Lumbar Spine and SIJ Module PDF

AHS2052H Lumbar Spine and SIJ module Content: Heather Talberg This pack contains the following resources Lumbar spine – copies of lecture slides; Lecture 1 to 6 Anatomy and Biomechanics Su...

AHS2052H Lumbar Spine and SIJ module Content: Heather Talberg This pack contains the following resources Lumbar spine – copies of lecture slides; Lecture 1 to 6 Anatomy and Biomechanics Subjective assessment Objective assessment Treatment Techniques Conditions (1 and 2) Rehabilitation SIJ Anatomy and Biomechanics Conditions and Treatment ideas The following additional resources are added Summary guide to Lumbar assessment Keele START back tool Oswestry Disability index Additional information pertaining to effect of aging on spinal structures Core articles of interest (Foster et al., 2018)(Zhou et al., 2024) (Laslett et al., 2005; Palsson et al., 2019) Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M.,…Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The lancet, 391(10137), 2368-2383. https://doi.org/https://doi.org/10.1016/S0140-6736(18)30489-6 Laslett, M., Aprill, C. N., McDonald, B., & Young, S. B. (2005). Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy, 10(3), 207-218. https://doi.org/https://doi.org/10.1016/j.math.2005.01.003 Palsson, T. S., Gibson, W., Darlow, B., Bunzli, S., Lehman, G., Rabey, M., Moloney, N., Vaegter, H. B., Bagg, M. K., & Travers, M. (2019). Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Physical Therapy, 99(11), 1511-1519. https://doi.org/10.1093/ptj/pzz108 Zhou, T., Salman, D., & McGregor, A. H. (2024). Recent clinical practice guidelines for the management of low back pain: a global comparison. BMC Musculoskeletal Disorders, 25(1), 344. https://doi.org/10.1186/s12891-024-07468-0  2024/08/26 LUMBAR SPINE 1 ANATOMY & BIOMECHANICS AHS2052H Maitland’s Clinical Companion pgs: 429-500 Heather Talberg 1 ANATOMY  Normally in lordosis  Consisting of L1-L5 vertebrae  Located btw Thoracic spine and SIJ  Designed to be strong protecting the spinal cord and spinal nerve roots.  Able to bear load  Highly flexible, providing for mobility in flexion, extension, side flex, and some rotation. 2 3 1  2024/08/26 MAIN STRUCTURES FOR CONSIDERATION  Vertebra ( Bony structure)  Disc  Ligaments  Muscles  Nerves 4 ANATOMY - VERTEBRAE  Their vertical height is less than their horizontal diameter. They are composed of the following 3 functional parts:  The vertebral body, designed to bear weight  The pedicles which transmit forces between the body and the posterior structures  The posterior bony processes (spinous and transverse) and lamina, which function to increase the efficiency of muscle action and protect the spinal column 5 ANATOMY - DISCS  Discs form the main connection between vertebrae. They take load during axial compression and allow movement between the vertebrae. Their size varies depending on the adjacent vertebrae size and comprises approximately one quarter the height of the vertebral column.  The nucleus pulposus  Water-rich (proteoglycan-rich), gelatinous centre of the disc.  Carries the downward weight (i.e., axial load) of the human body and acts as a 'pivot point' from which all movement of the lower trunk occurs. It's also binds the vertebrae together.  The annulus fibrosis  Is more fibrous and tougher than the NP.  Divided into the outermost, middle, and innermost fibres. The anterior fibres are strengthened by the powerful anterior longitudinal ligament (ALL). The annular fibres are firmly attached to the vertebral bodies and are arranged in lamellae.This annular arrangement permits limiting vertebral movements, reinforced by ligaments. 6 2  2024/08/26 DISCS – CONTINUED  Discs are avascular – nutrition through fluid exchange across end- plate  Most fluid absorbed by nucleus in non- WB positions- like sleeping. Fluid then expressed during the day  We are taller in morning than at night  With age water content decreases- able to store less energy – resists less load  Annulus  Has a nerve supply on outer parts- explains some pain referral with damage 7 DISC STRUCTURE 8 ANATOMY - LIGAMENTS  The Anterior Longitudinal Ligament ( ALL) covers the anterior surfaces of lumbar vertebral bodies and discs. It is intimately attached to the anterior annular disc fibres and widens as it descends the vertebral column. The ALL maintains the stability of the joints and limits extension.  The Posterior Longitudinal Ligament ( PLL) is located within the vertebral foramen over the posterior surface of the vertebral bodies and discs. It functions to limit flexion of the vertebral column, except at the lower L-spine, where it is narrow and weak.  The supraspinous ligament joins the tips of the spinous processes of adjacent vertebrae from L1-L3.  The interspinous ligament interconnects the spinous processes, from root to apex of adjacent processes. 9 3  2024/08/26  The ligamentum flavum (LF) bridges the inter- laminar interval, attaching to the interspinous ligament medially and the facet capsule laterally, forming the posterior wall of the vertebral canal. When taut, it stretches in flexion and contracts its elastin fibres in neutral or extension. It maintains constant disc tension.  The inter-transverse ligament joins the transverse processes of adjacent vertebrae and resists lateral bending of the trunk.  The iliolumbar ligament arises from the tip of the L5 transverse process and connects to the posterior part of the inner lip of the iliac crest. It helps stabilize the lumbosacral joint. 10 LIGAMENTS 11 ANATOMY - MUSCLES  Trunk movers : Divided into extensors, flexors, lateral flexors, and rotators.  The Extensors  Erector spinae: In the lower L-spine, the erector spinae appears as a single muscle. At the upper lumbar area, it divides into 3 vertical columns of muscles (iliocostalis, longissimus, spinalis).  Transverso-spinal muscle group, lies deep to the erector  Forward flexors  The iliothoracic group: Rectus abdominis, external abdominal oblique, internal abdominal oblique.  The femorospinal group is made up of the iliopsoas muscles.  Strong stabilising component in upright position.  Slow-twitch type 1 muscle.  If shortened and lack of normal tone = increased anterior pelvic tilt and lumbar lordosis and decreased hip ext – weakness and LB problems. 12 4  2024/08/26 ANATOMY - MUSCLES  Lateral flexors  True lateral flexion is a combination of s.flx and rotation. The obliques, rectus abdominis, multifidus and quadratus lumborum work together.  Rotators  Multifidus, semispinalis, obliques 13 ANATOMY- MUSCLES  Stabilisers  Stabilisation of the spine and the motion segment is created through the work of  Transversus Abdominus ( Tr A) – Anterior runs horizontally btwn pelvis And ribcage  Multifidus  Posterior, intersegmental 14 ANATOMY – MUSCLES 15 5  2024/08/26 ANATOMY – THE SPINAL CORD  The spinal cord is one of the 2 anatomic components of the central nervous system (CNS). It is the major reflex centre and conduction pathway between the brain and the body.  Normally terminates within the lumbar spinal canal at the lower margin of the L2 vertebra.  All lumbar spinal nerve roots originate at the T10 to L1 vertebral level. A sensory root from the posterolateral aspect and a motor root from the anterolateral aspect of the cord join in the spinal canal to form the spinal nerve root. The roots then course down through the spinal canal, forming the cauda equina below the L2 level. 16 ANATOMY – CAUDA EQUINA  The cauda equina  bundle of nerves in the spinal canal below the spinal cord,  nerve roots and rootlets attached to the spinal cord.  