Stanbridge - T4 - TE2 - W1 - Spine & Posture (Part 1)

Course Information

• Course title: Therapeutic Exercise II
• Course code: PTA 1010
• Topic: The Spine Part 1
• Date: 4/24/2024

Learning Objectives

• Students should be able to identify major components of spinal structure and function
• Students should understand the most common spine pathologies including pathologies like disc lesions, degenerative joint disease, stenosis, spondylolisthesis, facet dysfunction, soft tissue disorders, whiplash, and TMJ dysfunction
• Students should understand the basic management principles for these conditions
• Students should understand exercise prescription based on directional preferences

Outline

• Structure and function of the spine
• Common spine pathologies

Review: Structure and Function of the Spine

• Functional components of the spine
• Motions of the spinal column
• Structure and function of the intervertebral discs
• Intervertebral foramina
• Inert structures: influence on movement and stability
• Neuromuscular function: dynamic stabilization

Functional Components of the Spine- Anterior Pillar

• Weight-bearing, shock-absorbing portion of the spinal column
• Size of the disc influences the amount of motion between two vertebrae

Functional Components of the Spine- Posterior Pillar

• Facets provide gliding mechanisms for movement
• Processes (TP & SP) provide muscle attachment sites

Motions of the Spinal Column

• A functional unit consists of two vertebrae and their connecting joints (facet joints and intervertebral discs)
• Motion at a functional unit is determined by the superior vertebra

Arthrokinematics of the Facet Joints

• Coupled motions: consistent association of one motion with another motion about different axes
• Typically, rotation and side bending, but varies depending on the spine region, posture, and facet orientation

Coupled Motions of the Spine

• Examples of coupled motions in different spinal regions including Upper C/S (CO-C2), Mid-lower C/S (C2-C7), Thoracic Spine, and Lumbar Spine

Arthrokinematics of the Facet Joints

• Upper C/S (CO-C2): Sub-occipital or craniovertebral region with primary motion of capital flexion and extension (nodding) and Atlantal-Axial (AA); approximately 50% of all C/S rotation occurs at C1-2
• Mid C/S (C2-C5)
• Lower C/S (C5-T1)
• Average facet orientation is 45 degrees

Structure and Function of the Intervertebral Discs

• Discs are mobile structures
• Annulus Fibrosis: type I collagen
• Nucleus Pulposus: thin type II collagen, allowing better fluid movement
• Cartilaginous endplates: each disc has two endplates, enabling nutrient delivery and waste removal

Disc: Annulus Fibrosus

• Outer portion of the disc, primarily composed of type I collagen and fibrocartilage fibres that angle around 60-65 degrees to the axis of the spine
• Provides tensile strength during distraction, rotation, and bending

Disc: Nucleus Pulposus

• Central portion of the disc, a gelatinous mass
• Distributes pressure
• Nucleus imbibes water when pressure is reduced, and squeezes water out under compressive loads
• Moves away from compression during flexion and extension

Intervertebral Foramina

• Openings in the posterior pillar
• Allow for the exit of motor and sensory nerves, blood vessels, and meningeal or sinu-vertebral nerves from the spinal canal

Intervertebral Foramina- Size variations

• Changes in size during flexion and extension
• Larger during flexion and contralateral side bending, smaller during extension and ipsilateral side bending

Review (Page 21)

• Components of the spine
• Intervertebral discs' components
• Spinal motions that affect the intervertebral foramina
• Coupled motions of the spine

Pathologies within the Spine

• Disc pathology (lesions)
• Degenerative joint disease/stenosis
• Spondylolisthesis
• Facet dysfunction
• Soft tissue disorders
• Whiplash disorder
• Cervicogenic headaches
• Tempomandibular joint dysfunction

Disc Lesions

• Prevalence in L4/5 and L5/S1

Back Pain Prevalence

• Between ½ and ¼ of the population will experience back pain during their lifetime.
• 40% of people will have at least one episode of back pain during any one year. -80-90% recover within 6 weeks of an episode.
• Reoccurrence rate is 50% after the first episode.

