the spine - mercer county community college - mccc - west windsor, nj

THE SPINE

PTA 216

ORTHOPEDICS IN PTA

The Spine

• The functions of the spinal column include:– Supporting the majority of body weight

– Supporting the head, trunk, and UEs against the forces of gravity

– Protection of the spinal cord

– Shock absorption

– Providing a stable structure by which we can maintain an upright posture

Magee, 2008. pg. 92

Spinal Design

• 33 vertical segments, divided into 5 regions:

– Cervical (7)

– Thoracic (12)

– Lumbar (5)

– Sacral (5 - fused)

– Coccygeal (4 - fused)

Dutton, 2012. pg. 259

Spinal Design• 2 functional pillars that assist spine

functionality

• Anterior Pillar: vertebral bodies and

intervertebral disks provide hydraulics,

weight bearing ability and shock-absorption

• Posterior Pillar: consists of articular

processes, facet joints, transverse processes,

and spinous processes. This allows spinal

movement and serves as the attachment for

posterior musculature.

Dutton, 2012. pg. 260

Anatomy of vertebrae

THE INTER-VERTEBRAL DISC

• The inter-vertebral disc

• fibro-cartilagenous tissue

– in between vertebral bodies consisting

• an outer layer (annulus)

• an inner layer (nucleus pulposus)

• The inter-vertebral disc provides:

– Shock absorbtion

– Movement between vertebrae

– Separation between the vertebrae

– To allow passage of nerve roots through the inter-vertebral foramina

Magee, 2008. pg. 516-517

Spinal Mobility

• Flexion:

– Occurs in the sagittal plane

– Anterior portion of the vertebral bodies

approximate and the spinous processes

separate

• Extension:

– Occurs in the sagittal plane

– Anterior portion of the vertebral bodies

separate and the spinous processes

approximate

Dutton, 2012. pg. 262

Spinal Mobility

• Lateral Flexion

– Occurs in the frontal plane

– The vertebral bodies approximate on the side

toward which the spine in bending, and

separate on the opposite side

• Rotation

– Occurs in the transverse pain

– The body of the vertebra will rotate towards the

side in which the person is moving as the

spinous process moves toward the opposite

side

Dutton, 2012. pg. 263

Spinal Mobility

• Shear

– Occurs in sagittal, frontal, and transverse

planes

– When the body of the superior vertebra

translates over the body of the inferior vertebra

• Distraction/Compression

– Occurs in the transverse plane

– Result of longitudinal forces

– Vertebral bodies move either towards or away

from other vertebral bodies

Dutton, 2012. pg. 263

CERVICAL SPINE

Anatomy, Pathology and Treatment Options

Cervical Spine

• Consists of 37 joints, allowing more motion

than any other region of the spine

• Vulnerable to direct and indirect trauma

• Accounts for 15-34% of all outpatient physical

therapy referrals.

Dutton, 2012. pg. 267

Cervical Spine

Injuries to the cervical spine may manifest

themselves as localized

– “pain in the neck”

– or

– radicular

• symptoms that travel away from the site of

injury down one or both upper extremities

Radicular symptoms from the cervical spine may

affect the

– Face

– Head

– Neck

– Shoulder

– UE

– Peri-scapular region

Magee, 2008. pg. 133

Dutton, 2012. pg. 268

Cervical Sprain/Strain

• Result from an overload to the cervical

muscle-tendon unit by way of excessive

forces

– Causes elongation and/or tearing of muscles or

ligaments, edema, hemorrhage, and

inflammation

– Patient complaints:

• Pain

• Stiffness

• Tightness in upper back and/or shoulder

• Occipital headaches

Dutton, 2012. pg. 281

Intervention for Cervical Sprain/Strain

• Pain management

– Cryotherapy and electrical stimulation

• Possible cervical (Philadelphia) collar

• Gentle range of motion

• Strengthening as tolerated

• Postural education

• Self care/ Home Management

Dutton, 2012. pg. 281-282

Cervical Spine

Torticollis

• an abnormal twisting of the neck

• the head is rotated toward the side that muscular

tightness is found.

– may be congenital or acquired

– In many situations of torticollis, the anterior

scalene musculature will be visible when

viewing a patient from the front.