L1-5 and S1-5 nerve roots.  L4-S4 nerve roots form the sacral plexus  sciatic nerve  Compression, trauma or other damage to this region of the spinal cord can result in cauda equina syndrome.  NB to assess for cauda equina syndrome in assessment of spinal dysfunction 17 CAUDA EQUINA SYNDROME  An acute loss of function  Signs include of the lumbar plexus:  LL muscle weakness, Nerve roots below the loss of coordination termination of the  Incontinence or spinal cord are retention compressed or damaged.  Saddle anesthesia  Causes include  Decreased ankle  Trauma reflexes  Tumors  Management  Lesions  Spinal stenosis  Medical emergency (red flag) –  Inflammatory conditions decompression surgery 18 6  2024/08/26 BIOMECHANICS-  THE CONCEPT OF THE MOTION SEGMENT  A motion segment is an individual vertebrae on another with the disc in between, and the articulation between the 2 ( at the facet joints)  We need to consider movement and function in the spine relative to each motion segment.  While we see in client’s physiological movements of trunk Flexion / Extension etc they occur as a result of 1 motion segment moving on another 19 THIS DIAGRAM IS EXPLAINED ON THE NEXT SLIDE 20 THE MOTION SEGMENT  2 vertebrae with an intervertebral disc between them  Its articular facet joints  The muscles, ligaments, nerves that support and lie adjacent to it. 21 7  2024/08/26 BIOMECHANICS – JOINTS OF THE SPINE  The Intervertebral joint:  Consists of a disc and 2 adjacent vertebral bodies.  Supports the weight of the body. Shock absorber for the vertebral column  Cartilaginous joint  Closed pack position  flexion 22 BIOMECHANICS – JOINTS OF THE SPINE  The Zygapophyseal joint (facet joints):  between inferior articular process of a vertebrae with the superior process of the adjacent vertebrae.  allow gliding movements between the vertebrae.  Synovial joint  Closed pack position  Extension  Capsular pattern  Side flex and rotation equal limitation, then extension  Remember indicative of possible inflammation in connection with degenerative disease 23 ROLE OF DISC IN TRANSMISSION OF FORCES 24 8  2024/08/26 FORCE DISTRIBUTION  So discs help in distributing force up and down our spine  This relies on anatomical integrity of Nucleus and Annulus  This changes with Age and Injury 25 BIOMECHANICS OF THE LX SPINE  The ant long lig( ALL) helps to prevent hyperextension.  The post long lig ( PLL) helps to prevent hyperflexion and herniation of intervertebral discs.  Connecting adjacent lamina the ligamenta flava prevents separation of the lamina, which further protects the intervertebral discs.  Lumbar range of motion varies between vertebral levels and individuals  Flexion 0-60º Extension 0-25º Side flx 0-25º 26 BIOMECHANICS OF THE LX SPINE  Translation and rotation occur at each motion segment during lumbar spine movements in any of the cardinal body planes.  In other words movements are coupled  For example: Lumbar flexion involves anterior translation and rotation, and lumbar extension involves posterior translation and rotation of each lumbar motion segment in the sagittal plane. 27 9  2024/08/26 EFFECTS OF MOVEMENT  Extension  Upper vertebra moves posteriorly  Tension increases in ant aspect of disc  Flexion  Upper vertebrae moves anteriorly  Tension increases in post part of disc  Lateral flx  Upper vertebrae tilts twds flexing side  Disc moves twds opposite side increasing tension in that side 28 EFFECTS OF MOVEMENT  Lumbar Rotation  - very little rotation occurs at a segmental level  Probably about 3 degrees of movement around a central axis  Then Axis moves from disc to facet joint  Impaction of facet joint surfaces stops rotation  If more rotation happens, we see failure of annular fibres 29 30 10  2024/08/26 THE SHOCK ABSORBING SPINE  Impact forces: I.e. running and jumping are transmitted upwards to the spine from the lower limb.  Downward forces are transmitted through the spine to the pelvis, but a reduced significantly by the spinal curvature  This allows for a staggering of forces 31 BIOMECHANICS OF THE LX  The stabilising system of the lumbar spine  ACTIVE / PASSIVE / Control: NEURAL CNS  The functions of these 3 subsystems are interrelated, and Panjabi’s reduced function of Triangle of one subsystem may Stability place increased Passive Active system: system: demands on the other Skeletal Muscle subsystems to maintain stability  Known as Panjabi’s triangle of stability 32 11  2024/08/26 LUMBAR SPINE 2 SUBJECTIVE ASSESSMENT AHS2052H Maitland’s Clinical Companion Maitlands Vertebral Manipulation Heather Talberg 1 DESCRIPTION OF DISORDER  Pain – stiffness – weakness – instability  Onset  Acute  Insidious  Chronic  Post-surgical, trauma, MUA, bracing/support, traction 2 BODY CHART  Area of symptoms  P1, P2….  Be very specific as to location of symptomatic areas and their relationships!  Pain  Severity (VAS)  Nature of pain  Depth of pain  Constant / intermittent  Abnormal sensations  Clear unaffected areas 3 1  2024/08/26 BEHAVIOR OF SYMPTOMS  Aggravating factors  Stipulate for each P  Which mvt or position aggravates  What brings on what makes worse (I.e. moving or not moving)  If P1 is aggravated what happens to P2..etc  Ask for common aggravating factors;-consider functional tasks that involve trunk movement  Flexion (putting on shoes or bending down)  Sitting, standing, walking, sit-to-stand, running  Driving, coughing, sneezing  Ascending descending stairs, walking on uneven ground  Digging, sports activities (shearing, rotation, flx and ext)  Hand dominance  How do symptoms affect ADL (I.e. static vs active positions)  Highlight NB findings with * 4 BEHAVIOR OF SYMPTOMS  Easing  Ask for each relevant symptomatic area  Relate to mvt and position  How long does it take for symptoms to ease?  What happens to other symptoms once P1 has eased?  Common easing factors:  Walking, sitting in flx or ext, standing fwd lean (shopping trolley sign)  Symptoms easing with mvt indicative of mechanical problem, as opposed to inflammatory  Will help in interpreting SIN 5 BEHAVIOUR OF SYMPTOMS: 24 HOUR PATTERN  Night symptoms  Morning/Evening  Normal sleeping symptoms position?  Determine severity and  Present sleeping position irritability  Difficulty sleeping  Pain behaviour in the  Do symptoms wake pt at night morning and the evening  Pain wakes them up? = indicative of  Pain on turning wakes mechanical vs them up? inflammatory condition  Which symptoms  Stage of condition wake pt – how often  How long does it take  Getting better to get back to sleep  Getting worse  Pillows and mattress  Remaining unchanged 6 2  2024/08/26 HISTORY  Purpose  Structures involved  State of structures  Rate of progression  Degree of stability  Likelihood of being successful with specific kind of treatment 7 PRESENT HX  How long – acute vs chronic  Sudden or slow onset  Known cause  If insidious: any lifestyle changes  Management this far  Any changes in condition  What does the patient think is wrong? 8 PAST HX  Any similar episodes  How often, similarity, previous Rx  Compliance with physio?  Full recovery between episodes  Relevant medical hx  Surgery, trauma  Current status of this – has it fully resolved? 9 3  2024/08/26 SPECIAL QUESTIONS AND RED FLAGS  General health  Unexplained weight loss/gain  Medication  Steroids  Anticoagulants  CE signs:  Bladder retention/Incontinence  Saddle anaesthesia  Spinal Cord  Gait disturbance or LL weakness  Bilateral p&n in hands or feet  Medical history  Osteoporosis  Diabetes  Neuropathies  Medication for this condition  If imaging is available check it 10 SOCIAL & FAMILY HX  Relevant family history (arthritic diseases)  Job  What does it require?  