-
LBP is responsible for ____% of all lost workdays in the US
25%
-
loss or abnormality of physiological, psychological or anatomical structure or function---I can't bend over cause my back hurts
impairment
-
the inability to engage in age-specific, gender-related and sex specific roles in a particular social context and physical environment---I cant get a job cause of my back pain
disability
-
impairment rates have remained largely ____over recent years
stable
-
disability rates have ______ exponentially
grown
-
worst combination: (general spine info)
perception that LBP episode is work-related plus the absence from work for more than 2 weeks.
-
risk factors for back pain:
age
peaks for men in their 50s
increases after 50 in women
-
risk factors for bak pain:
level of physical fitness
better, less likely to have LBP
-
risk factors for back pain:
cigarette smoking
more likely to have LBP and last longer (decreased blood flow)
-
risk factors for back pain:
jobs that subject the individual to vibration (fatigue of collagen)
truck driver
-
risk factors for back pain:
jobs
low job satisfaction
-
pathomechanical basis of back pain tx
link impairments to functional deficits (pain with flexion)
foundation of PT diagnosis
identify poorly tolerate physiological stresses
tx is designed to avoid thoses stresses
-
pathoanatomical basis of back pain tx
anatomical structure at fault (herniated disc)
gives anatomical context in which tx occurs
-
positives of pathomechanical basis
do not rely on unsubstantiated diagnosis related to examiner bias
goal in function change, tx related to functional change
allow for tx without specific anatomical diagnosis
-
negatives of pathomechanical basis
no structural framework to make decisions
importance of constant eval of tx
lessens ability to give pt a direct "this is what is wrong with you"
-
positives of pathoanatomical basis
gives you a frame of reference to make decisions
able to give patient a clear explanation of what is wrong with them
-
negatives of pathoanatomical basis
80-90% of disabling LBP cannot be given a precise anatomical diagnosis
different professionals will give different diagnoses
if you follow "correct" tx for a diagnosis that might not be right and you could miss what would really help pt
-
segments:
cervical
thoracic
lumbar
sacral
coccygeal
- C-1-7
- T-1-12
- L-1-5
- S-1-5
- Coccygeal-1-4
-
what does sacralization mean?
L5 is fused with sacrum
-
what does lumbarization?
S1 not fused with sacrum
-
cervical and lumbar have what kind of curve?
lordosis (convex anterior)
-
thoracic, sacral and coccygeal have what kind of curve?
kyphosis (convex posterior)
-
these spinal curves do what for the spine?
increase flexibility
help with shock absorbing
maintain stability at IV joints
-
what causes cervical curves?
entirely disc shape (cervical vertebral bodies are shorter anteriorly than posteriorly)
-
what causes thoracic curve?
vertebral bodies are wedged shaped
disc is equal height
-
what causes lumbar curve?
mostly disc
lumbar vertebral bodies are shorter anteriorly than posteriorly
-
components of anterior vertebral body
body and disk
-
components of posterior vertebral arch
pedical, facets, transverse process, lamina, spinous process
-
differences of vertebrae:
cervical
uncinate processes
foramina trasversarii
-
difference of vertebrae:
thoracic
articular facets for the ribs
-
difference of vertebrae:
lumbar
mamillary bodies-attachment of multifidi muscles
-
anterior portion of the motion segment:
weight bearing
- 85%
- body consists of spongy bone
cartilaginous end plates btwn disk and body
body has ability to deform and act as shock absorber
-
when shifting weight what is involved with flexion, then what happens with extension?
flexion--disk (increased during WB)
extension--facets (decreased during WB)
-
posterior portions of the motion segment:
weight bearing
- 15%
- increased in extension, decreased in flexion
articular facets covered in hyaline cartilage
-
what is the pars interarticularis?
spot where lamina takes origin from the pedicle
(dog in the sagittal plane)
-
what is spondylolysis?
