Joint Motion Biomechanics

Terminology

• Thrust Manipulation involves high-velocity, low-amplitude therapeutic movements at or near the end range of motion.
• Non-thrust Manipulation are mobilizations that do not involve a thrust.
• Arthrokinematics refers to the motions of bone surfaces within a joint, including roll, spin, slide, compression, and distraction.
• Osteokinematics refers to angular joint movement as well as movements of bony levers in cardinal planes.

Biomechanics of Joint Motion

• Physiological Motion movements are done voluntarily by the patient.
• Concentric or eccentric active muscle contractions results in physiological motion.
• Physiological motion involves bones moving about an axis, or through flexion, extension, abduction, adduction, or rotation.
• Accessory Motion cannot be voluntarily performed.
• Accessory motion involves motion of articular surfaces relative to one another.
• Accessory motion is necessary for the full range of physiological motion.
• Ligaments and joint capsules influence accessory motion.

Indications for Manual Therapy (MT)

• Mechanical Joint Pain
• Joint Hypomobility also known as Joint Mobility Impairment
• ROM impairments
• Following Immobilizations
• Post-Injury
• Condition-Specific, such as adhesive capsulitis, impingement syndrome, carpal tunnel syndrome (CTS), lateral epicondylalgia, hip and knee osteoarthritis (OA).

Osteopathic Model

• Andrew Taylor Still developed it in 1874.
• Still was trained as a medical doctor, but rejected medicine.
• The American Osteopathic College was established in Kirksville, Missouri, in 1896.
• The Law of Artery posits that manipulation of the spine restores blood flow and the body's healing ability.
• Doctors of Osteopathic Medicine (DOs) today have the same practice rights as medical doctors (MDs) in all 50 states.

Chiropractic Model

• Daniel David Palmer established it in 1895.
• Palmer adjusted a patient at the T4 level, resulting in restoration of lost hearing.
• "Cheiros" (hands) + "praktos" (done by) is the basis of chiropractic.
• Palmer College opened in 1897 in Davenport, Iowa.
• Doctors of Chiropractic (DCs) compose the largest group of primary care physicians outside of medicine.
• Subluxations are treated with spinal adjustments.
• The Law of the Nerve states that adjusting spinal subluxations restores nerve flow and facilitates the body's healing ability.

McMillan’s Text

• Massage (manipulation) are defined as "movements done upon the body".
• McMillan used the word "manipulation" throughout her book to describe techniques such as effleurage, tapotement, friction massage, and paddle technique.

Legislative Challenges

• Opposition to physical therapists performing manipulation began in the 1900s.
• Opposition intensified in the 1990s due to the movement toward direct access and doctoral education for physical therapists.
• 23 states had legislative challenges by 1998.
• Challenges are less per year, the intensity of the legislative and regulatory issues continues
• The chiropractic profession is the primary challenger.
• Professional training for PTs is a focus of legislative challenges.
• Educational standards were unclear until the 2004 version of the Normative Model and CAPTE criteria.
• The Orthopaedic Section of the APTA founded in 1974 to mobilize an organized response to chiropractic challenges.
• The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) was founded in 1992 partly to meet international standards of residency and fellowship training in Orthopaedic Manual Physical Therapy (OMPT).
• In 1999, the APTA Manipulation Task Force was created to coordinate APTA/AAOMPT responses to legislative challenges.
• Many state practice acts are silent on manual therapy and manipulation.
• Four states restrict a PT's ability to perform manipulation: Arkansas, Washington (endorsement), West Virginia, and Indiana.
• Therapists must be aware of practice laws in their states.

PT Education/Curriculum

• CAPTE evaluative criteria require PT education programs to teach thrust and non-thrust manipulation of the spine and extremities.
• A Manipulation Education Manual (APTA/AAOMPT) developed in 2004 to enhance the level of instruction in manipulation.
• Textbooks such as "Manual Physical Therapy of the Spine" are written by PTs.
• Emphasis is placed on problem solving and an evidence-based approach to therapy.
• There is focus on clinical decision making and meeting educational objectives.
• Thrust techniques are integrated into clinical science courses.
• Advanced specialty PT training can be obtained through long-term fellowship programs.
• PT education emphasizes movement sciences and analysis.
• Expertise is grounded in anatomy, physiology, biomechanics, and pathology.
• Education provides a foundation for determining clinical decision making needed for thrust techniques.
• Students receive psychomotor training and testing required for the safe application of thrust and non-thrust techniques.

