msii review

7/27/2019 MSII Review

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MS 2 Midterm

Spine- protects spinal cord, mobility and stability, transmits weight from upper body, attachment site for

bones and muscles of UE and LE

Facets innervated by medial branch of dorsal primary ramus Ligament

o Anterior longitudinal ligament- covers anterior disc, anterior vertebral bodieso Posterior longitudinal ligament- prevents posterior disc protrusion, highly innervated by

recurrent sinovertebral nerve

o Interspinous ligament- connects spinous processeso Supraspinous ligament- covers spinous processes,o Ligament flavum- prevents separation of lamella or pedicles during flexion, attached

lamella to lamella or pedicle to pedicle

Deep muscles- core, multifidi, quad lumoborum, interspinalis, TrAo

Multifidus- segmental muscle, transverse and spinous processes, segmental stabilityo TrA- linea alba to thoracofascia, anticipates movement of limbs and keeps spine stable,

if weak then doesnt fire

Articulation- inferior articular process on one vertebrae on superior articular process ofvertebrae below

Cervical-o small body,o superior lip of body is concave and forces a U-shape (uncovertebral joint),o short, bifurcated spinous processeso facets oriented 45 degrees from horizontal,o SB and rotate same directions,o herniations most common between 20-30 yo, disc become fibrocartilagenous

consistency (no more nucleus fibrosus) at age 20, decreases blood supply and disc

height, no disc between OA and AA joint

Thoracic-o heart shaped body,o facets for ribs to attach,o facets in coronal orientation, rotation,o prevents forward translation, rotate and side bend opposite,

Lumbar- long spinous processes, large bodies, facets in sagittal plane,o translation, resists rotation, rotate and side bend opposite sideo L5- coronal plane for facets

Spine Movements- top vertebrae indicates the direction, planar movements are flexion and extension,

coupled motions are SB and rotation, compression, distraction

Flexion- glide superior and anterior, anterior disc is compression, limited by intraspinousligament, ligamentum flavum, and posterior/extensor mm


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Pain with inflamed facet joints, posterior disc herniations, muscle spasms,sprained posterior ligament, joint stuck in ext limits flexion

Extension- glide inferior and posterior, limited by spinous processes, anterior longitudinalligament, pars interarticularis often injured

SB- facets open up on one side (contralateral to bend), ipsilateral Z joint glides inferiorly,contralateral Z-joint glides superiorly

Pain with pars interarticularis, OA (CPP of facets) Rotation- ipsilateral facet opens up, contralateral facet compressed, opens lateral foramen,

optimal stimulus for disc

Distraction decreases pain, therapeutic effect on discs, facet joints, and ligamentsFryettes Law- in a flexed LS SB and rotation to the same side, in an extended LS SB and rotate to the

same side

Intervertebral Disc:

Function- mobility and stability, transmits load from one vertebral body to the next,proprioception

Nucleus pulposus- in center of disc, gel-like material, 70-90% water, 15-20% collagen II, 65%which is proteoglycans to hold in the water,

Annulus fibrosus- around the nucleus pulposus (no clear cut boundary), 60-70% water, 50-60%of dry weight is collagen type I and 20% is proteoglycans, has lamellae oriented at 65 degrees

from vertical to protect the nucleus pulposus and resist tensile forces, innervated by recurrent

sinuvertebral nerve, proprioception of spine

o Recurrent sinuvertebral nerve- innervates outer 1/3 of annulus fibrosis, dura mater,posterior longitudinal ligament, supplies the disc at its level and the level above

o Outer annulus and end plates are highly innervated Vertebral end plate- .6-1 mm thick of cartilage above and below the nucleus pulposus

o If have a break in the end plate then bone marrow and blood from the vertebrae fill into cover the nucleus pulposus

Disc Mechanics

1. Nuclear movement- Nucleus and annulus move together as one2. Tension- Annulus resists tension from rotation, compression and distraction3. Compression- Annulus fibrosus changes shape but volume always stays the same, transfers load

from one vertebral end plate to the next, with age the annulus fibrosus dries out and cant WB

as load or as much4. Distraction- Strains the fibers, annulus fibrosus resists5. Shear- Fiber orientation prevents shearing in all directions, only those fibers oriented in the line

of stress can prevent that direction of shear

6. RotationNutrition for Disc:


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Passive- imbibitions, diffusion due to concentration gradient Active- spinal motion No arteries or blood supply inside the disc, only get blood from arteries of vertebral bodies,

capillary beds of end plates, and outer 1/3 of annulus (not very much supplied there)

Tallest in morning bc at night the discs are hydrated (passive nutrition) and during the day mvmttakes out more than brings is (dehydrated discs by evening)

OPTIMAL STIMULUS FOR REGENERATION

Annulus- rotation, modified tension in line of stress

Nucleus- intermittent compression and decompression

Disc Injuries:

- Intra-spongy nuclear herniation: soft disc, break in endplate nucleus pulposus spreads intobone dries out, presents as LBP, localized pain, WBing and compression cause pain, can cause

Schmorls nodes later in life

- Protrusion- contained herniationo Normal disco Nucleus escapes periphery, may or may not cause paino Nucleus into outer 1/3 layer of annulus fibrosus, may or may not cause pain, still

contained in annulus, puts pressure on annulus, no pressure on nerve root

o Nucleus in outer 1/3 edge of annulus and pushing on spinal nerve, still contained inannulus fibrosus, pain in gluteal/buttock area, no radiating symptoms, morning stiffness,

sit in slouched position

- Extrusion- nucleus out of annulus, pain, + SLR, + Slump, neurological signs and symptoms,irritation of dura mater

- Sequestration- free fragment of disc, may migrate- Prolapse

Protrusion, extrusion, sequestration and prolapsed all are displacement of nucleus from end plate

Negative prognosis- severe nerve root pain, structural instability, deformity or structural anomaly

present, trauma, deteriorating condition according to history of condition

Oswestry- 50-points, how function is affected by LBP

Fear avoidance- how fearful the patient is about moving around, lower the score the better

Spinal Stenosis:

Usually age related (65+ yo), osteophytes, congenital Localized pain, back and leg pain, bilateral radiating symptoms, neulogical claudication