fracture of pars interarticularis
(decapitated dog)
-
zagopoophyseal joints
consists of cartilaginous surface, fluid filled capsule
capsule and synovium may be redundant have meniscal folds that can become trapped btwn articulating surfaces
-
C1-C2 facet
transverse plane
much rotation
-
C3-C7 facet orientation
45d from transverse plane and parallel to frontal plane
gradually changing to perpendicular to the transverse plane remaining parallel to frontal plane
allows for flexion, extension SB, and rotation
-
thoracic spine orientation
60d from transverse plane and 20d to the frontal plane
lateral aspect of the facet tipped anterior
upper thoracic and lower thoracic are termed (transitional)
motion limited by ribs
-
lumbar spine orientation
90d to transverse plane and 45d to the frontal plane
lateral aspect of facet tipped posterior
allows flexion, extension, and SB, almost no rotation
-
gross facet asymmetry is present in approx ____% of the normal, pain free population
20%
-
facet joint coupled motions--freyettes law
cervical
SB and rotation to SAME side
-
IV disk
none between C1 and C2 and occiput and C1
make up 20-33% of total vertebral height
greater disk height, lower body height = more ROM
-
3 components of disks
nucleus pulposus
annulus fibrosis
cartilaginous endplate
-
nucleus pulposus info
extension versus flexion
extension causes disk to move ANTERIORLY
flexion causes disk to move POSTERIORLY
-
nucleus pulposus info
normal weight bearing
normal weight bearing equally distributed over disk
-
nucleus pulposus info
degeneration/dehydration
with degeneration or dehydration of disk, WB shifts to outer area of disk that happens to be innervated
not good
-
do extension/flexion exercises aid in re-hydrating the disk, equalizing pressure
EXTENSION
-
outer 1/3 of annulus fibrosus is ______&________ which can be a source of pain and inflammation
innervated and vascular
-
if annulus has been torn and goes thru repair process vascularity and innervation can creep _____ causing it to be more _____than normal
inward
central
-
healthy disk:
flexion causes anterior annulus to _____
nucleus to move _____(ant/post)
annulus compresses
nucelus moves posterior
-
healthy disk;
flexion causes posterior annulus to _____ and tighten resisting the motion of the nucleus
elongate
-
with rotation or torsion the disk is ____(compressed/elongated)
compressed
-
what makes up the intervertebral foramen:
superior and inferior border
pedicles
-
what makes up the intervertebral foramen:
posterior border
capsule of facet
ligamentum flavum
-
what makes up the intevertebral foramen:
anterior border
dorsum of the intervertebral disk
posterior longitudinal ligament
-
anterior longitudinal ligament:
where does it connect to?
what does it resist?
is it innervated?
narrow band from occiput and broadens as it descends from C3 to sacrum
resists hyperextension
richly innervated
-
posterior longitudinal ligament
where does it connect to?
connect to annulus? vertebral bodies?
innervated?
occiput to the sacrum, posterior surface of the vertebral bodies, anterior aspect of the neural canal
attached to annulus, not vertebral bodies
richly innervated
-
ligamentum flavum:
segmental or continuous?
where does it go from?
what does it do?
when is it most taught? (flex/ext)
segmental
runs from lamina from C2-S1
helps retract capsule of facets so it doesnt get caught in facet joint
remains taught in extension
-
what are the 3 layers of the thoracolumbar fascia?
anterior, posterior, middle
-
thoracolumbar fascia arises from?
transverse and spinous processes that blend with quadratus lumborum and transverse abdominal
-
contraction of ____ _____ muscles tightens thoracolumbar fascia so it functions as part of an active mechanism for pulling the vertebrae posteriorly and controllin shear during lifting
erector spinae
-
on full flexion back muscles are silent and fascia is.....
resister against further flexion
-
on extension from fully flexed position, _____ ____ and _____ act in concert with the thoracolumbar fascia to initiate extension
glute max and hamstrings
-
the thoracolumbar fascia plus abdominal muscles help do what to the vertebral column?
stabilize
-
facet joint capsules
have 2 layers
innervated and vascularized
-
what 3 structures are not pain producing (innervated)?