APTA Position

• PTs are the leaders in the diagnosis and management of "Movement" Disorders.
• Evidence supports the judicious use of manipulation in PT practice.
• Professional associations promote and protect the scope of practice.

Safety

• The risk of cauda equina syndrome is estimated to be 1 in 100 million manipulations.
• Risks associated with NSAID use and gastrointestinal (GI) bleeding are 1-3/100 for reference.
• Serious complications of cervical manipulation range from 1 per 400,000 to 3-6 per 10 million.
• There are no reports of complications related to extremity manipulation.
• Most common adverse effects include headaches, stiffness, and local discomfort.

Studies: Cervical Manipulation

• A study on the effects of cervical manipulation on vertebral artery and cerebral hemodynamics consisted of 20 patients with neck pain and a mean age of 32.
• A decrease in contralateral blood flow velocity with neck rotation and with manipulation was observed.
• Brain blood perfusion changes were not seen with neck rotation.
• The observed changes are likely not clinically meaningful, suggesting manipulation may not increase cerebrovascular event risk through a hemodynamic mechanism.
• The incidence of cervical artery dissection (CAD) in the general population is 2.9/100,000.
• Reported cases have been unable to demonstrate causality with cervical mobilization/manipulation.
• It’s unknown whether CAD symptoms lead the patient to seek manual therapy or if manual therapy provokes CAD in a patient without CAD complaints.
• Headaches or neck pain are common symptoms of CAD.
• The World Health Organization (WHO) regards manual mobilization and spinal manipulation therapy (SMT) to be safe and effective.

Quantifying Risk

• It is impossible to determine the precise risk of manipulation.
• Not all events published in peer-reviewed literature, and there's no accepted standard for reporting injuries.
• The risk of serious complications is low.
• It is estimated that only 1 in 10 cases of serious adverse events with spinal manipulation (SM) are reported in literature.

Risk Assessment: Stroke

• History of cervical spine trauma
• History of migraine headaches
• Hypertension
• Cardiovascular Disease/Blood Clotting Disorders
• Diabetes
• History of Smoking
• Recent Infection

Red Flags

• Significant trauma
• Weight Loss
• History of Cancer
• Fever
• Steroid use
• Patient is over 50 years of age
• Pain is severe, unremitting at night time
• Pain that gets worse when lying down
• Intravenous drug use

Accessory Motion Grading

• 0 = No movement
• 1 = Considerable decreased movement
• 2 = Slight decreased movement
• 3 = Normal movement
• 4 = Slight increased movement
• 5 = Considerable increased movement
• 6 = Complete instability.
• Hypomobility is the joint assessment for grade 0, 1, and 2
• Normal is the joint assessment for grade 3
• Hypermobility is the joint assessment for grade 4, 5, and 6

Physiological Effects of Mobilization/Manipulation

• Stretching of periarticular tissue
• Disruption of intra-articular adhesions
• Restoration of normal articular relationships
• Enhancement of fluid exchange
• Hypoalgesia (increase in pain threshold)
• "Normalization" of neurophysiologic reflexes

Effects of Mobilization/Manipulation

• in vivo (intraosseous) measurements of effects of posterior-anterior, short lever thrust manipulation resulted in multiaxial, coupled vertebral displacements

Mechanical

• Multiaxial, coupled vertebral displacements increase in association with the amount of force and vary based upon contact point.
• Cavitation occurs in multiple joints with manipulation, with 2-6 cavitations per thrust.
• Cavitations mostly occur within one segmental level of target, and "general accuracy" can be achieved.

Neurophysiological Effects

• Stimulation of muscle spindle afferents and Golgi Tendon Organs (GTOs) alters muscle contraction.
• Altered pain processing results in increased pain tolerance or its threshold.
• It stimulates paraspinal muscle reflexes and alters motor neuron excitability.
• May "add a novel sensory input or remove a source of aberrant input".