ADLs  Leisure activities  What do they require?  Any change in lifestyle  Stresses and recent changes:  Death, moving, job change, family problems, divorce, socio-economic status, dependencies, house environment 11 PSYCHOSOCIAL RISK FACTORS  Psychosocial factors are the main predictors of whether someone with LBP will develop Chronic Lower Back Pain (CLBP)  Commonly referred to as “Yellow Flags” A Attitude B Behaviour C Compensatory issues D Diagnostic E Emotion F Family W Work 12 4  2024/08/26 RISK FACTORS FOR CHRONICITY  Any time off work in the past with back pain?  What is the patient’s understanding of cause?  What does the pt think will help him/her?  How is the employer/co-workers/spouse responding to the back pain?  What is the pt doing to cope with the pain?  Does the pt think he/she will return to work? 13 The Keele STarT Back Screening Tool Thinking about the last 2 weeks tick your response to the following questions: Disagree Agree 0 1 1 My back pain has spread down my leg(s) at some time in the last 2 weeks □ □ 2 I have had pain in the shoulder or neck at some time in the last 2 weeks □ □ 3 I have only walked short distances because of my back pain □ □ In the last 2 weeks, I have dressed more slowly than usual because of back 4 pain □ □ It’s not really safe for a person with a condition like mine to be physically 5 active □ □ 6 Worrying thoughts have been going through my mind a lot of the time □ □ 7 I feel that my back pain is terrible and it’s never going to get any better □ □ 8 In general I have not enjoyed all the things I used to enjoy □ □ 9 Overall, how bothersome has your back pain been in the last 2 weeks? Not at all Slightly Moderately Very much Extremely □ □ □ □ □ 0 0 0 1 1 9. Total score (all 9): __________________ Sub Score (Q5-9):______________ © Keele University 01/08/07 Funded by Arthritis Research UK 14 ASSESSING RISK  Use the STarT Back Screening Tool (Hill et al, 2008) in all patients presenting with LBP  Assesses yellow flags and biological factors which increase risk of LBP becoming CLBP  9 questions screening for  Referred pain, limited function  Fear avoidance behaviour (kinesiophobia)  Anxiety  Catastrophising  Depression  Score categorises risk 15 5  2024/08/26 EVALUATING START BACK SCORES Low – education and advice, one or two sessions only Medium – routine physio focussing on biomechanical/physical obstacles to recovery High – psychological obstacles to recovery, need enhanced physio with lots of education and graded exposure to activity and exercise 16 OUTCOME MEASURES The Keele STart Back screening tool Common outcome measures for lower back pain Brief pain inventory questionnaire Pain and disability Oswestry Low Back Pain Disability Questionnaire Roland Morris questionnaire 17 Oswestry Low Back Pain Disability Questionnaire 18 6  2024/08/26 19 SCORING INSTRUCTIONS  For each section the total possible score is 5  if the first statement is marked: score = 0  if the last statement is marked: score = 5  If all 10 sections are completed the score is calculated as follows:  16 (total score) divide by 50 (total possible score) x 100 = 32%  If one section is missed or not applicable the score is calculated: 16 (total score) divide by 45 (total possible score) x 100 = 35.5% 20 INTERPRETATION OF SCORES 21 7  2024/08/26 GENERATE A PROVISIONAL HYPOTHESIS BASED ON SUBJECTIVE FINDINGS  stage of disorder – acute versus chronic  source of symptoms (structure)  pathobiological mechanism (inflammatory/ mechanical)  contributing factors- consider lifestyle, work, previous incidents  SIN (Severity, Irritability, Nature)  precautions & contraindications  pain mechanisms (local, referred, chronic)  comparable symptom 22 8  27/08/2024 LUMBAR SPINE 3 OBJECTIVE ASSESSMENT AHS2052H Maitland’s Clinical Companion pgs: 429-500 Heather Talberg 1 RECAP OF SUBJECTIVE  Subjective should have answered the following:  Is this a SIN patient?  What structures are possibly involved?  Type of pain  What does it suggest?  What is the comparable symptom?  What is a possible comparable sign? 2 1  27/08/2024 OBJECTIVES OF OBJECTIVE  Purpose:  To eliminate or confirm my differential diagnosis  To eliminate or confirm my hypothesis  Testing structures objectively in an isolated and controlled manner using a set sequence.  Diagnosis by structural differentiation  Be able to establish a comparable sign  Be able to establish a comparable level on palpation  To be able to develop a treatment plan 3 OBSERVATION  Informal:  Before pt is aware of your scrutiny!  Check sitting posture, sit-to-stand, walking  Is pt hesitant to move?  Gives a lot of clues before formal observation  BUT be careful of making judgements based on informal observation 4 2  27/08/2024 OBSERVATION  Formal  General health:  Expression, wellbeing  Pallor etc  General build  Skin appearance  Postural Alignment  Poking chin, lordosis, scoliosis  Protective deformity  Fixed/mobile?  What is the effect if you correct the posture?  Contour and muscle wasting, swelling, spasm 5 POSTURE  Need to work through quickly  Work systematically  Top to bottom  Why is this important?  Posture not a predictor of LBP 6 3  27/08/2024 FUNCTIONAL DEMONSTRATION  Ask the patient to demonstrate the movement which causes the most problem  Analyse the mvt  How much Lumbar mvt involved  At which precise point do the symptoms occur?  Note the ROM  How long do the symptoms last or take to come on?  Time it (irritability, latency)  How severe are the symptoms? 7 QUICK TESTS  Walk on heels  Clue for L4 nerve root can they maintain dorsiflexion  Clue for L5 nerve root involvement can they maintain big toe extension  Unilateral calf raises x 6  Clue for S1 nerve root  Note these tests are relevant in presence of WEAKNESS/ not pain. 8 4  27/08/2024 CLEAR JOINTS ABOVE AND BELOW  Thoracic spine  Rotation, flx/ext (quadrants)  SIJ  Compression/distraction  Hip  Squat – provisionally clears hip, kn, ankle  As applicable:  Hip quadrant  (hip flx 90, add, compress and move in arc of flx)  Knee - Active mvts with overpressure  Ankle - Active mvts with overpressure 9 ACTIVE MOVEMENTS  Always conduct these in the same order for consistency in reassessment  Before beginning be clear about whether your patient will be moving to pain or moving to limit (i.e. determine the SIN)  Gives clues as to willingness to move and symmetry  Ask for symptoms before start the movements  These can be * signs- note ROM and Symptom throughout 10 5  27/08/2024 ACTIVE MOVEMENTS  Lumbar flexion  Active – if symptom free – overpressure  Guide and/or demonstrate to pt  Ask for symptoms throughout  Measure fingers to floor or note position with respect to a landmark on lower limb  Lumbar extension  Hands on back, no bent knees  Active – if symptom free – overpressure  Guide and/or demonstrate to pt  Ask for symptoms throughout  Lumbar side flx L and R  Hands sliding down side, keep good straight line  Active – if symptom free – overpressure  Guide and/or demonstrate to pt  Ask for symptoms throughout 11 ACTIVE MOVEMENTS  On all movements note:  Quality of mvt  Observe the Lu spine, are all the motion segments involved in the movement?  Behaviour of symptoms  Symptoms after returning to neutral  Intensity  Longevity  No symptoms at end of range apply overpressure  Gr IV-, IV and IV+ till jt cleared or symptoms reproduced 12 6  27/08/2024 WHEN APPLICABLE TESTS  Lumbar rotation – not done routinely.  