Thoracic-Lumbar-SI

Describe traction techniques Segmental distraction/lateral glide

Done to treat pain and centralize symptoms Pt is SL facing away Create a little SB, towel under side of thorax Perform a slight SB PPIVM grade 1-2 short of any ms resistance In this position can manually distract segment by segment

red flags of the T-spine

infection fx neoplasm inflammatory disorders primary tumors in T-spine are rare but spinal metastases (breast, colon, lung, prostate are most common that affect the T-spine)

interventions for someone with lumbar spinal stenosis

it all depends on what the pt is presenting with pain control centralization/specific exercise and traction - flexion specific exercises - traction: preposition into flexion with chair mobs/manips - jt mobs conditioning/stabilization for aerobics - bike (in flexion) over walking posture (neutral-flexion bias) - stretch what is tight, strengthen what is weak body mechanics - talk to them about maintaining that flexion to avoid extension educaiton on maintenance

when do you use which neural tension test for situations in the T-spine

potentially doing ULTT if in the upper T-spine problems, and sx radiating down UE think more slump test if lower T-spein and sx radiating down LE

how should you position a pt when doing jt play/mobs on someone with spinal stenosis

pre position into some lumbar flexion with pillow under hips otherwise you may just push them more into ext causing some pain

red flags of the L-spine

progressive neuro signs - cauda equina syndrome - acute bowel/bladder dysfunction, retention/frequency - foot drop/bilateral sciatica systemic involvement - gynecological (endometriosis, ectopic pregnancy): are they being f/u by a gyno? - urological (urolithiasis, renal tumors, perinepheric abscesses): any changes in bowel/bladder, any pain/discomfort when going to the bathroom? - abdominal (cholecystitis, pancreatitis, AAA): ask about drug/alcohol use, but biggest thing is you can't change pain - lungs (pneumonia) CA Trauma/fx/stress fx infection vascular - AAA

Overview of PT interventions for Scheurmann's Disease

pt education to improve postural awareness back ext and abdominal strengthening ROM & flexibility exercises

discuss breathing instruction as an intervention

pt in HL cue - inhale through your nose and as you exhale through your mouth tuck in your tailbone so that your back flattens on the mat and maintain this position as you breathe out, i want you to try to press your ribcage into the mat tactile cues - pushing down on lower ribs during exhale and maintain this position during inhale "press ribs into mat" "breathe with stomach, not chest" pt can place own hand on stomach can be done in varying positions

how can we get objective measures in a thoracic breathing assessment

tape measure around the axilla, xiphoid, and 10th rib norm would be a 1-3 in difference in expansion between exhalation and inhalation

generally, how big does the scoliosis curve have to be to be recommended for surgery

>45-50 deg

what level of severity of the curve of Scheurmann's disease would indicate they would best benefit from surgery/operative treatment

>75

when can you do jt mobs in someone with ankylosing spondylitis

CI in the late stages okay to be done in non active early stages

what is important in the hx for SIJ

any trauma/fall/bungee jump **anything causing a shear force is huge - any landing on one leg - can be minor or major any ligamentous laxity issues? - hypermob, pregnancy, PMS (hormone relaxin is inc) - any cyclical flares of pain: on period? habitual postures - does standing on one leg aggravate? PMH: RA, AS - AS starts in the SIJ, can start in a young person pain patterns **somatic pain referral is RARELY below the knee

some important subjective questions for T-spine

ask questions about sustained positions, coughing, sneezing --> thinking about things going on with the ribs special questions/red flags --> consider different hx for visceral pain referrals, and inquire if risks

pain and inflammation of the costochondral junctions of the ribs or sternocostal joints usually at multiple levels

costochondritis

what is the only provocation test for a hypermobile SIJ

(+) active SLR

Describe the sacral thrust test procedure results

(Clinical test of the SIJ) Pt is prone PT places pisiform or heel of hand to create a downward pressure on sacrum Force is vigorous and repeated several times *should be at midpoint of sacrum *start slow and progress to grade 1-3 then oscillate (+) test reproduces concordant pain during downward force

Describe the Compression test (anterior)/Posterior gapping of SIJ Procedure Results

(Clinical test of the SIJ) Pt is sidelying with painful side up Examiner presses down on iliac crest using BW Force is directed toward opposite iliac crest and held for 30sec (+) if reproduce concordant sign Alternate positioning is supine (this is both sides at same time rather than one at a time) *this is compressing anteriorly and gapping posteriorly *can also palpate the sacral sulcus for motion when in SL

Describe distraction test/anterior gapping procedure results

(Clinical test of the SIJ) Pt is supine Examiner crosses arms with pressure at medial aspect of both ASIS Force is applied in a posterolateral direction **force has to be LATERAL not down Force is held for 30 sec then a vigorous force is applied (+) if reproduce concordant sign (pain) **make sure pt classifies where they are experiencing pain to help r/o pain from palpation

Describe Patrick's Test/FABER Procedure Results

(Clinical test of the SIJ) Pt is supine Painful sided leg is placed in figure 4 Hip is flexed, abducted, ER by placing in this position CL pelvis is stabilized at ASIS, OP is applied to medial aspect of IL knee (+) test reproduces concordant pain on buttocks or groin Test commonly used for hip pathology SIJ symptoms will be in the buttock though, found posterior

Describe the Gaenslen's Test/Pelvic Torsion Test Procedure results

(Clinical test of the SIJ) Pt is supine with painful leg near end of table PT raises the opposite side to 90deg hip flexion with bent knee Painful side is pressed downward and opposite side is pressed upward (+) test reproduces concordant pain **make sure on edge of table to allow for full excursion, don't let table block the leg *not specific to SI, effects hips, etc.s

Describe the cranial shear test procedure results

(Clinical test of the SIJ) pt is prone PT stabilizes the ilium directly cranially directed force is applied to sacrum near coccygeal end along the Inferior Lateral Angle (ILA) - just off the midline, NOT pushing on coccyx *can be performed unilaterally at each ILA (+) test reproduces concordant pain

Describe the posterior shear test/thigh thrust test/posterior pelvic pain provocation test procedure results

(Clinical test of the SIJ) pt is supine hip on painful side flexed to 90 examiner applies a downward pressure through the femur (+) reproduces concordant pain posterior to hip or near SIJ on side being tested can place a hand or towel under sacrum for a stable surface

what is a MARM assessment

(manual assessment of respiratory motion) hands on lower rib cage in the back - thumbs parallel to spine and little finger horizontal assess that lateral expansion/bucket handle motion

Describe a jt mob technique to correct a counternutated sacrum

(stuck in extension) A/P force directed over sacral base (top)

Describe a jt mob technique to correct a nutated sacrum

(stuck in flexion) A/P force over the apex (bottom)

interventions for sacrum dysfunction

(when the sacrum is stuck in a position relative to innominate) restore alignment treating sacrum and innominate go hand in hand; always reassess the effectiveness of one on the other

Describe sacral mobility tests forward bending

**BE EYE LEVEL Intra-pelvic motion Pt standing Therapist standing behind pt palpating both PSIS's with thumbs Pt instructed to bend forward Both PSIS's should move equally in superior direction **looking for asymmetry, could indicate hypomobility of SIJ Nutation/Counternutation Pt standing Therapist standing behind palpating the PSIS with one thumb and parallel sacral base with the other Instruct pt to forward bend 1. Anterior movement of base relative to innominate for 45-60deg (nutation) then stops and 2. Innominate rotates anterior relative to sacrum (counternutation) **this is a test of the relative flexibility of the longitudinal system and the timing of sacral nutation/counternutation

Describe sacral mobility tests Gilet Test

**Be EYE LEVEL with PSIS Posterior Rotation Pt standing Therapist behind the pt palpating the PSIS with one thumb and parallel sacral base with the other Pt asked to flex the IL hip and knee to 90deg Note the inferior displacement of PSIS relative to sacral base (sacrum should stay the same) (+) if the PSIS does not drop *also watch for pts ability to transfer weight through CL limb to maintain balance Anterior Rotation Pt standing Therapist behind pt, palpate PSIS with one thumb and sacral base with the other Pt is asked to ext the IL hip and note the superior displacement of the PSIS relative to the sacral base

interventions for hypomobile SIJ

**focused on mobility mob/manip/restore alignment based on palpatory findings acute dec pain/inflammation, ms spasm gentle ROM modalities STM gentle SIJ traction (long through the leg) Gr I/II mobs sub acute inc ROM strength promote good posture/body mechanics chronic ergonomics dynamic stab self management think about the ms energy techniques

what should be assessed if you suspect a thoracic VCF

**identify the risk factors for a VCF may be asymptomatic significant historical height loss, wall-occiput or rib-pelvis distance acute fx may report abrupt onset of pain with position changes, coughing, sneezing, lifting pain that inc with standing, walking posture may be kyphotic thoracic ROM is painful - flexion worst tender to palpation/percussion over affected vertebrae neuro exam

the diagnosis of pelvic girdle pain can be reached once what has been R/O

*lumbar causes and make sure this is reproducible by specific clinical SIJ tests **think back pain first, treat back pain, then consider SIJ involvement

who would benefit from manips options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

*those with impaired jt mobility, but those that it would be big in would be: stenosis/DJD - in a flexed position facet dysfunction ankylosing - in early non active stage