spinal cord, nucleus pulposus, inner annulus
-
latissimus dorsi does what to the lumbar spine?
stabilizes the lumbar spine
-
glute max stabilizes the spine along with what else?
thoracolumbar fascia
-
activity of the lumbar spine muscles is low in relaxed ____and alternates with low levels of activity during ___ ___
standing
body sway
-
there is a small ___ (incr/decr) in activity of lumbar muscle in sitting
increase
-
during flexion from standing to sitting, ____ and _____ are active until full flexion is reached then they are quiet
glutes and erectors
-
______are very powerful low back extensors
multifidi
-
______ _____ attachements at L4 and L5 gradually turn into the iliolumbar ligament in your teens
quadratus lumborum
-
what is neutral spine?
not full posterior pelvic tilt
-
beginning spinal stabilization exercises
hip hinging
mass mmt patterns
sitting UE/LE progressions
bridging
beginning squat
advanced sqaut
-
ADLs progression in stabilization
hip hinging
hip hinging
sitting
sit to stand
stand to sit
-
mass mmt patterns in beginning stabilization
supine
sidelying
prone
prone on elbows
all 4s
kneeling
1/2 kneeling
stance
-
intermediate stabilization program
all 4s
advanced bridging
wall slides
swiss ball
-
advanced stabilization program
practice holding for longer periods
use weights
-
type of disk bulge:
no bulge
protrusion
-
type of disk bulge:
bulge but outer annulus remains intact
prolapse
-
type of disk bulge:
annular fibers disrupted, nuclear material still in 1 piece
extrusion
-
type of disk bulge:
free nuclear material present
sequestration
-
type of disk bulge:
nucleus breaks thru inner annular rings, finally reaching the innervated and vascular portion of the disk. no bulge noted
intra-diskal derangement
-
peripherlization = _____
centralization= ______
bad
good
-
generally...what is postural syndrome?
intermittent pain brought on by adoption of a position that is stressful for too long a time period
-
characteristics of postural syndrome (6)
- slow onset
- intermittent pain
- prolonged stress
- age 30 or under
- sedentary
- diffuse non-specific pain that gets worse as day goes on
-
on exam...postural syndrome will present with
no....
deformity, loss of mmt, pain on mmt, radicular symptoms
-
tx for postural syndrome
maintain perfect posture for 10 days
must correct muscular imbalances
-
how are dysfunctions named?
named for what you can't do...
example...can't extend? = extension dysfunction
-
characteristics of dysfunction (5)
- stiffness, sharp pain towards end range
- intermittent pain
- decr ROM
- over 30 am
- pain worse in AM
-
on exam of dysfunction
- poor posture
- deformity not common
- always loss of mmt
- pain at end range
- when you stretch it it hurts, when you left off its fine
- no radicular sx
-
tx of dysfunction
- might take 4-6 weeks
- stretch to cause some discomfort
- 10 reps 10 times a day good start
-
what is derangement syndrome?
symptom arising from motion segment
aka disk bulge
-
characteristic of derangement (7)
- sx sudden or gradual
- insidious onset
- constant pain that incr/decr with certain postures/motions
- pain thru range (before resistance) ACUTE
- early 40s
- may be worse in AM
- may have radicular sx
-
large derangements feel better when.....
lying down
-
small derangement feels better when.....
slightly active
-
on exam for derangement
- have deformity
- centralization of sx
- decrease ROM
-
with posterior-posterior/lateral bulges _____(flex/ext) might be VERY limited and painful (no _____periph/central of sx)
_____(flex/ext) will be painful (possibly limited) does cause peripheralization of sx
extension
peripheralization
flexion
-
with flexion if symptoms peripheralize suggests a what...?
DISK problem (derangement)
-
with extension if symptoms peripheralize suggests a what...?