As an active mvt more efficient to perform as combination mvt, i.e.:  Fwd flexion with rotation  Can assess from caudad to ceph and in reverse  Quadrant:  Perform when F, E, LF and R are negative  Extension – overpressure – lat flex and rot to side of symptoms  Must get to end ROM of each component and maintain before adding next  Compare sides 13 NEUROLOGICAL EXAMINATION  Full neurological exam is indicated if symptoms (any) are referred below the inferior gluteal fold  A full neurological exam consists of:  Neurological Conduction/ Integrity Tests  Sensation (Dermatomes)  Light touch  Motor (Myotomes)  Isometric break tests  Reflexes  Plantar response – Babinski * for SC involvement  Clonus * SC involvement  Neurodynamics to test mechanical sensitivity  SLR, PKB, Slump 14 7  27/08/2024  What are we assessing when we do a neurological Conduction exam?  The integrity of the nerve to conduct messages  Myotomes  Dermatomes  Reflexes  What are we assessing when we do a ND assessment? ◦ The mechanical sensitivity of the nerve and nervous system ◦ The nerve’s tolerance for movement i.e. can the nerve move, withstand tension and elongate as it should. 15 NEUROLOGIC VS ND ASSESSMENT  When is a neurological (conduction) examination indicated? ◦ Indication of nerve root involvement – symptoms in a dermatome or myotome ◦ Symptoms referred below the gluteal fold  What is included in a neurological examination? ◦ Dermatome (sensation testing) ◦ Myotome (break testing) ◦ Reflexes  What does this information tell you? ◦ This gives you information about the integrity of the nerves 16 8  27/08/2024 NEUROLOGIC VS ND ASSESSMENT  When is a ND examination going to give you more information? ◦ Symptom referral not restricted to a dermatome ◦ Any joint with symptom referral  What does ND assessment tell you? ◦ This gives you information about the sensitivity of the nerves to movement 17 NEUROLOGICAL CONDUCTION / INTEGRITY TESTS  Performed to assess the possible involvement of nerve roots in referred pain.  If strong evidence of acute nerve root involvement, you may need to refer to physician!  Make sure you know your neurological integrity tests of by heart! 18 9  27/08/2024 NEUROLOGICAL INTEGRITY TESTS  Dermatomes  Charts refer to sensory areas in which most patients experience symptoms if nerve-root involvement. A great deal of variation from person to person is possible.  Sensory changes can be due to lesion of the sensory nerves anywhere from the nerve root to its terminal branches in the skin  Sensory changes are most accurately determined along the distal points of dermatomes  Myotomes  The term is used to describe the muscles served by a single nerve root. Each muscle in the body is supplied by a particular level or segment of the spinal cord and by its corresponding spinal nerve. The muscle and its nerve make up a myotome.  Myotomes are tested isometrically with Break tests. Can give information about the level in the spine where a possible compression of a nerve root may exist 19 NEUROLOGICAL INTEGRITY EXAMINATION DERMATOMES Nerve Root Dermatome Testing Site L1 Groin L2 Medial thigh (half way down) L3 Medial knee L4 Medial malleolus L5 Web space between first and second toe S1 Lateral border foot S2 Heel  Use cotton wool – pt in supine, explain procedure  Test an unaffected area for sensation – ask for pt feedback  Pt eyes closed, apply light touch to dermatomal area, ask the pt if they “can you feel it/ me touching you ”, compare to other side “does it feel the same?” 20 10  27/08/2024 NEUROLOGICAL INTEGRITY EXAMINATION MYOTOMES Nerve Root Test L1/2 Hip flexion L3 Knee extension L4 DF & Inv L5 Big toe ext S1 Eversion S2 Toe flexion  Get in good position to test effectively: Supine  Get strong isometric contraction and “break” the contraction.  Look for weakness and inability to hold  Pain is not a positive finding but may be a factor in muscle inhibition – be aware of false positives.  Compare both sides.  If unsure of results – test again. 21 NEUROLOGICAL INTEGRITY EXAMINATION REFLEXES  Deep tendon reflexes tested for the spine:  L3/4: Knee Jerk  S1: Ankle Jerk 22 11  27/08/2024 NEUROLOGICAL INTEGRITY EXAMINATION  If you suspect spinal cord involvement the following tests are indicated:  Plantar Response (Babinski)  Pressure applied from heel and along lateral border of foot.  Normal : flexion of toes  Abnormal : extension of big toe and fanning of toes.  May indicate UMN lesion  Clonus  Knee ext with sharp DF  Exaggerated response if lesion of UMN 23 NEURODYNAMIC ASSESSMENT  Neurodynamics refer to  “Mechanics and physiology of the nervous system as they relate to each other and are integrated into musculoskeletal function” (Shacklock, 1995) 24 12  27/08/2024 REMINDERS ( FROM BASIC CONCEPTS MODULE ) NERVES MOVE  When you move your nerves move too  Movement results in:  Movement of nerves in their nerve bed (sliding)  Tension in the nerve  Elongation of the nerve  Pressure changes (up and down)  Nerves like this movement – they are normally not mechanosensitive  A pathological nerve has increased mechanosensitivity 25 NERVE MOVEMENT - SLIDING  Nerves have the ability to “slide” past or through the tissues surrounding them 26 13  27/08/2024 NERVE MOVEMENT - TENSION  When you pull on either end of a nerve you will increase the tension in the nerve.  Viscoelasticity  Nerves contain actin and as such are visocelastic  Repeated loading may change viscoelasticity - it is possible to change mechanical function through therapy, exercise and movement  Normal nerve can tolerate 19-22% elongation before structural failure 27 NERVE MOVEMENT - ELONGATION  Blood flow can be reduced during nerve elongation  8% elongation produces reduced blood flow  15% elongation occludes capillary flow  What clinical implication does this have? 28 14  27/08/2024 NEURODYNAMICS  Changes in the environment around nerves can increase their sensitivity and ability to move  This will result in symptoms along the course of the nerve  Need to understand if symptoms represent a conduction or a movement problem  The areas where our nerves come in to contact with other body structures are known as interfaces.  Changes to an interface – a muscle / joint/ ligament will potentially impact a nerve in the vicinity  In the Lumbar spine our nerve roots are vulnerable in the Intervertebral foramena 29 NEUROLOGIC VS ND ASSESSMENT  When is a ND examination going to give you more information? ◦ Symptom referral not restricted to a dermatome ◦ Any joint with symptom referral  What does ND assessment tell you? ◦ This gives you information about the sensitivity of the nerves to movement 30 15  27/08/2024 NEURODYNAMIC ASSESSMENT  In order to make a diagnosis all potential sources of symptoms must be tested  Structural differentiation  First determine whether symptoms are neural or musculoskeletal 31 NEURODYNAMIC ASSESSMENT  Must be familiar with what is normal  Abnormal neurogenic responses can be:  Overt abnormal response where the test reproduces pt’s symptoms  The range of Movement on testing is different to the unaffected side 32 16  27/08/2024 NEURODYNAMICS - OBJECTIVE EXAMINATION  Based on the SIN of pt’s symptoms you will determine how extensive ND testing will be  Level Zero – none  Severe pain, yellow flags, red flags  Level 1 – limited exam  Safety of primary concern  Examine remote to symptoms  Omit sensitising components 33 NEURODYNAMICS - OBJECTIVE EXAMINATION (CONT)  Level 2 – standard test  Reasonably stable and indication of neural involvement in subjective  Level 3 – advanced exam  Specific testing exploring several levels – high levels of performance expectation  Normal on level 2, symptoms difficult to evoke, no neural abnormalities 34 17  27/08/2024 NEURODYNAMIC ASSESSMENT  On completing the assessment evaluate whether problem is neural or musculoskeletal  What is your hypothesis regarding the cause of the dysfunction ◦ Decide on treatment for the cause ◦ Integrate this treatment into your other techniques ◦ https://www.youtube.com/watch?v=gdKldyXgk gs 35 REMEMBER  All conduction issues will have neurodynamic restrictions  Neurodynamic restrictions can occur without conduction changes. 