Describe this PPIVM of the SIJ: Anteroposterior translation

-- this is doing shear of the SIJ, you are directly on top of the ASIS and pushing straight down Pt is supine with hips/knees flexed: pillow under knees Find landmarks in SL then roll to supine - with the ring and long finger on one hand palpate the sacral sulcus just medial to PSIS (monitors translation between the innominate bone and the sacrum) - index finger on lumbosacral junction notes movement b/w pelvic girdle and L5 vertebrae) With heel of other hand palpate the IL ASIS and iliac crest Apply posterior pressure to the innominate through iliac crest and ASIS note the relative mobility posteriorly, compare to the other side Note the quality of the end feel, quantity of translation and the reproduction of any symptoms is noted

2 issues that could arise from vascular issues in terms of the LB

AAA - stomach, back, flank pain, normally L side - feels like a heartbeat, might be pulsating - constant and dull, does not get better/worse - can palpate this (3cm or bigger) **PMH: HTN, CAD, PAD, atherosclerosis, older PVD - leg pain, back pain, (B) aching, cramping - Claudication: leg cramping pain that is worse with walking ****need to diff b/w PVD & neurogenic claudication via bike test - other sx: numbness/tingling in feet, stocking glove distribution (vs. neurogenic is whole leg) - changes in skin color, diminished pulses, loss of cap refill, skin temp, woudns that don't heal, nail changes

Describe ROM assessment of L-spine

AROM of thoraco-lumbar spine - OP at end range if needed to stress structures - screen above and below for limitations (hip via FABERs and T-spine) Flexion - touch toes Extension - hands on hip Lateral flexion - hands on side Rotation - hands crossed over chest, PT stabs at hips *combined movement: ext/SB/rot & flex (quadrants) Looking for quality and quantity **note any aberrant movement patterns (underlying clinical instability - inability to maintain neutral zone) - step deformity w/ fold during ext d/t shear - reverse lumbar lordosis on flex-ext of LB - Gower's sign when coming up our of flex

5 main clinical features useful in raising/lowering the probability of vertebral fx

Age > 50 Female Major trauma Pain and tenderness A distracting painful injury (if they have another painful injury somewhere else in the body a VCF may go unnoticed)

how do you further classify a hypomobile SIJ

Anterior rotated innominate: ASIS is lower, PSIS is higher, ischial tub is higher, iliac crest is equal, leg length appears longer, HF tight, contract HS to counter Posterior rotated: HS may be tight, counter by contracting the HF Up slip: ASIS is higher, PSIS is higher, ischial tub is higher, iliac crest is higher, leg length is shorter, QL is tight, contract/relax the QL

Describe Thoracic PAIVMs what do we assess at? Which vertebrae are we on if we want gapping? Central PA Bilateral PA Unilateral PA Positioning, what are we looking for?

Assess at grade 3 If we want GAPPING we want to be on the LOWER vertebra *Lower c-spine and lumbar should eb relaxed Central Pt prone, therapist at head or to side Thumbs on SP, can do thumb over thumb Force through elbows in planes of facet Assess end feel, quality of motion, protective ms reactivity & pain response **if this is very TENDER we might try bilateral... Bilateral Use entire thenar eminence space - or place index and middle finger over the TPs, use other hand to transmit the force bilaterally through fingers Unilateral Using thumb over thumb Move thumbs to lamina direct force through facet jt along the jt plane

Describe the cervical rotation lateral flexion test What does this assess? Positioning/Method Results

Assesses for the presence of an elevated 1st rib Pt is sitting C-spine rotated passively and maximally AWAY from side being tested C-spine is gently SB as far as possible in this position, moving ear to chest + test: when SB motion is limited or blocked - suggestive of an elevated 1st rib

Describe Lumbar PAIVMs Central Unilateral

Central PA Glide Pt is prone *Pillow under chest & hips for a neutral not to lordotic spine Therapist stands at side of plinth Place hypothenar eminence distal to pisiform on L5 SP Force is applied by trunk flexion in the plane of the facet *For L5/S1: post/ant with a caudal bias *For all other L levels: force is straight PA Feel for: end feels, quality of motion, protective ms reactivity and pain response/provocation Unilateral PA Glide Pt is prone *Pillow under chest & hips for a neutral not to lordotic spine Place thumbs over lamina Force is from trunk flexion and is done in planes of facets *L5/S1: posterior/anterior with a caudal bias *Other Ls: straight PA glide

T/F PPIVMs/PAIVMs will be very important in identifying spondylolysis/spondylolisthesis

FALSE PPIVMs yes SHEER absolutely however no need to do PAIVMs and go pushing on them if you already suspect a fx

T/F biking is the msot beneficial aerobic activity to recommend to a pt with OP

FALSE the best aerobic activity for this pt will be walking, we want weight bearing

T/F if pain is going past the knee this is a big indicator it is coming from the SIJ

FALSE this is most likely coming from the LB radicular pain down leg is not the norm for SIJ

T/F a patient with a hx of OP reports severe pain following a coughing attack, we should perform rib springing to assess for rib dysfunciton

FALSE with trauma & minor trauma/cough with OP we have concern of rib fx and thus rib springing would be contraindicated in this case instead you are most likely limited to assess: (+) tender to palpation altered breathing mechanics

T/F when doing a mobilization with movement of the T-spine to help with extension you are applying a downglide

FALSE with both rotation and extension this is an UPGLIDE (in the plane of facet as mulligan calls for) even though when normally facilitating extension we are doing a caudal bias

Describe lumbar PPIVMs Flexion/Ext Rot SB

Flexion Pt is SL facing therapist Maintain neutral spine alignment Palpate ISP space Other hand cradles pts knees (rest their knees on your hip for extra support) Shift your weight side-side *do not rotate/SB, want a neutral spine --> Modified: induce hip flexion with only one leg movement Extension Pt SL facing therapist Pt on the diagonal to dec the excursion needed to impose ext Move top leg into ext Feel for closing of the ISP space - don't need to crank this, this can be more uncomfortable Rotation Pt SL facing therapist Palpate lateral to SP (on side closest to the table) Apply a posterior force to ASIS for rotation (rotating the pelvis to the R will induce a L trunk rotation) Stabilize upper trunk with forearm, feel for movement b/w SP **Lower SP should rotate into your finger, upper should remain neutral You want to assess both directions of rotation, but if they cannot flip to other sidelying position then... --> Modified: palpating hand will move to other side of SP (closer to ceiling) and the pelvis is rotated anteriorly SB Pt is SL facing therapist Therapist palpates lateral to SP while stabilizing the upper trunk with the forearm Mobilizing hand facilitates SB by applying an inferior force to the iliac crest (would be a superior force for SB in other direction) Palpate for changes in ISP space --> Alternative: if do not have good mechanical advantage at the hips (like most men) lift legs for tilting/SB the pelvis

Describe traction techniques Manual traction with flexion and extension biases

Flexion bias: lower table Ext bias: higher table PT is in hooklying Belt around your bum and pts calfs Your hands between calfs and belt Traction by leaning back with BW **looking for a centralization in bane Flexion bias with chair Pt supine with calfs on chair on table Towels for padding between thighs and belt Belt is through the legs of the chair Hips flexed > 90 is good for pts with stenosis or degenerative changes Self Traction - lean on table - towel over door - between 2 tables/plinths

Describe performing lumbar PA glides to inc flexion/ext

For Flexion progression - pre position into prone with pillow under hips, upglides - progress to Qped on hands, round in the back - progress to childs pose For extension progression -Lie POE - progress to POHands - downglide

Describe performing a lateral shift correction

Goal is to centralize symptoms and restore posture - people often shifting away to reliev pressure on nerve root Manual correction in standing Stabilize at sh and lat girdle with therapist body Pull pelvis towards you Force is a transverse flide to realign Guided by symptom reduction or peripheralization Self-Correction HEP can be taught Place the shift against a wall to stabilize thorax Shift hips towards wall Walk legs towards the wall Encourage to maintain a neutral spine and avoid flex/rot

describe a postural analysis of the T-spine

In standing look for rib humps, scoliosis in sitting can have people do task simulations and see what posture is maintained here what is their general appearance and willingness to move? head position, cervical lordotic curve sh placement, scap positioning kyphosis ms girth and symmetry/changes in body contour (atrophy, spasm, swelling) look at the ribs and palpate for any displacements or localized pain; observe breathing pattern Palpate SP as well for any localized pain

Overview of the PPIVMs done at the SIJ

Inferoposterior glide Superoanterior glide Anteroposterior translation

Overview of treatment for thoracic zygapophyseal jt/facet dysfunction

Jt mob/manip to address hypomobility follow jt mob with ROM exercises - ROM exercises can be isolated to thoracic by placing feet on a stool scap/paraspinal and abdominal strengthening stretch shortened muscles posture education

describe the difference in direction of force when performing PA glides in the lumbar spine (central or unilateral) in normal L-spine segments vs. L5-S1

L5-S1: A/P with a caudal bias other segments: straight A/P

overview of some assessments we should make of the trunk muscles in a PT eval of LBP

MMT - hip and trunk LE functional strength assessment trunk strength and specific ms activation trunk endurance and control what is weak - stabilization what is tight - look at the hip ms and ROM as it has a direct effect on L-spine

for neuro exam of the upper thoracic we might just do a cervical/UE assessment, what does this look like

Myotome C1 cervical flexion C2 cervical ext C3 cervical lateral flexion C4 sh elevation C5 sh abduction C6 elbow flex, wrist ext C7 elbow ext, wrist flex C8 finger flexion - grip T1 finger adduction Dermatome C4 ridge of sh C5 lateral brachium C6 lateral antebrachium C7 middle finger C8 medial antebrachium T1 medial brachium T2 axilla Reflexes C5-6 biceps C6 brachioradialis C7 triceps