STENOSIS
-
classic posterior/lateral disk
lateral shift--most shift away from disk bulge, but can depend on axillary or shoulder
decrease lordosis
painful thru range extension, centralizes sx
flexion peripheralizes sx
-
tx of derangement
reduction
maintainence of reduction
recovery of function
prevention of recurrence
-
requirements for having an unstable spine (4 characteristics)
1. average SLR ROM 91d or more
2. + prone instability
3. + aberrant movements
4. less than 40 yrs
-
disk generally presses on nerve root of segment ( at/below/above)
below
L1 on L2 root, L2 on L3 root
-
large posterior disk bulge at L4 can do what
can include all nerves in cauda equina and can result in bowel/bladder sx
-
when symptoms are worse with sitting suggests?
deformation of the spine/disk (flexion)
-
when symptoms are worse with standing?
extension/ wt on facets or extension dysfunction (extension)
-
do you do a scanning exam on every back patient?
YES!!
-
lumbar myotome:
L2
L3
L4
L5
S1
S2
- L2=hip flexion
- L3=knee extension
- L4=ankle dorsiflexion
- L5=great toe ext
- S1=plantar flex/eversion
- S2=knee flexion
-
lumbar dermatomes
- L1 groin
- L2 medial thigh
- L3 medial patella
- L4 medial malleoli
- L5 top of foot
- S1 lateral border of foot
- S2 behind knee
-
what is the SI compression test?
push down on ASIS for 60 secs
-
what is the SI distraction test/
patient sidelying, push down on iliac crests for 60 secs
-
standing ROM:
flexion
extension
SB
rotation
flex-40-60d
ext- 20-35d
SB 15-20d
rotation 3-18d
-
what are aberrant movements?
look for hitching or odd non uniform movements
indicative of unstable segment(s)
-
what is prone instability test?
prone PA glide contracting back extensors raising legs
if less painful when contracting back extensors + sign
-
standing (static) may be painful
prone lying --may be painful
extension in prone--pain at end range that dissipate quickly no peripheralization
repeated ext in prone--pain at end range that dissipate quickly no peripheralization
this explains what?
extension dysfunction
-
flexion in standing--pain during (peripher sx)
flexion in sitting--pain during (peripher sx)
repeated flex it sittin--pain during (peripher sx)
prone lying--may be pain (central sx)
ext in prone-pain during limited
repeated ext in prone --pain during limited (central sx)
this explains what?
posterior-lateral derangement
-
describe acute, severe LBP
patient complains/condition so severe that we cannot adequately evaluate it
-
exam for acute/severe LBP
- make sure bowels/bladder ok
- make sure the pain is constant and unchanging
-
acute/severe LBP contraindications/precautions
do not cause increase in pain after tx
NO PERIPHERALIZATION OF SX!!
-
inflammatory stage of acute/severe LBP characteristics (6)
- protect body mechanics
- anti-inflams
- grade 1 and 2 osteo/artho kinematic mobs
- PROM within pain free range
- gentle strengthening
- general conditioning
-
describe a muscular strain
definite history of trauma-they know they did it at the time
-
AROM and muscle strain
limited, possibly in both directions
TOWARD action of the muscle because of pain with contraction
LIMITED away from action of muscle due to pain with stretch
-
PROM and muscle strain
pain with stretch
-
management of muscle strain
do not cause overall increase in symptoms with or after tx
NO PERIPHERALIZATION of sx
-
disk derangement:
flexion produces______(periph/centr)
extension produces _____ (periph/centr)
flexion.......peripheralization
extension...........centralization
-
management of extension dysfunction
- proper posture
- prone on elbows
- add belt fixation
- add PA mobs
-
management of flexion dysfunction
- proper posture
- supine knees to chest
- ab strength
-
(reduction of derangement)
--correcting the deforomity
decrease lordosis (prone lying with stomach on pillows)
lateral shift (prone lateral shift)
-
if you have a shoulder bulge which side do you side bend to?
AWAY
-
if you have an axillary bulge which side do you side bend to?
TOWARD!!
