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

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  Facets innervated by medial branch of dorsal primary ramus
  
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  Ligament
  
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    Anterior longitudinal ligament- covers anterior disc, anterior vertebral bodies
    
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    Posterior longitudinal ligament- prevents posterior disc protrusion, highly innervated by recurrent sinovertebral nerve
    
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    Interspinous ligament- connects spinous processes
    
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    Supraspinous ligament- covers spinous processes,
    
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    Ligament flavum- prevents separation of lamella or pedicles during flexion, attached lamella to lamella or pedicle to pedicle
    
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  Deep muscles- “core”, multifidi, quad lumoborum, interspinalis, TrA
  

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  Multifidus- segmental muscle, transverse and spinous processes, segmental stability
  
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  TrA- linea alba to thoracofascia, anticipates movement of limbs and keeps spine stable, if weak then doesn’t fire
  

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  Articulation- inferior articular process on one vertebrae on superior articular process of vertebrae below
  
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  Cervical-
  
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    small body,
    
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    superior lip of body is concave and forces a U-shape (uncovertebral joint),
    
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    short, bifurcated spinous processes
    
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    facets oriented 45 degrees from horizontal,
    
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    SB and rotate same directions,
    
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    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
    
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  Thoracic-
  
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    heart shaped body,
    
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    facets for ribs to attach,
    
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    facets in coronal orientation, rotation,
    
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    prevents forward translation, rotate and side bend opposite,
    
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  Lumbar- long spinous processes, large bodies, facets in sagittal plane,
  
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    translation, resists rotation, rotate and side bend opposite side
    
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    L5- coronal plane for facets
    

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  Flexion- glide superior and anterior, anterior disc is compression, limited by intraspinous ligament, 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
    
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  Extension- glide inferior and posterior, limited by spinous processes, anterior longitudinal ligament, pars interarticularis often injured
  
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  SB- facets open up on one side (contralateral to bend), ipsilateral Z joint glides inferiorly, contralateral Z-joint glides superiorly
  
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    Pain with pars interarticularis, OA (CPP of facets)
    
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  Rotation- ipsilateral facet opens up, contralateral facet compressed, opens lateral foramen, optimal stimulus for disc
  
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  Distraction – decreases pain, therapeutic effect on discs, facet joints, and ligaments
  

Intervertebral Disc:

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

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  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,
  
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  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
  
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    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
    
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    Outer annulus and end plates are highly innervated
    

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  Vertebral end plate- .6-1 mm thick of cartilage above and below the nucleus pulposus
  
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    If have a break in the end plate then bone marrow and blood from the vertebrae fill in to cover the nucleus pulposus
    

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   Nuclear movement- Nucleus and annulus move together as one
   
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   Tension- Annulus resists tension from rotation, compression and distraction
   
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   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 can’t WB as load or as much
   
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   Distraction- Strains the fibers, annulus fibrosus resists
   
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   Shear- Fiber orientation prevents shearing in all directions, only those fibers oriented in the line of stress can prevent that direction of shear
   
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   Rotation
   

Nutrition for Disc:

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  Passive- imbibitions, diffusion due to concentration gradient
  
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  Active- spinal motion
  
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  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)
  
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  Tallest in morning bc at night the discs are hydrated (passive nutrition) and during the day mvmt takes 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

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  Intra-spongy nuclear herniation: “soft disc”, break in endplate  nucleus pulposus spreads into bone  dries out, presents as LBP, localized pain, WBing and compression cause pain, can cause Schmorl’s nodes later in life
  
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  Protrusion- contained herniation
  
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    Normal disc
    
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    Nucleus escapes periphery, may or may not cause pain
    
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    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
    
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    Nucleus in outer 1/3 edge of annulus and pushing on spinal nerve, still contained in annulus fibrosus, pain in gluteal/buttock area, no radiating symptoms, morning stiffness, sit in slouched position
    
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  Extrusion- nucleus out of annulus, pain, + SLR, + Slump, neurological signs and symptoms, irritation of dura mater
  
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  Sequestration- free fragment of disc, may migrate
  
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  Prolapse
  

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

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

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  Usually age related (65+ yo), osteophytes, congenital
  
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  Localized pain, back and leg pain, bilateral radiating symptoms, neulogical claudication (cramping in calf, thigh or buttocks)
  
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  Aggravated by extension, prolonged standing or walking, walking downhill, lying flat
  
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  Eased by flexion, sitting, squatting, walking uphill, bike riding
  
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  Flat back posture (lose lordosis bc don’t 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
  
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  Must manage or else surgical intervention
  

Vascular Claudication:

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  Plaque builds up inside the arterial walls  PVD  decrease in circulation
  
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  TM test- walking produces pain in calf, incline produces more pain, stop walking and pain goes away, worse with increased effort or incline
  
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  Change in spine position doesn’t affect pain
  
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  Aggravated by walking on level surface or up hills (buttock or calf pain)
  
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  Eased by stopping walking or supine lying
  
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  Skin color changes, temp changes, hair loss, LE cramping or tightness (calf muscles), no peripheral pulse
  
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  Rarely have back symptoms or problems
  

Acute Facet:

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  Sharp unilateral pain over facet, increased pain with stretching and compression of joint, local tenderness with palpation, feels like back is locked into position, no peripheral symptoms
  
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  History of unguarded movements (flexion and rotation)
  
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  Limitations with facets opening
  