Describe performing a lumbar neuro exam components and procedures

Myotomes *hold for R 5 sec L2 hip flexion L3 knee extension L4 ankle DF L5 1st MTP ext S1 PF **If younger pt incorporate WB - SL Squats (5) w/ support from table L2/3 - Walk on heels, maintain form - L4/5 - Walk on toes S1 Dermatomes *done on SKIN *socks off *do they feel the same on both sides? eyes closed - could do both sides at same time to screen and one more specifically for investigation: sharp/dull potentiallu L2 medial thight L3 anterio medial distal thigh L4 medial first toe, anteromedial calf L5 lateral calf S1 lateral foot DTRs * test 3x on each side Patella: L3-4 Achilles: S1; can be done with plantar surface pf 5th met; pt a little tension on the foot into DF

overview of intervention ideas for someone who is limited in thoracic flexion

Normal jt play with upglide bias - F/u w/ ROM - progress this to pre position (heel sit with elbows by head), or lean forward to table with sheet wrapped around trunk ROM: heel sit and go through cat/cow Strengthening flexors - heel sit to lock lumbar, bands behind them

Describe Thoracic Compression

Not well researched in the T spine can be applied to the sh to see if this INC the sx

Describe Thoracic Distraction

Not well researched in the T-spine have pt cross hands over chest and lift up at elbows to see if this DEC sx

Describe thoracic PPIVMs - Flexion/Ext/Lateral flexion Pt position Therapist position Palpation What are you feeling for?

PPIVMS assesses segmental ROM Pt is sitting - have them clasp their hands behind their neck Palpate the interspinous space (stabilizes lower vertebrae acting as a pivot point), other arm around pts arms to help with movement *Add OP to clear joints Flexion: feel for opening of interspinous - Upper thoracic: perform cervical flexion (at T3/4 you can begin to place your arm over theirs and begin to guide them through motion) - Lower thoracic: instruct pt to assist you by tucking elbows into belly Extension: feel for closing of interspinous - Upper thoracic: cervical ext or bilateral arm flexion - Lower thoracic: arm cradle spts ables in assisting them in pointing elbows towards the ceiling --> Flexion/Extension can also be assessed in sidelying with their hands clasped behind their neck and elbows in contact with therapist's body Lateral Flexion: palpate LATERAL to ISP space; when SB away feel opening - go down one direction then down the other - use pts arms/thoracic cage to lateral flex away from you - look for symmetry in sides

MMT Obliques

Pt in supine Pt hands behind the head, stabilize the opposite leg, instruct pt to bring elbow to stabilizing hand - looking to clear the scap (5) if pt cannot - cross hands over chest, stabilize (4) if pt cannot - hands by side; pre position one reaching across (3) for gr 2 encourage to turn or roll to side and palpate with some movement contraction with no movement (1) no contraction no movement (0)

Describe a jt mob technique for a right posterior rotated innominate

Pt is SL, L-spine in a neutral position Bottom leg is flexed, top in neutral Pillow between knees Therapist contact over posterior iliac crest and top ASIS Force is passive anterior rotation of the innominate Progress: lie prone, bring leg into extension and provide an anterior force over the posterior superior iliac spine, if they can tolerate bring the other leg off the table

Jt mob technique to correct an anterior rotated innominate

Pt is SL, pillow between knee-ankles Can face away or towards L-spine is neutral Top hip is flex, bottom is ext Therapist contact over top ASIS and ischial tub Force is a passive posterior rotation of the innominate PROGRESS by bringing the pt hip into further flexion

MMT back extensors (erector spinae

Pt is lying prone Hands placed on back of neck, stabilize back of thighs, palpate for activity, pt should be able to bring xiphoid off table (5) if pt cannot then fold hands back behind L-spine, stabilize, and want to do same thing (4) if pt cannot do this, ext the arms by side and do same thing (3) If pt in this position is unablt to move whole chest off table (2) If pt has no movement, palpated contraction (1) no movement no contraction (0)

Describe a first rib assessment Positioning Method Assessing for...

Pt is seated C-spine including T1 is rotated AWAY from assessment side Therapist stabilizing pt head/neck Mobilizing: radial side of index finger is on the dorsal aspect of the first rib To find the rib: go lat to T1 & under the mastoid Rib is moved in a ventral (anterior) and slightly caudal/medial direction **COMPARE side-side In Supine Pt head is SB towards and rotated away from assessment side (relaxes scalene) Direction of treatment: to CL ASIS **stay out of supraclavicular fossa - sensitive this can be used as treatment

when would you be concerned with GI ulcer, peptic ulcer, cholecysttis related thoracic pain//important hx to take note of

T5-T9 chole: might get worse with fatty foods pain pattern may be aggravated with/without food want an abdominal x-ray or exam

Describe performing MWM to improve thoracic rotation and extension, what are the keys in performing this

Pt is sitting on treatment table (towards edge) Arms crossed over chest Therapist on side of limited rotation With heel of hand apply an UPGLIDE glide of the superior vertebra, with legs simultaneously apply traction force (you are straddling the table) Other arm is over pts arms to assist the motion in rotated towards you or extending Maintain these glides through full motion Should be pain free

Describe performing a general Rib assessment Position Method/Assessment

Pt is sitting, arms crossed over chest Palpate TP with one thumb and conjunct rib with the other Feel for movement at the costotransverse joint Inhalation: rib rotates posterior relative to TP Exhalation: rotates anterior Trunk flexion: rib rotates anterior, glides superior, posterior, and lateral Trunk extension: rib rotates posterior, glides inferior, anterior, medial Rotation: IL rib glides medial, CL distracts SB: IL rib moves into flexion pattern, CL rib into extension pattern

MMT Rectus abdominis

Pt is supine Hands behind head Ask pt to lift up Need to see the inferior angle of the scap from table (5) If he cannot clear - repeat movement with hands crossed over chest (4) if he cannot clear - repeat movement with arms down by side and try to come up as far as they can (3) If they cannot clear - then palpate, if contraction, head and neck come off but not inf angle of scap this would be a gr (2) If palpate and nothing moves but can feel a contraction (1) If nothing moves and no contraction (0)

Describe this PPIVM of the SIJ: Inferoposterior glide

Pt is supine with hips/knees flexed: pillow under knees Find landmarks in SL then roll to supine - with the ring and long finger on one hand palpate the sacral sulcus just medial to PSIS (monitors translation between the innominate bone and the sacrum) - index finger on lumbosacral junction (notes movement b/w pelvic girdle and L5 vertebrae) With heel of other hand palpate the IL ASIS and iliac crest Apply anterior rotation force to innominate to produce an inferoposterior glide at the SIJ This glide is associated with counternutation of the sacrum Note the quantity, direction of ease and end feel of motion

Describe this PPIVM of the SIJ: Superoanterior glide

Pt is supine with hips/knees flexed: pillow under knees Find landmarks in SL then roll to supine - with the ring and long finger on one hand palpate the sacral sulcus just medial to PSIS (monitors translation between the innominate bone and the sacrum) - index finger on lumbosacral junction notes movement b/w pelvic girdle and L5 vertebrae) With heel of other hand palpate the IL ASIS and iliac crest Apply posterior rotation force to innominate to produce an superoanterior glide at the SIJ **coming under the ASIS to do this This glide is associated with nutation of the sacrum Note the quantity, direction of ease and end feel of motion

in terms of low level abdominal control tests - how do you test pelvic control

Qped with levers of UE/LE invovles cocontraction/isometrics with a lever - how well can the pt control the neutral spine can use laser at the hip

clinical exam of someone with spinal stenosis

ROM: ext inc pain, improved with flexion imaging: dec in AP canal diameter; gold standard in dx posture: look for alterations jt play if hypo - there will be significant stiffness d/t those degen changes - sx may inc when done in neutral (**might want to put them into pre position of flexion with pillow under hips to help open things up) special tests: differentiate NC vs. VS

special tests for neural tension of the LB

SLR/cross SLR (well leg raise test) cross SLR: you lift the opp leg and it reproduces sx in the CL leg (indicates a worse prognosis) Femoral nerve tension test - resulting pain down the anterior part of the leg slump test

when doing ms energy techniques to fix an obliquity of the SIJ, what level of contraction are we looking for?

SUBMAX should not be anything crazy

an adolescent presents to your clinic with an acute inc in kyphosis that has gotten progressively worse in a matter of months with pain described int he lower thoracic region, what is your likely dx and what else should be assessed

Scheurmann's Disease this can (+/-) be associated with cord compression radiographic findings can confirm the dx posture ROM trunk and LE flexibility trunk extensor & abdominal mm strength and endurance breathing pattern

this is a structural deformity of the thoracic spine, defined by anterior wedging of at least 5deg or more adjacent thoracic vertebral bodies

Scheurmann's Disease - spinal osteochondritis (Juvenile Kyphosis) this is uneven growth that results in the signature "wedging" shape of the vertebrae causing kyphosis this is rare, seen in adolescents 11-17 yo thought to be genetic T7 and T10 most commonly affected

overview of intervention ideas for someone who is limited in thoracic rotation

T spine rotation exercises - either SL with foam roll b/w legs doing an open book - or in Qped doing a thread the needle Thoracic MWM - always an upglide - pt is seated towards the edge of the table Pre position into T rotation Regular jt play for rotation - this is the staggered finger glide, with rotation occurring towards the lower finger - follow this up with rotation ROM Exercises: chop, lift, paloff press (more isometric), lunge with rotation

when would you be concerned with cardiac related thoracic pain//important hx to take note of

T1-T5 distribution mid scap substernal neck and arm L > R CAD age pain on exertion PMH in clinic check vitals but also might want ECG, cardiax enzyme studies

when would you be concerned with pleural/pulmonary related thoracic pain//important hx to take note of

T1-T5 distribution usually sharp worse with inspiration prior pulmonary diagnosis smoker PE, Ca, TB, pneumonia would want to perform auscultory findings refer for chest x-ray

this is a sympathetic reaction to a hypomobile segment

T4 syndrome

Pt presents with pain, paresthesia, numbness in a glove like distribution Pt has local tenderness to the thoracic region, (+) neural tension tests, local segmental hypomobility, and grip weakness what dx might we be thinking? other diff dx?