Disc pathology: Epidemiology

• 95% of disc problems are at L4/5 or L5/S1
• Only 5% of disc herniations become symptomatic
• 3:1 male to female ratio

Stages of a Disc Herniation

• Normal
• Degeneration
• Prolapse
• Extrusion
• Sequestration

Disk Injuries

• HNP: Herniated nucleus pulposus
• Protrusion: Nuclear material contained by outer layers of annulus & supporting ligaments
• Prolapse: Rupture of nuclear material into the vertebral canal
• Prolapse Extrusion: Extension of nuclear material beyond confines of the PLL or disc space, but still in contact with the disc
• Prolapse Free Sequestration: Extruded nucleus has separated from the disc and moved away from the prolapsed area

Disc Lesions

• Illustration of different types of disc lesions

Intervertebral Disc HNP: Fatigue Breakdown

• Most common etiology of repeated overloading of the spine in flexion (ex: sitting, bending, stooped postures, especially with rotation)
• Occurs in posterolateral corner, opposite to the rotation direction (weakest part)
• Radial fissures develop in annulus, outer layers rupture, allowing nuclear material to herniate through fissures (prolapse)

Intervertebral Disc HNP: Traumatic Rupture

• Usually from hyperflexion with rotation
• Gradual annular breakdown (most common)
• Fatigue breakdown may occur already, but symptoms may not appear until a traumatic event

Intervertebral Disc Overload

• Axial overload
• End plate damage or vertebral body fracture is usually prior to annulus fibrosis damage
• Scheuermann's Disease: Nucleus migrates through cracked end- plate

Intervertebral Disc HNP: Typical Age of Onset

• 30-45 years old (most common), 20-55 years old -Discs naturally begin to degenerate in the 40s
• Large amounts of imbibed water can cause pain in the morning after the antigravity sleeping position

Intervertebral Disc Injury: Effects on Spinal Mechanics

• Early stages: hyper-mobility of affected segments, leads to abnormal forces on facets, and supporting structures
• Late stages: may lead to DJD, and hypomobility

Signs & Symptoms of Disc Lesions

• Only the outer one-third of the annulus has nerve innervation, hence not all disc injuries are symptomatic

Signs & Symptoms of Disc Lesions and Fluid Stasis

• Discogenic pain: pressure from a swollen disc or tissues against pain-sensitive structures, e.g., ligaments, dura mater, blood vessels around nerve roots
• Chemical irritants of inflammation if disc material is herniated

Neurological Signs & Symptoms of L/S Disc Lesions

• Myotome specific muscle weakness
• Dermatome specific sensory changes
• Increased myoelectric activity (cramps common), especially in hamstrings
• Positive straight leg raise test (esp. cross straight leg raise test)
• Depressed deep tendon reflexes (hyporeflexia grade 0 or 1+)

Disc verses Nerve Root location

• Nerve root location varies between lumbar and cervical spine due to horizontal anatomy in lumbar and vertical anatomy in cervical spine

Lumbar disc herniation location

• Illustration of L3-4, L4-5, and other locations

Disc Herniation Location Classification

• Central: posterior back pain only
• Posterior lateral (paracentral): mostly common (90-95% of herniations)
• Foraminal (far lateral): less common (5-10% of herniations)

Lumbar HNP

• Posterolateral (most common) affects the lower nerve root
• Central- affects lower back only; nerve root not affected
• Foraminal (far lateral) affects the upper nerve root

Signs & Symptoms: Thoracic Spine Disc Lesions

• T/S disc lesions are rare
• Small disc to vertebrae ratio, stable osseous anatomy
• Most common at T11/12 level
• Posterior herniation increases risk of spinal cord compression

Signs & Symptoms of Disc Lesions

• Variability in symptoms depends on the direction of protrusion, degree of protrusion, and spinal level of the lesion

Onset of Symptoms: Disc Lesions

• Repetitive bending/bending and lifting
• Attempting to stand up after prolonged recumbent, sitting, or forward postures
• Pain increases with inactivity (prolonged sitting or flexion posture), often after resting

Pain Behavior: Disc Lesions

• Aggravated by activities increasing intradiscal pressure (sitting, bending, coughing, straining, moving from sit to stand, crunches)
• Peripheralization of symptoms may shift from side to side if annular wall remains intact, but can be alleviated by walking

Neurological Signs: Disc Lesions

• Anesthesia: total or partial sensation loss with muscle weakness if nerve root, spinal cord, or cauda equina are compressed
• Paresthesia: abnormal sensations, e.g., pins and needles

Common Objective Findings Associated with Lumbar Disc Lesions- Posterior Protrusion

• Pain & muscle guarding
• Flexion posture
• Lateral shift away from the symptomatic side
• Neurological symptoms following dermatome and/or myotome patterns of the affected nerve root