(cramping in calf, thigh or buttocks) Aggravated by extension, prolonged standing or walking, walking downhill, lying flat Eased by flexion, sitting, squatting, walking uphill, bike riding Flat back posture (lose lordosis bc dont like extension), painful extension, side bend towards

involved side, central and unilateral PAs reproduce symptoms, TM test (pain with level walking

less pain with incline, more pain with downhill walking), have peripheral pulse, X-ray and CT

scan tells where stenosis is at


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Work on ADLs with neutral spine, flexion and mobility exercises, stretch HS and hip flexors,traction, joint mobs in rotation to open foramina, TrA and glut muscle strengthening

Must manage or else surgical interventionVascular Claudication:

Plaque builds up inside the arterial walls

PVD

decrease in circulation

TM test- walking produces pain in calf, incline produces more pain, stop walking and pain goesaway, worse with increased effort or incline

Change in spine position doesnt affect pain Aggravated by walking on level surface or up hills (buttock or calf pain) Eased by stopping walking or supine lying Skin color changes, temp changes, hair loss, LE cramping or tightness (calf muscles), no

peripheral pulse

Rarely have back symptoms or problemsAcute Facet:

Sharp unilateral pain over facet, increased pain with stretching and compression of joint, localtenderness with palpation, feels like back is locked into position, no peripheral symptoms

History of unguarded movements (flexion and rotation) Limitations with facets opening Do manual therapy unilateral PAIVMs, manipulations, traction, mobility exercises, modalities

Chronic Facet:

Unilateral pain, less sharp over facet, increased pain with stretch of joint, local tenderness withpalpation, stiff

History of past acute facet Unilateral PAIVMs, traction, stretching and muscle re-education, ultrasound to decrease the

inflammation

Acute Nerve Root (ANR):

Irritation/inflammation/compression to nerve root Distal symptoms are greater than proximal, starts as proximal ache and then gets more distal Severely limits ROM and activity, neurological exam are level specific, modalities, manual

traction in supine or SLing, lumbar rotation

Epidural steroid injection 1st to calm symptomsChronic Nerve Root (CNR):

Chronic irritation or nerve root History of acute nerve root injury, LBP, arthritic changes, slipped disc Gradually symptoms return to lesser degree, proximal symptoms are worse than distal Minimal limitation of activity, minor responses in neuro exam, localized thickness of tissues with

palpation, stiff at segment

May have pain with ROM OP, SLR tests reproduces symptoms, + slump test Unilateral PAIVMs, rotation, traction, treat neurodynamic signs, mobility exercises, segmental

muscle re-ed


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3 weeks later- degenerative changes in myelin

6 weeks later- collagen deposition in the endoneurium

6-16 weeks later- decreases fiber diameter or myelinated fibers

ULTT- upper limb tension test

ULNT1- base test, tells what nerve to test next

ULNT2a- Median nerve bias

ULNT2b- radial nerve bias

ULNT3- ulnar nerve bias

Upper extremity entrapment:

Can occur anywhere there is a change in direction of the nerve or joint it goes around (orconnective tissue it goes through)

Common at C6, shoulder and elbow Causes: trauma (direct blow or traction), posture, overuse (microtraumas), arthritic changes,

soft tissue scarring, compression, chronic condition

Detensioned posture- thumb in pocket, hard to put elbow up with HBH (to do hair or put onshirt), protracted shoulder girdle, elevated scapula, head side bent towards affected UE,

supports affected arm

Presents with detensioned posture, irregular active mvmts, may or may not have neurologicalsigns, hypersensitivity of nerve palpation, + neural tension signs, symptoms are pulling, tight

band

Tension test-positive reproduces symptoms, abnormal or asymmetrical resistance through mvmt,

less available ROM in tensioned positions, change in symptoms with added components (ex. PNF-

cervical), and asymmetrical response to tests

*dont hold pt in a tensioned position any longer than have to to establish a positive test

NOT for- malignancy, vertebral column instability, neurological signs worsening, CE symptoms,

tethered spinal cord, unstable disc lesion, diabetes

Slump Test- started with pt complaining while getting into and out of car, for low back and LE symptoms,

elicits symptoms more proximally, more aggressive than SLR

Sit straight up with knees together at back of table hands behind the back slouch

thoracic OP neck flexion neck OP leg extension ankle dorsifleixon release neck OP

+ test- reproduces symptoms, restriction of mvmt, asymmetrical mvmt

Normal to have thoracic stretch with neck flexion, posterior thigh or knee restriction with

extension, DF intensifies symptoms, and releasing neck flexion should decrease the symptoms

and increase the ROM

SLR- tests sciatic nerve, elicits symptoms more distally, leg is lifted passively into hip flexion and knee

extension, determine symptom response, quality and range of movement, can wind up distally (before

lifting leg) or proximally (after lifting leg), should have s/sx between 35 and 70 degrees, greater than 70

degrees is likely to be HS tightness, DF- tibial nerve, DF + INV- sural nerve, PF + INV- common peroneal

nerve, medial rotation/hip add- lumbosacral plexus, EVER- posterior tibial nerve, can also do reverse SLR

in prone with leg hanging off table

Crossed SLR- indicates presence of large disc protrusion if SLR produces pain in contralateral leg

but no pain when it is then raised, pain in both legs, or when raising one leg and the leg on the

table has pain


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Bilateral SLR- can detect central protrusions if bilateral SLR + DF + PNF (passive neck flexion)

Slump and SLR NOT for: irritable and progressive disorders, unstable disc, recent progressive neuro

changes, and CE symptoms

Degenerative Disc Disease- males, 40-50s, commonly their occupation involves lifting, sitting, repetitive

movements, or history of contact sport, pain is constant, low grade ache, rarely have leg symptoms, due

to overuse, aggravated by bending, sitting, sit to stand, lifting, coughing, sneezing, sudden end of range

motions, compression activities, eased by lying down and unloading the spine, may have history of

repeated annular tear to produce disc narrowing, bone spur formation or hyper/hypo-mobility of a

segment, ROM limited during acute episodes, difficulty returning to neutral (+ Gowers sign), - SLR test,

minimal pain with palpation, diagnostics may reveal x-ray bone spur, narrowing space, breakdown of the

end plates, sclerosis of facets and vertebral margins

Cervical disc- thins with age bc loses H2O

Lumbar- disc thickens with age

Rare in thoracic spine- look for non-PT causes such as tumor

Intervention- McKenzie protocol, central and unilateral PAs, traction, unloading, aqua PT,

stabilization, body mechanics, stretches (SKTC, DKTC)