T4 syndrome - might be one of the last things we think about Some diff dx: - TOS - carpal tunnel - cervical disc disease - neuro disease - Paget-Schroetter Syndrome (effort thrombosis of the axillary-subclavian) -Parsonage Turner Syndrome (acute brachial neuritis)

describe a thoracic specific myotome assessment

T7-T9 assess upper abdominals T10-T12 assess lower abdominals pt in supine ask them to lift their head up to initiate a crunch and look for deviation watch the umbilicus, deviation from midline may suggest weakness in the opposite quadrant

PT interventions for R Thoracic scoliosis

This pt is L SB and R rotated posture work **use a MIRROR for BIOFEEDBACK education - compliance with the brace breathing exercises - working on lateral expansion strengthening - ms on the convex side (R) (because they are lengthened and thus weakned) - lateral curl ups (physioball - SL on the concave side) - R side planks Rotation - they are rotated to the R, want to encourage L rotation - T spine rotation exercises --> half foam b/w legs in SL & do an "open book" w/ UE - or in Qped doing a thread the needle to also get more extension stretching - ms on the concave side (L) of the spine - lateral bend over foam roller, or physioball sports -encourage activity that will help them work on their posture - swimming is really beneficial Scroth method: incorporate traction for elongation of the trunk **the key is interventions have to be done regularly and adherence to the plan is key

Pt complains of thoracic pain that is localized and achy in nature, they claim they moved in a weird way getting out of bed the other day and they have had the same symptoms consistently since what is the most likely diagnosis? what is important to clinically assess?

Thoracic facet/zygapophyseal jt dysfunction - referral pain patterns are usually localized - not extending down the extremities etc. Limited T spine AROM & PROM - fairly specific restriction/direction - limitations/pain at end range limited/provocative PPIVMs & PAIVMs (+) palpatory findings - ms tenderness and guarding over the facet and the SP/supraspinous lig - if acute: ms guarding - chronic: inc in ms density, structure changes neuro exam normal - simply facet involvemet

what are the deep/local ms of the L-spine and how are they best trained

TrA multifidus --> connected via the thoracolumbar fascia so when you contract you get this corset action of stabilization these are tonic in nature, and endurance should be the focus CNS provides anticipatory feed forward mechanism to these ms - pelvic floor and diaphragm are also anticipatory

what is cauda equina important subjective questions level of referral

UMN problem - bowel/bladder changes - retention and inc frequency - spasticity - sensory loss in the saddle region *ask about bowel/bladder *ask about sensation emergent, needs to be seen by ER

Describe the prone instability test of the L-spine Indication Procedure Findings

Used to identify lumbar instability *this is the inability of the spinal stabilizing system *(passive and active structures) to maintain the intervertebral neutral zone - potentially causing deformity, neuro deficit, and pain *this is a good test for pts that have pain with prolonged postures, have + Gowers sign, hypermobility or instability in LB at any particular segments 1. Lay pt prone w/ lower extremities off the table and feet resting on floor 2. PT applies a PA spring glide to a segment of the L-spine with pt relaxed using a pisiform grip 3. If provocation of pain is reported the pt is requested to lift his or her legs off the floor contracting the erector spinae and hip ext 4. the PT reapplies a PA force at the symptomatic level + test is when there is pain with a PA glide at rest that is relieved with contraction of the erector spine and hip ext **this pts would benefit from stabilization

overview of special tests for the LB for non organic (psych) signs

Waddels - reproduces sx more caused by heightened awareness of the sensory system flip test - SLR & this reproduces pain - then have them sit up and straighten their leg - say you are looking at knee strength - this is the same amount of strain but there is inconsistency in the symptoms hoover test - do a small SLR of one leg with hand under the opposite foot - you should be able to feel pressure into that hand - aka them working and trying to lift their leg, otherwise they are not even tryign

Describe a ms energy technique to correct an up-slip of an innominate

With an upslip the hemipelvis is pushed upwards and the QL might be tight Pt is supine Problem leg is slightly abducted & IR Long axis distraction force placed through the leg Pt asked to perform a hip hike by performing a sub max contraction of the QL for 5-10s As pt relaxes, inc the distraction force & Reassess landmarks

why would an elevated 1st rib cause dysfunction

ant/mid scalenes attach to the first ribs the relation of these structures to the clavicle leads to possible compression of neurovasc structures if this rib is elevated it may cause some dysfcuntion

when looking at someones quality of motion with extension you notice a presentation of reverse lumbar lordosis, what is this

abs could be weak, trunk is weak - looking at motor control and stability of the pelvis don't make that assumption though, you should test this

how long do LBP sx have to be present to be considered acute vs. subacute vs. chronic what does this impact?

acute: sx < 1 mo subacute: sx 1-3 mo chronic: sx > 3 mo the more chronic the longer the recovery time/prognosis for chronic you need a more multi-medical approach yellow flags/psychosocial risk factors play a big role in the development of chronic LBP

overview of those that would benefit from stabilization options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

all of the above esp hypermob, spondylolysthesis

this is when you have a spinal arthropathy that attacks the ligaments and the body lays down fibrosis this is a cycle of inflammation - laying down fibrosis this over time leads to a fused spine

ankylosing spondylitis

pt is a 21 yo male who complains of LBP stiffness and pain that is worse in the AM and last > 30 min, he states this is been going on > 3mo most likely dx?

ankylosing spondylitis young men 3:1 to women 17-35 yo onset LBP stiffness followed by loss of motion onset in SI region pain is worse in the AM and lasts > 30 min and has been going on > 3 mo pain dec with exercises and inc with activity

overview of interventions for spondylosis

based on presentation pain control centralizaion/specific exercise traction mobility/manip conditioning/stabilization flexibility ROM posture aerobic program (basically everything depending on presentation)

how to test for UMN when thinking LB/LE symptoms

babinski clonus

interventions for disc dysfunction

based on symptoms pain control - modalities - MT grade 1/2 - protection (position relief corset) - STM for ms guarding centralization/specific exercises and traction - are they having referred pain? - traction for unloading - McKenzie ext exercise (repetitive ext) list correction if there is one Mob/Manip - if there is a mobility problem, restore ROM conditioning/stabilization - are they not moving well bc their ms are not moving well or controlling well - trunk stab, aerobic exericse

Describe the Thoracic quadrant test what is the indication/dx this is best used for? method results

beneficial in the evaluation of intervertebral narrowing/facet dysfunction Examiner stands behind the pt who is standing Place one hand on T spine as a pivot point and guide the pt to bend backwards and TOWARDS involved side Test is complete when pt has performed entire combined ROM or experiences reproduction of sx (aka ext and SB to involved side) + test = ROM limited by provocation of symptoms Radiation of pain may indicate a nerve root problem and local jt pain = facet dysfunction

if you are performing a central PA glide on the T-spine and the pt cannot tolerate this d/t pain what is your next option

bilateral PA glide - pointer and middle are on the TPs, pressure from opposite hand with the TP you are dispersing the force a bit more with a central PA glide you end up with compression below and gapping above

what is more concerning - loss of neural conduction uni or bilateral in terms of a red flag with LBP

bilateral is way more concerning esp if this is progressive (B) sciatica should raise questions - is this progressive too?

assessment for someone with suspect 1st rib dysfunction

can have generla pain in the sh region - cervico/thoracic/sh pain (+) first rib palpation & mobility tests (+) cervical rotation lateral flexion test (+) upper limb tension test tight scalenes

Describe T-spine PAIVMS to help facilitate flexion how to help progress this?

can inc grade bias force cranial can pre position 1. Pt is heel sitting on mat with elbows flexed, therapist is kneeling to the side, applies a central PA glide with a cranial bias - encourage pt to round out back as much as possible - do the upglide with the heel of one hand and stabilize the vertebra below with the other hand 2. Pt is sitting in chair leaning forward supporting their head on their arms on table, therapist stands behind using a sheet around the upper torso to stabilize the trunk (at level of vert treating) - Other hand applies a central PA glide with a cranial bias

