Lecture #3 - Spinal Motion Assessment

Precautions to take before evaluating spinal movement to ensure patient safety. These include assessing bone health, ligament integrity, blood flow, and spinal cord vulnerability.

Critical elements to establish before a spinal motion assessment include patient safety to avoid harming them.

When a fracture is suspected, it needs screening and referral before any motion assessment.

Determine if it's safe and appropriate to assess spinal motion, involving active or passive movements, and all or some ranges of motion (ROM).

Vertebral motion varies depending on the spinal region and individual; each segment involves a superior vertebra moving on an inferior one.

The description of motion within a vertebra includes the anterior view, and the position of the vertebra above moves in relation to the vertebra below, regardless of which vertebra is actually moving.

The cervical and lumbar regions of the spine have the largest range of motion.

Spinal movement is sequential, meaning it starts at one segment and gradually moves down the spine.

Rotation of a superior vertebra around a longitudinal axis.

Simultaneous movements around different axes.

Movement between articulating surfaces without external forces.

Movement of bones in relation to each other, responding to external forces.

Upper part of the cervical spine.

Forward bending of the neck.

Rotation of the upper cervical spine.

The amount of movement a joint can achieve.

Lateral movement of the spine.

Tool used to measure spinal angles.

Active range of motion, movement done by patient.

Passive range of motion; healthcare provider actively moves the joint.

Limited joint mobility.

Excessive joint mobility.

The sensation felt when reaching the end of a joint's range of motion.

Shape and angle of the articular processes influencing spinal movement.

The space between adjacent vertebrae, through which spinal nerves pass.This space increases during spinal flexion.

The normal range of motion during cervical flexion, typically measured by two fingers distance from chin-to-chest.

Increased intervertebral foramen space during spinal flexion can alleviate nerve root compression.

Correct positioning of the patient's spine for a precise assessment of spinal range of motion by the clinician.

Range of motion achieved through external assistance (practitioner’s hands), without the patient actively moving.

Motion palpation technique to assess segmental spinal motion. Requires proper patient and therapist positioning to avoid influencing.

A possible problem where smooth spinal movements are disrupted and the sides of spine do no track properly.

Assessment of the patient's ability to freely move their spine.

A neurological condition where shooting pain with spine flexion can signal damage to nerve pathways.

Unintended movements in other parts of the body to compensate for restricted spinal motion.

A term used to describe how consistent different clinicians are in their findings during tests of spinal motion.

Moving beyond a neutral position to an extended position

Focusing on the movement of individual vertebral segments, rather than the spine as a whole.

A widening of the space between spinous processes during side bending.

A narrowing of the space between spinous processes during side bending.

Assessing multiple vertebral segments simultaneously.

Posterior to Anterior Central Vertebral Pressure, a type of PAIVM.

A PAIVM that involves moving a vertebra laterally.

Transverse Vertebral Pressure, a type of PAIVM.

Posterior to Anterior Unilateral Vertebral Pressure, a type of PAIVM.

PAIVMs can be used to assess for spinal instability by replicating potential unstable movements.

Lying on your stomach.

Lying on your back.

PAIVM testing begins by positioning the joint in its resting or loose-packed position, which is the most relaxed and stable position for that joint.

PAIVM assessments are categorized into two types: Local, which focuses on movement between individual segments, and Regional, which examines movement across multiple segments.

PROM (Passive Range of Motion) assesses the full range of motion of a joint, while PPIVM (Passive Physiological Intervertebral Motion) examines the movement between individual vertebrae.

Restricted joint glide during PAIVM indicates a problem with the joint capsule and surrounding tissues, like ligaments and muscles.

PPIVM is used to identify potential problems, while PAIVM is more challenging to interpret due to factors like guarding, which can make assessment more difficult.

A joint can exhibit accessory hypermobility even if its physiological motion is normal or restricted. This is often due to guarding or compensation mechanisms.

Before assessing PPIVMs, check for strength, length, and functional limitations of the tissues surrounding the joint.

To assess individual vertebral motion, a technique involving side flexion is used to facilitate segmental movement.

PPIVM is the movement that is least likely to cause pain, but can easily take the individual to their end range of motion.