Herniated Nucleus Propulsus- 20-55 year olds, common in construction works (poor body mechanics) or

individuals who sit a lot (poor posture), possible lumbar stiffness, muscle spasms, signs of nerve root

compression, aggravated by flexion, sitting, sit to stand, walking, sneezing, coughing, eased by lying

down and unloading, may have history of sudden onset but usually due to repetitive bending, lifting, or

frequent lifting activities, esp flexion + rotation, limited ROM, SLR test + or

Intervention- McKenzie protocol (repeated extensions migrate HNP back to normal, centralize

symptoms), central and rotation joint mobs, intermittent traction, stabilization, body mechanics,

stretches, epidurals or steroids, surgery

Supine rocking- rotation is optimal stimulus for annulus healing, intersegmental flexibility/motionUnloading- supine with legs up, hips at 90, pain relief position, no tension or rotation from the pelvis

Hyperextension- good to unload spine, rehydrate discs, and improve disc nutrition, decrease tension on

L5 nerve root

McKenzie-

Postural dysfunction- less than 30 yo, females, pain is next to spine, intermittent pain, due to prolonged

stress of normal tissues, no pathology or deformity, no ROM loss, sustained position symptoms

reproduce

Intervention- pt edu, postural exercises, neuromuscular re-ed

Dysfunction- more than 30 yo, males, pain next to spine, intermittent pain, pain with end range stress,

no deformity, ROM loss, end of range pain, repeated movements reproduce symptoms but not worse

Intervention- stretch shortened structures, posture education, pt edu

Derangement- 20-50 years old, pathology present, pain is local, referred or radicular, constant or

intermittent, has most success with centralization, deformity present, ROM loss, pain with movement

and end range


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Centralization:

Distal symptoms moves proximally with certain movements Only in derangement syndrome/instability Symptoms may shift from side to side Indicates correct movement

Means good prognosis for recoveryPeripheralization:

1. Symptoms that are proximal move distally with certain movements2. Not good for recovery

Extensions

Prone lying- 5-10 minutes

Intermediate step- progressive extension with pillows- start with one pillow under chest

and gradually add, hold 10 minutes, when finished take pillows away over several mins

Prone lying on elbows- weight on forearms and elbows, hips on mat, sag lower back, hold 5-10

minutes, want segmental extension of LS, no contraction of back muscles

Prone press-ups- repeated extensions, hips on mat, straight elbows, palms on mat, sag LS,

repeat 10 times

Standing extension- can do as HEP (nourishes spine), hands on small of back, hold 20 seconds,

repeat 3-5x, do after flexion activities

Spinal Stability

Functional spine- tension, compression and shear stresses, all can be controlled by stabilization, must

have proximal stabilization before distal mobility, stabilize in multiple positions, TA 24/7 (strength and

endurance, make habit)

*proximal stability safe dynamic mobility*

Stabilized spine:

1. Passive support- osseoligamentous system, bones, ligaments2. Active support- muscles3. Control of muscles by CNS

Segmental instability- abnormal movement of one vertebrae on another, increases size in the neutral

zone, decrease in ability of stabilization to maintain intervertebral neutral zone in its physiological limits,

leads to neurological dysfunctions, deformities, and pain

Physiological range of intervertebral motion:

Neutral zone- movement occurs with little resistance Elastic zone- between neutral zone and physiological range, mvmt occurs with internal

resistance

Clinical instability- reports signs and symptoms of instability, my back went out, shifting pain,

increases size of neutral zone, mechanical back pain

Due to instability in passive system (bones, ligaments), identified by radiographs, assessed withpassive intervertebral or accessory movement testing

Due to active system- unstable at low loads, decreased cross sectional area, decreasedcontraction with palpation, mm fatigue


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Due to neural system- change in muscle onset timing, change in pattern of recruitment, changein muscle stiffness, change in kinematic patterns

Anterior instability test- pt in SLing, pushing femur posteriorly, assessing anterior translation of superior

segment, assesses passive system (bones, ligaments)

Prone instability test- assesses active system (musculature), pt prone with legs hanging off table

touching the floor, do PAs, if hurts then pt actively raises feet off ground, do PAs, if doesnt hurt then

muscles are protecting the back, if still hurts then stabilization exercises wont be as effective and

potential surgery candidate

Beighton-Horan Ligamentous Laxity Scale- assesses laxity of joints, scored out of 9, if have 7 then prone

to instability

Muscle stabilization predictive factors- less than 40 yo, positive prone instability test, + Gowers sign,

muscle spasms from flexion neutral, lateral shifting, SLR 90 degrees

Negative factors- negative prone instability test, absence of lumbar hypermobility, FABQ score

of 9 or higher (pt doesnt think they will get better)

Global muscles- coactivation increases compressive load on LS, limited control of shear forces, can cause

spinal rigidity, control load and compression, cant control intersegmental stability

Rectus abdominis, internal obliques, external obliques, lateral fibers of quadratus lumborum,

thoracic part of lumbar iliocostalis

Local muscles- responds to WBing exercises, static WBing, antigravity working postures, intersegmental

stability, erect posture, joint compression, provide stiffness, control translation (no excessive shear),

anticipate load and movement, support and protect joints

Diaphragm, pelvic floor muscles, TrA, multifidus, medial fibers of quadrates lumborum, lumbar

part of ilocostalis and longissimus, posterior fibers of internal obliques attached to TFL

Lumbar stabilization- TA and multifidus, submaximal contraction, regular breathing, 24/7

Multifidus- controls the neutral zone, lordosis, tension on the thoracolumbar fascia, adjusts

spine, controls pelvic rotation, intersegmental muscle

TA- 1st muscle to work when there are forces on the spine (UE or LE movement)

Move UE- TA, multifidus and pelvic floor are all contracting beforehand

Prone test- pt in prone, inflate cuff to 70mmHg, biofeedback under abdomen, draw in abdominal wall

for 10 seconds while breathing normally, repeat 10 times for endurance, watch for compensations