Describe T spine PAIVMs to increase ext how can we progress this

can inc grade force should be in a caudal bias Can pre-position 1. Pt is heel sitting with arms extended in front of them, therapist kneels to side of them and applies a central PA with a caudal bias 2. Pt is prone supporting their head on folded arms, therapist is at pts head in a rocking motion uses one hand to extend the trunk by lifting the arms, other applies a central PA with a caudal bias *not done with people with neck issues

interventions of a hypermobile SIJ

control pain, correct obliquity, stabilization acute: dec pain, inflammation, and ms spasm, stabilization sub acute: correct obliquity, inc pain free ROM, strength, promote good posture and body mechanics, stabilization chronic: ergonomics, dynamic stabilization, self management

how do you test abdominal control on the table (other than general TrA and multifidus activation)

can use PBU to monitor pelvic neutral and document the amount of time the pt is able to maintain neutral while performing the exercise i.e. pt performed an unsupported dead bug 30sec to form fatigue document their ability to maintain a pelvic neutral and how long they can maintain in HL can do heel slides, marches, unsupported dead bugs find the form that is difficult for them and that is the one you will use for assessment and documentation

Pt reports falling on buttocks/missing the chair and has pain localized over the coccyx most likely dx? treatment?

coccyxadynia fx/sublux sitting postures are really painful here - so an ext posture to avoid the pain is common pain with palpation/mobs treatment - mob or protect: use seat cushions with cut outs - function/strength

what is central (neuropathic) LBP where is this pain coming from and how is it exacerbated?

comes from central processing/brain ongoing pain after healing, hyperalgesia, allodynia exacerbated by emotion, poor response to medication think yellow flags

pt comes into your clinic describing unrelenting LBP back pain that is worse at night, has been running a fever and has had significant wt loss over the last few years, pt is 60 yo what is the most likely dx

concern of CA based on hx, refer out *cluster 3 of 4 findings with this concern - age > 50 - prior hx of CA - unexplained wt loss - no relief with bed rest

Pt describes pain and tenderness localized to the joints of the anterior chest wall, pt describes intense pain with deep breathing and horizontal abd/adducation what dx are we thinking of what PT interventions?

costochondritis - pain and inflammation of the costochondral junctions of the ribs/sternocostal joints at multiple levels usually PT - manual therapy (look at T-spine and ribs for mobility) - breathing exercises - IASTM - taping

what is the space between the 1st rib and the clavicle called in which many structures between this can become compressed

costoclavicular space this compression can lead to TOS

clinical exam for ankylosing spondylitis

dec ROM general hypomob imaging late stage effects - mobility, gait, breathing (rib cage), and morbidity

what jt mobs do we want to take a look at if we suspect a hypomobile SIJ

definitely looking at the SIJ yes but also the LB - if mobs in the LB prove to be provocative or impaired then you need to treat the LB prior to treating the SIJ

overview of interventions for spondylolysis/spondylolisthesis

depends on presentaiton pain contol - rest, posture centralization/specific exercise and traction - if radiating sx we want to centralize - this pt will experience it with flexion based exercises mobility/manipulation - may have limited mob above/below the hypermob condition/stabilization restore posture and quality ROM **overall goal - usually in a more ant pelvic tilt, we want to get them out of ext and into more neutral to restore posture education/coach too - teach them to move through and have good control, not sheering at that level at all

describe the bike test - what is this used to differentiate

differs PVD from neurogenic claudication walk on treadmill until onset of pain then bike until onset of pain compare these amounts of time **if they can bike without pain this is NEUROGENIC - aka is better with flexion

overview of those who would benefit from specific exercise options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

disc dysfcuntion - better with ext stenosis/DJD - better with flex spondylolisthesis - better with flex ankylosing spondylitis - ext exercise; since it will begin to fuse into flexion

overview of who whould benefit from traction options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

disc dysfucntion stenosis/DJD facet dysfunciton

which of these is flexion AGGRAVATING for facet dysfucntion disc dysfunction spinal stenosis spondylolisthesis

disc dysfucntion the rest flexion would relieve

in which of these when first restoring ROM/mobility do you want to start in a non WB position options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

disc dysfunciton we want to relieve this compression of the discs child pose trunk rotation KTC cat/camel

30 yo Pt complains of LBP which began following a heavy lift with a twist at the gym, pain inc with flexion and sitting, pain dec by sleeping in fowler and walking short distances what dx are we thinking

disc dysfunction 25-40yo disc herniation or older degenerative trauma: high load/lift and twist excessive repetitive motion insidious - could be prolonged poor positioning inc with flexion/sitting, cough/sneeze dec pain with slieeping in fowlers (spine in neutral), walking short distances (lubricating the system and getting some normal motion)

someone with lumbar disc dysfunciton would have inc pain with (flexion vs. extension) compared to someone with facet dysfunciton who would have inc pain with (flexion vs. extension)

disc dysfunction: inc with flexion/sitting facet dysfcuntions: inc with extension, prolonged standing positions/CLOSING of facet patterns

Describe observing the ROM of the thoracic spine

do AROM with OP at end range if need to stress structures have pt cross arms over chest and OP is done at the shoulders - Flexion - Extension: hinge at the hip and ext back - Lateral flexion Rotation: to isolate thoracic rotation go POE on knees, keep one hand on head and one on table and rotate to either side, can place an inclinometer b/w scap Can also assess rib motion - pump handle, bucket handle, caliper - one hand on chest other on stomach: want both to come out - bucket handle: hands lat to ribs - feel for pump handle anterior to sup ribs - palpate b/w ribs as you SB

individuals who display divergent breathing patterns that have breathing problems that cannot be attributed to a specific medical diagnosis such as asthma is called

dysfunctional breathing

what education should be provided for someone with OP who may or may not have had a VCF

educate on safe movement/spine sparing strategies educate on body mechanics, avoid flexion//end range movements (bending, twisting - this movement causes fxs) attention to posture during movement to protect the spine

clinical exam findings with pain with normal mobility of the SIJ

everything is negative when you look at the SIJ leg length/trendelenburg ms imbalance look down the kinetic chain for problems

T/F we would expect someone with disc dysfucntion to be aggravated by ext movement

false pain inc with flexion/sitting

Norms for thoracic flex, ext, SB, rot ROM

flex: 20-45 ext: 15-20 Rot: 35-50 SB: 25-45

When performing the gilet test when the pt is asked to flex their leg what movement should we feel at the PSIS? with ext?

flex: posterior rotation, inferior displacement ext: anterior rotation, superior displacement

options for higher level endurance and control assessment abdominals/trunk

for a more athletic population DL lower and isometric hold lateral side plank and bridging (DL or SL) can document isometric hold or repetitions whichever is harder for the pt

what position does the spine fuse in in ankylosing spondylitis what does this impact

fuses in a flexed position and this effects the resp system some morbidity later on related to pulmonary issues important to work on breathing, some cardiopulm interventions

describe the gross motor muscles for force closure of the SIJ

glut max and CL lats glut med and CL adductors these all cross over the SIJ and compress

For prone scap exercises - Is/Ys/Ts how might you progress this

go from on table to on physioball to activate more of the back ext and abdominals add weight

what is key to dx of SIJ/pelvic girdle pain

history and R/O LBP reproduction of sx with 3 of 5 provocation tests is huge - need to determine this pain is in fact coming from the SIJ

which of these may you see the pain presentation begin to switch sides options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

hypermob

a young female pt describes that once a month she experiences pain in the pubic symphysis/groin area, but this can sometimes switch sides, pain inc with unilat WB and wt shift most likely dx? other exam components to take a look at?

hypermobile SIJ Pain location: buttocks/tight/pubic symphysis/groin **pain location can switch sides (+/-) clicking/popping (if not with pain then not a problem) Pain inc with unilateral WB & wt shift Positional faults: (+/-) out of alignment (+/-) gowers sign (motor control issue) Poor control w/ wt shift (trendelenburg) Poor isolation & endurance of stabilizing ms (multifidus, TrA) Antalgic gait (poor hip control as they walk) Change in dynamic and static palpatory tests (an inconsistency of findings) inc arthrokinematic glides (+) active SLR (this is the only provocation test used)

someone presents to clinic with LBP that often switches sides, pt reports being unstable with an inc in pain with walking, sit - stands, and prolonged positions most likley dx? other clinical exam?

hypermobility +/- list gowers sign catch pain aberrant motion through motion reverse lumbar lordosis + sheer + PA protective spasms poor ms patterning dec tone

when would you be concerned with intercostal neuritis related thoracic pain//important hx to take note of

hypersensitive/burning sensation without the rash formation as seen in herpes zoster hx of osteophytes common

Pt describes of pain directly over the SIJ, pain inc with walking/stairs/rolling/sit to stand, pt demonstrates dec/fixed mobility with dynamic testing most likely SIJ dx? other subjective/exam findings

hypomobile Looking for a trauma where there was a change in the transfer of weight/shearing For insidious look for positional stressor, might be associated with how sitting and standing all the time Pain over SI/into buttocks or posterior thigh Pain usually right over SIJ (**if going into knee take a look at LB) Pain inc with WEIGHT shift Neg LB scan Hip ROM WNL Palpatory obliquity is fixed - does not change from supine to standing Dex/fixed mobility with dynamic testing Dec arthrokinematic glides (jt mob) **but any jt mob on the LB that reproduces sx you need to treat LB) Provocation tests (+) Look for: associated ms length and leg length (fixed/apparent)

overview of potential classificaitons of pelvic girdle dysfunction

hypomobile hypermobile pain with normal mobility pelvic girdle fx coccyxadynia

if you determine someone has lumbar disc dysfunciton you have to determine if that is d/t what 2 types of presentations

hypomobility - posture - quality of ROM hypermobiilty - (+) sheer - poor motor control