A hypermobile segment within the spine is often accompanied by a hypomobile segment in an adjacent region. This is the body's way of compensating for instability in the hypermobile joint.

Flexing the neck can relieve pressure on spinal nerve roots by increasing the intervertebral foramen space.

A widening of the space between spinous processes during side bending.

A narrowing of the space between spinous processes during side bending.

PAIVMs are applied with the goal of replicating normal joint movements, assessing the quality of that movement, and identifying any restrictions or pain.

A technique used to assess mobility and pain in the rib cage, distinct from PAIVMs.

Before evaluating spinal movement, it's crucial to assess 4 key factors:

1. Bone health: Ensure there are no fractures or bony abnormalities.
2. Ligament status: Check for ligament integrity and stability.
3. Blood flow: Assess circulation to the area, especially in the cervical spine.
4. Spinal cord vulnerability: Consider the potential risk to the spinal cord during movement.

Before moving forward with a spinal motion assessment, it is imperative to rule out three critical conditions:

1. Fractures, particularly in the cranio-vertebral or cranio-sacral region, specifically focusing on the alar and transverse ligaments.
2. Ligamentous injury: Ligament integrity is vital for any motion assessment, especially segmental motion.
3. Vertebral or internal carotid artery compromise: This is of particular concern for the cervical spine.

The primary consideration before any spinal motion assessment is patient safety. Before proceeding, it's essential to establish that all conditions are safe, and there is no concern for a fracture or other contraindication.

Vertebral motion involves the superior vertebra moving on the inferior vertebra. This applies regardless of the actual position of the spine. For example, if you lift your shoulder off the table, T8 is described as rotating to the left on T9, even if you're lying prone. This is because we describe movement based on the anterior surface of the vertebral body.

The spine has 6 degrees of freedom, representing the types of movements possible. These are:

• Flexion/Extension/Hyperextension
• Lateral Flexion
• Lateral Translation
• Anterior/Posterior Translation
• Rotation

Two factors influence the decision to proceed with a spinal motion assessment. First, whether active or passive movements will be used. Second, whether all or just some movements will be assessed.

Patient positioning and the load on the spine during the assessment are vital for three reasons:

1. Convenience and efficiency: Optimal positioning makes the assessment easier and faster.
2. Patient comfort: Positioning should be comfortable for the patient to avoid discomfort or pain.
3. Maximizing/minimizing the impact of gravity: Proper positioning can help to maximize or minimize the effect of gravity on the spinal segments being assessed.

The cervical and lumbar regions of the spine have the greatest range of motion compared to other spinal regions.

Flexion describes the movement of the spine forward, like nodding your head. Extension is the opposite, moving the spine backward.

When you side bend your spine, the top vertebra rotates in the direction you are bending. So, if you bend left, the top vertebra rotates left.

The joint between the first and second vertebrae (atlantoaxial joint) doesn't follow this rule. You can side bend this joint without any rotation.

The shape of the joints, the size and location of the bones, and the strength of the muscles and ligaments all contribute to how the spine moves.

If a cervical joint is restricted, side bending and rotation are typically limited equally, and flexion is less restricted than extension.

Osteokinematic motion is the movement you see (e.g., flexing your neck). Arthrokinematic motion is the movement between the joint surfaces themselves (invisible).

The cervical spine is divided into two sections: Upper cervical, which connects the head to the spine, and lower cervical, which is the rest of the neck region.

We measure how much a patient can move their spine in different directions. We assess flexion, extension, side bending, rotation, and combinations.

We may use inclinometers, goniometers, or measuring tapes to assess motion. Most often, we observe visually.

We rate a joint's movement as hypomobile (limited), normal, or hypermobile (excessive) to describe its mobility.

Active ROM is a patient moving their spine themselves. Passive ROM is when a therapist moves the patient's spine.

When assessing neck flexion, cue the patient to tilt their head forward, not bend the entire neck forward.

Be careful when assessing spinal motion, especially in cases of suspected fractures. Always do a thorough examination to ensure safety.

PROM (Passive Range of Motion) assesses the entire range of motion of a joint, while PPIVM (Passive Physiological Intervertebral Motion) assesses the movement between individual vertebral segments.

Restricted joint glide during a PAIVM can indicate problems with the joint capsule, ligaments, or muscles surrounding the joint.