(pelvic tilts, flexed spine, rib cage depression)

Correct- decreases 6-10 mmHg; incorrect- increase in pressure, decreases less than 2 mmHg, no

change

Contraindications- obesity, unable to lie prone, respiratory pts

Leg load test- supine, hooklying, biofeedback under LS on opposite side of leg moving, inflate to 40

mmHg, leg moving is the loaded leg

Ex. Load L leg cuff under R LS


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Steps: heel slide with opposite leg support unsupported leg extension with opposite leg

support heel slide with unsupported opposite leg unsupported leg extension with

unsupported opposite leg

Traction

Effects of traction

- Distraction of vertebral bodies- Distraction and gliding of facets- Tenses ligament structures (helps with HNP)- Widens intervertebral foramen- Straightens spinal curves- Stretched spinal muscles

Technique

- Determine force- start with lighter force and then increase (25-50% of body weight)- Determine duration start with 3-5 minutes and then progress- Static vs intermittent

o Static- sustained pull for irritable mod-severe conditionso Intermittent- hold-rest time, use with less severe and irritable conditions

- Pt positiono Flexion

Supine with posterior pull Prone with anterior pull

o Extension Supine with anterior pull Prone with posterior pull

- Harness-o secure pelvic belt first, then thoracico

belts should be on skin

o top of the pelvic belt should be at umbilical, and top buckle should be above iliac cresto Take up all the slack in the harness

Guidelines

- Pt must be relaxed- Dont leave unattendedleave bell and stop button- Continually monitor symptoms- Consider SINS before treatment- Ask special questions- Traction is a short term treatment (less than 6 weeks) and should be used in conjunction with

other interventions

- Always test with manual traction before trying mechanicalIndications for traction

- HNP- distracts vertebra so creates negative pressure to suck the disc back ino Sustained or long hold-rest (60 on, 20 off) for intermittent, 5-10min treatment time,

extension position

- DDD/DJD- reduces intradiscal pressure to help nutrition of nucleus pulposuso Intermittent (20 hold, 10 sec rest), prone or supine, extension is preferred


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- Joint hypomobility- passive mobilization of jointso Intermittent with short hold-rest, prone or supine position

- Facet impingement- releases restriction of facet jointso 20 hold, 10 off

- Muscles spasm- separates painful joint structures so muscle spasm is relaxedo 60 hold, 20 offlonger hold times

Contraindications

- structural disease secondary to tumor or infection- vascular compromise- RA- TMJ- A condition where movement is contraindicated

Precautions

- Acute sprains or strains- Inflammatory condition- Joint instability- Pregnancy- Osteoporosis- Hiatal hernia- claustrophobia

Predictors of who will benefit

- Low level fear avoidance beliefs- No neurological deficit involvement- Older than 30- Non-involvement in manual work

Cervical traction- Force 5-20 pounds- Consider 5 Ds for vertebral artery/ c-spine

o Dizzinesso Diplopiao Disarthriao Disphagiao Drop Attacks

SI Joint- transfers load from trunk to legs during gait, WBing activities and changing positions, absorbs LE

motions, joint made to limit mobility, cartilage increases friction to decrease mobility, irregular joint

surface, covered by lots of ligaments, 2 innominates + 1 sacrum, 2 SI joints, innervated by L2-S5, usually

have pain over buttock, lower lumbar, and sometimes radiates down post leg to knee (rarely past knee)

Joint type- anteriorly diarthrodial (synovial), posteriorly (non-synovial), gaps more anteriorly

than posteriorly

Sacral surface- hyaline cartilage

Sacral base is superior, sacral apex is inferior, sacral alae like TPs of spine, S2 at PSIS

(only one palpable)

Iliac surface- fibrocartilage


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Lumbosacral junction- L5-S1, facets in frontal plane, dense superior articular process of sacrum,

iliolumbar ligament crosses

SIJ Ligaments: all connected to thoracolumbar fascia and back muscles- can MMT

Iliolumbar ligament- L4/L5 transverse processes to iliac crest, restricts all planes of movement(extension and opposite side flexion), covers superior aspect

Ventral/anterior sacroiliac- limits anterior gapping, covers anterior joint and superior capsule,weakest of all lig, if injured then hypermobility and source of pain, tested in anterior gapping

test

Interosseous- limits posterior gapping, can palpate below PSIS, tested with posterior gappingtest

Long dorsal ligament- limits counternutation Sacrotuberous- limits nutation, ischial tuberosity to spine of sacrum (S3, S4, and S5), prevents

forward movement of sacrum, palpate above ischial tuberosity, blends with gluteus and biceps

femoris

Sacrospinous- limits nutation, deep lig, lateral sacrum to ischial spine, prevents forward rotationof sacrum

Outer tube muscles: compress on inferior muscles side

Anterior oblique system- internal and external oblique, abdominal fascia, contralateraladductors

Posterior oblique system- latissimus dorsi, contralateral glut max and TFL Lateral system- glut medius and minimus and contralateral adductors Longitudinal system- erector spinae, TFL, biceps femoris, and sacrotuberous ligament

Inner tube muscles: TA, multifidus, diaphragm, pelvic floor muscles, core stability

Sacroiliac Motion- according to base of sacrum, sacrum moves on ilium

Nutation- anterior + inferior movementCounternutation- posterior + superior movement

Normal position in body: 30-45 degrees of anterior tilt

Long arm- anteriorposterior plane, S2 to S4

Short arm- covers S1, superior to inferior aspect of joint, vertical plane

Trunk bends forward- sacrum nutates of way, innominates anteriorly rotate

Trunk bends backward- sacrum nutates to increase lordosis, innominates posteriorly rotate

Trunk rotation- sacrum rotates with spine

Gait- rotation + flexion/ext, lots of pain with walking if injured

Iliosacral Motion- ilium moves on sacrum, ex. When hips are moving, anterior and posterior rotation,

upslip and downslip, inflare and outflare (reference is midline or umbilicus)Hip flexion- unilateral innominate posterior rotation

Hip extension- unilateral innominate anterior rotation

Assess SIJ Stability- SLR test

Form closure- passive stability, may need SI belt, anatomy and structure of joint