Peripheralization vs. Centralization

• Peripheralization (worsening): Symptoms travel further down the leg into the periphery
• Centralization (improving): symptoms recede up the leg or become localized to the back, closer to the center

Centralization

• Progressive reduction and abolition of distal pain in response to loading strategies
• Pain abolished distally to proximally until all symptoms resolve

Characteristics of Centralization

• Lasting abolition of peripheral and radiating pain, often quickly or gradually
• Occurs in response to loading strategies, often with an increase in spinal pain
• Usually happens quickly or gradually, occurs in acute and chronic patients

Peripherialization

• Distal symptoms remain or worsen with repetitive movements, sustained postures, and sequential patterns

Research Findings

-If centralization or peripheralization occurs, probability of discogenic pain is 72% -If pain remains unchanged, probability of non-discogenic pain is 87%

Common Objective Findings Associated with Lumbar Disc Lesions Posterior-lateral (Posterior Protrusions)

• Initially limited extension causing compression from bulging disc material
• Repeated backward bending causes centralization in symptoms if annulus layers are intact
• Lateral shift has to be corrected before extending exercises.

Disc Pathology: Lateral Shift

• Described by superior movement of vertebrae on the bottom

Disc Pathology: Acute Lumbar Kyphosis

• Patient unable to stand straight
• Likely from a large posterior herniation
• Postural deviation needs correction before other treatments

Interventions for Posterior HNP

• Correct any postural deviation (lateral shift or kyphosis)
• Assess how different extension and positions affect the response
• Positions can include prone lying, prone on elbows, and REIL & REIS exercises

Extension Bias Approach

• Lying Prone
• Prone on Elbows
• REIL - Repeated extension in lying

Extension Bias Approach continued

• Repetitions and sustained holds, 2/3 sets of 10 reps, 2-3 hours awake

Disk versus Nerve Root location (Lumbar & Cervical Spine)

• Illustration highlighting the variations in disc and nerve root relationships in different spine regions

Intervertebral Disc HNP: C/S

• C5 and C6 are common causes of radicular pain
• C6/7 disc affecting C7 nerve root.
• C5/6 disc affecting C6 nerve root.

Common Objective Findings Associated with Cervical Disc Lesions

• Cervical nerve root symptoms according to dermatome/myotome patterns -Faulty forward head posture
• Possible deviation or rotation away from the affected side -Peripheralization can occur with flexion and centralization with extension and traction
• Nerve mobility impairments

Severe Cervical Cases (B)- upper extremity involvement

• Cervical myelopathy (spinal canal narrowing leading to cord dysfunction)
• Congenital, spondylosis, HNP
• Cord compression causes gait abnormalities, upper motor neuron signs and symptoms, leg weakness, and paresthesia

Treatment of Posterior Cervical HNP

• Correct sitting posture and forward head posture
• Repeated movements reduce cervical spine symptoms

Healing of Disc

• Poor and slow
• Endplates feed nutrition
• Fibrous repair may occur, but is weaker than normal, takes a long time, due to relative avascular status

Pathomechanical Relationships of the Intervertebral Disc and Facet Joints-The three-joint complex

• Disc height diminishes from bulging/degeneration
• Increased stress on facet joints
• DJD (degenerative joint disease) of spinal segments

Degenerative Disc Disease (DDD)

• Decrease in water content and disc height
• Vertebral bodies approximate
• Intervertebral foramen and spinal canal narrow (stenosis)

Intervertebral Disc: Degenerative Changes-DDD

-Strong genetic component

• Loss of disc integrity from infection, disease, herniations, and end plate defects
• Smoking and heavy lifting have a less significant correlation

Structural Changes in Intervertebral Disc DDD

• Progressive fibrous changes (lose ability to imbibe fluid) -Decreased size of nucleus -Loss of organization of annulus rings -Loss of cartilaginous end plates

Stenosis & Radiculopathy

• Narrowing of a passage/opening by disc protrusion, fibrotic scars, swelling, osteophytes, spondylolisthesis, and faulty posture
• Progression leads to neurological symptoms, especially worsened during extension

Stenosis

• Narrowing of the spinal canal (central stenosis)
• Narrowing of the nerve root canal and intervertebral foramen (lateral stenosis)

Typical Stenosis Presentation

• Patients with stenosis often feel better with flexion-biased exercises to increase foraminal volume and relieve facet pressure