Torticollis

• Treatment for infants with torticollis

– Parent education

– Patient positioning

– Manual stretching activities

Acute Torticollis (Wry Neck)

• Effects young and middle –aged adults

• Typically happens overnight as a result of an

injury to the muscles, joints, or ligaments

while sleeping

• Patient will complain of painful muscle

spasms which will be visible and/or palpable

• Patient will demonstrate significant

limitations with neck mobility

• Patient will most likely hold head in a position

of comfort (leaning towards the side of the

involved muscles)

Dutton, 2012. pg. 285

Acute Torticollis (Wry Neck)

• “Hanging Head” method

– Patient in supine with head in 20 degrees of

extension with or without manual traction for

approx. 5-10 minutes

• Moist heat

• Massage

• Postural education

– -including sleeping with painful side on low,

firm pillow

• Gentle range of motion

– Upper extremities and cervical spine

• Cervical collar PRN for first 24 hours

• Medication as per MD

– Muscle relaxants and analgesics

Dutton, 2012. pg. 285

Cervical Spine

Thoracic Outlet Syndrome

• compression of blood vessels and/or nerves

coming from the spinal cord as they pass through

the space between the clavicle and upper ribs

– Brachial plexus and/or subclavian artery or vein

Dutton, 2012. pg. 283

Thoracic Outlet Syndrome• Chief Complaint: diffuse arm pain

• Other complaints:

– Pain in neck, face, head, upper extremity,

chest, shoulder, scapula

– Upper extremity parasthesia, weakness,

heaviness, edema, ulceration, or Raynaud

phenomenon

Dutton, 2012. pg. 284

Thoracic Outlet Syndrome

• Conservative Treatment

– Correction of postural abnormalities

– Strengthening of weak muscles

– Stretching shortened muscles

– Mobilization by the PT of hypomobile joints of

the shoulder complex, clavicle, and first rib

Dutton, 2012. pg. 284

Special Tests for the Cervical Spine

• The patient is interviewed for signs of VBI.

• Prior to other testing/examination, the practitioner

performs end range cervical rotation in either

sitting or supine and holds test position for 10

seconds while observing for signs and symptoms

of VBI.

• Head is put in neutral for 10 seconds, followed by

rotation to the opposite side for 10 seconds.

Cook, 2013. pg. 129

Vertebral Basilar Instability (VBI) Test

Special Tests for the Cervical Spine

Vertebral Basilar Insufficiency (VBI)Test

Positive results are identified by:

-Dizziness

-Diplopia

-Dysphasia

-Dysarthria

-Drop Attacks

-Nausea

-Nystagmus

Patient should be referred for an appropriate medical consult following a positive response.

Cook, 2013. pg. 129

Special Tests for the Cervical Spine

FORAMINAL COMPRESSION

TEST

• The patient is seated on a

plinth with the examiner resting

the palmar surface of his or her

hands on top of the patient’s

head.

• The patient will then laterally

flex the head while the tester

applies a downward pressure.

– This is to be done with lateral

flexion bilaterally

Konin, 2006. pg. 11

Special Tests for the Cervical Spine

Foraminal compression test• Positive Finding

– increase in pain on the same side that the head is laterally flexed to

– demonstrating possible nerve root compression.

• This would then be compared with dermatomal distribution to find the level of lesion.

**This test should be performed carefully and with caution, especially in patients previously diagnosed with OA, RA, osteoporosis, and spinal stenosis.**

Special Tests for the Cervical Spine

Foraminal Distraction Test

• The patient is seated and the examiner places

one hand under the patient’s chin and the other

hand around the base of the occiput.

• The examiner distracts the patient’s head from

the trunk while the patient remains relaxed.

Konin, 2006. pg. 14

Special Tests for the Cervical Spine

FORAMINAL DISTRACTION TEST

• Positive if the patient reports

– decreased pain

– and/or elimination of pain with distraction

• indicative of nerve root compression with

normal positioning/posture

*****This should not be performed on a patient

who has vertebral instability.*****

STRETCHING ACTIVITIES

FOR THE CERVICAL SPINE

Therapeutic Intervention

Stretching activities for Cervical Spine

Corner Stretch: Pectoralis Minor

Note: Avoid forward head posture during stretch

Dutton, 2012. pg. 288

Upper Trapezius Stretch (Self)

Ensure that the shoulder is in a depressed position

Dutton, 2012. pg. 289

Upper Trapezius Stretch (Manual)

Stabilize scapula into depression and downward rotation

Dutton, 2012. pg. 289

Levator Scapula Stretch (Self)

Education tip: Have patient look at their opposite hip to ensure

appropriate stretch

Dutton, 2012. pg. 289 and 292

Levator Scapula Stretch (Manual)