Force closure- active stability, need neuromuscular re-ed, muscles, fascia, ligaments, and neural

control


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Sacral axial rotation- torsion: rotation + SB

Pubic symphysis- no direct muscle attachment, fibrocartilaginous disc

Painful side of SIJ is the problem side. Innominate dysfunction- rotations, upslips, and flares. Sacral

dysfunction- torsions and rotations. Can have pain in pubic symphysis- change in activity contract

adductor mm to help stabilize, adductors attach close to pubic symphysis

Hypermobility- WBing activities, changing positions in bed, history of trauma or pregnancy, pain with

change in position, deep shift of clunk, difficult load shift test, positive pain provocation test

Test- SLS, hop on one leg, sit to stand

Intervention- work in diagonal/transverse planes, support/brace, strengthen inner and outer tub

muscles, pt edu to avoid agg activities, modalities to decrease inflammation

Hypomobility- LS and hip movements, anterior or posterior direction, positive mobility tests, asymmetric

palpation

Intervention- mobilization, manipulation, muscle energy

SIJ Syndromes:

Systemic disease- infection, inflammation, AS Trauma- pregnancy, high velocity, falls, infants, hypermobility, hypomobility Chronic dysfunction- hip and spine pathologies put too much force on SIJ

Always work on/assess LS or hip related dysfunctions with SIJ problems!

SIJ Success Prediction Rate- FABQ below 18, symptoms for 15 days or less, no symptoms distal to knee,

LS hypomobility at any level, hip with IR greater than 35 degrees

UPPER CERVICAL SPINE

Anatomy C1:


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C2:

Ligaments: from T spine-> to what they are in C spine

Ant long ligament becomes-> anterior atlantooccipital membrane

Post long lig becomes -> tectoral membrane

Lig flavum-> becomes post atlanto-occipital membrane

Transverse lig across posterior articular facet of dens, holds C1 to C2

Facets- convex, only joint where both surfaces convex, allows rotation, 50% comes from C1/C2

LOWER CERV spine problem more problems with SB, UPPER difficulty with ROT

Alar lig: prevents mvmt in ROT and SB

-holds C2 to occiput

UPPER CS Innervation: Dorsal and ventral rami of C1-C3 supplies all structures: muscles, the OA, AA

joint and C2-3 Z joint, all ligaments and the vertebral arteries

BIOMECHANICS:

OA joint: primary flex/ext motion AA joint: primary rotation motion


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**ROTATION & SIDEBENDING OCCUR IN OPPOSITE DIRECTIONS**

VERTEBRAL ARTERY:

Avoid treatments that combine EXT and ROT

These progressively occlude VA: Rotationrotation + extension Rotation + extension + traction

CLINICAL SYNDROMES: UPPER CERVICAL SPINE

FORWARD HEAD POSTURE: Forward head posture can stress upper cervical structures and lead to

headache -> Correction of posture starts /C T-SPINE

Vertebral Artery

o Agg: N/T around lips, dbl vision, dizziness, dysarthria, dysphagia, drop attacko Rotation and extension is more painful (occlude the artery).o

Hx: MVA (extension injury), trauma (compression from osteophytic or disc,o Stretching, kinking). Cervical instability and fractures, manipulation oro Sudden neck movements.

Cervicogenic HA

o Agg: reproducible with neck movmt, posture, position. 50% are occipital (mayradiate into ear) and suboccipital.

o Ease: medications, change in position/posture, lying down.o Hx: hx of neck pain. Due to hypo/hyper mobility, DJD, trauma.o Objective:AROM, alar lig, transverse lig, central PAs,o Manual Therapy: Central PAs, traction,o

Ther-ex: cervical isometrics, thoracic stretching/strengthening Postural correction,scap squeezes, neck stretches.

Tension HA

o Agg: bilateral, trigeminal distributiono Hx: stress or lack of sleep. Women more than men.o Objective:AROM, central PAs, unilateral PAs.o Manual Therapy:Central PAs, Unilateral PAs, traction.o Ther-ex: Postural correction, neck stretches

Whiplash

o Agg: Pain is dominant complaint. Cautious/apprehensive with active Movements ofneck. Dizziness with active movements. Pain location: Suboccipital, neck, shoulders,

scapulae, back, frontal HA, retro-orbital, Facial/throat pain, larygneal disturbances,

numbness/parasthesia in UE


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o Hx: MVA. Special questions: hearing or vision disturbances? Dizziness? Feelings ofunsteadiness? Depression or fatigue? Irritability? Insomnia?

o Light-headed? 5 Ds? Vertebral artery?o Objective:, ALAR lig, transverse lig, central PAs, AROMo Manual Therapy:Central PAs, traction,o Ther-ex: Chin nod, cervical stretches, AROM, scap squeezes.

OTHER TRAUMATIC UPPER CS INJURIES

A-O dislocation: 100% fatal, shear force of occiput on atlas Fracture of posterior arch of atlas: result of vertical compression; results in massive subocc HA A-A dislocation: rupture of transverse ligament, JEFFERSON Fx: fracture of ant. and post. arches of C1, usually from blow to back of head DENS Fx: common in MVA, seen on open mouth x-ray, Dens will Fx b4 alar ligaments will tear Hangmans Fracture:results in dens into brainstem, not always fatal Rotary A-A Subluxation: face mask injury

CERVICAL SPINE Consists of 37 joints, which allow for more motion than any other region of the spine Stability is sacrificed for mobility More vulnerable to both direct and indirect trauma The lordotic curve develops secondary to the response of an upright posture provides a shock-absorbing mechanismANATOMY

Each pair of vertebrae in this region is connected by a number of articulations: a pair ofzygapophyseal joints, the uncovertebral joints, and the intervertebral disc

very little bony stability Intervertebral foramina

oprincipal routes of entry and exit for the neurovascular systems to/from vertebrae

o intervertebral foramen decrease with full extension and ipsilateral side bending ofthe cervical spine, uncovertebral osteophytes may compress the nerve root and

cervical cord posteriorly

Ligamentso Anterior longitudinal(ALL).

narrower in the upper cervical spine but is wider in the lower CS than in TSo Posterior longitudinal(PLL).

considerably thicker in the CS than in the thoracic & lumbar regions Neurology

o cervical spine is the only region that has more nerve roots than vertebral levelso structures supplied by the upper three cervical nerves can cause neck and head paino mid to lower cervical nerves can refer to shoulder, anterior chest, upper limb, and

scapular area

BIOMECHANICS

Segmental side bending is extension of the ipsilateral joint and flexion of thecontralateral joint

Rotation, coupled with ipsilateral side bending, involves extension of the ipsilateral jointand flexion of the contralateral


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FORWARD HEAD POSTURE

causes neck muscles to lose blood, suffer damages, fatigue, strain, cause pain, burning andfibromyalgia.

