase segmental stability* Less nuclear material than in the Csp or Lsp Greater amount of dorsal annular material Limits flexion and axial rotation - If SB limitation, look at ribs. If rotation hurts & SB doesnt, pay more attention to disc

Rehab essentials on scoliosis due Monday - Scolisosi

- *Always describe in it in the convexity*

Examination: Location - What should you clear first? - What could produce local pain? - What pain pattern may indicate a ZAJ arthropathy/facet? CVJ/CTJ arthropathy? - Referred pain patterns from facet joints at which segment levels? -

- Clear the cervical spine Local: Acute IDD, disc protrusion ZAJ arthropathy (Reproduce pain with 3D motion---If disc, it will be in 1D motion limitation) CVJ/CTJ arthropathy (SB will reproduce Sx) Referred pain patterns of the facet joints from segments T3-4 to T10-11

2 reasons for spinal surgery

- Create space - Create stability 1. Decompression: Tx priority is controlling inflammation & controlling irritability...nerve that's had anything touching it is irritable & takes time to chill out; 2. Stabilization

Neuropsychological mechanisms

- Immediate effects vs long lasting effects - Changes in fMRI in pain processing centers--> acquisition of new memory not accompanied by pan Immediate effects --> reflexogenic or mediated by the dorsal horn Long-term effects --> in response to staged release of neurotransmitters (not fully substantiated)

Intervention: lumbopelvic manipulation, exercise, patient education

1-2 sessions over 4-8 days, sessions included: Lumbopelvic manipulation Lumbopelvic rotation HVT If cavitation is heard or felt, proceed to therapeutic exercise If no cavitation on 1st attempt, reposition and repeat, if no cavitation on 2nd attempt, treat opposite side a maximum of 2 attempts per side Therapeutic exercise Supine pelvic tilt home exercise program (10 reps, 3-4 x /day) Patient education Instruction to maintain usual activity levels within pain limits

IVD L-spine - What is the nucleus made up of? What about the annulus? - Annulus: Which is polysegmental/monosegmental innervated? Local pain vs diffuse?

1. Nucleus - 85% H2O - Increased Proteoglycans - Collagen type II 2. Annulus 60% H2O DecreasedProteoglycans Collagen type I - Outer Annulus Poly-segmental innervation Diffuse pain - Inner Annulus Mono-segmental innervation Local Pain (IDD)

Brachial plexus - What is considered the upper brachial plexus? How can this get compressed? - Lower? What other fibers does this include? What are compression Sx commonly?

1. Upper plexus C5, C6, C7 Scalene compression 2. Lower plexus C8, T1 Includes sympathetic fibers Temp and trophic changes often sympathetically mediated

Clinical bottom line

4 or more predictor variables, 95% probability that a patient with acute LBP will experience at least 50% improvement in function (modified ODI) from lumbopelvic manipulation and exercise within 2 treatment sessions (4-8 days) Having symptoms for less than 16 days was the most accurate individual variable in the rule

Mobilization wedge - Pros & cons

A mobilization wedge can be used effectively for thoracic spine mobilization and even manipulation. The draw back is that the therapist can not feel the joints during positioning or treatment. Some patients like to use them at home in place of a rolled towel for self mobilization.

Deep segmental muscle activation strategies

Abdominal drawing-in maneuver (ADIM)--> neutral spine Abdominal bracing maneuver (ABM)--> neutral spine Posterior pelvic tilt (PPT)

LBP severity - Acute, subacute, chronic, recurring - What condition do we not really see as much? What are common conditions?

Acute: less than 1 month Sub-acute: 2-3 months Chronic: greater than 3 months since onset of LBP Recurring: episodes of LBP that recur between periods of time where the pt has We as PTs will not see acute back pain that much. Seen most often: Recurring episodes of LBP--> Doesn't necessarily mean it's a chronic problem

Thoracic rotation - How could you provoke a disc problem?

Add neck flexion (+) disc

Neurodynamic mobility evaluation

Adverse neural tension is an abnormal response of the neural tissue to mechanical stimuli. Neural provocation tests: apply controlled mechanical and compressive stresses to dura and nerve in a sequential and progressive manner using longitudinal traction force attempting to reproduce patient symptoms are performed as special tests towards the end of a full orthopedic evaluation

Movement System of L-spine - What is the architecture suitable for? - What creates the lordosis? What level is the lateral foramen at? - What is the ratio of IVD height to vertebral level? - Explain the cartilaginous endplate? What is a disc prolapse through the endplate? - Explain disc hydration? What to do if a patient feels stiff in the morning?

Architecture suitable for increased load Lordosis d/t wedge shape of disc Lateral foramen lies at disc level Cartilaginous endplate plays a role in disc nutrition and can be involved with disc lesions--> Endplate can absorb hydrostatic pressure dissipated by disc under loading IVD 3:1 ratio vertebral body to disc height Disc prolapse through endplate - Schmorl's node When the disc is unloaded, the disc becomes imbibed with water, when the disc is loaded, the water leaches out For a patient that feels stiff in the morning: Tell them to "do hulas" aka get the disc water out by doing a little bit of side bending and rotation, right when they get out of bed in the morning. Tell them to go for a walk and DO NOT do any side bending, or sitting for the first couple hours of the day.

Regionalization using provoking/alleviating tests (Is it C-spine or t-spine) - If axial compression is painful, how can you differentiate Csp vs Tsp? - If rotation is painful, how can you differentiate? - Extension?

Axial compression is painful (distraction may relieve) Could be CSp or TSp Differentiate by comparing with TSp compression through the shoulders (still painful? TSp) Rotation CSp is painful Could be CSp or upper TSp Differentiate by rotating trunk & neck together to the opposite side to end range, fix TSp at this end range, then rotate CSp away (still painful? CSp) CSp extension is painful Could be CSp or upper TSp Differentiate with full C & T spine flexion (slump), fix both 1st ribs (preventing TSp extension), now slowly extend CSp (still painful? CSp)

Biomechanical theory - What is this theory based on? - What is the success of treatment dependent on?

Based on: The assumption that we are identifying and treating a biomechanical dysfunction The implication that the success of treatment depends on the correction of the biomechanical abnormality Reliance on biomechanical constructs Conceptual models include terms like 'Subluxation', 'stiffness during passive movement', 'trigger points', 'rupture of joint adhesions', 'adjustment'

Manual Traction for specific to the spine - Lumbar

Biasing extension

Acute LBP with Movement Coordination Impairment - Spondylolisthesis: How does this develop? What actual is it? - Where in the spine is this usually seen? Why? - What does this frequently lead to? - Which age group/gender is this more prevalent in? - What are common Sx? When is pain relieved? - What is surgical management like?

Bilateral pars defects can progress to spondylolisthesis Anterior slippage of a vertebral segment relative to the segment below it; congenital, developmental issues, athletic Usually in lumbar spine region, most common at L5-S1 (Transition area More rotation at L5-S1 than any other segment) Frequently leads to spinal instability Slippage common ages 10-15, usually not common in pts over 20yo More common in girls/women Symptoms - pain with lumbar extension/rotation, painful but not disabling, chronic mid line pain at LS junction Pain relieved with rest, sensation and reflexes normally intact Does not always need surgery, might be congenital

Pitfalls of biomechanical model

Biomechanical effects not substantiated Structural changes have not been demonstrated Identifying positional and movement faults - poor reliability Effects short-lived, neurophysiological mechanisms may be at work

Biomechanical mechanisms - Give an example of a syndrome that incorporates regional interdependence

Biomechanical link between the thoracic spine and the neck and shoulder Shared muscle attachments Restoring biomechanics allows healing and restoration of function Interdependence = Thoracic Outlet Syndrome Neck pain and dysfunction Shoulder pain and dysfunction

Exercise: Osteoporosis - What are women in menopause more likely to develop this? - If bone is degenerating, what is the physiologic process that occurs?

Bone - living tissue, continually remodeling and replacing itself Osteoclasts resorb bone, especially if Ca is needed (resorption is accelerated in women during menopause owing to the decrease in estrogen) Osteoblasts build bone Physical activity - affects bone remodeling, muscle contractions and mechanical loading deform bone, which stimulates osteoblastic activity and improves BMD

Osteoporosis: Considerations & management - What is the norm for normal, osteopenia, osteoporosis? How is it measured?

Bone disease process that leads to decreased mineral content and weakening of the bone May lead to fractures (pathological) - spine, hip, wrist Affects approximately 10 million Americans, 80% women T score of a bone mineral density (BMD) scan T score is the # of SD's above or below a reference value (young, healthy Caucasian women) Normal = -1.0 or higher, Osteopenia = -1.1 to -2.4, Osteoporosis = -2.5 or less

Femoral nerve - How do you sensitize?