Clinical Prediction Rules (CPR) for Manipulation

CPR For Lumbar Spine

• Recent onset (16 days)
• Low FABQ score (
• No symptoms distal to the knee
• Lumbar stiffness/hypomobility
• Good hip internal rotation (IR > 35°)
• Presence of 4/5 variables = +LR 24.38

CPR for Neck Pain

• Symptoms less than 30 days
• No symptoms distal to the shoulder
• Extension does not aggravate symptoms
• FABQ score less than 12
• Decreased upper thoracic spine kyphosis
• Cervical extension ROM less than 30°
• 3/6 variables (+LR 5.5) = the probability of success improved from 54% to 86%

Joint "End Feel"

• Normal end feels include: Capsular (Firm), Bone-to-Bone (Hard), and Tissue Approximation (Soft).
• Abnormal Pathologic end feels include: Capsular*, Bone-to-Bone*, Spasms, Springy Block, and Empty.

James Cyriax

• Correct diagnosis is essential to ensure effective treatment.
• selective tension examination is essential.
• 3 basic principles: All pain arises from a lesion (a pathological or traumatic discontinuity of joint or soft tissues).
• All treatment must reach the lesion.
• All treatment must exert a beneficial effect on the lesion.

Cyriax Interventions

• Steroid injections for acute conditions
• Deep friction massage for soft tissue adhesions
• Mobilization/manipulation to break adhesions and mobilize loose cartilage
• Sclerosing injections to treat unstable joints (prolotherapy)

Freddy Kaltenborn

• First to relate mobilization and manipulation to arthrokinematics
• The purpose of mobilization is to restore normal glide between joint surfaces.
• Mobilizes according to the convex/concave rule in open chain.
• Cave on vex results in same motion.
• Vex on cave results in opposite motion.

Treatment Direction

• Treatment plane lies on the concave articulating surface, perpendicular to a line from the center of the convex articulating surface.
• Joint traction techniques are applied perpendicular to the treatment plane.
• The entire bone is moved so that the joint surfaces are separated.
• Joint glides applied parallel to the treatment plane.
• Traction is applied in 3 stages: Stage 1 neutralizes pressure in joint without separating surfaces that is primarily used for pain control. Stage 2 separates joint surfaces. stage 3 creates distraction and stretches soft tissue.
• Accessory movements are applied with sustained tractions.
• Stretch is localized to tight portion of capsule or surrounding soft tissue-mechanical effects that are emphasized, and It treats to the anatomical limit of the joint.

John Mennell

• Joint dysfunction is a loss of one or more movements of an involuntary nature, that occur at any synovial joint.
• Involuntary movement is joint play.
• Causes of joint dysfunction include: disuse, aging, immobilization, and intrinsic trauma.
• Addresses diagnosis from a standard, systems review approach.

Mennell’s Basic Truisms

• When a joint is not free to move, the muscle that moves it cannot be free to move.
• Muscles cannot be restored to normal if the joints which they move are not free to move.
• Normal muscle function is dependent upon normal joint movement.
• Impaired muscle function perpetuates and may cause deterioration in abnormal joints.

Mennell Tx

• Manipulation is used to treat joint dysfunction by passively moving the joint beyond the physiological limit of range but within the anatomical limit of joint motion.
• Mobilization is followed by muscle reeducation procedures.
• "Spray and Stretch" technique is utilized to treat muscle dysfunction.

Geoffrey Maitland

• Careful examination is the foundation of treatment.
• The correlation of pain, stiffness, and spasms during active and passive physiologic and accessory movements determines treatment.
• Functional limitations are noted and reassessed.

Maitland - Subjective History

• The patient is questioned extensively, and the importance of verbal communication is emphasized.
• The central theme of the approach is a positive personal commitment to understanding the patient's pain experience.
• The relationship between the patient's symptoms and functional activities must be established.

Maitland - Physical Examination

• It should include a combination of pain, stiffness, and spasms that the examiner finds on examination and considers comparable with the patient's symptoms.
• It includes reproduction versus production of pain.

Maitland - Treatment

• Mobilization is performed with oscillatory movements, which are divided into four grades: Grade I: Small amplitude at the beginning of the range.
• Grade II: Large amplitude within range.
• Grade III: Large amplitude at end range.
• Grade IV: Small amplitude at end range.