Creep: When spinal tissues are subject to a significant load for a sustained period of time,they deform and undergo remodeling changes that could become permanent.

o this is why it takes time to correct FHP.EXAMINATION

o Screen!! the patient first Instability, trauma, 5Ds, The examination must be graduated and progressive so that the testing can be

discontinued at the first signs of serious pathology

Hx: pain source, MOI, Aggs= washing hair, turning around in car, getting dressed, reading Combined motion testing

o A restriction of cervical extension, side bending and rotation to the same side as thepain is termed a closingrestriction.

Can interfere with nerve root Treat differently, may combine movement to facilitate closing

o A restriction of cervical flexion, side bending and rotation to the opposite side of thepain is termed an opening restriction

Special Testso Foraminal compression

Fingers laced across top of head, Axial compression, looking for increased symptoms

o Axial distraction Tell them you are going to cover their ears

o Upper limb neural tensionMedian, Ulnar, RadialINTERVENTION STRATEGIES

postural re education neck specific strengthening stretching exercises mobilization ergonomic changes at work

CLINICAL SYNDROMES: C-SPINECervical Disc

o Agg: extension, rotation to painful side, prolonged flexion. ADLs limited,o Speed of movement altered, driving and sitting is uncomfortable. Clowardo Sign, ache/stiffness, may or may not have distal sxs (nerve root involved).


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o Hx: Not associated with incident. May be related to sustained posture. Slowo Onset or wake with pain. May have history of MVA.o Objective:central PAs, PPs, dermatomes, reflexes, Spurlings test, AROMo Manual Therapy: Central PAs, unilateral PAs, traction.o Ther-ex: postural correction, chin nod.

Spondylosis (Cspine)

o Agg: sustained flexion, quick movements, EOR movements. Bilateral oro Unilateral. Ache may refer to suprascapular fossa. May c/o sharp pain.o HX: long history of neck pain. May have history of MVA.o Objective:, central PAs, unilateral PAs, AROMo Manual Therapy: Central PAs, Unilateral PAs, traction.o Ther-ex: cervical isometrics, postural, scap squeezes, neck stretches.

Acute Nerve Root (Cspine)

o Agg: any movement of the neck (closing down of foramen), arm movements,o Sustained flexion. +/- cough, awakes at night. Pain worse distally ino Dermatomal pattern. Possible cloward sign.o Ease: NSAIDSo Hx: Older patients that have degenerative changes. May occur in youngero Individuals, trauma included. May start with neck stiffness or from scapularo Area. Insidious, then spreads out. Prior episodes of neck stiffness.o Objective: Unilateral Pas, AROM, dermatomes, reflexes,o Manual Therapy: Traction, unilateral PAs (if severity allows)o Ther-ex: postural exercises, scap squeezes, chin nod, cervical stretches.

Chronic Nerve Root (Cspine)

o Agg: sustained flexion, movements that narrow foramen. Can be nagging,o Able to sleep at night.o Hx: more common in middle age and older population with alreadyo Established degenerative changes. Dermatomal pattern, not necessarilyo Distal. Usually intermittent. Patchy distribution. Result of past acute nerveo Root that didnt completely resolve. Prior episodes of neck stiffness.o Objective: AROM, dermatomes, reflexes, neurodynamics,o Manual Therapy: Unilateral PAs, traction, neurodynamics.o Ther-ex: Postural exercises, scap squeezes, chin nod, cervical stretches,

MS II Comp Review Part 4

Thoracic Spine Anatomy

Joints


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Costotransverse Joint: The synovial joint between the articular facet on the posterior aspect of

the rib and the articular facet on the anterior aspect of the transverse process. Found on T1-T10.

Costovertebral Joint: Where the rib articulates with the disc and vertebral body at the same

level and the level above the rib.

Zygapophyseal Joint: Limits flexion and anterior translation of the vertebral segment. Allowsrotation.

Rule of Three: used to determine location of transverse processes

T1-T3: spinous process and transverse process at same level

T3-T6: transverse processes are half a level above the spinous process

T7-T9: transverse processes are a full level above the spinous process

T10- T12: gradual return to same level

Ligaments

Anterior Longitudinal Ligament: narrow but thick compared to the rest of the spine

Posterior Longitudinal Ligament: wider at intervertebral disc level but narrower at the vertebral

narrower at the vertebral body than the lumbar region

Ribs

True Ribs: ribs 1-7 which attach directly to the sternum

Typical Ribs: ribs 3-9 which have a posterior end (head, neck, tubercle)

Ribs 11-12: no anterior articulation and no articulation with superior vertebra

Ribs 1, 6, 7: have costal cartilage that is linked to the sternum by a synchrondosis

Ribs 2-5: connected to the sternum by a synovial joint

Blood Supply: Provided by the dorsal branches of the posterior intercostal arteries. Venous drainage

occurs through the anterior and posterior venous plexuses. Overall the spinal cord is poorly vascularized

between T4-T9.

Thoracic Spine Biomechanics

Flexion: Initiated by abdominal muscles, continued with gravity, and eccentrically controlled by the

erector muscles. Vertebral body translates anteriorly, transverse processes upwardly rotate, and ribs

downwardly rotate.

Extension: Produced by lumbar extensors and results in an inferior glide of the superior facet of the

zygapophyseal joint. Overall thoracic extension ROM is 15-20 degrees with 1-2 degrees available per a

segment.


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Side Bending: Initiated by the ipsilateral abdominals and erector muscles and continued with gravity.