-
(reducing the derangement)
--start with extension (flexion for ant. bulge)
prone lying
prone lying in ext
press ups
-
(reducing the deranagement)
--progressions if not improving
therapist ext mobs
over corrective lateral shift in prone if posterior lateral
-
(maintenance of reduction)
completed after derangement is reduced-pain free or near pain free
proper posture/body mechanics
reduce prone press ups, standing ext
-
(recovery of function)
after symptoms are very stable, symptom free for 3-5 days
lumbar stabs
flex dysfunction? gentle supine to knee to chest no periph of sx
-
(prevention of recurrence)
contd education, posture, general fitness
-
what is the hallmark sign of a facet capsular strain?
sudden, unexpected trauma to the lumbar spine often including a rotational component with acute symptoms that resolve to include increase end range pain with the same motion of the facets
-
with a facet strain there is pain:
on the R side with ______(SB/rotation)
on the L side with ______(SB/rotation)
R side with SB
L side with rotation
-
what is spondylolisthesis?
failure of the pars interarticularis and forward slipping of the vertebrae
-
_____(ant/post) element slips forward, spinous process might go forward somewhat and you will feel and indentation where spinous process is supposed to be
anterior
-
management of spondylolisthesis
NO EXTENSION EXERCISES!!!!
flexion could help manage sx
-
lumbar spinal stenosis
(bilateral/unilateral)
central canal produces _______ symptoms
intervertebral foramen produces _______symptoms
central canal......BILATERAL
intervertebral foramen ...........UNILATERAL
-
symptoms of lumbar stenosis
- extension makes symptoms worse
- flexion makes symptoms better
lumbar pain that might include nagging leg pain
-
management of lumbar stenosis
- educate on body mechanics
- flexion exercises
- address weak abs/tight hip flexors
-
what is ankylosing spondylitis?
progressive joint sclerosis and ligamentous ossification which 1st appears in the SI joints and later spread to the lumbar and thoracic spine and rib cage
-
how does ankylosing spondylitis present?
- between 20-35 yrs old
- vague lower back pain and stiffness
-
management of ankylosing spondylitis
- patient education
- firm bed
- exercise upper back in extension
-
does the C1 vertebrae have a body?
no
-
where does the body of C1 go?
turns into the odontoid process of C2
-
rotation past ____d may lead to kinking of the contralateral vertebral artery
ipsilateral vertebral artery will kink at _____d rotation
50 contra
45 ipsil
-
what direction do the superior facets face?
upward and backward
-
what direction do the inferior facets face?
downward and forward
-
because of the placement of the facets in the cervical spine this causes rotation and side bending in what direction?
SAME DIRECTION
-
nucleus is generally more ______ant/post in the disk when compared to lumbar spine
anterior
-
what is the capsular pattern of the cervical spine?
side flexion and rotatation equally limited
extension
-
a tight capsule on R is most limited in what?
SB on R
rotation on R
extension
-
what are the cervical mytomes?
- C1, C2=neck flexion
- C3-neck SB
- C4-shoulder elevation
- C5-should abduction
- C6-elbow flexion
- C7-elbow extension
- C8-thumb extension
- T1-adduction of hand intrinsics
-
what are the cervical dermatomes?
- C3-clavicale
- C4-top of shoulder
- C5-distal lateral bicep
- C6-tip of thumb
- C7-tip of middle finger
- C8-tip of little finger
- T1-distal tricep
- T2-axilla
-
when do you do a shoulder clearing?
only do if sx are at shoulder or below
-
what is the sharp purser test?
flex the head, web space of PTs hand goes on C2, feel clunk = positive
-
what is the anterior shear test?
supine and bring head up and forward
+ test = (B) symptoms down arms
sliding occurs if transverese ligament torn or dens fractures
-
Right side pain with right SB and right rotation suggest inability of the facet on painful side to glide _______(downward or upward)
downward
-
right side pain with left SB and left rotation can suggest inability of the facet on the painful side to glide _____(upward/downward)
upward
-
pain on right side that increases with right side bending and left rotation can suggest what?
impingement of capsule of facet or painful facet joint surfaces themselves
-
cervical flexion with palpation---no change
repeated flexion--no change
cervical ext with palpation --incr in pain no periph ERP
repeated ext--incre in pain no periph ERP
coupled motion toward painful side--incr pain no periph ERP
coupled motion away painful side--incr pain no periphe ERP
suggests what?