Can also be performed in sidelying

Massage

-Can be performed on any muscles in the cervical spine

-Goal is to place the patient in position where the muscles are

non – weight bearing

Dutton, 2012. pg. 291

THORACIC SPINE

Anatomy, Pathology, and Treatment Options

Anatomy of Thoracic Spine

• 12 thoracic vertebrae

• Each vertebrae is involved in at least 6

articulations

• Decreased mobility in order to protect the

thoracic viscera

Dutton, 2012. pg. 298

Anatomy of Thoracic Spine

• The rib cage in conjunction with the thoracic

spine provide stability

– Influences motion in other areas of the spine

as well as the shoulder girdle

– Provides assistance with weight bearing

– Increases potential for postural impairments

Dutton, 2012. pg. 298

Thoracic Spine

• Prone to both postural and biomechanical

dysfunction

• Treatment goals:

– Decrease pain, inflammation, and muscle

spasm

• Cryotherapy

• Electrical Stimulation

• Gentle exercises

• Possible bracing

• Heating agents after 48-72 hours

– Promote healing of tissue

• Join mobilization as performed by PT

• Massage

• Ultrasound

– Increase pain free range of vertebral and costal

motion

• Diaphragmatic breathing with stretching

Dutton, 2012. pg. 300

Postural Dysfunction

• Create an imbalance between agonists and

antagonists.

– Results in adaptive shortening and muscle

weakness

– Not typically reproducible with physical

examination

– Pain is typically aggravated by stress, fatigue,

and possibly change in weather.

Dutton, 2012. pg. 304

The Spine

Kyphosis:

• an increase in the thoracic convexity

• resulting in a rounded back with protracted

scapulae

– Also know as the “hump-back deformity”

STRETCHING ACTIVITIES

FOR THE THORACIC SPINE

Therapeutic Interventions

Supine Shoulder Sweep

-Important for the patient to maintain contact with their arm on

the plynth.

-Manual assistance may be used on the scapula or rib cage

- Perform with diaphragmatic breathing Dutton, 2012. pg. 301

Thoracic Spine Flexion

-Cat/Camel Stretch

Dutton, 2012. pg. 301

Thoracic Spine Extension over foam roll

-Allows focus to be made over a specific vertebral segment

Dutton, 2012. pg. 302

Supine Thoracic Spine Rotation

Keeping shoulders, trunk, and feet on the plynth, drop legs

down to one side together as far as comfortable and then

repeat on the opposite side

Dutton, 2012. pg. 302

Supine Thoracic Rotation using one leg

Progression as patient’s tolerance increases

Dutton, 2012. pg. 302

LUMBAR SPINE

Anatomy, Pathology, and Treatment Options

Lumbar Spine

-almost entirely flexion and extension

-minimal rotation and lateral flexion

-Motions occur in sagital, coronal, and

transverse planes

Dutton, 2012. pg. 315

Low Back Pain

Did you know that it is….

• the 2nd leading cause of physician visits in the

United States

• affects approximately 80% of the adult

population at some point in their lives

• one of the leading causes of Physical

Therapy referrals in the orthopedic setting

Some of the primary causes of low back pain

include:

• Muscle Strains

• Ligamentous Sprains

• Disk Injuries

• Spondylolisthesis

• Spinal Stenosis

• Spinal Fractures

The Inter-vertebral Disc

• Health of the intervertebral disc maintains the

health of the integrity of the mechanics of the

spine

• Low back pain may be due to

– Aging

• Reduces the moisture content in the disc

– Reduces overall height

– account for 20-25% of the total length of the

vertebral column

– natural degeneration of the disc

– trauma, inter-vertebral discs can be

responsible for causing low back pain in many

individuals.

Magee, 2008. pg. 516

The Inter-vertebral Disc

1 Disc Herniation

A general term used to describe when there is any change in the shape of the annulus

2 Disc protrusion

The nucleus of the disc bulges against an intact annulus

2 Extruded disc

The nucleus of the disc bulges through the annulus however remains within the posterior longitudinal ligament

3 Sequestrated disc The nucleus of the disc breaks

through all barriers and is free within the spinal canal

Magee, 2008. pg. 369

Dutton, 2012. pg. 338-339

Inter-vertebral Disc Herniations

Treatment will depend upon– Pain

– Flexibility

– Strength

– Dermatomal and myotomal involvement

– Pain with movement

– Patient understanding

• This may include:

– physical agents

– therapeutic exercise

– therapeutic activity

– strengthening

– flexibility training

– patient education

– body mechanics training

– manual intervention

Shankman, 2011. pg. 371

Surgical Intervention for lumbar disk disease

• Discectomy

– Surgical removal of the herniated disk material

• May also be performed with laminectomy

• Microdiscectomy

– Surgical removal of only the portion of the disk

that is impinging on the spinal nerve root

• Requires decreased recovery time

• Percutaneous discectomy

– Decompression of the disk performed through

needles

Dutton, 2012. pg. 343

The Spine

• Scoliosis

– a lateral curvature of the spine

– usually demonstrated by an abnormal

curve and a second curve that results due

to compensatory movements in the

opposite direction.