36 18  27/08/2024 STRAIGHT LEG RAISE TEST (SLR)  Indications  Symptoms in posterior/lateral leg  Thoracic spine  Heel pain  Starting position  Pt supine, no pillow if possible  PT stride standing facing pt  Distal hand grasp prox to ankle  Proximal hand over ant K – tibial plateau or prox to patella 37 STRAIGHT LEG RAISE TEST (SLR)  Gently raise the leg – keep plane  No Knee mvt  Structural differentiation  Use Dorsiflexion  Note change in symptoms  Can lift head 38 19  27/08/2024 STRAIGHT LEG RAISE TEST (SLR)  Structural differentiation for Proximal symptoms – use DF  PT faces cephalad resting K on couch with leg on shoulder  K held straight with distal hand  Add DF at onset of leg symptoms  Note response- care not to provoke 39 STRAIGHT LEG RAISE TEST (SLR)  Further Sensitising mvts especially if distal leg symptoms are produced by the SLR  Int rot and add of the hip  Normal responses  Pulling and stretching posterior thigh/knee/calf  ROM 50°-120  Abnormal responses  0-35° disc lesion  35-70° L4/5 or S1/2 tension, root involvement, facet joint  70-90° stiffness, facet joint 40 20  27/08/2024 ALTERNATES TO STANDARD SLR  Tibial nerve bias – DF/eversion  Sural nerve bias – DF/inversion  Peroneal nerve bias – PF/inversion  SLR test may be started with foot held in these positions.  Useful for peripheral pathologies , and identifying the interface issue along the course of the nerve. 41 PRONE KNEE BEND (PKB)  Indications  Mid lumbar nerve roots and femoral nerve  LBP  Uses the innervated tissues to produce test  Starting position  Pt in prone symmetrical  PT facing pt 42 21  27/08/2024 PRONE KNEE BEND (PKB)  Passive Kn flexion  Structural differentiation 1. Stabilise the pelvis with support over sacrum – then perform PKB 2. Return leg to neutral and stabilise the pelvis again without performing PKB  Sensitising mvts  Hip ext 43 PRONE KNEE BEND (PKB)  Normal response  Stretch in ant thigh  ROM 110°-150°  Abnormal response  0-45° very significant if producing symptoms  5-90° tension sign and good comparable sign 44 22  27/08/2024 ALTERNATE POSITION FOR PKB  Position patient in side lying 2020  Physio stands behind and stabilizes hip 45  Moves Hip ( with knee bent) into Extension  Asks re-symptoms- expect some tension/ stretch over anterior thigh  To differentiate- ask patient to Flex head ( neck flexion) or curl into Thoracic Flexion ( modified Slump)  Note Change in symptoms 45 PASSIVE NECK FLEXION  Indications:  Neck pain is not significant to LBP, but serves more as a tension sign for canal structures  For more severe root problems – to establish pain  When testing:  Pt in supine, PT hand on chest and other behind head.  Flex head passively  Normal response:  Pain-free FROM 46 23  27/08/2024 PALPATION  In prone  Pillow under abdomen if prone is uncomfortable  Temp and sweating  Back of hand, compare areas of the spine  Cx usually warmer than other areas  Increased temp and sweating may indicate possible inflammation 47 SOFT TISSUE PALPATION  Superficial  Flat hand  Pt relaxation and confidence  Introduces pt to palpation and reduces fear  General status of connective tissue  Middle  3 fingers across fibres  Status of muscles – paraspinals  Deep  1 finger,  Status of ligament and capsule  Interlaminer area Note thickenings and differences between left and right 48 24  27/08/2024 BONY PALPATION  ALIGNMENT  May show contributing problem area  Lateral displacement  Depression/prominence 49 PALPATION - PAIVMS  Passive Accessory Intervertebral Movements  NB for pain response  Feel for resistance and grade  Only move through grades until symptoms are produced – the symptom producing grade becomes your comparable sign  Give indication of hypomobility, hypermobility, protective muscle spasm  Look for level most likely source of symptoms 50 25  27/08/2024 LUMBAR SPINE PALPATION  Bony palpation:  Done to establish the spinal level most responsible for the pt’s symptoms  L3 is in line with the umbilicus  L4 is located in line with the iliac crest  L5 lies between the crest of the pelvis  Central and unilat PAs on L1 – S1 51 PAIVMS  Postero-anterior central vertebral pressure - PA  Preferably Pisiform grip (Fig 21.33 and 21.34)  Don’t use pads of thumbs pointing to each other over the spinous process  Stand on side of pt  Postero-anterior unilateral vertebral pressure – UniPA  Pads of thumbs pointing to each other immediately adj to the spinous process (Fig 21.35)  Feel for the transverse process below through the muscle bulk  Mobilising facet joints 52 26  27/08/2024 FACTORS TO THINK ABOUT  Examine other relevant factors  X-rays (only look at these after you have palpated otherwise they may bias your palpation)  Blood tests – if available  Other joints or contributing factors  Core stability (use biofeedback cushion) 53 DOCUMENTATION  Mark all * signs  Note ROM etc and changes in pain scale  E.g.  Flex (act) hands to knees: P1 5/10; P2 3/10  R SLR – 60° Hip Fl, K ext P1 3/10; Add Dfl P1 6/10.  L3 Gr II P1 3/10  L4 Gr IV- P1 5/10; P2 3/10 54 27  27/08/2024 BY END OBJECTIVE ASSESSMENT - ANALYSE  Should have  *Sign/s  *Level  Have a hypothesis about what structures involved including:  stage of healing;  what contributes or perpetuates symptom production in your client  level of disability, impairments, activities, participation 55 PLAN  Treatment choice based on Analysis  Define outline of management plan  Technique  Grade  Frequency of treatment  Other techniques  Reassessment of comparable sign and symptom  Pt education  Warning of flare following assessment  Feedback on details  Treatment responsibility and pt monitoring 56 28  2024/08/26 LUMBAR SPINE 4: TREATMENT TECHNIQUES AHS2052H Maitland’s Vertebral Manipulation (7th) pgs: 337-400 Heather Talberg 1 TREATMENT APPROACHES  Treatment can draw on several techniques to address areas of dysfunction within the Neuromuscular skeletal system  A treatment plan may consist of Joint techniques for pain and stiffness ( in the short term) Soft Tissue techniques for pain, muscle length, tension, Neurodynamic techniques – to address mechanical sensitivity in the neural system Exercise for ongoing rehabilitation and benefits Education – for context and lifestyle  All treatment should be sustainable and relevant and progress over sessions 2 1  2024/08/26 RX TECHNIQUES  Selection of joint technique based on  Signs and Symptoms - consider unilateral vs central  Irritability and stage of healing - consider grading  Source of symptoms - what structure do I want to address?  