Considerations - Grade I and II Mobilizations

• Neurophysiological effect of pain control
• Neutralizes joint pressures

Considerations - Grade III and IV Mobilizations

• Increases ROM through stretching of shortened tissues
• It is performed at the end range of tissue resistance

General Considerations - Orthopedic Manual Therapy

• The therapist should utilize good body mechanics.
• Patient position should be comfortable.
• Therapists must respect the patient's "personal space".
• Long lever versus short lever technique is an important consideration.
• The hand contact point should be altered based upon the relative size of the target structures.
• Modification of techniques may be necessary to accommodate individual therapist or patient impairments.

Application - Grade I & IV Movements

• Rapid movements (60-120/min).
• Grades II & III slow and smooth, regular oscillations (5-60/min).
• 1-5 repetitions and reassess.
• Slow speed stimulates mechanoreceptors and inhibits muscle guarding.
• Faster speeds with low amplitude to inhibit pain.
• Open packed position and distraction techniques for painful joints.
• Sustained holds at end range can be used for restricted joints, 6-30 seconds, repeat several times.

Technique Variables

• Pt position and if it is oscillations vs sustained hold
• Joint position
• Oscillations frequency
• Amount of force
• Treatment duration
• Direction of force
• Addition of traction (and level) prior to mobilization force
• Combination of accessory and physiologic movement

Post Mobilization

• Severity of condition and Mechanical vs non-mechanical pain
• Level of irritability of joint and patient dependence on PT for pain relief
• Patient previous experience with mobilization and patient directed vs therapist directed forces
• Fear avoidance beliefs and contraindications/precautions

Contraindications

• Malignant lesions in the region of treatment
• Joint infection/osteomyelitis
• Fracture
• Metabolic bone disease
• Bony fusion of joint
• Compromised joint integrity

Standardized Terminology

• Rate of force application
• Location in the range of available movement
• Direction of force
• Target of force
• Patient position

HA Visceral and Systemic Red Flags

• Stroke/TIA
• Hypertension
• Infection
• Digestive Disturbances
• Kidney Failure
• Glaucoma
• Head Injury
• Meningitis
• Brain Tumor

Red Flags - Sx

• "Thunderclap headache” which is Intense/hyperacute
• New onset HA age >50; age 1 hr, include motor weakness, different than previous aura, or first time after starting oral contraceptives.
• Each distinct type of headache in a patient must be separately diagnosed and coded.
• When it is suspected that a patient has more than one HA type, it is helpful to use a diagnostic HA diary.
• HA diaries improve diagnostic accuracy
• HA Diaries allow for judgement of medication consumption
• HA Diaries establish the quantities of each of two or more different HA types or subtypes
• HA diaries teach the patient to distinguish between different HA’s

Primary HA types

• Migraine (with or without aura)
• Tension-type headache (most common)
• Cluster headache and other Trigeminal Autonomic Cephalalgias (TAC)
• Other primary headaches

Migraine W/O Aura Description

• HA attacks lasting 4-72 hours when treated unsuccessfully

• 2 of the following characteristics: Unilateral location, pulsating quality, moderate or severe pain intensity and aggravation by or avoidance

• 1 of the following during symptoms: Nausea or vomiting and photophobia and phonophobia

• Symptoms cannot be better accounted for by another ICDH-3
• Migraine in children and adolescents more often bilateral
• Migraine HA usually frontotemporal; Occipital HA in children is rare and a red flag

Migraine W/ Aura Description

recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other CNS sx usually developing gradually and followed by HA and associated migraine sx

• 1 of the following fully reversible aura sx: visual, sensory, speech and/or language, motor and brainstem or retinal

• 3 of the following 6 characteristics: at least 1 aura symptom that spreads gradually >5 minutes; two or more aura symptoms occur in succession; each individual aura symptoms is unilateral; at least 1 aura symptoms is unilateral; and aura is accompanied or followed within 60 minutes by HA

• Many patients w/ migraine w/ aura also have migraine wo aura; The aura usually occurs before the HA but can begin after the HA phase; and is most common w/ Visual aura most common (90% of pts w/ this classification)

Tension-Type HA: Infrequent Episodic Diagnostic Criteria

• At least 10 episodes occurring on 3 months.
• HAS lasting 30 min to 7 days with >2 of the following characteristics: bilateral location, pressing/tightening that is non-pulsating quality, mild or moderate intensity and not aggravated by routine physical activity.
• and contains to both of the following: no nausea or vomiting (anorexia may occur) and no more than one of photophobia or phonophobia

Tension-Type HA: Frequent Episodic Diagnostic Criteria

• At least 10 episodes occurring 1-14 days or month for more than 3 months.
• HA lasting 30min-7 days with has greater than 2 of the following characteristics: bilateral location, pressing/tightening and non-pulsating, milk or moderate intensity and is not aggravated by routine physical activity.
• And contains both of the following: no nausea or vomiting and no more than one of photophobia and or phonophobia.