Branch of lumbar plexus from ventral rami L2-L4, through psoas, between psoas and iliacus, under inguinal ligament into thigh Locations for femoral nerve entrapment: IVD (L2-4) Spinal canal IVF Psoas major Between psoas and iliacus Under inguinal ligament Sensitization: Hip extension & knee flexion Provocation test for saphenous nerve would be: Hip extension, hip abduction, hip lateral rotation, knee extension, ankle dorsiflexion, ankle eversion Although femoral nerve terminates in anterior thigh, the saphenous continuation is the reason why knee flexion is a component of the femoral nerve provocation test Saphenous nerve is a sensory only continuation of femoral nerve supplying medial tibia Saphenous nerve provocation test Hip extension, hip abduction, hip lateral rotation, knee extension, ankle dorsiflexion, ankle eversion

Clinical reasoning

Capsular pattern: ext > flex, SB and rot equally limited

What are red flags to refer out? - What kind of surgery will often result with these Sx?

Cauda Equina Syndrome Large central disc prolapse Severe LBP Sciatica - often bilaterally,often L5/S1 Saddle and or genital sensory disturbance Bladder, bowel and sexual dysfunction Emergency decompression surgery

Side lying slump sensitization options

Cervical extension may reduce symptoms Pre-position contralateral leg in SLR position Pre-position trunk in side bend away

Descending inhibition from the brain

Change in the release of neurotransmitters Rostral ventral medulla (RVM) via noradrenergic and serotonergic receptor mediation Periaqueductal grey (PAG) in the midbrain releases enkephalins raphe nuclei release seratonin inhibition of substance P production

Mechanical Traction - CPR

Clinical Prediction Rule predictor variables: Peripheralization of symptoms with repetitive lumbar extension Positive crossed SLR SLR with reproduction of symptoms @ 45o or less Presence of 1 or more predictor variables helps identify patients with nerve root compression, who will have a likelihood of experiencing a 50% reduction in disability after 6 weeks of the following protocol: Lumbar traction in the first 1-2 weeks, positioned in prone to maximize centralization, static traction at 40-60% of patient's body weight, for 12 minutes, patient remains prone for 2 minutes after completing traction, 10 prone press up performed after above 2 minutes prone rest prior to standing up manual therapy (grade III or IV lumbar spine PA's), extension exercises (sustained and repeated extensions in prone and standing, exercises progressed as tolerated aiming to achieve max extension ROM without peripherilization, 3 sets x 10 reps, throughout the day every 4-5 hours), Patient education for functional activities, centralization principles Going in pool with 5 lbs lbs

Joint specific treatment and pain management -Regional Interdependence

Clinical exam goes beyond the local complaint Regional dysfunction can contribute to local pain and dysfunction Distinct from referred or radicular pain Allostasis = The body's response to injury Assumption: tissue damage leads to adaptation Allostasis is the body's efforts to restore homeostasis following stress or injury

Spinal stenosis - What can compression of a nerve create? How do you test this?

Compression of the nerve in spinal canal can also compromise arterial supply (compression of blood supply to nerve), resulting in neurogenic claudication Leads to nerve rt ischemia, and symptomatic claudication- Symptoms are poorly localized pain, paresthesias, or cramping in one or both legs, brought on by activity, relieved by rest/sitting, Central stenosis- can result in symptoms of cauda equina compression LBP, unilateral or bilateral sciatica, saddle anesthesia, change in bowel/bladder function, LE motor weakness and sensory changes, decreased DTR

Recovery Potential

Consider patient factors: Work status. Confounding health issues. Job satisfaction. Smoking.

Thoracic spine: General health screen - What health concerns may have an impact in your care? - What may increase their risk of fx? Is this a common occurrence? - Surgical history: What types of procedures may impact thoracic function? - What are other Sx may indicate cancer?

Consider the patient's general health... Long term asthma or COPD RA: use of corticosteroids, increased risk of osteoporosis Osteoporosis: 50% of all vertebral fractures in the thoracic spine Surgical history: Thoracotomy or CABG--> rib dysfunction d/t rib spreading Fever, chills, nausea > 1 week Unexplained weight loss, anorexia, malaise Changes in bowel or bladder function Rectal or vaginal bleeding History of cancer Consider visceral pathology

Thoracic spine management

Considerations Mobility Posture Regional interdependence Thoracic spine management plays a role in the management of conditions in other regions UQ - C-spine, shoulder, elbow Pain reduction Sympathetic chain lies anterior to the vertebral bodies "It's a means to an end to be able to get you move on your own--not putting a band-aid or putting antyhign back in"

When - ALARMS/red flags - What is the capsular pattern? - When are the ribs approximating the most?

Constant or night pain (not associated with positioning in bed & severe) Metastasis Infection Unexplained capsular pattern - Red Flag! - Extension > bilateral & equal in SB/rotation Large limit -Pain with coughing/sneezing--> suspicious of disc bc increase in intrathecal pressure If approximating ribs with expiration & SB (compression) or flexion & inspiration--> Think ribs

T4 Syndrome - Common clinical symptoms

Constellation of symptoms Unilateral or bilateral upper thoracic spine pain Ventral chest pain Glove-like paresthesias of the hands Headache Occasionally: Weak grip, sense of hand fullness or tightness, difficulty breathing

Spinal fusion with metal and bone graft replacing disc - What to avoid after surgery? What do you need to teach these people?

Critical to teach someone how to move the segment thats not moving Don't give them early mobility Teach them how to move the segment thats inactive

Patient Education Explained - What TO DO

DO: Promote an understanding of the anatomical structure and strength of the human spine Explain the neuroscience of pain perception Emphasize the overall favorable prognosis of LBP Teach active pain coping strategies Encourage an early return to activity even if still painful Promote importance of an increased activity level

Patient Education Explained - What to NOT do

DON'T Promote extended bed rest Provide in depth explanations of pathoanatomical reasons of pain Label your patient

Lateral spinal stenosis: Surgery - What if the pt doesn't want surgery?

Decompression= removal of all anatomy causing stenosis after strong anti-inflammatory treatment of soft tissues - If pt doesn't want surgery or isn't appropriate--> anti-inflammatory goes a long way, positioning in flexed position (bike test), lifestyle changes

Spondylolysis - What positions MUST you avoid?

Defect in pars articularis MUST avoid extension, are braced often

Central Spinal Stenosis - Measurements of an absolute vs relative stenosis

Degenerative changes causing narrowing of the spinal canal and or foramen--> A consequence of aging Midsagittal diameter (CT): Less than 10mm = absolute stenosis. Less than 13mm = relative stenosis. Cross sectional area (CT): 100mm2 or less = stenosis. sequence of aging

Basic principles

Develop awareness Train in neutral or positional bias Develop control Spine --> Extremities Simple--> Complex Increase reps, load, cognitive demand Isometric, rhythmic, perturbations Progress from a stable to an unstable surface

Prevention: Osteoporosis

Diet rich in calcium and vitamin D Weight-bearing exercise Healthy lifestyle with moderate alcohol consumption and no smoking

Spinal stenosis - Differential Dx Bike test: How can this differentiate between vascular claudication?

Differential Diagnosis Bike test: Vascular claudication symptoms present with walking and biking due to increase vascular demand with activity Neurogenic claudication symptoms worse with walking and better with biking due to flexion of the spine during biking- opens up AP diameter of canal allowing more room for neural elements and improving microcirculation Hairless LE's, absent or diminished pulses, cold feet =signs of vascular insufficiency

LBP: etiology - What are common issues with imaging and this population?

Difficult to determine the pathoanatomical cause of LBP. Any innervated structure in the low back can cause pain and refer pain to the lower extremities. False positive findings on imaging studies are common. Pain can occur in the absence of findings on imaging and imaging can show abnormal findings in the painfree population.

IVD - In which direction does the disc height increase? - What structures is the disc attached to? - Which structures act as a natural abutment to protrusion of the disc?

Disc height increases moving caudally Attachments to the anterior and posterior longitudinal ligaments (ALL & PLL) Attachments to ribs via intra-articular ligaments Ribs act as a natural abutment to protrusion

Nerve mobilization - Precautions

Do not over lengthen a nerve bed Do not tension the nerve for prolonged periods Sustained mobilization with quickly lead to ischemia in the nerve Within 7 seconds, all the beneficial effects of nerve mobilization have occurred. Continued hold can lead to ischemia

Precautions to neural mobilization

Do not over lengthen a nerve bed Do not tolerate prolonged neural tension Sustained mobilization of the nerve bed will quickly lead to ischemia in the nerve Within 7 seconds, all the beneficial effects of nerve mobilization have occurred, further hold of the position begins to cause ischemia of the nerve Sit up to unload your nervous system AND intervertebral discs!

Neurodynamic mobility evaluation

During a joint movement: Slack in the nervous system is taken up (eg SLR 0-35o) Whole peripheral nerve moves as does adjacent connective tissue In mid range, there is maximal nerve sliding (eg SLR 30-70o) Sliding occurs adjacent to and toward the moving joint (convergence) At end range, tension builds as nerve sliding ends (eg SLR >70o) Sliding occurs further from the moving joint When tension is released (joint returns to resting position) Sliding occurs away from the moving joint (divergence) The spinal canal is 5-9cm longer in flexion than in extension (perhaps even longer in hypermobile individuals) Early range = taken up slack - Between 30-70 degrees that a positive test is truly a postive test Beyond 70 dg = soft tissue resistance

Acute LBP with related (referred) Lower Extremity pain - Lumbar Disc lesion

Dx of disk herniation based primarily on history and objective findings Imaging can be misleading (evidence of HNP found in 20-30% of imaging tests)

Maximum protection phase

Educate pt in self management strategies Rx: instruct in safe positioning and limb mvmts and any post operative precautions Decrease post operative pain Rx: relaxation/breathing exercises, modalities, ROM Prevent infection Rx- review wound care Minimize post operative swelling RX: elevation, compression, ms pumping, lymph drainage massage Prevent post operative complications RX: active ex to stimulate circulation, deep breathing ex,

Interventional evidence - What do the effects of manipulation have on the body?