Please refer to Maitland's Tables on technique selection:  Vertebral manipulation  5th edition page 117  7th edition page 184 3 PA – CENTRAL POSTERIOR-ANTERIOR  Symbol:  Uses:  Bilateral pain – even distribution  Marked bony changes, from  Degenerative changes,  Old injuries with associated tight structures  Long standing postural problems – structural changes  When pain and/or protective spasm present, technique is performed without provoking symptoms further Pt with increased lordosis: A pillow can position vertebral joints better 4 2  2024/08/26 UNILATERAL PA – UNILATERAL POSTERIOR-ANTERIOR  Symbol: L R  Uses:  Unilateral pain, performed on the same side as pain  Very useful for pain felt in the intra-segmental muscles  Done to provide movement at facet joints  Can be applied from a Grade l to a Grade IV – dependent on pain and stiffness 5 TRANSVERSE VERTEBRAL PRESSURE  Symbol: From L to R  Or From R to L  Symptoms of unilateral nature  Performed by pressing spinous process towards painful side ( move from non-painful to painful side)  Opening up of joint and intervertebral foramina  Most useful for upper lumbar spine, less so in lower lumbar spine 6 3  2024/08/26 ROTATION  Symbol: to Left to Right:  Uses:  Most useful technique in LBP  For Unilat symptoms: especially useful for discogenic symptoms  Both for referred symptoms and localised  Positioning:  Side lying with painful side uppermost  Pillow supporting head  Isolate level through use of a PPIVM  Pt must remain relaxed – PT moves pt into right position passively  NB to know the technique and handle the pt correctly  Be very familiar with the different positions for all the grades!!! 7 LONGITUDINALS  Symbol:  Uses:  Double leg: evenly distributed painful conditions, especially in presence of acute pain and muscle spasm  Legs raised around 25 degrees  Pillow under head, PT face pt and pull both legs towards you  Won’t be able to do in presence of very limited straight leg raise and marked nerve root symptoms. 8 4  2024/08/26 SOFT TISSUE STRUCTURES THAT MAY NEED RELEASE TRIGGER POINT PATTERNS 9 10 5  2024/08/26  Also consider muscle length of surrounding structures  Think about Back extensors/ Hip Flexors/ Quadaratus Lumborum  How would you stretch these as part of treatment? 11 TREATING A NEURODYNAMIC DYSFUNCTION  Treatment techniques- once interface released  Start distal  Don’t provoke pain  Slow progression and reps  Consider the approach  Position away; move away  Position towards: move away  Position away: move towards  Position towards; move towards 12 6  2024/08/26 EXERCISE  The role of exercise and rehab in treating LBP will be discussed in the next lecture recording 13 7  2024/08/26 LUMBAR SPINE 5: CONDITIONS AHS2052H Maitland’s Clinical Companion pgs: 429-500 Heather Talberg 1 AIMS OF THIS LECTURE  By the end of this lecture you will be familiar with:  The conditions which present in the Lu spine  The diagnostic signs and symptoms of these conditions  Management and rehabilitation of the conditions of the Lu spine 2 1  2024/08/26 CONDITIONS OF THE LU SPINE  Using principles of  Subjective structural contribution differentiation  Pain type identify possible  Pain behaviour anatomical structures  Pain area which could be  Objective contributing to the  Testing of structures symptoms which confirms or nullifies your hypothesis 3 CONDITIONS OF THE LU SPINE Structures which could contribute to symptoms in the region of the Lu:  Joint  Muscle  Disc  Postural Dysfunction  Facet  Trigger point  Neural  Acute Muscle Injury  Root compression or  Visceral may mimic LBP irritation  Kidney  Neurodynamic  Pelvic pain  Spinal cord 4 2  2024/08/26 CONSIDER – THINKING ABOUT WHAT YOU LEARNT IN BIOMECHANICS  What happens to a disc in flexion or extension?  What happens to the facet joints ( think capsule/ ligaments/ joint surfaces) in Flexion or extension?  What is an optimal position?  So what activities may injury or effect these structures.? 5 CONDITIONS IN THE LU Flexion dysfunctions Extension dysfunctions  Disc predominating  Facet predominating Why? Can you develop a hypothesis to support this? 6 3  2024/08/26  Discogenic problems  With or without Nerve root involvement  May be termed Flexion Dysfunctions  Facet Joint problem  Maybe termed Extension Dysfunctions  Spondylosis – aging in the spinal motion segment  Also  Muscle conditions  Spondylolysis and Spondylolisthesis ( separate slides) 7 DISCOGENIC PROBLEMS  Role disc  To distribute load through the spine  Relies on intact annulus to contain gel like nucleus  Not in itself pain sensitive  Terminology  Disc Bulge  Disc herniation/ protrusion  Disc Extrusion  Discs do not SLIP ( consider terminology on patient outcomes) 8 4  2024/08/26 9 TERMINOLOGY  Internal Disc Disruption  innermost layer of the annulus tears and the protein-laden nucleus pulposus irritates the nerves in the disc’s wall.  Causes the collagen content of the annulus wall to break down.  Bulging Discs  Disc’s inner nucleus pulposus, which is under constant pressure, presses on the disc’s annulus wall, causing it to bulge or protrude into the spinal canal.  Normal?  Herniated Discs  Annulus tears and nucleus pulposus extrudes into the spinal canal, causing nerve compression.  Normal? 10 5  2024/08/26 11 CAUSES OF LBP  Any acute LBP that is not resolved have the potential to become Chronic LBP  Assess for Psychosocial factors which increase risk of chronicity (Yellow Flags)!  THE PRESENCE OF CHANGES ON RADIOLOGICAL IMAGING IS NOT DIAGNOSTIC ON ITS OWN IN LBP (Brinjikji et al 2015) 12 6  2024/08/26 CONDITIONS OF THE LUMBAR SPINE  DISCOGENIC SYNDROMES  Subjective:  Flexion movts or positions aggravate  Eased by extension positions, side ly with pillow or crook ly  Mechanism of injury  Mostly prolonged fw flexion; flex/ rot activities (as posterior part more vulnerable) or in younger patients sudden overload in Flexion or flexion/ rotation activity or position  Think lifestyle factors and loading. Overuse, low fitness levels  Pain  sudden or gradual weakening, with delayed onset symptoms after day or 2 stiffness.  Vague, deep, ache & nagging  Central or only unilateral  Radiation to groin normal, but less referral pain  Aggravated by cough , sneeze  Worse with sitting , better in standing, lying 13  DISCOGENIC SYNDROMES  Objective:  Postural deformity  May stand with a list  Active movements  Pain ( and limitation)  On flexion  Lateral flexion  Possibly extension  Neural – no conduction element; but can produce some changes in neurodynamic tests  Palpation  Bilateral muscle spasm  Central PA’s most painful and stiff  Acute disc injuries can not be seen on x-ray and even if seen on MRI need clinical signs to confirm diagnosis (>30% of the population has abnormalities on radiological screening and they are NOT all symptomatic!) 14 7  2024/08/26  DISCOGENIC SYNDROMES  Management  Education of condition, strength of the spine, ability of the disc to regenerate, need to increase activity based on tissue healing not pain dependent. Movement is good- minimise fear avoidance Manage pain and muscle spasm  Appropriate EPA depending on stage of healing  Heat/ Ice  Soft tissue techniques  Mobilisations  Rotation PPIVMs  To reduce displacement  Longitudinal PAIVMs  Gap joint and reduce pain PAs and uniPAs (for above and below level)  Correct predisposing factors  posture, kinetic handling, ergonomics  Progressive rehabilitation for segmental and global control  Also remember Overall muscles strength of movers- trunk muscles as well as lower limb/ gluts/ quads for over all control and function. 15 DISCOGENIC INJURIES WITH RADICULOPATHY  Onset – as with disc , watch for history of progressive and deteriorating Lumbar episodes  Symptoms – leg pain, weakness, pins and needles with Lx symptom suggest nerve involvement  Distal worse than prox. If severe no back pain at all  Signs- list, decreased ROM, Positive neurological findings and altered neurodynamic  Can be irritable / latent element 16 8  2024/08/26 DISCOGENIC INJURIES WITH RADICULOPATHY  REFER on if neuro condition deteriorates – ie progressive weakness/ altered sensation or Red flags  May need surgical intervention  Neural symptoms do not disappear immediately post op 17  Clinically patients present somewhere between the 2 scenarios  Careful assessment will determine the extent of problem and guide treatment Disc syndrome Disc injury Disc syndrome with nerve root with true / Lx pain only irritation radiculopathy 18 9  2024/08/26 SUMMARY REVISION OF SIGNS/ SYMPTOMS AND SOURCES NEURAL INVOLVEMENT IN THE LX SPINE  Pain referral below the inferior gluteal fold suggests neural involvement – often referred to as Lumbar Radiculopathy or Sciatica  Subjective:  Tingling, numbness or pain in dermatomal areas  Loss of motor control in lower limbs  Burning, throbbing or electrical pain  Symptoms in distal leg more severe than proximal  Latency  SIN  Postural avoidance of painful positions!!!  