Radiculopathy

• Condition where one or more nerves are affected, causing pain, weakness, numbness, or difficulty controlling specific muscles

Causes of Radiculopathy

• Disc pressure on spinal cord/nerve roots
• Degenerative disc disease (DDD)
• Osteophytes on facets or vertebral bodies that decrease spinal canal or intervertebral foramen size
• Instability, spondylolisthesis from excessive vertebral translation
• Inflammatory response from trauma or degeneration
• Scarring or adhesion formation from prior injury/surgery

Radiculopathy Treatment

• Focus on centralization and reducing signs & symptoms
• Manual therapy (thrust/non thrust manipulation)
• Repeated, patient-directed movements that create centralization of symptoms

Spondylolisthesis

• Hypermobility of spine/spinal segments
• Anterolisthesis: anterior slippage of one vertebra on the one directly below it
• Retrolisthesis: posterior slippage of one vertebra on the one directly below it
• Causes: congenital malformation of pars interarticularis, traumatic fracture of the intervertebral arch, degenerative spinal changes

Spondylolithesis- Types

Retrolisthesis: RARE (Extension bias exercises described)

Spondylolithesis- Types- Anterolisthesis

Flexion bias exercises described to address this condition

Treatment for Flexion Bias Diagnosis (DJD/Stenosis/Anterior Spondylolisthesis)

• Similar positional progression creates lumbar flexion
• Most common exercise involves supine DKTC or REIL, bringing knees to chest to increase posterior pelvic movement & lumbar flexion repetitions.

Facet Joint Dysfunction/Pathology

• Synovial joint containing meniscoid-like structures
• Entrapment of these structures leads to pain and limited mobility

Facet Motion

• Flexion- Opens with contralateral side flexion, ipsilateral rotation
• Extension- Closes with ipsilateral side flexion, contralateral rotation, showing examples facet joints in motion as they open during flexion, and close during extension

Facet Movement- Example

• Referring to right facet -Opening: Flexion, left side bend, and right rotation
• Closing: extension, right side bend, and left rotation

Facet Joint Pathologies

• Facet sprain/joint capsule injury, leads to effusion, limited ROM and muscle guarding
• Spondylosis (umbrella term representing age related spinal changes), early DJD leads to hypermobility, and late DJD leads to hypomobility with osteophytes, pain, and neural impingement. Descriptions of facet pathology related to specific spinal sections is provided in the text.

Soft Tissue Injury

• Pain, muscle guarding (initially to protect affected area)
• Pain with contraction/stretch, interference with ADLs (e.g., transfers, sitting, standing, walking)

Causes of Soft Tissue Injuries in the Spine

• Acceleration/Deceleration (Whiplash)
• Postural strain
• Emotional Stress

Interventions for Soft Tissue Injuries in the Spine

• Muscle performance strengthening
• Stretching
• Stabilization exercises
• Postural education and awareness, and ADL modifications

Whiplash-Associated Disorder (WAD)

• Acceleration/deceleration injury
• Common method of injury is being struck from behind resulting in hyperextension, then rebound hyperflexion.
• Occurs with diving into shallow water
• Injury to ligaments, and sometimes fractures.

Most Common Categories of Headaches

• Vascular (migraines, cluster headaches)
• Inflammatory (tumors, diseases of eyes, nose, throat)
• Resulting from muscle tension, cervical spine impairments, and Temporomandibular Joint (TMJ) dysfunction.

Signs and Symptoms of Headaches

• Headache reproduced with provocation of involved C/S segments
• Limited cervical ROM
• Restricted upper cervical (C0-C2) segmental mobility
• Strength & endurance deficits of deep neck flexor muscles

Cervicogenic Headaches: Etiology

• Tissue Ischemia (due to soft tissue injuries & faulty postures)
• Greater occipital nerve irritation or impingment (muscle guarding)
• Sustained muscle contractions, tension, or temporomandibular dysfunction (TMJ).