Effects of manipulation: Alters paraspinal muscle activity Decreases peripheral muscle inhibition, increases strength Results in hypoalgesia Reduce allostatic protective responses (muscle guarding) Joint specific Tx can improve pain pressure thresholds, decrease protective responses & allow people to move better Autonomic changes: - Post manipulation changes in BP, respiratory rate, HR, reductions in cytokine production

Which grade & how many reps/sets for manual therapy? - End range: How long would you want to do mobs for? What immediately after? How long would you tell pt to do these?

End range (grade IV) Reassess after every few reps (this will constitute 1 set for this session) Continue if pain &/or ROM is improved Discontinue for the session when significant improvement has been achieved, or when improvement plateaus 4-5 minutes of mobilization Follow with resisted isometrics, AROM, functional exercises into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session MWM or HVT (grade V) If using MWM 6-10 reps 2-3 sets, re-assess after each set Follow up with self MWM at home 6-10 If using HVT Prepare the tissue using STM, AROM, active warm up.... 1-2 reps only on each joint Follow up with AROM, resisted isometrics in new range

Chronic LBP with Movement Coordination Impairments

End range becomes more painful as the condition becomes more chronic.

Exam: Etiology of pain - Macrotrauma vs microtrauma - What might you have to rule out for a macrotrauma axial load? High velocity rotation?

Etiology: Does it make sense? - Microtrauma v Macrotrauma Macrotrauma (i.e. MVA) - Axial load: disc lesion vs compression fx - High velocity rotation: disc lesion vs rib fx Microtrauma E.g. Golfing, repetitive work in manufacturing

Clinical examples of interdependece - Give more examples. - With bilateral arm elevation, where does this travel down the spine? Unilateral elevation?

Excessive kyphosis Protracted scapulae Reduced upward elevation and backward spin of the clavicle during arm elevation Bilateral arm elevation = extension down to T10 Unilateral arm elevation = rotation to T6 Forward head, excessive kyphosis and increased angulation at the cervicothoracic junction associated with upper thoracic spine mobility limits Shoulder pain & dysfunction: Thoracic posture and segmental mobility associated with: Shoulder ROM Scapular position Impingement syndrome

Principles

Figure out the patient's baseline function and progress from there Develop awareness Gradually challenge control Spine--> extremities Simple--> complex

Side lying gaping

Figure out the pts bias and position them accordingly 9090 supine = put hand on thighs for additional traction (self attraction--good for acute discogenic problem) - Early in the morning after disc hydration = lower hip rotation - Late afternoon = side lying or 90/90 position Lay over the bed, let legs hang & hips sink down (use 2 chairs or do it on chairs)

Inspection: Scoliosis - What is functional scoliosis vs congenital? - What will happen if they try to SB? - What happens arthrokinematically?

Functional scoliosis - Leg length discrepancy Structural scoliosis - Congenital - Abnormal coupling pattern (side bending left--> there will be a contralateral side bending) ie. picture = SB to left, rotated to right (rib hump on right) - Primary problem is where the rib hump is

Acute LBP with related (referred_ LE pain - Lumbar disc lesion

Gait- may detect muscle weakness AROM- trunk deviation during flexion may occur-direction of deviation determined by relative compression on nerve Flexion tends to increase pain, sitting increases intradiskal pressure/pain; walking and standing and extension appear to move NP into more central location, decreasing pain + neural provocation tests- slump, PKB, SLR- the lower the angle of a +SLR the more specific (SPin>>>) the test becomes, and the larger the disk protrusion found at surgery PKB (femoral nerve) best screening tool for high lumbar radiculopathy- + in 84-95% of pts with high disk lesions

A good surgeon's indications for spinal surgery

Healthy nonsmoker (smoking increases risk of failure 2-3x) Realistic goals: simple ADLs. Many years of other modalities: Including weight loss and exercise. 1-2 levels involved

Subjective Hx - What helps to ID priority for Tx? - Biopsychosocial considerations

Helps to identify priorities for treatment - Patient-identified problems - Functional measures - self-reported inventories - Oswestry Disability Index - Roland-Morris Biopsychosocial considerations Hx of depression or anxiety Evidence of fear-avoidance (FABQ, Tampa Scale of Kinesiophobia) Catastrophizing (PCS) STarT Back Tool

Basic Clinical Exam of the Thoracic Spine: Unique to thoracic spine - What red flags are most consistent in this section of the spine? - What is the critical zone?

High incidence of neoplasms and metastatic disease T4-9--> Critical zone Narrow spinal canal (look out for cord Sx) Relatively lower blood supply

Acute & Subacute LBP with mobility deficits: Pathoanatomic Dx - Facet jt dysfunction - Explain what this is due to? How can you tell what it's d/t by your testing?

Hypo mobile facet jt- due to extra-articular, periarticular or pathomechanical causes Determined by end feel of passive physiologic flexion/extension, side bend, rotation 1. Extra-articular cause will see decreased passive physiologic motion, but normal accessory motion 2. Periarticular- will see restriction in both passive ROM and accessory motion, and will have a hard/capsular endfeel 3. Pathomechanical- restriction in ROM of both passive and accessory motion tests, with abrupt, slightly spring end feel

2 leg rotation (very useful)

If pt presents with pain or limited straight leg raise (SLR) and no signs or sx below the knee try 2 leg rotation TOWARDS THE SIDE OF LIMITED SLR. Pt position: supine and holding onto plinth with opposite hand if necessary. Therapist position: stand on side of symptoms, flex up both hips and knees with feet off table. Rotate toward painful side, you may need to stabilize opposite shoulder. Alter the degree of hip flexion and rotation to resolve pain *For radicular pain, looking for a reduction in their Sx*

Mid & Lower Ribs (posterior aspect) - How can you isolate if the rib is the problem?

If stabilize spine on opposite TP & PA on rib, the rib is the problem AIM Assess motion, test for pain provocation/alleviation PATIENT POSITION Prone, positioned closer to therapist's side of plinth THERAPIST POSITION Hypothenar eminence over angle of rib to be tested (test the side opposite where you are standing), elbow straight, shoulder and elbow aligned directly over the transverse process to be tested TECHNIQUE Apply a posterior to anterior force through the arm onto the angle of the rib. To confirm spinal level, palpate the spinous process while performing the unilateral PA on the rib, if the spinous process moves you have identified the associated rib To isolate the rib motion, stabilize the spinous process of the associated rib

Lumbar HNP Tx - What is the surgery? How invasive is it?

If the indications are good, over 90% success can be expected: Surgery -Laminectomy with Discectomy = minimally invasive approach

LBP with mobility deficit - Acute & subacute

If the lumbar spine is restricted, need to look at the hip and the thoracic spine to see whats occurring there too

Mobility tests in sitting - Arm elevation - When should you use this technique?

If the patient is unable to rotate through the cervical spine, use arm elevation Motion possible to T6

SLR - What does pain in the 0-30 dg range indicate?

In 1st 30o of SLR the slack or crimp in sciatic nerve is taken up Pain provocation in 0-30o of SLR may indicate: Acute spondylolisthesis Tumor in the buttock Gluteal abscess Very large disc protrusion Acute inflammation of the dura Sign of the buttock (refer) Between 30-70o of SLR the spinal nerves & dural sleeves and the roots of L4-S2 stretch 2-6mm. After 70o there is further tension but no further stretch, also hamstrings, gluteus maximus, and the hip sacroiliac and lumbar spine joints are now involved.

Acute or subacute LBP with cognitive or affective tendencies

In this population: There is no one treatment that has shown to be better.

Zygopophyseal joints (facets) - What degree are they inclined in transverse plane? - What degree in the sagittal plane? - What motion do they limit in each of these planes?

Inclined 20 dg in the transverse plane Coursing ventrolateral to dorsomedial Inclined 50-60 dg in the sagittal plane Coursing cranioventral to caudodorsal Limit motion in the sagittal plane (flexion/extension) Do little to limit motion in the transverse plane (rotation) or frontal plane (SB)

Chronic LBP with radiating pain

Increase in chronicity, end ranges tend to be more provocative

Nerve Mobilization

Indicated when neurodynamic provocation tests are (+) SLR, slump (sciatic and femoral n.) Use supported by the Clinical Practice Guideline for Low Back Pain Patients with subacute and chronic LBP with radiating pain

Examination - Why?

Insidious onset or MOI Micro- or microtrauma Look for patterns--> It should make sense Screen for serious pathology

Mechanics of breathing: 1. Inspiration - Upper ribs: What are they doing? - Lower ribs: What are they doing? - What does the thoracic spine do? 2. Expiration - Upper ribs: What are they doing? - Lower ribs: What are they doing? - What does the thoracic spine do?