Total thoracic side bending ROM is 25-45 degrees with 3-4 degrees available in the upper segments and

7-9 degrees available in the lower segments.

Axial Rotation: Produced by abdominal muscles, other trunk rotators, or by unilateral elevation of the

arm.

Coupled Motions

Cervicothoracic Region: Side bending and rotation occur to the same side

Thoracolumbar Region: Side bending and rotation occurs to the opposite side

Mid Thoracic Region: Variable coupling

Respiration

Upper Ribs: Pump handle which results in an anterior elevation to increase the anterior-

posterior diameter of the thoracic cavity

Middle and Lower Ribs: Bucket handle which results in a lateral elevation to increase the

transverse diameter of the thoracic cavity

Clinical Prediction Rule for Thoracic Manipulation for Neck Pain

1. Symptoms less than 30 days2. No symptoms distal to shoulder3. Cervical extension does not aggravate4. FABQPA score less than 125. Decreased upper thoracic kyphosis6. Cervical extension less than 30 degrees*3/6 variables = 86% success rate

Thoracic Syndromes


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Syndrome Pt profile Causes Symptoms Assessment Intervention

Upper Rib

Conditions

Elevation of

ribs, thoracic

outlet

syndrome,

forward head

posture, open

mouth breather,

cervical trauma

Pain, tingling,

numbness, and

vascular

changes in arm

and hand

1st rib

assessment and

x-ray

Muscle

stretching,

posture

education,

mobs/manip,

C/R technique

Flattened

Upper Thoracic

Spine

Increased

tension in

nervous system,

natural posture,

constant

loading of joint

Mid-back pain

and stiffness

Stiff

cervicothoracic

junction or

thoracic spine,

x-ray

Unload joints,

improve

mobility,

scapular and

thoracic

stability

Generalized

upper/mid

thoracic

stiffness

Middle or

older age

Prolonged

acquired

posture, natural

posture,

metabolic

changes

Stiffness,

limited arm

elevation

Stiff and painful

PAIVMs,

limited arm

elevation,

muscle

imbalance

Mobilization,

flexibility and

strengthening

exercise,

posture

education,

breathing

techniques, rib

screw

mobilization

T4 Syndrome Sympatheticreaction due to

hypomobile

joint from T2-T6

caused by

trauma or

posture

Aggravated bypushing/pulling,

headache, N/T

in arm and

fingers, ache in

mid back

Localizedtenderness and

stiffness with

PA,

hypermobility

of adjacent

segment,

thickening of

soft tissue, +/-

slump/ULTT

Flexibilityexercises,

central PA,

transverse glide,

soft tissue work,

rib mobility,

mobility

exercise,

manipulation if

appropriate

Upper/mid

Thoracic

Hypermobility

History of

trauma,

gymnast,

ballet

dancer

Trauma

including

microtrauma

Mid scapular

pain, pain with

prolonged

position,

constantly

changing

position, pain

with overhead

Pain and

muscle spasm

with PA,

increase

segmental

mobility,

positive

stability test

Mobilize

adjacent

segment,

generalized

strengthening,

avoid end range

movement,

caution with


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lifting manipulation

Costal Joint

Derangement

Reduced costal

mobility

(rotation)

Aggravated by

twisting or

reaching, pain

with breathing

Painful trunk

rotation,

painful

unilateral PA

over

costotransverse

joint, pain and

stiffness with

rib mobility

Acute stage:

limit trunk

rotation;

chronic stage:

mobilize and

exercise

Thoracic Disc

Lesions

Acute: forceful

rotation injury;

Chronic:

degenerative

changes

Pain shooting

around or

through chest

wall,

aggravated by

any movement,pain with

cough/sneeze,

pain with

breathing

Positive

cough/sneeze,

painful PA

Scapulocostal

Syndrome

Unknown may

be due to

scapular muscle

imbalance, soft

tissue irritation,

or postural

changes

Snapping

scapula

Palpation Trunk mobility,

scapular

stability

exercises

Tietzes

Syndrome

Costochondritis

(localized

irritation of

costosternal

joint of rib 2)

due to posterior

lesion,

inflammation,

or repetitive

movement

Anterior chest

pain, localized

or superficial

pain, pain with

breathing, pain

with trunk

movement

Pain and

swelling over

joint

Treat posterior

lesion, RICE

Ankylosing

spondylitis

Young men Systematic

rheumatic

disease causing

inflammation of

the spine

Starts in SI joint

and migrates

up the spine,

gradual onset,

progressive

stiffness

Pain, limited

chest

excursion,

limited spinal

mobility, x-rays,

bone scan

Mobility

exercise, active

lifestyle


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Osteoporosis Female,

petite, use

of steroids,

lack of

nutrition

and

exercise

Wedging and

increased

kyphosis,

compression

fractures due to

lack of bone

density

Can be

symptomless, if

there is a

compression

fracture there is

pain with

breathing and

movement

Increase

kyphosis, x-ray,

bone scan

Weight bearing

exercise, muscle

strengthening,

dietary advice

Scheuermanns

Disease

Male child Wedging of

multiple

vertebral bodies

Pain and

stiffness

Rigid curved

spine

Exercise to

improve

mobility and

back car,

bracing, surgical

intervention

Non-Neuromuscluloskeletal Conditions of the Thorax

Non-Neuromuscluloskeletal Causes of Thorax Pain

Cancer: Occurs in thoracic spine most often from lymphoma, breast, or lung cancer. Patients

usually report symptoms of cancer and have neurological signs due to spinal cord compression.

Patients with prostate and lung cancer usually present with back pain as initial complaint.

Patients with breast, kidney, or colon cancer usually present with visceral symptoms as the

initial complaint.

Cardiac Conditions: aortic aneurysm, angina or acute MI. These are usually accompanied by

cardiac symptoms such as weak pulse, abnormal BP, unexplained perspiration, or a pulsating

sensation in the abdomen.

Pulmonary Conditions: Symptoms should increase with coughing or deep breathing.

Renal Conditions: Pain is usually dull and constant with possible radiation to groin. For an acute

infection the patient will experience chills, frequent urination, and blood in their urine.

Percussion should be positive in the flank areas in patients with renal problems.

Gastrointestinal Conditions: severe esophagitis, peptic ulcer, and an acute gallbladder infection.