Describe the ms energy technique to correct an anterior rotated innominate

if innom is rotated anterior - HF is tight, strengthent the HS Pt is supine Unaffected leg off of plinth to stabilize that innominate Affected leg placed in hip flexion to induce posterior rotation of innominante Pt asked to do a submax contraction of the HS to produce a posterior rotation moment arm - can have them push into sh to do this; hold 5sec PROGRESS by moving hip further into flexion with each rep; repeating this 2-5x Then perform a bridge to neutralize pelvis Reassess by checking landmarks - is ASIS level; if not successful then do a Jt mob HEP: - same position, have them bring hand under knee - or push into door with other leg ext **educate on SUBMAX CONTRACTION

Describe the ms energy technique to fix a posterior rotated innominate

if innom is rotated posterior - HS is tight, strengthen the HF Pt is supine Unaffected leg in full HF stabilize that innominate Affected leg placed in extension off plinth to induce anterior rotation on the innominate Pt asked to do a submax contraction of the HF to produce an anterior rotation moment arm - can have them push into sh to do this; hold 5sec PROGRESS by moving hip further into extension with each rep; repeating this 2-5x Then perform a bridge to neutralize pelvis Reassess by checking landmarks - is ASIS level; if not successful then do a Jt mob HEP: Lie half on plinth, problem leg should be ext across the plinth, opposite leg on the ground Or teach someone at home to do it **educate on SUBMAX CONTRACTION

how would you treat a pt that demonstrates neural sx (radiculopathy/sciatica; loss of sensation, strength, hyporeflexia) that is progressive in nature

if it is progressive this is a RED FLAG

describe performing the modified thomas test, why would you do this

if someone demonstrates postural abnormalities that could be d/t tight HF potentially (anterior pelvic tilt) this test can assess for iliopsoas and RF tightness, as well as TFL/ITB tightness pt sits on edge of table and asked to bring their knee to chest and lie in supine while holding the uninvolved knee to chest the pt releases the involved leg and lowers it over the end of the table towards the floor therpaist observes the position of the hip and knee inc HF = iliopsoas tight knee ext: RF tight Hip abduction or IR: TFL or ITB normal range knee flexion: 70-90deg

with SIJ why are we concerned about leg length

if there are true discrepancies there will be shearing present if there are apparent discrepancies this could be indicative of an obliquity or stuck of pelvis positioning

if you suspect rib dysfunction as the dx, when would you NOT want to do rib springing as an assessment

if you suspect a fx - this is contraindicated!

how is a thoracic VCF diagnosed

imaging - radiograph - MRI/CT - dual energy x-absorptiometry should be performed soon after the dx of VCF to evaluate for OP and determine seveirty

what hx may raise concern of infection

immunosuppressed fever hx of IV drug use recent UTI celluitis penumonia surgery procedure - infection can go wherever it wants

overview of interventions for rib fx

incentive spirometer breathing exercises, splinting if in significant pain may need rib protection

describe the roles of the different tonic stbailizer ms of the SIJ

levator ani and multifidus - direct fibers controlling sacral position TrA and pelvic floor - both inc intra abdominal pressure - corset action of TrA - this is indirect force closure, does not directly attach

what are the most common causes of SIJ pain

lumbar and hip these both play a role in the sacrum - need to make sure these are not the sources of pain can try to treat one and see if this helps the pain it is important to treat and R/O lumbar prior to treating the SIJ

Pt 25 yo comes in with sharp localized LBP, he sometimes feels stuck and the pain increases with extension and prolonged standing what dx are we thinks what should we clinically assess

lumbar facet dysfunction 20-40 yo common/all ages quck twist sharp localized pain - somatic referral can feel stuck, pain worse at times then dec looking for pain with CLOSING of the facets inc with ext pattern,quadrant, prolonged standing positions dec with sitting/flexion/movement +/- list paravertebral tenderness - some guarding of ms with palpation (+) quadrant/compensated movements --> if they go into extension and it hurts too much they might move away from it to keep the facet open (+) unilateral PPIVMs/PAIVMs

when would you be concerned with herpes zoster related thoracic pain//important hx to take note of

might have a unilateral dermaotmal pattern (rash) HTN/burning sensaiton vesicle formation may be recurrent exacerbation with stress

overview of intervention for 1st rib dysfcuntions

mob of 1st rib & T-spine (probably upper) stretch tight mm - scalenes: sitting on towel/band and bringing it over the sh girdle & SB away - stretch pecs to correct posture if tight strengthen scap mm - traps - serratus - Is, Ys, Ts correct bretahing patterns - reduce apical breathing, emphasis on diaphragmatic breathing

how would you treat someone who has facet dysfunction d/t hyper mobility

mobility/manip to restore ROM as needed conditioning/stbailization - prevention - trunk stabilization

This is a tool that can be used for T-spein for joint mobilization, bilateral PA glides

mobilization wedge should be pointed away from pts head can palpation the SP in the hole

overview of interventions for rib dysfunction

mobilize the rib and adjacent hypomobile segments - fix the facets first, if they still have issues address the ribs ms energy work on breathing patterns strengthening posture education, incorporate breathing mechanics STM taping helps to restore posture or along the rib can be helpful - not a lot of evidence but case-case basis

if palpatory obliquities are consistent from supine to standing in the SIJ what does this most likely indicate

more likely hypomobility, jt dysfunction representing this obliquity

rib dysfunction should be differentiated from which diagnosis what can be key in this differentiation

must differentiate rib from facet dysfunciton in palpation of the ribs feel to see if they are smooth - with rib dysfunciton there may be post/ant rotation and you will feel prominences or concavities

Which of these would we expect to be normal with a zygapophyseal/facet jt dysfunciton neuro exam ROM jt play palpation

neuro exam

difference between neurogenic and vascular claudication

neurogenic: intermittent pressure on SC - when they go into a bit more ext (but gets better with flexion) --> spinal stenosis vascular claudication - a result of insufficient blood supply d/t PVD - seen with activity thus in the bike test, someone with neurogenic claudication would see a good change in using the bike compared to walking

in a breathing assessment you note the pt has inwards motion with inhalation and outwards with exhalation - is this normal?

no this is paradoxical breathing - should be the other way around

overview of intervention ideas to improve thoracic extension

normal jt play with a downglide bias - progress to a pre position (heel sit with arms ext), or lie prone w/ head on hands and we bring them into ext MWM: always an upglide, pt is seated very close to the edge of the table AROM - seated, ext over the back of the chair Strengthening - rowing - focusing on retracting/adducting scaps Stretch - supine, HL, foam roll behind the T-spine - or move through this as an exercise

describe the findings/results of provocation testing of the T-spine

not too much research on these compression - through sh girdle, does this inc sx distraction - unload from crossed elbows, does this dec sx quadrant: ext/SB/rot would provoke sx

what are key components of an SIJ examination

observation ROM palpation - in WB and non WB - kinetic tests/dynamic palpation **guides for treatment ms length - helps to find confounding factors leg length measurements provocation tests - confirms SIJ jt mobilizaiton

what assessments should be performed in someone with scoliosis

often they have no c/o pain or functional limitations in adolescents except for the more severe curves posture assessment is significant Special: Adam's test: bends forward and can see asymmetry of the ribs that does not correct itself with FB Soliometer is used to measure the angle ROM Strength Resp function - are they getting good lateral expansion in the lower ribs in particular Jt play Flexibility Leg length

Thoracolumbar flexion/extension ROM

one inclinometer over S2 (b/w PSIS) other over T1 pt flexes forward take the difference between the two degrees to understand the thoracolumabr flexion can also measure flexion with a tape measure with hand reach ext: cross arms and ext

when would you be concerned with esophageal related thoracic pain//important hx to take note of

pain in midline of the chest radiates to center back substernal may or may not have dysphagia hot/cold food may trigger pain would want a barium swallow endoscopy done

when would pain inc with thoracic VCF

pain inc with standing walking with thoracic ROM flexion is worst

this is when there is pain in the SIJ but it is not coming from the SIJ, there is nothign wrong with the SIJ there is instead a problem further down the kinetic chain

pain with normal mobility could be d/t overuse articular and myofascial structures or dysfunciton somewhere else - biomechanical

when would you be concerned with anxiety related thoracic pain//important hx to take note of

pain/quick stabbing or heavy constant pain over the heart hx of depression, may appear anxious important to r/o cardiac and GI psych eval

what component of the exam of the SIJ will help to guide us in our treatment decision

palpation

how would you treat someone who has facet dysfunction d/t hypomobility

posture work quality ROM manip Gr 1-2: relieve pain 3-4: restore mobility 5: HVT education pain control - modalities - MT Gr 1-2 - protection - STM for ms guarding Mobility/manip **restore ROM

what clinical exam should be performed on suspected disc dysfunction

posture +/- list (could be how they are relieving their sx) splinting if cough inc their pain? ROM - limited flexion & ext - (+) repeated motions; flexion worse ext better - (+) stretch quadrant (flex/SB) Special tests - neuro exam for radiculopathy - (+) SLR - (+) sheer/ (+) PA (pain)

how can you check to see if your 1st rib mobs have made an impact on a patient

perform the cervical rotation lateral flexion to see if they have an improved ROM

Overview of interventions for thoracic disc herniation

posture correction scap/back strengthening jt mob ROM stretching HEP if they have neuro involvement they would require some surgery

Describe an active SLR test Positioning Method Results

pt is supine Therapist stands by the bed Instruct pt to raise their leg (only doing so about 20 cm) Observe ease of ability to do this Note any compensatory motions of the trunk If unable to do this or significant pain then try... Form closure: manually compress through the innominates and ask pt to repeat the test - if better, they would benefit from an SIJ brace Force closure: ask the pt to flex and rotate the trunk towards the raised leg, manual resistance to the shoulder - if better they would benefit from stabilization exercises

describe procedure of performing mobilization with movement in general

pt should be in wt bearing position apply glide to selected vertebral level and mantain throughout the motion have pt move actively into the previously painful range if pain free apply OP at end ROM maintain the glide until pt returns to neutral repeat 6x assess effectiveness of treatment if painful check hand placement, and or treatment level try a different glide to achieve pain free ROM only proceed when able to relieve symptoms

T4 syndrome management

remember this is a sympathetic repsonse to a HYPOMOBILE segment mobilization/manipulation of the involved segment exercise progression if not improving - refer back to clinician for more workup

which repetitive motion will help centralize sx of disc dysfunction

repetitive extension (flexion will inc their pain)

overview of intervention for rib stress injury

rest followed by gradual return to activity over 3-6 weeks taping STM spine mobilization biomechanical assessment of the rowing/rotational athletic movement consider all intrinsic and extrinsic risk factors e.g. reduced bone density, amenorrhea in female athletes, training errors, etc.