Inspiration Ribs 1 and 2 - very little movement Upper ribs move up and fwd (Pump handle) Lower ribs move up and lateral (Bucket handle) Thoracic spine extends Expiration Ribs 1 and 2 - very little movement Upper ribs move down and back Lower ribs move down and in Thoracic spine flexes

Spondylolysis

Instability Forward slip

Cervical Rotation ROM Intervention

Intervention (thoracic manipulation and cervical ROM exercises) Cervical ROM "3 finger ROM" exercise - patient places the fingers over their manubrium, w/chin on the fingers, Patient then rotates to one side as far as possible, then back to neutral, Performed alternately, to both sides within pain tolerance 10 reps, 3-4 x /day Can start with 4-5 fingers if ROM limited, decreasing fingers as Rom improves Patient Education Maintain usual activities within limits of pain

Potential treatment interventions for thoracic manipulation

Intervention (thoracic manipulation and cervical ROM exercises) Patients treated for 2 sessions over 4-8 days Manipulation - 3 techniques repeated twice each session Seated distraction "high velocity low amplitude, mid to end range, posterior-to-anterior thrust, to the mid thoracic spine on the lower thoracic spine, in a sitting position" Supine upper t-spine (T1-4) "high velocity low amplitude, mid to end range, anterior-to-posterior thrust, to the sternum and upper thoracic spine on the mid thoracic spine, in a supine position" Mid t-spine manipulation (T5-8) "high velocity low amplitude, mid to end range, anterior-to-posterior thrust, to the sternum and upper thoracic spine on the mid thoracic spine, in a supine position"

Nerve mobilizaiton- Irritability

Irritable nerve tissue Constant pain Easily provoked Long time to dissipate once provoked Paresthesia Spasm Requires gentle treatment Non irritable nerve tissue Intermittent pain More difficult to provoke Resolves quickly once tension released Tolerates more aggressive treatment

Schroth Method - Scoliosis

Katharina Schroth - Dresden, Germany 1894 Suffering from moderate scoliosis Inspired by a balloon, she tried to correct by breathing away the deformities of her own trunk by inflating the concavities of her body selectively in front of a mirror Institute in Meissen late 30's and early 40's First prospective controlled trial from a patient group 1989-1991

Lumbar HVT L3-4 right rotation detailed technique notes

L) Side ly is LSp R) side bend Extend segments above L3 Turn patient forward, to allow mob or HVT direction down and forward through line of femur Flex LSp from below up to L4 using top leg as lever [ligamentous tension locks lower segments] R) Rotate upper segments down to L3 [non coupled motion helps to lock] Rotate pelvis to L) so L4 rotates L) under fixed L3 [creating R) rotation at L3-4] Mobilisation or HVT delivered through PT's L) forearm against pt's iliac crest and lateral hip, good body contact, PT's weight on L) leg to 'drop' to deliver HVT Patient L) side lying, L) leg extended, R) hip and knee flexed Therapist facing patient at level to mobilise Procedure The most efficient delivery of thrust is with body weight shift, drive force along the long axis of patient's femur, therapist's upper extremities should be maintaining the joint position at the end of available range Indications restore lumbar motion in any direction since this is a gapping technique, CPR for acute low back pain, reduce pain

LBP Px: - What is a worse prognosis? Good? - What is a good tool to use to check this? - What interventions should clinicians prioritize to increase pts prognosis?

LBP is common and most of the time resolves--> Emphasize this with your patients with first time LBP Worse prognosis with reoccurring pain, excessive spine mobility, general excessive joint mobility, sx below the knee, high intensity pain, depression, and fear of pain & movement Clinicians should prioritize interventions to reduce reoccurring LBP and reduce the transition from subacute to chronic STaRT Back Tool: good to utilize to know the chronicity of the LBP

Which side up for LSP rotation HVT? When would you NOT want to do an HVT?

LBP that fits the CPR Sorest side up If both sore, flip a coin! If no cavitation on first choice side, try the other side Radicular symptoms in the buttock and thigh Sore side down This closes down the affected side Radicular symptoms in the buttock, thigh and lower leg NO HVT?

Convergence - Lamina 1 vs Lamina 5 review

Lamina I Nociceptive specific Low convergence Lamina V Wide dynamic range neurons High convergence

Convergence

Lamina I Unimodal Localized, defined pain pattern Descending inhibitory control Lamina V Polymodal Vague, non-focal, referred pain pattern Reduced descending control

Laminectomy and Discectomy - What can these result in post surgery? - What does a full discectomy require? - What is important to remember after having a discectomy after a HNP?

Laminectomy- can be partial or full, indicated for small unilateral disc protrusion, can result in loss of anatomic stabilization (complete laminectomy) - Take out the bone causing the obstruction, may take part of disc out Discectomy- can be partial or full. Full discectomy requires spinal fusion Despite immediate gratification, remember that the HNP = disc degeneration--> Therefore They May Be Back.

Psychosocial factors - How do these relate to physical factors? What about expectation to recover?

Larger prognostic role than physical factors! Fear, distress and depression play important roles in LBP in the EARLY stages so clinicians should focus on these factors Patients expectation of recovery is a predictor of return to work Pts with higher expectations had less sickness absence Coping style (active coping associated with better outcomes)

Sciatic nerve pathway - How do you sensitize?

Largest in body Consists of 2 nerves, tightly bound together by connective tissue Sciatic nerve passes through or anterior to piriformis muscle, lateral to ischial tuberosity, anterior to hamstring muscles, before dividing into tibial and fibular nerves somewhere in middle third of the posterior thigh Locations for sciatic nerve entrapment: Low lumbar spine IVD Spinal canal IVF Piriformis muscle Hamstring muscles Sciatic nerve sensitization: Hip adduction and internal rotation (common for hamstring tendinopathy to actually be entrapment of sciatic nerve)

Tibial nerve pathway - How do you sensitize?

Largest terminal portion of sciatic nerve, popliteal fossa, Between heads of gastrocnemius muscle posterior compartment of shin, posterior to medial malleolus, Through tarsal tunnel plantar aspect of foot as medial and lateral plantar nerves Locations for tibial nerve entrapment: Tarsal tunnel (posterior to medial malleolus, with Tom Dick and Harry) Tibial Nerve sensitization position of the foot and ankle: Dorsiflexion and eversion

ABM

Lateral flare of the abdominal wall Global muscle activation Cues "Widen your waist" "Don't let me push you in" Watch for people sucking in or holding their breath

Unilateral PA (rotation)

Left TP pressure creates right rotation AIM Assess intersegmental motion, test for pain provocation/alleviation PATIENT POSITION Prone, closer to therapist's side of plinth THERAPIST POSITION Hypothenar eminence over transverse process to be tested (test the side opposite where you are standing), elbow straight, shoulder and elbow aligned directly over the transverse process to be tested TECHNIQUE Apply a posterior to anterior force through the arm onto the transverse process. Feel for quality and quantity of movement, and assess for pain provocation. To confirm spinal level, palpate the spinous process while performing the unilateral PA, if the spinous process moves you have identified the associated transverse process

Axial rotation - What is this motion limited by primarily? - If pain in this position, what you be inclined to think if the problem?

Limited primarily by the disc If pain provocation is worst with 1D axial rotation......think disc dysfunction Facets do little to limit motion in the transverse plane

SB - What is this motion primarily limited by? - If pain in this position, what you be inclined to think is the problem?

Limited primarily by the ribs If pain provocation is worst 1D side bending........think rib dysfunction

Local vs referred pain

Local pain = experienced at the site of origin Referred pain = perceived in different area than that of the site of origin

Fibular nerve pathway - How do you sensitize?

Locations for fibular nerve entrapment: wraps around fibular neck, through fibularis longus muscle injury from extrinsic factors crossing legs below knee cast that is too tight knee high stockings that are too tight intrinsic factors fibula fracture rupture LCL biceps femoris tendon trauma Fibular Nerve sensitization position of the foot and ankle: Plantarflexion and inversion

Vertebral body - How is this different than the cervical spine?