Take a thorough history to identify GI conditions vs. musculoskeletal conditions.

Scapular Pain: Respiratory viral infection or pneumothorax cause scapular pain that is aggravated by

respiratory movements

Location of Systemic Thoracic/Scapular Pain


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Systemic Origin Conditions Location

Cardiac MI Mid thoracic spine

Pulmonary Basilar pneumonia R upper back

Emphysema Scapular

Pneumothorax Ipsilateral scapula

Renal Acute Infection Lower costovertebral region or

angle posteriorly

GI Esophagitis Midback between scapulae

Peptic ulcer (stomach/duodenal) 6-10 vertebral region

Gallbladder diseases Midback between scapulae; R

upper scapula or subscapular

area

Biliary colic Midback between scapulae; R

upper back; R interscapular or

subscapular area

Pancreatic carcinoma Midthoracic or lumbar spine

Recognizing Pain Patterns

Vascular Neurogenic Systemic Musculoskeletal Visceral

Throbbing Stabbing Knife-like Aching Knife-like

Pounding Burning Boring Sore Stabbing

Pulsing Shooting Coming in waves Heavy Boring

Beating Pricking Deep aching Hurting Deep, poorly

localized

Stinging or

pinching

Progressive

pattern with a

cyclic onset

Dull or sharp

Neuromusculoskeletal vs. Visceral Pathologies


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Neuromusculoskeletal Visceral

Description of Symptoms Dull ache, sharp or shooting pain

with movement or breathing,

localized pain or pain may

radiate along dermatome

pattern

Throbbing, pounding, cramping,

heaviness, dull and difficult to

localize

Mechanism of injury History of trauma, episode, or

incident, postural dysfunction,

etc

Insidious onset, history of cancer

or constitutional symptoms

(fever, chills, nausea, fatigue,

etc)

Behavior of Symptoms Typically better with rest and

worse with activity

Unrelenting or worse with rest;

insignificant relief with rest

Unremitting night pain; night

pain not relieved by change in

position

Pain may be associated with

food intake or physical exertion

Associated Symptoms Unexplained weight loss, loss of

appetite, muscular weakness,

cyclical and progressive nature

or symptoms

TMJ Lecture

Pain due to: inflammation of ligaments/capsule, internal derangement, arthritis, muscle imbalance

Clicking

Loud click on opening is disc reduction

Smaller click on closing is disc dislocation

If disc fully anteriorly displaced no clicking will be present and the patient will have limited range

of motion when opening their mouth. This is called a locked joint.

If disc is fully posteriorly displaced then it is an open lock. This occurs most frequently after a

dental procedure

Local vs. Global Muscles


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Local: A deep muscle that controls a single segments translation. Most likely to become

inhibited or down regulated with pain.

Global: A muscle that produces movement. Most likely to become up regulated with pain.

Actions and Muscle Involvement

Elevation (closing): masseter, temporalis, medial pterygoid, superior fibers of lateral ptyergoid

Depression (opening): inferior fibers of lateral ptergoid, supra hyoids, infrahyoids, gravity

Protrusion: superficial masseter, medial pterygoid, lateral pterygoid

Retrusion: deep fibers of masseter, temporalis, suprahyoids

*medial pterygoids are the most common muscle to cause problems*

Normal Kinematics

Elevation (closing): teeth approximation

Depression (opening): maximum 40-50 mm or 4 finger widths, to be functional only need 35 mm

or three finger widths

Posterior rotation of condyles during first half of the movement with anterior rotation

occurring during the second half of the movment

Protrusion: 6-9 mm

Mandible and disc translate anterior and inferior

Retrusion: 3 mm

Lateral Deviation: the opening range

Physical Therapy: mobilize restrictions, stabilize hypermobility, improve stabilizer muscle control

through full range, educate about posture, empower the patient with self-management techniques,

stretches, address pain control and daily activities

Rehabilitation After Cervical Spine Surgery

Imaging: Not necessary unless there is a neurological deficit. MRI used for soft tissue definition.

Surgical Indications: fractures from major trauma, fractures from minor trauma patients with

osteopenia, progressive myelopathy (sensory disturbances in hand, intrinsic muscle wasting of hand,

trouble walking, hyperreflexia), neoplasm

Posterior Approach: used for lateral herniation, allows patients to avoid fusions, more technically

difficult surgery, more pain due to increased musculature

Anterior Approach: problems with swallowing and vocal changes

Cervical Radiculopathy


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Description: nerve root impingement usually from disc herniation

MOI: forced hyperextension, rotation or both

Initial Treatment: non-operative, rest/NSAIDS/oral steroids, cervical traction

Surgical Indications: failed conservative management of at least 2-3 months, progression ofneurological dysfunction (weakness), persistent numbness in dominant hand

Surgery: discectomy, possible fusion

Cervical Stenosis

Description: narrowing of spinal canal causing compression on spinal cord and nerve roots

MOI: congenital or acquired, acute trauma with fracture or herniation

Surgery: laminectomy

Cervical Myelopathy

Description: spinal cord compression causing upper/lower extremity weakness, bowel and

bladder dysfunction, gait disturbance

Indication for Surgery: always, no indication for conservative care

Surgery: removal of vertebral body and disc and insertion of prosthesis, possible fusion

Rehabilitation Strategies

Acute Phase

General Rules: brace/collar for fusion patients (doctor will specify), no ROM, keep head

of bed elevated (sleep in recliner), no lifting over 5-10 lbs

Physical Therapy: bed mobility, ambulation, stairs (may have trouble seeing with brace

on the way down)

Outpatient

Physical Therapy: precision of movement including intrinsic muscles for fine control and

making sure the extrinsic muscles do not become dominant, posture education, proper

alignment of shoulder girdle

Rehabilitation After Lumbar Spine Surgery

Indications for Imaging: back pain in children less than 18 or adults older than 55 with severe pain,

history of violent trauma, night pain, history of cancer, systemic steroids, drug abuse, HIV, marked

morning stiffness, persistent severe restriction of motion, severe pain with motion, structural deformity,

difficulty with urination, loss of bowel/bladder function, saddle anesthesia, motor weakness or gait

disturbance, peripheral joint involvement


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msii review

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