May be associated with disc or facet presentations  Disc more common but anything can cause nerve root irritation or compression 19 NEURAL INVOLVEMENT IN THE LU SPINE  Objective  Positive SLR or PKB  Nerve root impingement with nerve integrity/ conduction impaired (nerve may be squashed)  Pain in dermatome  Weakness in myotome  Associated reflex loss  Neurodynamic involvement (nerve irritated; becomes sensitive to normal biomechanical input)  Pain in nerve distribution  Palpation of nerve may be painful  ND tests may produce or provoke pain  Conduction always associated with neurodynamic dys.**  Can get neurodynamic dysfunction with normal conduction** 20 10  2024/08/26 NEURAL INVOLVEMENT (RADICULOPATHY ) IN THE LU SPINE  Treatment  Similar approach to disc injury but slower progress and add techniques with care  Must initially decrease pressure on nerve- use techniques that open the Intervertebral Foramina  Must release neural interface before start any neural mobilisation  Teach pain free resting positions  Careful education, graded increase of activity  Remember these patients are all at medium to high risk of becoming chronic  ND dysfunction  Release interface causing impingement  As improves mobilise neural system  Start distal  Don’t provoke symptoms  Slow mvt 21 JOINT CONDITIONS IN THE LU  FACET JT SYNDROMES  Subjective  Localised unilateral pain  Either sudden onset  Synovium gets stuck at EROM, folding over  Mostly happens in flexion or side flexion  May present with acute flexion lock ( cant come back to extension)  Else symptoms from excessive loading in Extension.  Eased with flexion 22 11  2024/08/26 JOINT CONDITIONS IN THE LU  FACET JT SYNDROMES  Objective  Often obese or poor posture – posture loads facet – progressive loading- differentiate from possible locked facet joint  If locked ; present with fixed flexion deformity- unable to move into Extension-  Usually pain with Extension movement and lateral Flexion, may have some End Range Flexion symptoms  Unilateral muscle spasm  Unilateral PA most stiff and painful  Not usually accompanied by significant distal referral or neural pain 23 JOINT CONDITIONS IN THE LU  FACET JT SYNDROMES  Management  Education  About the condition and expected outcome, need to increase activity not dependent on pain  Pain free resting positions  Pain  Appropriate EPA  Treat the joint:  Start transverse and rot in gr 1-2(stronger if truly locked) to open up the joint  Longitudinals to open up  Once local pain and tenderness reduced mobilise directly over the joint with Unilat PA; Including the joints above and below  Rehabilitation  Movers and stabilisers – normalise movement  Address predisposing factors 24 12  2024/08/26 SPONDYLOSIS- AGING IN THE SPINE IMPACT OF MOTION SEGMENT  Must be considered with respect to all structures with in motion segment  Aging is a normal physiological process and doesn’t have to imply the development of pain  Follows a process of  Reduction disc height and thinning of annulus  Narrowing of space in intervertebral foramina through  Bony encroachment  Buckling of ligamentum flavum  Changes to synovial facet joints  Adaption of soft tissue structures to new height- capsule/ ligament 25 DEGENERATIVE CONDITIONS – SPONDYLOSIS  Must consider the entire motion segment Affect of degeneration on Lumbar facets  Mainly affects cartilage, which becomes fibrillated and destroyed  Changes thought to relate to loading of joints:  Anterior aspect in compression and flx  Posterior aspect in shearing and rotation mvts  Stresses peel cartilage off from jt surface  Osteophyte formation develop  Degenerative changes are normal with age, its only once they produce pain and disability they can be regarded as pathological  Everyone over the age of 60 has degenerative changes on X-ray 26 13  2024/08/26 DEGENERATIVE CONDITIONS Affect of degeneration on the Intervertebral disc Degeneration of one or more IVDs of the spine, often called "degenerative disc disease" (DDD) can be painful (but is NOT always painful) and can greatly affect the quality of life.  Disc degeneration is a normal part of aging and for most people is not a problem, for certain individuals a degenerated disc can cause severe constant chronic pain (Brinjikji et al 2015)  Theory of development:  IVD is always under load, with age calcification of end-plates occurs, leading to a decreased flow of nutrients and O2 from blood  Nucleus shows more signs of changes  Young discs have 85% H2O content, this is reduced to 70% in young adults with further reduction with every year of age  As a response collagen levels increase and thereby become fibrillated  Annulus thickens anteriorly, posterior part is therefore more vulnerable  These changes result in:  Decreased H2O content with reduced distribution of forces  Spine gets more rigid and reduces in height 27 SPONDYLOSIS – OA OF THE SPINE 28 14  2024/08/26 SPONDYLOSIS  Onset  Usually History recurrent episodes of back pain- sometimes can identify a precipitating episode that resolved at time  Symptoms  Degen involves all structures of motion segment and can all provide symptoms  Will mimic disc or facet presentation – clarity on area, stage and progression will determine what is most responsible for current symptoms  Present with stiffness, Pain with sustained positions- as structures cant maintain loading ( both flex and extension)  Symptoms worsen over the day  Don’t like over or underactivity  SIGNS  Loss of mvt- physiologically and segmentally  Possible neurological findings 29 SPONDYLOSIS CONTINUED  SIGNS  Loss of mvt- physiologically and segmentally  Possible postural changes  Changes in muscle control very likely  Possible neurological findings, depending stage  Exam will determine main source and level symptoms  TREATMENT  Treat pain and dysfunction depending on findings- think do I want to open or close joint area- generally like large amplitude mobilistaion  Consider other areas hypomibility  Addres soft tissues – length and strength  Educate and empower- explain condition, lifestyle factors, self management 30 15  2024/08/26 SPINAL STENOSIS  Arises as a consequence of severe degenerative change and results in extreme narrowing of one or both of nerve root canals and central spinal canal with compression of spinal cord, CE or sciatic nerve roots  Subjective  Lumbar and leg Pain, numbness, paresthesia, possible weakness usually bilateral.  The location of the stenosis determines which area of the body is affected  Watch for SC and CE symptoms  Classic flexion posture relieves symptoms – hate extension (shopping trolley sign) WHY  Must differentiated from vascular cause of calf pain  Rx:  Flexion type exercises in supine  Avoid puppy prone positions  Mobilisation of joints – what type ??  