• This results in a deformity resembling

the letter S.

Shankman, 2011. pg. 337

The Spine

• Functional scoliosis

– not caused by an actual spinal deformity

• secondary to another condition

– such as leg length discrepancy

• The curvature usually resolves itself

when the primary condition is

addressed.

Dutton, 2012. pg. 307

The Spine

Non-functional (structural) scoliosis

• the opposite of functional scoliosis

• the curvature is incorporated into the natural

growth and development of the spine

• curvature and the vertebral bodies are rotated

toward the convexity.

The Spine

More severe cases of scoliosis

• may require bracing

• to prevent further curvature of the spine from

occurring

– bracing is not intended to correct the curvature

already in place

– prevents further curvature

• minimal correction may occur

Shankman, 2011. pg. 338

The Spine

Lordosis:

• an abnormal anterior

convexity of the

lumbar spine

• Persons with lumbar

lordosis will present

as if they are sticking

out their stomach and

their buttocks.

**Both Kyphosis and

Lordosis can be

congenital,

neuromuscular, or

postural**

The Spine

What effects can these have on a person

clinically?– Pain

– Poor posture

– Change in functional mobility

– Decrease in muscle strength

– Respiratory difficulties

– Neurological symptoms

– Psychological concerns

Muscle Strains and Ligamentous

Sprains can be caused by:• Sudden movements

• Rapid Stretching

• Overuse injuries

• Treatment goals include:

– Decreasing pain and edema

– Increasing flexibility and strength

– Improving aerobic fitness to achieve prior level of

function

Treatment Plan for Sprains/StrainsPhysical Agents as needed for

• Pain

• Inflammation

• Muscle guarding

Therapeutic Exercise

• Core stability

• Flexibility training

• Strength training

Manual Therapy

• Joint and muscle flexibility

• Soft tissue massage

Patient education

• Posture

• Body mechanics

• Aerobic capacity/fitness

• Home exercises

Piriformis Syndrome

• The sciatic nerve runs through the muscle

belly of the piriformis as opposed to

underneath it

– occurs in approximately 15% of the population

– characterized by pain reported deep in the

buttocks

– may be irritated by sitting

Magee, 2012. pg. 696

Spondylolisthesis

• condition in which

one vertebrae

anteriorly glides over

another

• usually occuring at

the L4-L5 and L5-S1

levels

• graded through X-ray

• measured by the

percentage of

displacement noted

Shankman, 2011. pg. 374-375

Spondylolisthesis

• Congenital

– Results from dysplasia of the 5th lumbar and

sacral arches and zygapophyseal joints

• Isthmic

– Caused by a defect in the pars interarticularis

resulting from an acute or stress fracture or an

elongation of the pars

• Degenerative

– Usually affects older population

– Most common at L4-L5 level

• Traumatic

– Occurs with fracture or dislocation of the

zygapophyseal joint

• Pathologic

– Resulting from a systemic disease causing

weakness of the pars, pedicle, or

zygapophyseal jointDutton, 2012. pg. 346

Grading for Spondylolisthesis:

Grade 1: 0-25%

Grade 2: 25-50%

Grade 3: 50-75%

Grade 4: 75-100%

Example: Grade 2

Shankman, 2011. pg. 375

Spondylolisthesis

• Patient complaints

– Chronic midline pain at lumbosacral junction

– Pain worsened with activity

– Pain alleviated with rest

– Pain exacerbated by repetitive extension

– Possible reports of radicular symptoms

Dutton, 2012. pg. 346

Spondylolisthesis Treatment Options

Conservative Treatment

-pelvic positioning

-lumbar stabilization

-flexibility of rectus femoris

-flexibility of iliopsoas

Surgical Intervention

-remove pressure on spinal nerves

-provide stability

Dutton, 2012. pg. 347

Spinal Stenosis

• Narrowing of the spinal canal secondary to

degenerative changes or trauma to the

lumbar spine.