A pt who is a competitive rower explains that he has been experiencing pain with rowing and breathing, he notes that at one of his ribs he experiences pain just from touching it what diagnosis are you anticipating how would you continue the assessment based on the hx

rib stress injury this is common in rowers as well as any rotational athlete in ribs 5-9 d/t repeated high energy ms contractions palpation - (+) point tenderness over the stress rxn on the rib imaging potentially

When performing T-spine PAIVMS to facilitate rotation, fingers are on alternate TP levels, but which way is the rotation occurring in

rotation occurs to the side of the lowest finger

Pt reports to PT following a trauma to the SIJ, they heard a pop, we palpate the sacrum and notice that it is stuck in a position what is this called

sacrum dysfunction can be d/t trauma, lift, twist Positional fault of the sacrum associating with the innominate We can palpate the ligaments, the difference feeling of the sides (Can look at prominence as well as reproducing any symptoms with palpation) if sacrum is stuck in a certain position, if you bring that person into a certain position the obliquity will become more apparent (i.e. with counter nutation seeing the effects of doing a prone push up) can be stuck in nutation or counter nutation

for ROM exercises to the T-spine how can you isolate this to the T-spine specifically

seated in chair, place feet on a stool

Describe T-spine PAIVMs treatment to help facilitate rotation

similar techinique to PA glides, but fingers are on ALTERNATE levels TP rotation occurs to the side of the lowest finger motion is straight down

a rib springing assessment is CI in who

someone with osteoporosis or osteopenia & suspected rib fx

this is your progression of degenerative changes - when it starts to become worse and there are more changes that we need to be aware of that will affect the prognosis

spinal stenosis this can be anything that narrows the SC or IVC - disc - tumor - hypertrophy

pt is 75 with a hx of CLBP and no reporting specific incident of cause, radiculopathy, pain is worse with walking, standing, extension; better with sitting, rest, stooped over most likely dx

spinal stenosis with the radiculopathy you want to see if it is bilateral - it may be if there is SC involvement - more of a red flag if bilateral AND progressive: you should ask about cauda equina sx most likely worse with ext because this is when you close on the IVC/SC

anterior slippage of the vertebra spondylosis spondylolysis spondylolisthesis

spondylolisthesis

which may present with excessive lordosis and maybe a lumbosacral step options (lumbar) disc dysfunciton stenosis/DJD spondylolisthesis facet dysfunciton hypermobility ankylosing spondylitis

spondylolisthesis

this is a defect in the aprs articularis, a stress fx over time of the pars articularis spondylosis spondylolysis spondylolisthesis

spondylolysis

in terms of low level abdominal control tests - how can you test the TrA and multifidus activation

supine HL hold contraction 10sx10 roll thumbs over ASIS to feel for contraction "pull belly button in towards spine" stomach should NOT be pressing up/out

Overview of the clinical predictor rules of someone who would benefit from HVT symptoms < (duration) segmental (hypo/hypermobility) Hip IR > ____ no symptoms (locaiton) FABQ work scale < ___

symptoms < 16 days segmental hypomobility Hip IR > 35deg no symptoms (distal to knee) FABQ work scale < 19

pt is a 16 yo gymnast that has LBP that she claims inc with jumping (landing), running, twisting, and extension motions most likely dx other clinical exam components

spondylolysis/spondylolisthesis adolescents that do a lot of ext based exercises is most common (also volleyball, swimming) with this can see radiating pain, (B) pain, dull pain in the back - very variable no clear pattern with this better with flexion biased motions Posture - excess lordosis -lumbosacral step (when they arch their back into ext you see an area where they fold) Jt signs **avoid PA for confirmation - tends to be provocative no matter what so will not give you additional info - if you suspect an underlying fx there is no need to go pushing on them can assess PPIVMs **(+) SHEER there will be a lot more motion at that level ms imblance: HF tightness/ab weakness

a normal change in the body d/t aging process spondylosis spondylolysis spondylolisthesis

spondylosis

this occurs as a result of new bone formation in areas where the annular ligamanet is stressed

spondylosis (DJD & OA) - normal process of aging

60 yo pt presents with insidious LBP and mostly general complaints of stiffness/soreness, it gets worse in the morning but better with a hot shower and movement m0st likely dx and other components of examination

spondylosis: DJD or OA ROM: loss of ext, IL SB and rot are the greatest effected (+) joint signs at MULTIPLE LEVELS (feels very stiff)

describe the lumbar lock rotation test what is the purpose and how is this done

start heel sitting with elbows under sh keep one forearm grounded and rotate the opposite UE Inclinometer can be placed on the spine in the interspinous space at the T1-T2 level mean ROM: 40.8 +/- 10.7

when doing ROM exercises to improve ROM in lumbar disc dysfunction, what position do we want the pt to be in to start?

start in non WB positions prior to WB ROM so there is not as much compression through the disc child pose trunk rotation single KTC double KTC pelvic tilt (supine just to get the back moving) - progress to sitting on ball for WB HS and HF stretch Cat camel

which grade of spondylolisthesis would you begin to see SC symptoms grades 1/2 grades 3/4 grade 5

start to be seen at grades 3/4 because SC begins to narrow (at grades 1/2 the IVC begins to narrow)

prolonged use of what drug may make you more concerned for fx?

steroids/corticosteroids

S&S of a posterior lateral ruptured disc with a radiculopathy at disc levels L4-L5 strength sensation reflexes pain

strength: ext of big toe sensation: big toe reflexes: none pain: back of thigh, lateral calf

S&S of a posterior lateral ruptured disc with a radiculopathy at disc levels L5-S1 strength sensation reflexes pain

strength: gastroc PF sensation: lateral foot and heel reflexes: achilles pain: back of thigh and calf

S&S of a posterior lateral ruptured disc with a radiculopathy at disc levels L3-L4 strength sensation reflexes pain

strength: quads, tib ant sensation: med knee, shin reflexes: knee jerk pain: ant thigh

in someone with 1st rib dysfunction which ms should we stretch and which should we strengthen scalenes traps serratus pecs

stretch - scalenes - pecs strengthen - serratus - traps

for PT interventions for scoliosis we should be stretching the muscles on the (concave/vex) side and strengthening on the (concave/vex)

stretch the concave side strengthen the convex side

Describe performing slump test purpose positioning method results

testing mobility of the pain sensitive structures within vertebral canal and intervertebral foramina by placing them into stretch (dura, nerve root sleeves, ventral nerve roots, blood vessels in epidural space) *doing one movement at a time to see if any sx present 1. Pt is seated w/ hands behind back, pt slumps forward with flexion of spine and shoulder sagging, PT holds head in neutral 2. PT flexes head and applies overpressure to maintain 3. PT DF the foot 4. PT slowly ext the knee and measure how much able to get 5. Test is repeated to see if sx present + if symptoms are produced at any point in the test neck flexion is released and/or foot is PF to see if sx subside - if they do immediately this is neural stress **HS tightness pain would be unchanged with the release of neck flexion of PF --> a + test detects adverse nerve root tension caused by spinal stenosis, extraforaminal lateral disk herniation, disk sequestration, or nerve root adhesions

if someone has a R thoracic scolioses, what is the configuration of the curvature

the curve is named based on the side of convexity the convex side of the curve will be on the R side thus the pt appears to the L SB and R rotated ribs move with the vertebrae - will be pushed posteriorly on the side of convexity

if palpatory obliquities are inconsistent from supine to standing in the SIJ what does this most likely indicate

the pt is moving too much and are hypermobile

if someone has a R list/shift, how are they phsyically presentign

their shoulders are pushed laterally over their waist

interventions for someone with lumbar hypermobility

therex - co contraction - trunk stability - functional strengthening body mechanics education pain control centralization/specific exericse and traction mob/manip conditioning/stabilization

what are the global muscles of the L-spine and what is their role

these are the ms that actually move the trunk - tightness in these ms can alter posture and positioning Psoas QL HS

L-spine posture assessment

think of what might be tight/weak that is impacting their presentation look for a list/shift **named based on what side the sh are leaning towards when looking at the posture think about what else you should be looking at based on how the posture is presenting - i.e. ms length if you find someone is tuck in this position you want to correct this prior to working on their ROM