HA Diagnostic Critea: Tension-Type HA: Chronic

HA occurring on more than 15 days/month on average for greater than 3 months HA lasts hours to days or may be continuous with HAS containing >2 of the following: bilateral location; pressing/tightening with non-pulsating activity, mild or moderate intensity and is not aggravated by routine physical activity.

Cluster Headache Diagnostic Criteria

• At least 5 attacks are noted for cluster headaches
• Severe or very severe unilateral orbital, supraorbital and or temporal pain lasting 15-180 min if untreated
• Either or both of the following: - HA is accompanied by at least 1 of the following: IPs conjunctival injection and or lacrimation, IPs nasal congestion and or rhinorrhoea, IPs eyelid edema, IPs forehead and facial sweating and IPs miosis and or ptosis AND a sense of restlessness or agitation

Causes of HA: 2ndary HA

Another disorder known to be able to cause HA has been demonstrated

• HA occurs in close temporal relation to the other disorder and or there is other evidence of a causal relationship. It may also include a brain tumor.
• HA is greatly reduced or resolves within 3 months after successful treatment and or spontaneous remission of the causative disorder

Cervicogenic HA Clinical exam findings

• Exam indicates that the pain is arising from cervical spine structures which include bony, disc, and soft tissue elements
• Most significant physical examination findings include: an increase from cervical ROM and a Positive cervical flexion rotation test Diagnostic Factors Include:
• Clinical evidence found by the healthcare provide of an issue lesion or disorder known to be able to cause HA

Cervicogenic HA Causation Factors

• Causation shows up if HA has developed in temporal relation to onset of cervical disorder or appearance of the lesion HA has significantly improved or resolved in parallel with improvement in or resolution of cervical disorder or lesion Cervical ROM reduced and HA worse by proactive maneuvers OR
• HA abolished following diagnostic blockade of involved structure or its nerve supply Anatomy of Cervicogenic HA

Cervicogenic HA Anatomy

• The fundamental mechanism is Convergence: When afferents from 2 parts of the body coverage on same 2nd order neuron in spinal cord noiceptive
• Cervicogenic HA often perived in forhead and Orbit and resuts of convergence between trigeminal and cerival affernt
• Cervicogenic HA is perceived in is the occiput results results from convergence b/w fferent cervical afferents (greater and lesser coccipital nerve, etc)

Cervicogenic HA PT Management

• Patient Education
• soft tissue education
• Joint Mobilization
• Cervical or thoracic
• Modalities
• Postural
• and Relaxation Exercise
• Ergronomic Evaluation
• Stress Management
• Spinal Manipulation for Chronic HA

Headaches Systematic Review

Systematic Review of 9 RCT’s includes TTH, MH, and CGH types and manipulation is More effective than massage for CGH and just as effective as pharmacologic treatment for TTH and MH

• Systematic Review of 6 RCT’s SM may be effective to reduce migraine days and Pain intensit.
• It Provides limitations to studies included in this meta analysis results and its considered preliminary and methodology rigorous with large scale RCTs are warranted

Upper Cervical And Thoracic Manipulation

• Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic HA
• A multi-center randomized clinical trials with 6 to 8 sessions shows to be More effective than mobilization and exercise in patients with CH and Effects had been maintained for 3 months.

Headaches and Exercise Combinations

A combination of orthopedic Manual PT and exercise is more effective in decreasing frequency and intensity of headache than "control "therapy with short and long term effects. includes deep cervical flexor endurance exam, scapular retraction exam, postural education and low load cervical flex or ext resistive exam

Biopsychosocial Model

• Has a growing body of evidence supporting the use of a biopsychosocial model in a PT practice
• Shows limitation to the biomedical in terms of management of chronic pain which is more often a passive approach with is focused on focusing on with pathology or disease recognizes a complex mix of biomedical and psychological variables that can impact health experience

Cognitive Behavioral Therapy

Seeks to enhance the Patients control over pain using diverse psychological techniques in which a Patients beliefs attitudes and behaviors play a central role in deterermining the pain experiences Goals: Teach a patient specific cognitive and behavioral skills to better manage pain inform a Patient regarding effects of certain cognitions and behaviors on their pain and emphasize role that it's can play in controlling their plan combing exercise and CBI is the common approach.