Long, wedge shaped Responsible for the kyphotic angle (up to 45o) Multiple rib attachments Short, thick pedicle Small, round foramen

Neural smudging

Loss of discrete cortical organization in the somatosensory cortex Brain mapping studies using transcranial magnetic stimulation (TMS) show an association between cortical changes and pain intensity on motor control Motor changes in CLBP Poor differential activation of spinal muscles Deep multifidi (DM) Long, superficial erector spinae (LES) "Motor cortex reorganization supports the notion that the nervous system adopts a new strategy for movement/stability with LBP." Loss of discrete motor control New motor strategy "protects the part" with increased global stiffness, effectively "splinting" the spine Motor training can restore cortical organization (i.e. allostatic protective responses)

Coupling patterns - Cervical spine - Lumbar - Thoracic

Lower cervical spine coupling: ipsilateral side bending and rotation in both a flexed and extended position Lumbar spine coupling: ipsilateral side bending and rotation in a flexed position, contralateral side bending and rotation in an extended position (some debate) "True Thoracic spine" coupling: Synkinetic movement is reduced, little agreement on coupling pattern

Centralization and directional preference

Lumbar Flexion vs Extension Can also include correction of a lateral shift Use of repeated movements to assess the effect of motion on the symptoms Do lower extremity symptoms peripheralize? Or centralize? Concepts well-developed by Robin McKenzie Exercises are used for pain relief - ie. if someone says they have pain with extension but not flexion--> do extension based HEP

Clinical Exam- Sitting

Lumbar rotation ROM Myotomal testing (L2-L5) Dermatomal testing (L1-S1) DTR - Patellar (L3-4), Achilles (L5-S1), Babinski Slump test--neck flexion, foot DF, slumped thoracic*

Thoracic mobilizations reminders

Make sure head is in neutral & arms arm on the side so tissue is on slack Remember how far away the transverse process is from the spinous process (you have to go deep to the tissue to access & feel bone)...then move lateral from the transverse process to the find the rib space (lateral to this is the rib angle)

Mobility tests in sitting - Axial rotation of cervical spine - Where should you be feeling rotation down to?

Move the patient into cervical rotation Assess the motion between SP's Should feel rotation to T4

Nerve Mobilization- Dosing

Movement is better and safer than stretch Gentle, painfree (Nee et al. 2013) Hold 7 seconds, repeat 5 times per treatment session (Dutton, 3rd ed, p 419) Please note: Dutton describes a variety of dosages on pages 417-419 Other sources - 1 per second, 20 reps or 1-2 minutes (IAOM) Instructions to the patient - no reproduction of symptoms

Clinical Exam - Side lying

Muscle length - Ober Muscle strength - hip abductors, lateral trunk flexors Palpation

Subacute and Chronic LBP with radiating pain - Spinal stenosis - What are the differences between central and lateral?

Narrowing of spinal canal, nerve rt canal, or intervertebral foramina of lumbar spine Disorder of elderly, most common dx in pts older than 65 yo 1. Central - narrowing of spinal canal around thecal sac of cauda equina- due to facet jt arthrosis, thickening of LF, bulging of IVD, spondylolisthesis--> Can result in cauda equina Sx 2. Lateral- encroachment of spinal nerve in the lateral recess of spinal canal or IVF- due to facet jt hypertrophy, loss of IVD height, IVD bulging, spondylolisthesis Can see neurogenic claudication, that is a nerve compromise that occurs with activity. You can do a bike test (this will tell you if its neurogenic vs. vascular will be able to go farther in a recumbent bike) Vascular claudication is going to be brought on regardless of position.

Neural provocation testing

Nervous system is a continuous structure that moves and slides as we move Nerves may be irritated, damaged or constricted by: Scar tissue /adhesions Swelling Stretch injury (tension) other extra neural restrictions, like an osteophyte close proximity to an unstable joint Any damaging effects could lead to pain

Nerve mobilization - Contraindications

Nervous system malignancies Infection Spinal cord injuries Worsening neurological symptoms Cauda equina symptoms CNS disorders Suspected disc lesions (to distraction for this no nerve mob) Extreme pain

Clinical instability/Radiographically appreciable

Neural control --> wobble, lack of stability from passive constraints An inability to efficiently coordinate the passive, active and neural control subsystems to allow functional movements without neurological dysfunction, major tissue deformity or incapacitating pain

Thoracic Outlet syndrome - What is it also known as? - What type of event typically causes this?

Neurogenic thoracic outlet syndrome (NTOS) Diagnosis of exclusion Cluster of symptoms Compression or tension event PT's don't really see vascular TOS (vascular surgeon), but neurogenic we Tx

Which grade & how many reps/sets for manual therapy? - Grades 1-2 mobs: How long would you want to do mobs for? What immediately after? How long would you tell pt to do these?

Neuromodulation of pain (grade I-II) Treatment (grade II or III, the largest amplitude tolerated by patient) Reassess after every few reps (this will constitute 1 set for this session) Continue if pain is reduced Discontinue for the session when significant improvement have been achieved, or when improvement plateaus 30 seconds to 2 minutes of mobilization Follow with resisted isometrics or AROM into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session Through range pain (grade II or III, the largest amplitude tolerated by patient)

Nociceptive vs non-nociceptive

Nociceptive = inflammatory pain in response to activation of peripheral nociceptors by mechanical, pressure, temperature changes or chemical activation Non-nociceptive = "neurogenic" or "neuropathic," result of direct stimulation of nervous tissue, PNS or CNS

Mediated by dorsal horn

Nociceptive input from Aδ and C-fibers converge on dorsal horn Aδ - first response C-fiber - delayed response d/t temporal summation

Disputed NTOS Sx

Numbness/paresthesia Pain - non-radicular Paresthesia - 4th & 5th digits only or whole hand Subjective weakness - rarely a true, objectifiable weakness Subjective reports of swelling Vasomotor instability - discoloration of the hand "Release phenomenon"-- return of sensory info after limb "falling asleep"

Vertebral Body - Frontal plane: Why is this view different? - Why are nerve root dysfunctions not likely in the thoracic spine?

Oblique spinous processes, roughly equal length Asymmetric orientation in the coronal plane d/t multiple muscle attachments Foramen high, above the level of the disc Unlikely for nerve root dysfunction, not as common to see related nerve root impairment (foramen is so high)

Lumbar Clinical Exam: Standing - What helps you ID if it's a facet/nerve root problem vs disc?

Observation Posture, Gait, Heel walking (L4), Toe walking (S1), Functional movement Lumbar AROM Quantity, quality (aberrant movement), pain provocation Watch lumbopelvic rhythm, Assess response to OP, Measure (inclinometer) Flexion - add neck flexion at end range Quadrant test--considered a special test--Extend, SB & rotate with overpressure. If local pain = facet or nerve root (closing restriction on facet & foramen), if disc will be more painful in 1D motion Posture Kyphosis, lordosis Flat back Lateral trunk shift *Dural sensitiziation: Have them flex forward, then tuck neck, the extend neck....Disc attached to PLL & ALL innervation so this could trigger* *Lumbopelvic rhythm--usually erector spinae aren't weak, extensors start the extension & glutes finish Gower's sign = instability not erector spinae weakness Forward bending + overpressure

Thoracic Exam: When - Onset of pain/provocation: If pain changes with head movement, what might you suspect it to be? UE movement? Trunk movement? Cough/sneezing/breathing?

Onset or provocation - Does pain change with head movement? C spine - UE movement? Upper thoracic - Trunk movement? Mid thoracic - Cough, sneeze, strain (CSS) Breathing When breathing increases motion and increases pain--> disc (or rib)

Primary benefits of exercise: Scoliosis management

Optimize postural alignment Maintain proper respiration and chest mobility Improve overall spinal mobility Maximize functional skills Maintain or improve muscle length and strength

PAIVM - Lumbar spine

PA Unilateral PA

Clinical Exam - Supine

PROM of the hips, knees and ankles SLR Vascular tests - palpate pulses, screen for AAA Abdominal strength Muscle length (hamstrings, hip flexors) Rule out SIJ if indicated - compression, distraction, thigh thrust Ms length test: hamstrings 90/90 usually doesn't provke radicular pain??

Fusion

PTs must teach patients how to move again without stressing segment above and below the fusion Common for a fusion patient to "wear out" the segments above and below the fusion.

LBP Examination: What - What types of pain? - What are signs of instability? - What is paresthesia considered?

Pain Local and/or referred Referred - radicular or non-radicular Signs of Instability: Catching, painful arc, minor perturbations major pain, transient neuro signs Paresthesias Lowest degree of nerve root irritation, vasonervorum compromise Peripheral nerve conduction disturbances--> Follows dermatomal pattern Radicular in nature, true axonal disruption, motor disturbances, numbness When there is nerve root involvement, there are a few stages. Once nerve conduction is involved, you see sensory changes first and then motor

LBP Examination: Where? - Where would L3-L4 pain refer? - L4-L5 - L5-S1 - Which one is the most common?

Pain drawings and CT discography Strong relationship between pain drawings and levels of pressurized provocation L3-4 disc (71.4%): no posterior thigh or leg pain, referred to anterior leg L4-5 disc (>63%): anterior thigh pain, with or without posterior thigh or leg pain L5-S1 (> or = 75%): pain in posterior thigh or leg, no pain anterior

Multifidi

Palpate intersegmentally Instruct the patient to "make the muscle swell" Can facilitate with ADIM or pelvic floor activation

Clinical Exam - Prone

Passive knee flexion with hip extension - femoral nerve Resisted knee flexion (S2) Accessory motion (mobility) testing (L1-L5) - central and unilateral PA's/spring *Pain provocation Muscle strength - trunk extensors, hip extensors Prone Instability, Passive Lumbar Extension Test* Palpation Passive knee flexion & resisted knee flexion are part of the LQ screen

Clinical exam - Prone

Passive knee flexion with hip extension - femoral nerve Resisted knee flexion (S2) Accessory motion testing (L1-L5) - central and unilateral PA's/spring *Quantity of Motion and Pain provocation Muscle strength - trunk extensors, hip extensors Prone Instability, Passive Lumbar Extension Test* Palpation

Lumbar HVT L3-4 R) rotation(can be viewed on ipad dynamic spine app > lumbar > HVT > lumbar rotation)

Patient L) side lying, L) leg extended, R) hip and knee flexed Therapist facing patient at level to mobilise Procedure The most efficient delivery of thrust is with body weight shift, drive force along the long axis of patient's femur, therapist's upper extremities should be maintaining the joint position at the end of available range See next slides for detailed positioning notes and options Indications restore lumbar motion in any direction since this is a gapping technique reduce pain low back pain that fits CPR *Make sure elbow in line with femur, get to end range & then shift weight*

Maximum protection phase

Post operative management similar for fusion and laminectomy Recovery time quicker with laminectomy Pts may be placed in Philadelphia collar or lumbosacral orthosis

Post-operative principles for any surgical procedure - What are they based off of?