PAIVMs are more challenging to interpret because factors like guarding or compensation can make it difficult to isolate and assess the true movement.

Accessory hypermobility can occur due to guarding or the body's attempt to stabilize an unstable joint by adapting movements in adjacent segments.

Before assessing PPIVMs, check for strength, length, and functional limitations of the tissues surrounding the joint.

PPIVM (Passive Physiological Intervertebral Motion) is the movement that can be performed with the least amount of pain and allows for reaching the end range of motion.

PAIVM testing typically begins by positioning the joint in its resting or loose-packed position, which is the most relaxed and stable position for that joint.

The two types of PAIVM evaluation are local, which focuses on movement between individual segments, and regional, which examines movement across multiple segments.

Checking for fractures or other bony abnormalities in the spine before proceeding with motion assessment.

Evaluating the strength and stability of the ligaments surrounding the spine, crucial for safe motion assessment.

Verifying adequate blood circulation to the spinal region, especially important for the cervical spine.

Considering the potential risks to the spinal cord during movement, ensuring precautions are taken to prevent injury.

These are major concerns for the spine's stability, requiring immediate attention before any motion assessment.

The different types of motions the spine can perform, including flexion/extension, lateral flexion, rotation, and translations.

Optimizing the patient's position and the amount of stress on the spine during motion assessment for safety, comfort, and efficiency.

Bending the spine forward, like nodding your head.

Moving the spine backward, the opposite of flexion.

Turning or twisting the spine around its vertical axis.

The upper region of the cervical spine, connecting the head to the spine.

The lower region of the cervical spine, including the rest of the neck.

A characteristic pattern of limited movement in a joint, typically indicating a problem with the joint capsule.

Typical, expected amount of joint movement.

The location of the transverse spinous processes (TSPs) changes in the thoracic spine, making it more challenging to differentiate between them and the ribs during PAIVMs.

Transverse spinous processes in the lumbar spine are approximately one inch deep from the posterior aspect of the back, making palpation less accurate.

PAIVM (Passive Accessory Intervertebral Motion) assesses joint movement using a force applied to the joint, while PPIVM (Passive Physiological Intervertebral Motion) assesses the joint's natural movement without external forces.

Restricted joint glide during PAIVM indicates issues with the joint capsule, ligaments, or muscles surrounding the joint.

A joint can be hypermobile (excessive movement) even if its normal range of motion is limited. This can happen due to guarding or compensation in nearby segments.

Before assessing PPIVMs, check the strength, length, and function of tissues around the joint.

PAIVM testing starts by positioning the joint in its resting or loose-packed position, which is the most relaxed and stable position.

PAIVM assessments are categorized into local (individual segment movement) and regional (multiple segment movement).

Evaluating the stability of ligaments surrounding the spine, crucial for safe motion assessment.

The space between vertebrae increases by 20-30% during spinal flexion, which may relieve nerve root compression.

A standing position where the arms are resting on the shoulders, elbows are up and pointed toward the hips, and the back is rounded.

Instruct the patient to stick their chest forward and use their elbows to pull back while maintaining the hands-on-shoulders position.

The neck should flex and extend passively along with the thoracic spine.

Pelvic positioning is used to isolate movement to the thoracic spine, preventing lumbar spine movement.

Ensure that the shoulders do not elevate or move forward during side bending.

Repeat spinal movements to assess for myofascial restrictions, which may limit movement.

These movements are considered more 'active assisted' than truly passive, as the patient uses some muscles to maintain their sitting posture.

For true passive movement in the lower thoracic spine, the patient should be positioned side-lying, with the clinician flexing the hips toward the chest for flexion and moving the heels toward the buttocks for extension.

With the patient supine, the clinician crosses the patient's arms across their chest and uses their own shoulder and elbow to press the patient into rotation.

This movement is rarely done in practice as it often involves pushing the head forward against resistance.

The patient lies supine with their head on the bed, and the clinician uses their thumb/forefinger to gently glide the head in an anterior-posterior direction.

A PPIVM assessment is considered normal if the joint demonstrates a normal range of motion and a normal end-feel.

The patient should be relaxed, well-supported, and in a neutral spinal position. The therapist should use good body mechanics, be close to the patient, and apply firm, professional contact.