Cognitive Behavioral Variables Impact Pain

• The cognitive thoughts, patterns of thinking and or apparsal
• The Emotions like mood
• The daily Patterns Behaviors and or activity; the behavioral response to pain

Key Beliefs that Impact Patients Variables

include- the cause for belief about pain and the prognosis, previous experience, perceived control and self-efficacy with coping strategies being distraction and or peasant imagery

Emotional variables includes a cyclical relationship between depression and pain. For example: depressed Patients with LBP report higher levels of their previous pain and demonstrate more pain related behaviors

Behavioral Variables

• Maladaptive behaviors like Decreased activity is most common maladaptive response for musculoskeletal pain And or Inappropriate Illness Behaviors

Cognitive Behavioral Therapy Interventions

• Psychotherapeutic approach to treating a variety of conditions that combines cognitive restructuring with behavioral modifications
• pt education for chronic musculoskeletal pain
• The parameters show that it have not been specifically defined.
• pt education- with coping sills training and a cognitive restructuring the activity will show a reset.
• Activities show a rest while cycling and with quota base exercise where one is more relax for one can work graded for an exercise.

P.T. Role

Pt education based on fear can help avoidance model which encourages confrontation and educates Patient to reduce the view of pain and it is a common condition, rather than As a serious disease That Can lead To Patient protection from pain.

• Pain comes with a neuroscience education that teaches one to about neurobiology and neurophysiology of Pain and is helpful to redirect the pain conversion from tissue-source of pain and can help one to increase muscle strength.

Pain Neuroscienze Skills

Has been found to be effective in reducing pain and improving function in people w/ chronic conditions to reestablish Pain unique skills; use of stories, metaphors, examples , -explained at a 5th grade level and has no reference to patho-anatomical models No discussion of emotional or behavioral aspects of pain and focus on neurophysiology of pain Coping Skills

Coping Skills Training

• Relaxation Skills, Exercises
• Activity-rest cycling
• Pleasant activity scheduling
• Distraction techniques
• Cognitive restructuring
• include Relaxation Techniques

Activities for Educations for exercise

• It is to to educate patients how to reduce rationale for exercise, with helping reduce access excess muscle tension this it can result in pain, muscle spasm and fatigue Which can also be caused be stress

Activity Rest Cycle

Pain associated with osteoarthritis can be increased after periods of over-activity Therefore in order to prevent flare ups of pain one need to to pacing with daily activites In order to doing this one should break activities into smaller periods with limited rest in order to to not be over doing.

The process of The Cognitive

• This includes one recognize negative thoughts that occur during times of increased pain to help them can replace them with more adaptive and calming thoughts
• Its to know Reaffirming, positive thoughts can help To Patient control over pain instead of letting the pain control your life

Graded Exercise & Goals

• Graded exercises should focus on improving a patients activities by progressing in small goals: Intensity -Duration -Frequency reported that some patients a symptoms were improved
• Pt's symptoms, they can be noted with intensity while not limited exercise which would help them from progression sx abatement is not the primary goals

Key Signs of Skeep

The Disturbances occur in 1/3 of up to US population, in which a CDC considers insufficient sleep a public health problem studies shows that Pts need to acknowledge sleep deprivation results in poor health and function.

Insomnia

-Difficulty sleep patterns of falling asleep, maintaining sleep, or walking up in excess in a way early and its occurs least 3 nights per week for the past 3 months

Sleep Apema

includes Recurrent episodes of upper airway blockage during sleep which leads to decreased O 2 saturation and increased effort to breath includes Nuerological condition characterized by persistent urge to move legs while resting: includes itchiness and sometimes some burning pain

Exercise and sleep characteristics

Improve with function to treat increased slow wave sleep and REM which helps to decrease the sleep onset latency

Increase the time that to improves depressive with the weight loss to help one improves sleep if needed