Post-operative protocol: healing times and procedural based Know all Restrictions- dependent on surgeon Typically- no heavy lifting (>10lbs) for up to 3 months, movement restrictions- depends on procedure and surgeon Brace use

Inspection - What is considered a normal kyphosis? - What is Tietze syndrome?

Posture Kyphosis: < 30° is normal Upper trap contour, 1st rib position Supraclavicular fullness Palpation: Tender ant ribs 2 & 3: Tietze syndrome (chondrosternal inflammation) Manubriosternal junction: Ankylosing spondylitis

Acute LBP with related (referred) Lower Extremity pain - Lumbar Disc Lesion

Posture: Lateral shift- commonly seen; pt may list away from side of pain; direction of list believed to result from relative position of the disk herniation relative to the spinal nerve root With disk herniation lateral to the nerve root, pt leans away from involved side , drawing nerve away from disk fragment or matter (with AROM to involved side, get marked increase in symptoms) HNP medial to nerve root, pt leans toward involved side, to try to decompress nerve root All theoretical to date.... "Shoulder lesion leaning away to relieve pain. Axial lesion leaning towards to relieve pain "

CPR for when to use lumbar manipulations - Who is appropriate for lumbar manipulations?

Predictor variables Symptoms < 16 days (strongest) At least 1 hip with >35o IR Hypomobility with LSP spring test FABQW score <19 No Symptoms distal to knee Probability of success = 95% when 4/5 variables present

Maximum protection phase

Prevent jt stiffness and soft tissue contracture Rx: Continuous passive motion (CPM) PROM, AAROM Minimize ms atrophy Rx: isometric exercises Maintain strength and motion in areas above and below surgical site Rx: A/ARROM Maintain functional mobility while protecting the operative site Rx: adaptive equipment as needed

Diff Dx of LBP - What is the primary goal of diagnosis? - What are other factors to consider may be playing a role in their LBP?

Primary goal of diagnosis: match patients clinical presentation with most efficacious treatment approach Concept of red flags Yellow flags Psychosocial risk factors for persistent pain

LBP Exam: When? - What types of Sx would lead you to think disc or stenosis?

Prolonged postures or with movement Flexion or Extension Time of day Stiff in a.m., better with movement, achy in p.m. Strong suspicious of disc . Better in a.m., pain increases throughout the day more suspicious of a stenotic event Cough, sneeze, strain suspicious of disc

Thoracic side bending - If someone experienced severe pain, what would you assume is the problem? - What motion could you add to provoke lower ribs?

Pure SB, no rotation PT stands opposite to SB Front arm around shoulder Back hand stabilizes the iliac crest Most provocative of rib dysfunction Add expiration= provokes lower ribs (5-10)

Traction - Manual and Positional

Purpose Increase the intervertebral foraminal space Decrease nerve root compression and intradiscal pressure Facilitate improved circulation/blood supply to the tissues Aid in muscle relaxation Elongate muscles, decrease sensitivity to stretch, decrease muscle guarding

Referred pain - radicular vs non-radicular

Radicular = follows the nerve root distribution Non-radicular = perceived in an unrelated site, can be generated by structures other than the nerve root (disc, facet, ligament)

Nerve Mobilization - Rationale - Benefits

Rationale To improve nerve conduction velocity by restoring dynamic balance between the relative movement of the neural tissues and surrounding mechanical interfaces To reduce intrinsic pressure on the neural tissues Proposed benefits Improved mobility of the connective tissue Facilitation of the nerve glide Reduction of intraneural edema Dispersion of noxious fluids Increased neural vascularity and intraneural circulation Improved axoplasmic flow

Red flag! Cauda equina syndrome

Recent onset of pain Severe constant bilateral radicular pain Bowel and or bladder changes- urge to urinate Saddle paresthesia (anal> genital) Severe multi directional movement restrictions, bilateral SLR on exam +/- neuro signs Refer out!

When to refer out - What is not an indication for surgery, but relative indication?

Red Flags Trauma Intractable pain Primarily leg pain >6-8 weeks. Neurologic sign Significant motor weakness: NOT an indication for surgery, but a relative indication. Progressive instability - Progressive neurologic symptoms not successfully treated with conservative Tx

Acute, subacute and chronic LP with movement coordination impairments: intervention

Reduce pain by improving patient awareness of muscle activity and lumbopelvic control Therapeutic exercise to improve spinal stability, increase strength, increase endurance, and improve coordination Pt education to stay active

Neurophysiological mechanisms

Reflexogenic Group Ia & II mechanoreceptors Influencing skeletal muscle reflexes Dorsal horn Aδ & C fiber convergence Temporal summation Wind up Supraspinal structures Δ in neurotransmitter release RVM raphe nuclei PAG substance P inhibition

Biomechanical links - Regional interdependence tells us what? Give an example of a shared characteristic between the body and thoracic spine - Give an example of synchronous motion?

Regional Interdependence = Regional dysfunction contributes to local pain and dysfunction Multiple shared muscle attachments for the spine and UE's Synchronous motion & Compensatory motion --> If lift right arm up, thoracic spine will rotate in clockwise

Patient education - What is the typical weight you can't lift?

Rehab program, expectations Restrictions- dependent on surgeon Typically- no heavy lifting (>10lbs) for up to 3 months, movement restrictions- depends on procedure and surgeon Wound management and pain control Functional mobility Exercises- walking, isometrics in supine, AROM- heel slides, SAQ, ankle pumps

Oswestry and neck disability index

Remember to use a functional assessment tool at the initial exam as your objective exam post surgery is limited to basically a screening exam and function.

T4 Syndrome - What is this truly representative of? - What are biomechanical Sx and neurophysiological Sx?

Representative of the biomechanical and neurophysiological links between the thoracic spine and the upper extremities, head and neck Biomechanical Fwd head, accentuated kyphosis, increased angulation at CTJ Upper Tspine mobility limits Neurophysiological Paresthesias Headache Difficulty breathing Double crush: Not uncommon to see CTS or cubital tunnel syndrome in conjunction with TOS

Release phenomenon: NTOS - When does this often occur? Why? - What are the 3 relevant time periods?

Return of sensory info "Pins and needles" - like a foot waking up after it has fallen asleep Often happens at night - reduced tension around the scapulae during sleep 3 relevant time periods: Better prognosis 1. Irritation period 2. Delay 3. Release period

Ribs: biomechanics - Ribs 1-2 - Ribs 3-6 - Ribs 7-10

Ribs 1 & 2 = stiff ribs allowing for little movement Ribs 3-6 move in an ant-post direction, like a pump handle Ribs 7-10 move more laterally, like a bucket handle

Anterior rib cage - Explain how each "section" of the rib cage is attached to the sternum.

Ribs 1-7 have direct sternal connections, true ribs Ribs 8-10 have indirect sternal connections, false ribs Ribs 11 & 12 have no sternal connections, floating ribs

CONSIDER

SINSS

Consider

SINSS Severity Irritability Nature Stage Stability

Acute, Subacute LBP with radiating pain

Sciatica: nerve root problem. Does not have to go through the whole dermatome. Can be in patches. You will see paresthesia's first. Common for the symptoms to be in both these categories

Slump TestingSciatic Nerve (& terminal branches) Provocation Testing

Sensitization Cervical extension should reduce symptoms DF+Ev = tibial nerve bias DF+Inv = sural nerve bias PF+Inv = fibular nerve bias Patient Seated well back on plinth, hands behind back Therapist Standing or sitting beside patient Test Sequence Slump ("best slouch you can do"), now adjust the upper body until sacrum is perpendicular to plinth Guide (but do not push) head and neck into flexion ("chin to chest and keep it there") Active knee extension Active ankle dorsiflexion Alternate Sequence Passive lower extremity movement

SLR testing - Sciatic nerve (& terminal branches) provocation testing

Sensitization Cervical flexion may increase symptoms (pulling dura from above) Hip adduction+internal rotation (sciatic nerve passes lateral to ischial tuberosity) Ankle dorsiflexion (pulling dura from below) Thoracolumbar side bend away may increase symptoms Pre-positioning in cervical flexion Pre-positioning in ULTT median nerve one or both arms Addition of DF+Ev = tibial nerve bias Addition of DF+Inv = sural nerve bias Addition of PF+Inv = fibular nerve bias Test Sequence Passive hip flexion maintaining full knee extension Hip must pass 35o to take up slack in the sciatic nerve At 70o hip flexion sciatic nerve is at maximum length, symptoms after 70o flexion should be attributed to the hip jt, SIJ or lumbar spine (unless the patient is hypermobile, eg ballerina, gymnast, martial art practitioner) Positive Test SLR <70o limited by pain Pain is neurologic in nature Pain is "the patient's pain"

Brachial plexus - What are the 2 ways sensitization can occur? - How can sensory info get back to the ANS? - What spinal levels do sympathetic fibers to the head originate from?