R side facet dysfunction (superior cant glide down)
-
cervical flex with palpation--R upper trap pain PDM
repeated flex--incr cervical R upper trap PDM
cervical ext with palpation--cervical pain PDM
repeated ext--cervical pain decr r upper trap PDM
couple motion toward pain side--cervical R upper trap pain PDM
coupled motion away --no change
suggests what?
R posterior derangement
-
what is acute facet impingement?
sudden, unexpected trauma to the C spine often including a rotational component with acute symptoms that resolve to include increase ERP with SB TOWARD PAINFUL SIDE AND ROTATION AWAY FROM PAINFUL SIDE
-
treatment for acute facet impingement
attempt to dislodge the impingement
-
what ribs articulate with a single vertebra?
1, 10, 11, 12
-
ribs ______articulate with 2 adjacent vertebrae and intervening intervertebral disc
ribs 2-9
-
T1 facet position
superior facet faces up and backward
inferior facet faces down and forward
-
T2-T11 facet position
superior facet face up, back and slightly lateral
inferior facet face down, forward and slightly medial
-
Rule of 3's:
T1, T2, T3
spinous processes AT SAME LEVEL AS BODY
-
Rule of 3's
T4, T5, T6
spinous processes ANGLE DOWN AND ARE LOCATED 1/2 BETWEEN LOWER VERTEBRAE
example (T4 spinous process half way between T4 and T5)
-
Rule of 3's
T7, T8, T9
spinous processes are located ONE FULL VERTEBRAE BELOW
example (T7 located in same plane at T8)
-
Rule of 3's:
what do T10, T11, T12 do?
T10...follows suit with T7-T9 one full vertebrae below
T11 follow suit with T4-T6 halfway between vertebrae
T12 follows suit with T1-T3 at same level as body
-
noraml, developmental, asymptomatic small invasions of the vertebral body by the nucleus protruding superiorly.
most common in lower thoracic and upper lumbar spine
Schmorl's Nodes
-
Scheuermann's Disease is what?
Where spinous processes become very sharp over time
occurs between 13-16
-
if there is a problem with the upper thoracic do you do cervical or lumbar myotomes?
if there is a problem with lower lower do you do cervical or lumbar myotomes?
UPPER----CERVICAL
LOWER----LUMBAR
-
what is levator scapulae syndrome?
stiff neck and have difficulty with rotation, SB, flexion
patient will complain of thoracic pain near the upper scapular region
(rotation and SB to the R affected by L levator scapulae)
-
if unilateral levator syndrome: will have _____SB and rotation ______ and flexion
extension will be full
decrease
away
-
if bilateral levator syndrome: will have bilateral ______in SB and rotation
decrease
-
rib disorder:
elevated/exhalation restriction
rib will not descend with exhalation
past trauma
pain usually posterior
pain with full exhalation
-
rib disorder:
depressed/inhalation restriction
rib will not ascend with inhalation
pain with full inhalation
-
what is nutation?
top of sacrum goes forward
-
what is counternutation?
top of sacrum goes backward
-
when the ilium goes anterior it is also referred to as ____
counternutation
-
when the ilium goes posterior it is also referred to as _____
nutation
-
patient history for SI joint issue:
unilateral pain ______ SI joint
if symptoms are periph/central means SI joint issue
@ or below SI joint and peripheralization
-
if you have a hypo right PSIS what does this mean?
think vorlauf
right ilium rotated early
-
if you have a hyper right PSIS what does this mean?
think vorlauf
right side doesnt move because of laxity of joint
-
what is the 1st verse and chorus of the MU fight song?
1st verse: old missouri, fair missouri, dear old varsity, our hearts that fondly love thee, here's a health to thee
- chorus: Proud art thou in classic beauty,
- Of thy noble past;
- With thy watchwords, Honor, Duty,
- Thy high fame shall last.
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