Ms 2 Midterm

Effects of traction

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

Technique

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  Determine force- start with lighter force and then increase (25-50% of body weight)
  
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  Determine duration— start with 3-5 minutes and then progress
  
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  Static vs intermittent
  
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    Static- sustained pull for irritable mod-severe conditions
    
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    Intermittent- hold-rest time, use with less severe and irritable conditions
    
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  Pt position
  
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    Flexion
    
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      Supine with posterior pull
      
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      Prone with anterior pull
      
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    Extension
    
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      Supine with anterior pull
      
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      Prone with posterior pull
      
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  Harness-
  
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    secure pelvic belt first, then thoracic
    
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    belts should be on skin
    
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    top of the pelvic belt should be at umbilical, and top buckle should be above iliac crest
    
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    Take up all the slack in the harness
    

Guidelines

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  Pt must be relaxed
  
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  Don’t leave unattended—leave bell and stop button
  
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  Continually monitor symptoms
  
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  Consider SINS before treatment
  
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  Ask special questions
  
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  Traction is a short term treatment (less than 6 weeks) and should be used in conjunction with other interventions
  
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  Always test with manual traction before trying mechanical
  

Indications for traction

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  HNP- distracts vertebra so creates negative pressure to suck the disc back in
  
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    Sustained or long hold-rest (60 on, 20 off) for intermittent, 5-10min treatment time, extension position
    
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  DDD/DJD- reduces intradiscal pressure to help nutrition of nucleus pulposus
  
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    Intermittent (20 hold, 10 sec rest), prone or supine, extension is preferred
    
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  Joint hypomobility- passive mobilization of joints
  
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    Intermittent with short hold-rest, prone or supine position
    
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  Facet impingement- releases restriction of facet joints
  
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    20 hold, 10 off
    
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  Muscles spasm- separates painful joint structures so muscle spasm is relaxed
  
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    60 hold, 20 off—longer hold times
    

Contraindications

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

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

Predictors of who will benefit

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

Cervical traction

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  Force 5-20 pounds
  
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  Consider 5 Ds for vertebral artery/ c-spine
  
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    Dizziness
    
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    Diplopia
    
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    Disarthria
    
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    Disphagia
    
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    Drop Attacks
    

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
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

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  Iliolumbar ligament- L4/L5 transverse processes to iliac crest, restricts all planes of movement (extension and opposite side flexion), covers superior aspect
  
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  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
  
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  Interosseous- limits posterior gapping, can palpate below PSIS, tested with posterior gapping test
  
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  Long dorsal ligament- limits counternutation
  
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  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
  
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  Sacrospinous- limits nutation, deep lig, lateral sacrum to ischial spine, prevents forward rotation of sacrum
  

Outer tube muscles: compress on inferior muscle’s side

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

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

Nutation- anterior + inferior movement

Counternutation- 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 ½ 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

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
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

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

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

Anatomy C1:

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

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

-holds C2 to occiput

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

**ROTATION & SIDEBENDING OCCUR IN OPPOSITE DIRECTIONS**

Avoid treatments that combine EXT and ROT

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  These progressively occlude VA:
  
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    Rotation→ rotation + extension → Rotation + extension + traction
    

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  Agg: N/T around lips, dbl vision, dizziness, dysarthria, dysphagia, drop attack
  
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  Rotation and extension is more painful (occlude the artery).
  
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  Hx: MVA (extension injury), trauma (compression from osteophytic or disc,
  
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  Stretching, kinking). Cervical instability and fractures, manipulation or
  
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  Sudden neck movements.
  

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  Agg: reproducible with neck movmt, posture, position. 50% are occipital (may radiate into ear) and suboccipital.
  
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  Ease: medications, change in position/posture, lying down.
  
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  Hx: hx of neck pain. Due to hypo/hyper mobility, DJD, trauma.
  
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  Objective: AROM, alar lig, transverse lig, central PA’s,
  
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  Manual Therapy: Central PA’s, traction,
  
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  Ther-ex: cervical isometrics, thoracic stretching/strengthening Postural correction, scap squeezes, neck stretches.
  