Sensitization can occur through the trigeminal nerve and sympathetic wind up Sensory info from the brachial plexus relays back into the ANS via cervical ganglia Sympathetic fibers to the head originate C7 to T3

Mechanical traction

Signs and symptoms of nerve root compression Helpful for pts that couldn't centralize symptoms w/movement Treat with mechanical or auto-traction Lack of evidence supporting use of traction in patients with LBP Problems with use of heterogenous patient groups in these studies More research needed to identify patients with LBP who might respond to traction More research needed to determine optimal dosage of traction force, patient position, duration, frequency

Outcomes: Reducing neck pain

Single manipulation at C7-T1 increased pressure pain thresholds in facet joints of C5-C6 in asymptomatic subjects RCT in 36 patient's with primary c/o neck pain, thoracic manipulation reduced pain scores on VAS Outcomes better among patients who receive OMPT in addition to other treatment modalities, such as therex Long-term improvements (e.g. 1 month and 6 month f/u) have been reported in patients with acute and chronic neck pain

Scoliosis management - At what curve angle are orthoses commonly prescribed? - What is the theory behind why orthoses work? - What does evidence not really support?

Skeletally immature children with curves 25-45 dg are typically prescribed orthoses Theoretically, curve progression is halted by the muscles contralateral to the orthoses strengthening Exercises are often taught to improve active forces, although there is little evidence to support this

Nerve Mobilizations - Sliders vs. Tensioners

Sliders (movement without tension) Mobilize nerves in nerve bed with a minimal increase in nerve tension Simultaneous application of longitudinal force one end of the nerve bed (increasing tension) and release of tension at the other end (unloading/reducing tension) Larger longitudinal excursion of nerve than tensioners Large amplitude movement through mid range, minimal increase in nerve strain Tensioners Like a neural provocation test. Elongation of the nerve bed by moving one or several joints (creates tension) Nerve movement occurs near end range of nerve bed elongation Larger strain increases, and smaller longitudinal excursion of nerve than sliders Two Types 1 ended: tension applied at one point along the nerve bed while other end is stabiliszed 2 ended: tension applied in opposing directions at two points along the nerve bed

Slump test - What are the advantages of the slump test over the SLR?

Slump test is considered a general test of neurodynamic mobility Assesses excursion of neural tissues within the vertebral canal and IVF and detects impairments to neural tissue mobility from a number of sources. During full spinal flexion the cauda equina becomes taut and the lumbosacral nerve roots and root sleeves are pulled into contact with the pedicle of the superior vertebra Advantages of Slump over SLR Slump increases the compressive forces through the IVD Slump highlights the presence of dural adhesions Slump may reproduce the functional position the patient experiences symptoms in Slump may provoke symptoms in a patient with posterior instability of the lumbar spine

Traction - Contraindications & precautions

Spinal infections - meningitis, arachnoiditis Spinal cancer - traction may increase the danger of metastases or promote instability Cord involvement RA Osteoporosis Recent fracture Precaution Ligamentous laxity d/t sprain, pregnancy, generalized hypermobility (e.g. Ehlers-Danlos syndrome) Traction anxiety

Reflexogenic - What do spinal manipulations actually do?

Spinal manipulation introduces new sensory information Changes in group Ia and group II mechanoreceptor discharge Possibly facilitates sensory processing in the spinal cord, influencing skeletal muscle reflexes Different mechanical input

Traction - Indications

Spinal nerve root compression d/t disc pathology (protrusion, prolapse, extrusion, sequestration) or stenosis Generalized hypomobility of the lumbar spine Separates the facets, general capsular stretch Muscle spasm that may be aggravating nerve root, facet or disc signs/symptoms

Intervention

Spinal stabilization Dynamic stabilization Rhythmic stabilization Core strengthening Neuromuscular rehabilitation *good lumbopelvic control with exercise*

Final points

Spine structure and mobility may influence motion, function and pain in the periphery Spine is an access point for the sympathetic nervous system Thoracic and lumbar spine are safe regions of the body for manipulation, no compromise to vascular structures Evidence supports the use of MT for reduced pain and increased function of the spine and extremities

What direction are the spinous processes oriented?

Spinous process angle = shingles on a roof

Biopsychosocial on movement system - What should you be educating the pt on? - What types of movements should be encourages/discouraged? - How long does it take for a disc lesion to heal?

Strong biopsychosocial component--> Education is important Explanation given to a patient was pivotal in generation of a good Rx outcome 1. PT's need to be aware that their pain beliefs may influence patient management 2. Reassure the patient: the disc will heal Avoid end-range positions to prevent stress on healing tissues Utilize postures and activities to enhance ebb and flow of disc hydration If herniated material reaches vascular supply at posterior vertebral body, it will be absorbed; takes about 10 months

L-spine exam

Studies ID certain pain patterns are sensitive & specific for certain pain issues

Acute LBP with related (referred) Lower extremity pain - Lumbar Disc Lesion

Subjective findings: Pain with lumbar flexion, sitting, driving, bending (+) cough, sneeze, strain Worse in a.m. Better when on the move Pain increases again in p.m. Paresthesia's, possible radicular pain, motor disturbances, numbness With flexion: increase load on the disc, creating tension through the whole dura. Once the disc starts to impact the nerve root, it becomes radicular.

Thoracic manipulation CPR

Symptoms < 30 days (strongest predictor) No symptoms distal to shoulder Looking up does not aggravate symptoms FABQPA score <12 Diminished upper thoracic spine kyphosis (T3-5) Cervical extension ROM < 30o (inclinometer) When 3/6 variables met, 86% probability of success Patients with cervical spine pain and 3+ the above findings are likely to experience moderate perceived global improvement from thoracic spine manipulation and cervical ROM exercise within 2 treatment sessions (4-8 days)

Innervation of T1-T4 axons - Which nerves are included? - What are the clinical implications/dysfunctions that arise from these nerves?

T1-4 Axons: Brachial plexus Posterior cutaneous n (sensory branch of radial n) Medial cutaneous n Clinical Implications: Thoracic outlet syndrome (TOS) T4 syndrome

True thoracic spine - Classification of T1-T4; T11-T12, T4-10 - What is considered the true Tsp?

T1-4 behave like cervical segments T11-12 behave like lumbar segments bc floating ribs, transitional zones more likely for injury T4-10 often referred to as the "True Thoracic Spine"

Clinical Examples: T4 Syndrome - What has research shown about effective tx methods?

T4 most commonly affected segment Suggested that noxious stimuli activate nociceptors in the dorsal horn of the spinal cord and spinal medulla Autonomic involvement Three studies have reported relief with treatment of the T4 segment Conroy study - full resolution of symptoms after six visits involving grade III mobilizations of the T3-4 segment Melick study - two female patients who responded to bupivicaine injections to T4 with full resolution of symptoms Jowsey study - double blind RCT, 36 healthy subjects, isolated mobilization of T3-4, increased skin conductance in the 2nd and 3rd fingers

ADIM

Targets transversus abdominis Co-contraction of multifidi Cues "Draw the belly button toward the spine" "abdominals like a corset" "Pull your belly away from your pants" Allow normal

Low back pain: prevalence - What is the incidence rate of LBP? What are the chances of reoccurrence? - Which gender is more susceptible to back pain? - What are other factors that increase prevalence?

The incidence LBP ranges from 1.5-36%. Once you have had LBP the chances of it recurring are 24-65%. Chronic LBP is increasing. 3.9% of LBP was described as chronic in 1992. 10.2% of LBP was described as chronic in 2006. Women > men Increased age increases prevalence, up to age 60-65 Lower educational status increases prevalence, duration of LBP, and worse outcome Manual laborers > sedentary workers Psychosocial factors : fearful, distress, depression, dissatisfaction at work increase risk of acute LBP becoming chronic

Scoliosis management - What are main factors that increase the risk of progression?

The younger the patient at diagnosis Double-curve patterns Curves with greater magnitude Sex - females are at higher risk of progression Risk increases when curves develop before menarche

MWM

Therapist placement: Stand behind pt. Place a belt on pts ASIS and around your backside. (Belt prevents pt from losing balance) Place your hypothenar eminence over the spinous process. Stabilize pt with opposite hand Mobilization: cranially Active movement: trunk flexion or extension Note: pt can be sitting or standing

Assistance of lateral shift

Therapist-assisted correction of a lateral shift

PAIVM

These are joint gliding movements that test the accessory range of a joint's movement. These are movements that are an integral part of the overall joint movement but cannot be actively generated by the client. They are performed on a specific joint level by the therapist. They will give you information about the normal, hypo or hyper-mobility of the joint to be tested In the periphery these are your accessory joint mobilisations.