Pt describes a sharp pain in chest that is aggravated with breathing, coughing, sneezing, laughing, and trunk movement what is the thought for possible dx what else should be assessed to confirm

thinking rib dysfunction - should be differentiated from facet dysfcuntion check BREATHING MECHANICS - look for both that pump handle and bucket handle motion - in the area of dysfcuntion it might not feel like they are moving as much (+) palpatory findings - looks for displacement or changes in positioning of the ribs jt play assessment: (+) ribs springing do not do rib springing if suspect fx

Pt presents with variable and dull pain on the thoracic spine, this sometimes refers to the abdomin or inguinal areas Pt has some radiculopathy sx of shooting pains down the legs what are you beginning to think as a dx what else should you assess

thinking thoracic disc, however these are RARE may be associated with a loss of sensation in the affected dermatome posture assessment limited AROM repeated movements (+), may make pain worse compression/distraction (+) (+) neuro exam

Describe a shot gun technique

this is a nonspecific general ms energy technique To produce a firing of all the ms around the pelvis, not aimed at any specific obliquity **works well for a pubic symphysis subluxation; used a lot with pregnant women or immediately postpartum Therapist resist adduction of hips then abduction for 5-10 seconds 5x on each side Self-treat/HEP - seated, push into themselves or pillow - can be done at desk, etc.

what is a hi lo assessment

this is to assess breathing one hand on chest one on upper abdomen looking for - paradoxical - upper chest dominant (some 1st rib concerns if using a lot of accessory ms) - diaphragm dominant

when there is pain in the l-spine how does that impact the musculature firing

this normally inhibits the local stabilizing muscles and global muscles become more excitatory need to retrain the feed forward mechanism for the local stabilizing ms

describe the 90/90 test, why would you do this

this test assesses HS length do this if maybe there are some postural impairments that may be subjected to dec HS length (posterior pelvic tilt) pt is positioned in supine, hip and knee both at 90deg passively ext the knee with CL leg in ext knee angle is then measured (+) = inability to ext knee 20deg within full knee extension

what tests can be incorporated to assess flexibility/MS length for the LB

thomas test modified thomas test obers elys/prone knee bend SLR or 90 90 **these all have connections to the back

when would you be concerned with renal organ disease (pyelonephritis, nephrolithiasis) related thoracic pain//important hx to take note of

thoracolumbar region T9-L2 any urinary sx/fever?

what would raise concern for a pelvic girdle fx?

trauma +/- radiographs understand the MOI - what ha sben done, any imaging pain/unable to WB, significant pain where is the pain? pt may have point tenderness over the bony prominences treatment in outpt following external fixator: asses for hypo/hyper mobility

what hx might we look for if we suspect first rib dysfunction

trauma repetitive overuse of UE poor breathing pattern/upper chest breather - using the accessory ms all the time tight/hypertrophy of scalene prone rotation sleeper leading to tightness of scalenes TOS postural - shoulders pretty elevated

T/F radiculopathy may be present with thoracic disc herniation and may benefit from centralization of symptoms

true

T/F someone with disc dysfunciton/herniation may have a + sheer indicating hypermobility

true

T/F a disc herniation can cause cauda equina syndrome or bilateral symptoms

true a psoterior central herniation if severe enough could lead to this

other than the cervical rotation lateral flexion test, what other special test can we do if we suspect an elevated first rib

upper limb tension test

Describe the shear test for the lumbar spine purpose positioning results

used to assess for hypermobility Pt is SL facing therapist Hips flexed to 60deg with knees also flexed Palpate b/w two SP of the segment being tested Remaining part of palpaitng hand stabilizes the vertebra above the level tested Force form therapists body is directed anteriorly and posteriorly through the pt's thighs

Describe what Waddell's Signs are indication what are they

used to determine if pts have non-organic causes of LBP, which may be related to Malingering, Manchausen's Syndrome of psychosomatic disorders Malingering: fabricating pain for secondary gain (i.e. workman's comp, seeking medication, seek sympathy) Manchausen's Syndrome: Intentionally producing clinically convincing evidence to receive unnecessary medical treatment Psychosomatic: pain is psychological or emotional, often pt is unaware that pain not d/t physical cause 3 signs or > is (+) & significant 1. Tenderness: not related to a aprticular skeletal or NM structure; may be either superficial or nonanaomtic - Superficial: skin in lumbar region is tender to light pinch over a wide area not associated with ramus distribution - Nonanatomic: deep tenderness, which is not localized to one structure, felt over a wide area and ext to t-spine, sacrum, or pelvis 2. Simulation tests: gives the impression a particular test is being carried out when it is not - Axial loading: LBP reported when examiner presses down on the top of the pts head; neck pain is common and should not be considered indicative of nonorganic sign - Rotation: back pain reported when sh and pelvis are passively rotated in the same plane as the pt stands relaxed with feet together (this is not rotating at the back and should not have pain) 3. Distraction tests: finding is checked while pts attention is distracted; nonorganic sign if the pt sx disappear when pt is distracted - SLR: examiner lifts pt foot as when testing the plantar reflex in the sitting position; nonorganic if leg is lifted higher than when tested in supine 4. Regional Disturances: dysfunction involving a widespread region of body parts that cannot be explained based on anatomy, care to take in distinguishing from multiple nerve root involvement - Weakness: demonstrated on testing by "giving way" of many ms groups that cannot be explained by localized neuro deficits - Sensory: diminished sensation to light touch, pinprick, or other neuro tests fitting a stocking rather than a dermatomal pattern 5. Overreaction: may take the form of disproportionate verbalization, facial expression, ms tension, and tremor, collapsing, sweating; judgments should be made with cuation **however this is old and we have learned a lot more about pain so should be taken with a grain of salt

who should you be concerned as having risk of vertebral body compression fractures?

very common in older women with OP people who have had one OP VCF are at a 5x risk of sustaining a second need to modify treatment to minimize the risk of this lower thoracic/upper lumbar area is most common osteopenia, osteoporosis older age > 50 hx of VCFs or falls inactivity/does not exercise regularly prolonged use of corticosteroids weight < 117 lbs/BMI < 22 female consumption of > 2 alcoholic drinks/day in women and > 3/day in men smoking vit D deficiency depression **because these are all risk of OP too

if someone has a VCF they most likely have corresponding osteoporosis - what should you incorporate with rehab and what are some of the goals of rehab with this

want to dec their pain and get them to return to activity quicker prevent further loss of bone density - wtbearing aerobics (walking program) and resistance as able posture, body mechanics (back ext strength) caution with flexion and extension; avoid extreme ROM - stretch ms restricting optimal posture - train back ext to improve endurance dec fall risk - balance program

PT for someone with ankylosing spondylitis (in the remission stage bc active stage is CI)

want to get them to have as much motion and maintain as much as possible posture - promote ext sleeping ext exercise - not good for biking - want swimming backstroke maybe jt mob only early on, CI in late stage bamboo spine aerobic exericse

Overview of treatment concepts to keep in mind with mobilization with movement techniques

we are applying SNAGS - sustained natural apophyseal natural glides - facet mobs along the movement planes, pt then actively moves through the restricted range, OP applied for max benefits Concepts: 1. All spinal MWM are performed in a WB position 2. Must be pain-free ROM 3. Poor handling can cause pain (take up slack prior to mobilization) 4. Apply overpressure 5. Know your spinal facet planes

Describe a rib spring assessment Positioning Method Feeling for? who is this CI in?

we are not doing this on an older person/OP Stand on side opposite of assessment Palpate lateral to TP - where the rib starts to angle/turn Pressure is in the A/P direction, translate anterior Can use finger of lateral border of hand angled at 45deg If they have pain try stabilizing the T-spine and see if it goes away - this could indicate a T-spine rather than rib problem (for a rib/T-spine differentiation) When using for treatment we can do this mobs with DBE, oscillations, etc.

what is important to note about the fact that the multifidus attaches to the long SI lig in terms of considerations for interventions

we cannot change the ligaments but we can strengthen the multifidus to help improve stability

what is our role in the othotic intervention for scoliosis

we play a big part in education make sure the pt is adhering to the brace, encourage compliance and monitor for skin reaction

overview of the ULTT, when should this be done

when a pt has upper limb radicular symptoms that is believed to be coming from c-spine nerve roots can be very provocative - add each element of the test slowly and individually assess change in sx pt is in HL (+) = inc in numbness, pain perform (B), compare findings sensitize with lateral flexion - IL will dec, CL will inc Median n - stand b/w pt and arm forearm supination hand in hand to ext W/F depress sh abduct sh 110deg, stabilize with leg ER to 80deg gradually ext elbow to ms guarding, document amount of elbow ext Radial n - stand lat to arm abduct arm to 10-30deg depress sh and IR forearm pronation, W/Thumb flexion, ulnar deviation elbow ext, can be documented Ulnar n - making the fake glasses sh depress, abd to 110 ER to 80 forearm pronation, W/4th&5th digit ext elbow flexion to onset ms guarding

when can we work with someone who has ankylosing spondylitis

when they are in the non active phase if they are in the active phase - this is when they are in the inflamm process that is affecting their ligs causing progressive fibrosis and low grade fever - the inflamm is actively happening and they would not be appropriate for PT

what is gowers sign

when they bend over and perform back extension they have to walk their hands up their leg they use the hands because the lack stability of the trunk

when is there torsional motion at the pelvis

with running and walking upstiars with one LE forward and flexed this innominate will be posteriorly rotated while the opposite will be anteriorly the sacrum not moving relative to innominate