– Facet joint arthrosis and/or hypertrophy

– disc bulging

– spondylolisthesis

• Most common in middle-aged and older

males

Shankman, 2011. pg. 374

Dutton, 2012. pg. 343

Spinal Stenosis

• Postural education

• Flexibility

• Core stabilization

• Aerobic conditioning

Dutton, 2012. pg. 344

Spinal Fractures

• Lumbar spinal fractures are usually a result of a traumatic event and may be classified according to the mechanism of injury (compression, flexion, extension, etc…)

• Compression fractures are most commonly noted in the osteoarthritic population as a result of a rapid deceleration when transferring to a seated position.

Shankman, 2011. pg. 330

Spinal Fractures

• Spinal fractures will most likely be

immobilized

– Casting

– Bracing

– until such time that physical therapy

intervention is appropriate

Shankman, 2011. pg. 330

Special Tests for the Lumbar Spine

Special Tests for the Lumbar Spine

WELL LEG RAISE TEST:

– the patient lying

supine on a plynth

– the examiner holds

the calcaneous of the

uninvolved leg and

places their superior

hand on the anterior

surface of the

patient’s thigh to

prevent knee flexion

– the examiner

passively flexes the

patient’s hip while

maintaining the knee

in extension

Cook, 2013. pg. 301

Special Tests for the Lumbar Spine

• A positive result for the Well Leg Raise

Test is demonstrated with complaints of

pain on the involved side, indicating

vertebral disk damage.

Special Tests for the Lumbar Spine

SLUMP SIT TEST:– The patient sits at the end of a table with the arms

behind the back and legs together.

– The patient slumps as far as possible, producing full trunk flexion

– If no changes are noted, the examiner asks the patient to extend their knee or passively extends one of the pt’s knees, symptoms are assessed

– If no changes are noted still, the examiner passively dorsiflexes the pt’s ankle with the knee in extension, symptoms are assessed.

– Neck flexion is then added to assess symptoms, then released to see if symptoms subside

– This is to be performed on bilateral LE’s

Cook, 2013. pg. 302

Special Tests for the Lumbar Spine

SLUMP TEST

• Positive Findings

– Concordant reproduction of symptoms,

sensitization, and asymmetry findings.

Special Tests for the Lumbar Spine

VALSALVA’S MANEUVER:

– The patient should sit with the examiner next

to the patient

– The tester asks the patient to hold their

breath and bear down as if having a bowel

movement

• This test is considered positive if

– increase in pain secondary to the increase in

intrathecal pressure.

– May indicate:

• herniated disk, tumor, or osteophyte in the lumbar

cana.

• pain may be localized or referred to a

corresponding dermatome

Konin, 2006. pg. 132

Special Tests for the Lumbar Spine

• FABER TEST: (also known as the Patrick Test)

– This test is used to determine iliopsoas,

sacroiliac, and/or hip joint abnormalities.

• The patient lies supine on a table

• The examiner passively flexes, ABDucts,

and externally rotates the involved LE until

the foot rests on top of the opposite knee.

• The examiner then provides a gentle,

downward pressure on both the knee of

the painful side and the ASIS of the non-

painful side

Cook, 2013. pg. 333

Special Tests for the Lumbar Spine

FABER’S TEST

Concordant pain is assessed

-location

-type of pain

STRETCHING ACTIVITIES

FOR THE LUMBAR SPINE

Treatment Interventions

Single Knee to Chest

Dutton, 2012. pg. 344

Lower Trunk Rotation

Hamstring Stretch

Childs Pose Stretch

Gastrocnemius Stretch

Piriformis Stretch

Quadriceps Stretch

CORE STABILITY EXERCISES

Lumbar Spine

Posterior Pelvic Tilt Dutton, 2012. pg. 328

Bent leg fall out

Dutton, 2012. pg. 329

Bridging

Dutton, 2012. pg. 332

Quadruped Activities

Dutton, 2012. pg. 331

Bibliography

• Dutton, Orthopaedics for the Physical

Therapist Assistant. Jones&Bartlett. 2012

• Shankman, Fundamental Orthopedic

Management for the Physical Therapist

Assistant, 3rd edition. Mosby.2011

• Konin, Wiksten, Isear, Brader, Special Tests

for Orthopedic Examination, 3rd edition. Slack.

2006

• Cook, Hegedus, Orthopedic Physical

Examination Tests, 2nd edition. Pearson. 2013

• Magee, Orthopedic Physical Assessment, 5th

edition. Saunders. 2008