Thoracic Exam - How large are thoracic dermatomes? - Organ pain can present how? - What pain can be attributed to thoracic not cardiac? -

Thoracic dermatomes do not follow a single intercostal space, occupy 2-3 intercostal spaces Unilateral organ can produce bilateral pain Sternal pain with inspiration --> thoracic not cardiac Pain in the UE's and headache --> T4 syndrome

Overall consideration in thoracic manipulation - Who is it appropriate for? Where are the improvements seen? When are the improvements seen?

Thoracic manipulation for acute and chronic mechanical neck pain patients Improvements in craniovertebral angle and cervical ROM Gains seen immediately and maintained at 6 months post-intervention

Cervicothoracic junction & shoulder joint mechanics - What motion does a stiff Tsp limit? What does this also influence ? - How should the clavicle be able to move? - Hypomobile SCJ/ACJ: ? - Hypomobile GHJ: How can this impact neurovascular structures? - First rib position

Thoracic stiffness/excessive kyphosis--> limited thoracic extension Influences scapulae position--> posteriorly tilted or downwardly rotated - Clavicle should be able to elevate and spin posteriorly - Elevated first rib = Compromises the thoracic outlet container - Hypomobile SCJ/ACJ = excessive dorsal translation of clavicle - Hypomobile GHJ = can stress brachial plexus at end-range elevation

Subacute or chronic LBP with movement coordination impairment: Pathoanatomic Dx - Lumbar Instability

Thought to be significant cause of chronic LBP Any pain provoking activity that damages the structural integrity of the lumbopelvic complex is by definition a "clinical instability" (ms strain, lig sprain, disk herniation)* (Dutton) Controversy as to what is spinal instability- lack of radiographic findings - difficulty in accurately detecting abnormal or excessive intersegmental motion

Goals of the Schroth method - What does PT focus on? - What degree of a curvature is appropriate for this method?

To de-rotate, elongate and stabilize the spine in a 3-dimensional plane Physical Therapy focuses on: Restoring muscular symmetry and postural alignment Breathing into the concave side of the body Teaching postural awareness Orthoses only for immature skeleton, for curves between 25-45 degrees, & Schroth method is only effective for curve 10-30

Transverse process - Where is the widest transverse process? As you progress through the t-spine, what happens? - Where are the transverse processes relative to the spinous process?

Transverse processes widest at T1 Progressively more narrow Dorsal to the articular pillars--> Allows for rotation - Transverse processes sit above (not straight to the side like c-spine)

True NTOS vs Disputing NTOS - How is this confirmed? - Which type responds best to conservative tx?

True Neurogenic TOS: confirmed electrodiagnostically Cervical rib EMG - axon loss More difficult to treat conservatively Disputed Neurogenic TOS NCS/EMG (-).....not sensitive enough? Clinical exam for symptom provocation Responds to conservative treatment

Exercise - Precautions/Contraindications for osteoporosis

Trunk flexion ex's (e.g. supine curl ups) should be avoided d/t increased wedge shape of vert bodies (increased kyphosis) - increases the risk of fx Avoid combining flexion and rotation of the trunk to reduce stress of IVD Increase intensity progressively but within the structural capacity of the bone

TOS Clinical Exam - Inclusion criteria for Roos test

UE pain and sensory changes - brachial plexus distribution Pain worse with UE use Pain with palpation over the brachial plexus

Thoracic spine examination

UQ screen - Add LQ reflexes (patellar, achilles, babinksi) - Reflex changes suggestive of SC lesion or serious pathology Thoracic ROM RI First rib: cervical flexion lateral rotation (CRLF), rib spring Supine - Trunk MMT/Muscle Length UE neural provocation tests/ULTT Prone - Trunk MMT - Spring testing, PA's - Rib spring testing Extra tests: mobility in sitting, regionalization

Facet jt dysfunction - Signs/Sx

Unilateral LBP aggravated by movement- end range extension or flexion 3D motion increases symptoms (e.g. extension, SB, rot) Remember: Capsular pattern of lumbar spine (ext > = limitation of SB/rot) (if its bilateral—usually in older adults) Intervention priority? Bilateral limitations you will see a capsular pattern

Anatomy of thoracic spine - What is the t-spine designed for? What happens typically with dysfunction?

Unique architecture Rib attachments Designed for stiffness--tends to become too stiff with dysfunction

Additional tests - Upper thoracic mobility tests--> Cervical/thoracic spine relationship

Upper thoracic mobility tests using cervical rotation or arm elevation Determining if the problem is in the cervical spine or the thoracic spine Which region is involved? - regionalization

Prone Knee Bend TestFemoral nerve - If positive, which spinal levels may you think are involved?

Used to indicate presence of upper lumbar (L2-4) disc herniations or nerve root impairments Dura is stretched at 80-100o knee flexion Acute L4-S1 disc protrusions may yield a positive PKB

Posterior pelvic tilt

Uses lumbar flexion Targets rectus abdominis Sometimes used to teach patient awareness of a neutral spine If really having trouble, facilitate the action and then ask them to hold

Thoracic extension - What could you do to add to your assumption of disc? Rib?

Verbal cues "Bring your sternum to the ceiling" Therapist can stroke the back into extension Add breathing: Increased pain with inspiration and decreased pain with expiration = disc Increased pain with expiration = ribs

Scoliosis management - How does the arthokinematics change? - How do you describe a scoliosis? How do you name it?

Vertebral body will rotate contralateral (Will bend left & rotate right which then presents with rib hump) Lateral curvature of the spine 3D - rotatory component Rib hump - vertebral bodies rotate toward the convexity Described by the side of the convexity (right or left) Named at the level of the apex

Chronic LBP with related generalized pain

Very multidisciplinary: Nutrition, psychology etc.

Thoracic spine

Visceral afference somatic afference c8-L2 Gives us access to SNS Example: T4 syndrome Unilateral or bilateral upper thoracic spine pain Ventral chest pain Glove-like paresthesias of the hands Headache Occasionally: Weak grip, sense of hand fullness or tightness, difficulty breathing Suggested that noxious stimuli activate nociceptors in the dorsal horn of the spinal cord and spinal medulla Autonomic involvement

Intercostal nerves - What are you trying to balance with your treatment? - When would you want to try to "treat" this area?

Want a balance between hands on & hands off If irritability is low for someone thats sensitized, this might be a good place to go to downregulate nervous system

Thoracic rotation - What is this motion most provocative of?

Wedge or sand bag under IT you are rotating toward PT stands in front and blocks the knees Rotation = most ROM in Tsp Rotation is most provocative of a disc lesion d/t axis of rotation

Exercise - Recommendations for osteoporosis: NWB & WB - How many reps/sets/1-RM?

Weight-bearing ex: walking, jogging, climbing stairs NWB ex: stationary bike Resistance training - 2-3x/week, 1-day rest in between sessions Intensity - 80% 1RM with resistance training for the UE's, 1-3 sets, 8-12 reps, 16/20 on the Borg scale of perceived exertion for trunk exercise

Post-operative principles for any surgical procedure

What are the Structural impairments? Post operative swelling Potential circulatory and pulmonary complications Jt stiffness and decreased motion due to injury and post op precautions Muscle atrophy due to immobilization Decreased strength What are the Functional impairments?

Clinical Reasoning

What is the ideal order of these tests? When do I modify and/or change the order of the tests? Acute vs. Chronic Post-operative considerations s/p discectomy, laminectomy, fusion

Thoracic Exam - Who & What

Who: Age, Gender, Occupation, Sports, Pertinent medical history What: Pain (Local or referred), Quality of the pain, Sensory changes, Spinal cord signs:, L'hermitte sign, Cold feet, Electrical currents

Acute LBP with Movement Coordination Impariments

Will often these as recurring. Might be an acute exxacerbation. Mid range tends to be more painful because there may be some shearing and wobble through the joint where as end range there is more ligamentous support. Fatty infiltrations can occur in the multifidi. The smaller segmental stabilizers begin to be used less so the erector spinae and the obliques begin taking over and the multifidi begin not doing anything. Need to retrain the muscles. Segmental stabilizers: multifidi, transverse abdominis, internal obliques

Does order matter?

Yes! If the neurodynamic sequence is slightly different, the test is completely different. The direction of neural sliding is influenced by the order of tension build up The region moved 1st or strongest is more likely to have a localized response Greater strain in the nerves occurs at the site of 1st movement

Dosing for merve mob

gradual progressive neuromobilization therapy" treatment to address movement between nerve and adjacent tissue Sliding neuromobilization targeting IV foramen and proximal sciatic nerve 3 x 15 oscillations of knee extension in right side lying mild hip flexion neutral ankle 3 x 15 oscillations hip adduction in right side lying mild hip flexion and knee flexion 3 x 15 oscillations lumbar lateral flexion in right side lying mild hip flexion and knee flexion

Pain definitions

local vs referred radicular referred vs non-radicular referred nocicpetive vs non-nociceptive

Tissue before HVT

prepare tissues before HVT (soft tissue mobilization/warm up) and exercise after HVT (posterior pelvic tilts)