Lumbosacral Surgery- Goals

Failure of extended conservative therapy (6-12 weeks) needs a medical consult and Abnormal diagnostic imagine that consistent needs to be reviewed. Also there needed to be conformity of radicular pattern in a Pysical exam One more of the following needs to be reviewed from a sensory motor functions and loss of reflex integrity can cause issues or is indicated that there would need Spinal surgery

Goals of Spinal Surgery

• to Decompress nerve root the spinal cord
• stabilize an unstable segment to help Reduce or correct a deformity General Risks Associated with Spinal Procedures which can cause Dural Tears and Nerve damage Bowel and Bladder incontinence and or Bleeding Can also cause Infection which can cause the body and and also known as "Failed Back Surgery Syndrome.
• Lumbar laminectomy/laminotomy/foraminotomy and Cervical Discectomy can cause spinal fusion

Indications for Lumbar Discectomy

More effective at relieving radicular (leg) and axial (bad pains) with that that help with 90% of lumbar issues from conservative care in 6-12 weeks the cases will involve to and typically discharged that will help and can be used with those who have Radicular pain

Microdiscetomy Procedure

Erector is spinae is lifted from the lamina to removed ligaments from material to help The Procedure that involves with Minimall invasive

Indications for Lumbar Laminectomy

typically used to treat spinal stenosis resulting as Disc changes such as and Osteophytes that form to make room on tight ligament. The goal of this will be to decompress neural elements and has a removal facet to risk instability known to and create the body is to develop instability with its spondylolisthesis

• The lumbar discectomy with a process called Early neural stabilization can reduce the risk of adhesions and can return normal in as Early of after 3-4 weeks has been reported and this can cause alot of issues

Lumbar Surgery Variables

Include age , recent activity level , Spine alignment. extend of bone removal, subsequent with the following activities.

spinal fusion for long term

With the use Bone graft and placed to help allow Posterolateral the spines "Grow"; A surgical intervention for The insertion of bone grfat and use is Spinal and the to create a implant in the disc.

The Process/ Technique- the key Components

• Discetecomy can help intialize the following in 1-2 weeks like with an to help with mobility ad for the body to start to go endurance
• The 7 wk the process will progress to neural level for strengthening to help with trunk with maintain function the in with is in control with a Lumbar FUsion

cervical fusion in terms of benifits

• better access to the disc
• will creatr less post op pain
• less muscle stripping
• a better fixation to the fusion

Cervical Fusion Complications

Difficulty swallowing and will show swallowing in 24- 5 wks. and a may creat speech issues

Spinal Fusion

Protect Post Operarive in many cases of the fusion and needs in to strength and restore the Posture the the neck that with help minimize the strain in some cases. it create a stabilization with can also create fix the issue,

Cervical fusion is the focus with the use of strength and conditioning

A cervical Fusion must show -bone growth stimulation show the a previous failed spined cord and or diabetes can be effected with Steriod issues

• This shows the use of and in the spine- with penetrating screws for a better connection and stabilization.

Some Process - the use bone material ( or stimilar matter) to get Bone Growth Stimulation - Grade III previous failed spinal fusion diabetes grade and more levels

• renal disease alcoholisme steroid use. one will have to go though a Prosthetic Vertebral Disc Replacment to help to reach the Goals

Proshetic Disc replacement Benefits

Goal: To Replicate the biomechanics of natural disc To restore the disc heigh and normalize to the to help with challenges such mechanical strength with immediate fixation and is normal with biomenchal function

Ballon Kyphosplasty

• Use with with severe injury
• Insert guide tube
• Inflate to expand
• Inject bone cememnt to stabilize and reduce with back surgey failure has the folliwing: - aInappropriate Patient selections , poor diagnois or a failed techinque. If its been noted its usually shows a issues with Nerve pain- with pain if you free but 1 month latershow with scar fromation, with back surgery fail

Avoid / Rehab

Discectomy

• The Patient needs to avoid the following Bending an will the following: Help increase Walking to to Light stretches- Core

Laminectomy

They Patient will need to the bend and twisting and has the the potential Core work

Spinal Fusion

Avoid Bending, twisting, heavy lifting, and high impact activities focus help patient to Core strengthening and walk on a flat surface. ###Proshetic Disc Replacement Avoid Excessive bending, twisting, lifting heavy objections will need to heal with a smooth movement and stailizatin

Kyphoplasty

• Needs Muscle healing with high stable movements