Common Associated Findings-Cervicogenic Headaches

• Faulty T/S joint mobility (usually upper T/S)
• Faulty posture (forward head, protracted shoulder posture)
• Trauma, DJD, sedentary lifestyle, etc.
• Restricted upper C/S joint mobility
• Impaired strength and endurance of postural stabilizers (e.g., deep cervical flexors, suboccipitals, scapular muscles)
• Impaired lumbar posture and muscle imbalances

Neck pain with Headache: Interventions

-Pt education, kinesthetic awareness -Stretching exercises

• Cervical mobilization/manipulation
• Coordination, strength and endurance exercises

Potential Cervicogenic HA Interventions

• Cervical spine joint mobilization, Upper T/S joint mobilization, Soft tissue mobilization (myofascial release of suboccipitals)
• Stabilization and endurance exercises
• Patient education
• Non-provocative activities; reassurance of good prognosis; and full recovery is common.

Potential Cervicogenic HA Interventions Continued

-Postural training and relaxation training

• Flexibility exercises focusing on T/S rotation and extensions, OA flexion, decreased protracted shoulder postures, improved C/S ROM

Temporomandibular Joint Dysfunction

• Structure- Mandibular condyle articulates with the TMJ disc and glenoid fossa of the temporal bone
• Necessary for chewing, talking, yawning, etc.

Temporomandibular Joint Motions

• Mandibular depression/elevation (mouth opening and closing)
• Lateral deviation
• Protrusion/retraction

TMJ- Muscles and Action

• Illustration showing jaw in closed position, mid position, & open position

TMJ AROM- Depression/Opening

• Measurement should be performed from upper incisor to lower incisor.
• Functional mouth opening is typically 35-50 mm, allowing for a variety of normal everyday activities.

TMJ AROM- Protrusion

• Measurement of distance between upper and lower central incisors with a ruler.

TMJ AROM- Lateral Deviation

• Distance between center of upper central incisors and the lower incisors is measured.

TMJ AROM Normative Values

• Table provides age-related normal values for TMJ opening, protrusion, & lateral deviation based on author, sample, and measured age demographics

TMJ Dysfunction: Etiology

• Trauma, poor posture, faulty movement patterns (3 most common causes) •Poor oral hygiene, gum chewing, heavy kissing, bruxism, smoking, and rheumatoid arthritis or other inflammatory conditions are additional causes

TMJ Dysfunction: Signs and Symptoms

• Pain in the TMJ during movement
• Joint noise during movement of the jaw
• Restrictions or limitation in jaw movement

TMJ Dysfunction: Sources of Pain

• Pain in the vascularized retro-discal pad
• Pain from muscle spasms (masseter, temporalis, medial pterygoid, lateral pterygoid)
• Tension in cervical muscles can irritate the greater occipital nerve

TMJ Assessment

• Subjective assessment (DOI, MOI, healing phases)
• Functional assessment (abnormal breathing, jaw thrust during speech/swallowing)
• Opening and closing patterns: normal C-curve & pain involvement within disc & capsule
• intra/extra oral examination
• AROM assessment

Additional TMJ AROM Measurements

• Images provide visual representations of how to perform a TMJ AROM measurement for depression (opening), protrusion, and lateral deviation

TMJ Dysfunction: Principles of Management

• Relaxation and breathing training
• Soft tissue and joint mobilization (as per POC)
• Postural correction.
• Eat soft food
• Avoid items requiring wide mouth opening
• Avoid chewing gum

TMJ Dysfunction Principles of Jaw Muscle Control

• Proper jaw resting position: closed lips, teeth slightly apart, tongue resting lightly on the hard palate
• Diaphragmatic breathing -Tongue controlled mouth opening exercises
• Isometric exercises (10 reps for each x 10 seconds)

TMJ Principles of Management: Isometrics

• Tongue on roof of mouth exercise, lateral deviation, and mandibular depression: image guides

TMJ Dysfunction: Principles of Management - Stretching for Restricted Jaw Opening

• Using layered tongue depressors to increase the jaw opening range.

TMJ Dysfunction: Principles of Management- Joint Mobilization

• Refer to images and exercises for specific joint mobilization techniques.
• Identify upper quarter muscle imbalance, and evaluate strength, endurance, and flexibility deficits.

TMJ: Joint Mobilization Techniques

• Illustrations that show unilateral mobilization and bilateral distraction

Consider Addressing the Faulty Posture Loading the TMJ Joint

• Images show how incorrect posture (forward head posture) exerts different amounts of force on the TMJ joint.

This quiz covers essential concepts related to soft tissue injuries, cervical spine mechanics, and exercise recommendations for clinicians. It assesses knowledge on symptoms, strain causes, and the role of intervertebral discs. Perfect for students and professionals in physical therapy and rehabilitation fields.