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

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  Agg: Pain is dominant complaint. Cautious/apprehensive with active Movements of neck. 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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  Hx: MVA. Special questions: hearing or vision disturbances? Dizziness? Feelings of unsteadiness? Depression or fatigue? Irritability? Insomnia?
  
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  Light-headed? 5 D’s? Vertebral artery?
  
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  Objective:, ALAR lig, transverse lig, central PA’s, AROM
  
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  Manual Therapy: Central PA’s, traction,
  
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  Ther-ex: Chin nod, cervical stretches, AROM, scap squeezes.
  

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  A-O dislocation: 100% fatal, shear force of occiput on atlas
  

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  Fracture of posterior arch of atlas: result of vertical compression; results in massive subocc HA
  

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  A-A dislocation: rupture of transverse ligament,
  
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  JEFFERSON Fx: fracture of ant. and post. arches of C1, usually from blow to back of head
  
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  DENS Fx: common in MVA, seen on open mouth x-ray, Dens will Fx b4 alar ligaments will tear
  
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  Hangman’s Fracture: results in dens into brainstem, not always fatal
  
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  Rotary A-A Subluxation: face mask injury
  

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

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  Each pair of vertebrae in this region is connected by a number of articulations: a pair of zygapophyseal joints, the uncovertebral joints, and the intervertebral disc
  
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  very little bony stability
  
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  Intervertebral foramina
  
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    principal routes of entry and exit for the neurovascular systems to/from vertebrae
    
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    intervertebral foramen decrease with full extension and ipsilateral side bending of the cervical spine, uncovertebral osteophytes may compress the nerve root and cervical cord posteriorly
    

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  Ligaments
  
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    Anterior longitudinal(ALL).
    
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      narrower in the upper cervical spine but is wider in the lower CS than in TS
      
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    Posterior longitudinal(PLL).
    
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      considerably thicker in the CS than in the thoracic & lumbar regions
      
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  Neurology
  
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    cervical spine is the only region that has more nerve roots than vertebral levels
    
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    structures supplied by the upper three cervical nerves can cause neck and head pain
    
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    mid to lower cervical nerves can refer to shoulder, anterior chest, upper limb, and scapular area
    

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  Segmental side bending is extension of the ipsilateral joint and flexion of the contralateral joint
  
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  Rotation, coupled with ipsilateral side bending, involves extension of the ipsilateral joint and flexion of the contralateral
  

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  causes neck muscles to lose blood, suffer damages, fatigue, strain, cause pain, burning and fibromyalgia.
  
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  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. 
  
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    this is why it takes time to correct FHP. 
    

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  Screen!! the patient first →Instability, trauma, 5Ds,
  
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  The examination must be graduated and progressive so that the testing can be discontinued at the first signs of serious pathology
  
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  Hx: pain source, MOI, Aggs= washing hair, turning around in car, getting dressed, reading
  

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  Combined motion testing
  
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    A restriction of cervical extension, side bending and rotation to the same side as the pain is termed a closing restriction.
    
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      Can interfere with nerve root
      
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      Treat differently, may combine movement to facilitate closing
      
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    A restriction of cervical flexion, side bending and rotation to the opposite side of the pain is termed an opening restriction
    
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  Special Tests
  
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    Foraminal compression
    
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      Fingers laced across top of head,
      
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      Axial compression, looking for increased symptoms
      
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    Axial distraction
    
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      Tell them you are going to cover their ears
      
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    Upper limb neural tension →Median, Ulnar, Radial
    

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

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  Agg: extension, rotation to painful side, prolonged flexion. ADL’s limited,
  
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  Speed of movement altered, driving and sitting is uncomfortable. Cloward
  
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  Sign, ache/stiffness, may or may not have distal sx’s (nerve root involved).
  
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  Hx: Not associated with incident. May be related to sustained posture. Slow
  
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  Onset or wake with pain. May have history of MVA.
  
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  Objective: central PA’s, PPs, dermatomes, reflexes, Spurling’s test, AROM
  
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  Manual Therapy: Central PA’s, unilateral PA’s, traction.
  
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  Ther-ex: postural correction, chin nod.
  

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

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

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

Joints

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. Allows rotation.

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

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.

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.

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