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  Do manual therapy unilateral PAIVMs, manipulations, traction, mobility exercises, modalities
  

Chronic Facet:

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  Unilateral pain, less sharp over facet, increased pain with stretch of joint, local tenderness with palpation, stiff
  
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  History of past acute facet
  
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  Unilateral PAIVMs, traction, stretching and muscle re-education, ultrasound to decrease the inflammation
  

Acute Nerve Root (ANR):

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  Irritation/inflammation/compression to nerve root
  
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  Distal symptoms are greater than proximal, starts as proximal ache and then gets more distal
  
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  Severely limits ROM and activity, neurological exam are level specific, modalities, manual traction in supine or SLing, lumbar rotation
  
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  Epidural steroid injection 1^st to calm symptoms
  

Chronic Nerve Root (CNR):

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  Chronic irritation or nerve root
  
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  History of acute nerve root injury, LBP, arthritic changes, slipped disc
  
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  Gradually symptoms return to lesser degree, proximal symptoms are worse than distal
  
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  Minimal limitation of activity, minor responses in neuro exam, localized thickness of tissues with palpation, stiff at segment
  
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  May have pain with ROM OP, SLR tests reproduces symptoms, + slump test
  
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  Unilateral PAIVMs, rotation, traction, treat neurodynamic signs, mobility exercises, segmental muscle re-ed
  

Instability:

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  Defect in pars interarticularis of the spine (separated), most common at L5-S1, then L4-L5
  
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  Usually in teens, congenital or repeated trauma activities- flexion or extension activities
  
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  Asymptomatic or pain with extreme extension and rotation, symptoms fluctuate, severe LBP after vigorous activity, must constantly change positions, “catch” pain, + Gower’s sign (can flex but hard to get back to neutral), hinge (skin crease) at one segment with extension, central PAs are painful and have different end feel
  
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  Flexion decreases pain
  
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  Aggravated by end of ROM, flexion at 30-40 degrees (hesitation point)
  
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  Need to avoid aggravating activities, extreme ROM and sustained posture
  
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  Work on stabilization exercises, use external support (lumbar brace)
  

Spondylolisthesis:

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  Pars interarticularis slips due to spondylolysis
  
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  Anterior slippage- superior vertebrae moves anterior on vertebrae below it
  

Nerves:

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  Nervous system gets 25% of circulating blood
  
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  Need blood, space, and movement!
  
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  Have axoplasmic flow continuous with nervous system- flow goes in both directions
  
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  If myelin sheath is damaged then more receptors come to help heal  hypersensitive
  
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  PTs treat the disruption
  
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  Bad to immobilize
  
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  Fascia, dura mater, pia mater, meninges, unhealthy tissue, and decreased foramina space can impact neurons
  
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  Responds to pressure, absence of movement and lack of blood supply
  
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    Like movement and blood supply, don’t like pressure
    
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  Median nerve slides 2 cm in upper arm and 1 cm with wrist and fingers
  

Sick nerve:

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  AIGS- abnormal impulse generating sites (too much input  hypersensitivity)
  
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  Types: double crush or reverse double crush
  
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    Double crush- proximally compressed nerve, makes it vulnerable to secondary distal lesion
    
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    Reverse double crush- distal neural compression, causes effects on proximal nerve lesion
    
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  Causes ischemia, inflammation, and disruption of axoplasmic flow
  
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  Pain can be caused by changing the ion channels along the axon or injury  inflammation  C-fibers increase the concentration of substance-P
  

CNS- dura mater, arachnoid mater, pia mater

PNS- epineurium, perineurium, and endoneurium, covered by 50% connective tissue

If nerve is immobilized…nerves become more resistant to tensile stress (ROM)

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:

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  Can occur anywhere there is a change in direction of the nerve or joint it goes around (or connective tissue it goes through)
  
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  Common at C6, shoulder and elbow
  
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  Causes: trauma (direct blow or traction), posture, overuse (microtraumas), arthritic changes, soft tissue scarring, compression, chronic condition
  
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  Detensioned posture- thumb in pocket, hard to put elbow up with HBH (to do hair or put on shirt), protracted shoulder girdle, elevated scapula, head side bent towards affected UE, supports affected arm
  
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  Presents with detensioned posture, irregular active mvmts, may or may not have neurological signs, 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

*don’t 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

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

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

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 (+ Gower’s 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

Unloading- supine with legs up, hips at 90, pain relief position, no tension or rotation from the pelvis

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

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

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   Symptoms that are proximal move distally with certain movements
   
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   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:

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   Passive support- osseoligamentous system, bones, ligaments
   
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   Active support- muscles
   
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   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

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  Neutral zone- movement occurs with little resistance
  
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  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

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  Due to instability in passive system (bones, ligaments), identified by radiographs, assessed with passive intervertebral or accessory movement testing
  
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  Due to active system- unstable at low loads, decreased cross sectional area, decreased contraction with palpation, mm fatigue
  
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  Due to neural system- change in muscle onset timing, change in pattern of recruitment, change in 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)

Negative factors- negative prone instability test, absence of lumbar hypermobility, FABQ score of 9 or higher (pt doesn’t think they will get better)

Rectus abdominis, internal obliques, external obliques, lateral fibers of quadratus lumborum, thoracic part of lumbar iliocostalis

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

Multifidus- controls the neutral zone, lordosis, tension on the thoracolumbar fascia, adjusts spine, controls pelvic rotation, intersegmental muscle

TA- 1^st 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

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