Need neuro rehab due to irritation of neural tube  Med surgery to open canal- laminectomy and decompression- relieves neural symptoms. Rapid post op mobilisation 31 MUSCULAR CONDITIONS  Subjective  Non-specific pain history or specific pain behaviour relating to muscle use  Mechanical or inflammatory depending on injury and stage of healing  Objective  Trigger point diagnostic criteria  Muscle strain diagnostic criteria  Impaired muscle function  Rx:  Identify predisposing factors  Rehabilitate based on tissue healing times, consider all factors contributing to stability of Lu region  TP therapy – direct compression  Stretching 2 x 30s, 3/daily  Postural re-education  Progressive rehabilitation 32 16  2024/08/26 Iliopsoas 33 Glut med 34 17  Spondylolysis; Spondylolisthesis AHS2052H 1 Aims of this Lecture  Demonstrate an understanding of the pathology of Spondylolysis, Spondylolisthesis  Discuss the similarities and differences between these spinal conditions  Set realistic outcome and treatment aims for a patient with any of these spinal conditions  Holistically manage a patient with any of these spinal conditions 2 1  What is Spondylolysis  Defect of the Pars Interarticularis  Loss of continuity between superior and inferior articular processes replaced by fibrous tissue  Usually caused by repetitive load with resulting stress fracture of pars 3 Spondylolysis 4 2  How does spondylolysis occur? Spondylolysis occurs more frequently in the young athletic population. Increased risk in sports involving hyperextension with rotation; gymnasts, rowers, cricketers, swimmers, divers, throwing sports. stress fracture- occurs due to repetitive loading and micro-trauma on the already weakened pars inter-articularis. – may lead to slippage of vertebra L5 is mostly affected by these movements 5 Spondylolysis – S&S  May be symptom-less if no displacement  Deep low back pain ( unilateral)  May have referred buttock pain  Pain aggravated with lumbar extension and rotation  Some patients could present with abnormal gait pattern and postural deformities (hyperlordotic)  Symptoms aggravated after athletic activity and eased with rest- if severe may limit activity ( both ADL and sport)  May have trauma history 6 3  On examination  Pain is produced on extension with rotation  And/or on extension while standing on affected leg  Unilateral lumbar extension test – pain  Palpation reveal unilateral tenderness over site of fracture  Diagnosis confirmed with Oblique view Xray  Scotty dog deformity 7 Unilateral lumbar extension test  The patient performs hyperextension of the lumbar spine while standing on one leg.  In a positive test, pain is reproduced with extension. Unilateral lesions often produce pain when standing on the ipsilateral leg  Watch the video: One leg standing lumbar extension test 8 4  Scotty dog 9 10 5  Spondylolysis – Medical Rx  Symptomatic rx  Medication for pain and inflammation  Restricting athletic activity spinal brace to prevent motion at the injured pars Physiotherapy  If Unstable and in rare cases- surgery 11 Physiotherapy in Spondylosis  Restricting athletic activity responsible for pain to allow fracture time to heal  Stretching hamstring and gluteal muscles  Strengthening abdominals and back extensor muscles as soon as these can be performed pain free  Start with progressive exercises that doesn’t include extension and rotation until pain has subsided  Rehab must target local and global muscles and work to normalise movement patterns  Address extrinsic and intrinsic factors that maybe predisposing factors to injury  Training – load and technique  Nutrition  Areas of hypo or hypermobility . 12 6  Treatment Stages 1. Control pain and Inflammation 2. Local stretch and strengthen - hamstrings, gluts, spinal extensors 3. Stabilisation- strengthen abdominals and back extensors 4. Restore functional movement and activity- consider hydro as exercise to start 5. Return to sport with graded sports specific exercises and training advise – consider MDT 13 Spondylolisthesis 14 7  Spondylolisthesis The slip or Displacement of one lumbar vertebral body on segment below Forward displacement – anterolisthesis Posterior displacement – posterolisthesis Caused by: Congenital/spontaneous (usually children aged 9-14) Spondylolysis OA (of facets) 15 Spondylolisthesis  Failure of posterior facet joints to engage with joints below  Entire vertebra slides forward  Most common at L5-S1 level with anterior translation of L5 on S1  Second most common location is Lu- sacral junction or L4-5 16 8 17 Spondylolisthesis- Meyerding classification grading 18 9  Causes of Spondylolisthesis  Type 1 Uncommon Congenital malformation Anterior mvt can result in trapping of cauda equina 19 Spondylolisthesis  Type 2  Defect of pars interarticularis (Spondylolysis)  Body and superior facet slides forwards  Most common type- often associated with sports activity  Displacement may gradually increase – NB in adolescents  Some neural referral to sciatic 20 10  Spondylolisthesis  Type 3  Secondary to OA of posterior facet jt and spondylosis of motion segment  May occur at any Lumbar level-but most affects L4:5  Neuro structures not initially involved but if progresses with encroach central canal 21 Spondylolisthesis – S&S  Objective: Subjective:  Increased lumbar lordosis  Varying depending on underlying cause  Palpable step if grade 2 or greater  Types 1 and 2 typically present in adolescence or young  Slight decrease ROM adults  SLR with sensitisation may be  Type 3 beyond middle age positive  Chronic back pain, worse on  X-ray diagnosis standing, may have neuro  Neurological signs symptoms 22 11  Spondylolisthesis – Medical Rx  Symptomatic – stabilise with bracing if severe  Surgery if unstable or spinal cord involvement ( spinal Fusion)  Physio 23 Physiotherapy Management of spondylolisthesis 24 12  Physio Assessment  Subjective  History , Pain  Function etc  Consider Outcome measures ( Roland Morris, Owestry)  Objective  Posture  ROM  Neuro Status  Step palpable on palpation, care with end Range movements  Muscle Power Local stabilisers (Core) and Global muscles 25 General Overview of Physio Rx tools - similar to any patient with LBP  Pain  Stabilise spine  ET  Core  Exercise  Movers  Manual - symptomatic  Educate  Posture  Confidence  Stabilise  Fear of moving  Stretch  Normal pain  Exercise  NB of activity  Ergonomics  Off load Joints 26 13  Physiotherapy-Spondylolisthesis Conservative therapy: heat, light exercise, traction, bracing, and/or bed rest Initial resting and avoiding movements like lifting, bending A brace may be useful to decrease segmental spinal instability and pain NO MOBS ON SLIP LEVEL- why? Rehabilitation exercise program: should be designed to improve muscle balance rather than muscle strength alone Isometric and isotonic exercises beneficial for strengthening of the main muscles of the trunk Core stability exercises Movements in closed-chain positions Postural and Gait-retraining Hydrotherapy, low impact sports (walking, swimming, cycling). No impact sports like running Education: ergonomics, self-management, weight-loss Psychological support: A bio-psychosocial approach involved reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms 27 Extra considerations  Extension exacerbates symptoms of patients with Antero –listhesis  Consider how this affects treatment positions/ exercises  Often need to avoid prone – use side lying or crook lying. Encourage flexion positions or exercises that open space. 28 14  Summary Similarities Conditions may be symptom-less When present symptoms include vague back pain Diagnosis on X-ray Management symptomatic 29 Differences  Age  Adolescents and young adults Spondylolysis and acute Spondylolisthesis  Middle age Spondylosis and chronic spondylolisthesis caused by degenerative change – may have period