Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column PDF

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 5 Functional Anatomy and Rehabilitation of the Vertebral Column Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Functional Anatomy and Rehabilitation of the Vertebral Column FUNCTIONAL ANATOMY AND BIOMECHANICS Functional Anatomy and Biomechanics Cervical spine (Cx): C1 – C7 Thoracic spine (Tx): T1 – T12 Lumbar spine (Lx): L1 – L5 Sacrum: S1 – S5 Coccyx Intervertebral discs (shock absorbers) Ligaments (stability) Muscles (movement) Spinal cord, nerve roots, peripheral nerves Flexion, lateral flexion, extension (limited), rotation C3 – L5: Transverse & spinous processes (attachments for ligaments & muscles) Articular processes Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 4 Vertebrae Structure Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 5 Vertebrae Structure Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 6 Vertebrae Structure Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 7 Intervertebral Discs (IVDs) Both the IVDs (the outer one-third) and facets have nociceptive fibres and can therefore contribute to pain Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 8 Muscles of the Back - Superficial Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 9 Muscles of the Back - Deep Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 10 Muscles of the Anterior Trunk Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 11 Muscles of the Trunk Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 12 Functional Anatomy and Rehabilitation of the Vertebral Column VERTEBRAL COLUMN – GENERAL TREATMENT APPROACH General Rehabilitation Considerations Exercise rehabilitation should be commenced early Includes posture, stability, flexibility, strength & endurance exercises Posture examination – Poor posture can complicate spinal injuries Standing & sitting posture Include body mechanics / ADLs For example, picking up objects from the floor, sit to stand Gait examination ROM, strength, special tests, palpation, outcome measures Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 14 Rehabilitation Techniques – Soft Tissue Mobilisation Used to release trigger points in muscles that are becoming hypertonic in response to a nearby injury & actually contributing to more pain Spinal injuries refer pain to other areas of the spine & limbs (& vice-versa) May provide pain relief enabling the patient to perform exercise rehabilitation more effectively Pressure temporarily reduces blood & O2 supply to muscle = relaxation response Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 15 Rehabilitation Techniques – Soft Tissue Mobilisation Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 16 Flexibility Exercises Generally held for 30 seconds or more and repeated several times daily Restore muscle imbalances Improve posture Regain lost joint ROM Specific stretches will depend on the injury and the associated restrictions Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 17 Posture, Core and Stabilisation Exercises Core (lumbo-pelvic-hip complex) provides spinal stability Increase intra-abdominal pressure Transverse abdominis, multifidus, pelvic floor & diaphragm Spinal stiffness important to prevent LBP Depends on both active (muscles) & passive (ligaments, capsule, fascia) structures For example, co-contraction of glute. max. & lat. dorsi = tension through thoraco- lumbar fascia (stabilises Lx & SIJ) Both the deep core (transversus abdominis, multifidus, pelvic floor and diaphragm) & global (e.g. rectus abdominis, erector spinae) muscles provide spinal stability Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 18 Posture, Core and Stabilisation Exercises Isolated re-education (e.g. TrA activation in supine) vs. global movement (e.g. squat) techniques in rehab Core instability – Linked to acute & chronic knee & ankle injuries Hip & pelvic stabilisers also need to be considered in the treatment of low back pain Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 19 Posture, Core and Stabilisation Exercises Common issues in low back pain include: 1. Reduced proprioception 2. Reduced muscle endurance 3. Lack of muscle co-activation 4. Delayed recruitment of core muscles 5. Diminished LBP with co-activation 6. Hip muscle strength imbalances 7. Reduced stability Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 20 Proprioception and Balance Exercises Introduce proprioception and balance exercises early in the rehab program once a neutral spine and level pelvis have been achieved without movement of the arms or legs Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 21 Strengthening Exercises Aim is to improve both muscular strength & endurance Maintaining correct posture – Primarily an endurance activity Stabilising muscles (deep) – Predominantly slow twitch fibres Global muscles (also contribute to stability) – predominantly fast twitch fibres Shoulder & hip muscles: Lat. dorsi, rhomboids, trapezius, QL, hamstrings, glut. max., glut. med., lateral hip rotators are often also included in Lx stabilisation programs Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 22 Agility and Coordination Exercises Only to be introduced when sufficient strength & endurance has been developed (pain-free) Includes trunk rotation & plyometric exercises Higher forces, quicker movements & functional multiplane motions Patient must maintain pelvic & Lx stability throughout Exercises may need to be regressed if can’t maintain control & alignment Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 23 Functional Anatomy and Rehabilitation of the Vertebral Column COMMON PATHOLOGIES Upper and Lower Crossed Syndromes Upper and lower crossed syndromes – maladaptive postural patterns that, in themselves, can cause pain Muscle imbalance is often the first offender, leading to poor posture and additional stresses and injury Part of the problem is that we often overuse some muscles and underuse their opposing muscles Over time, muscles that are predominantly used tend to shorten. On the other hand, their opposing muscles tend to be stretched during this time. If a muscle is chronically stretched, it becomes weaker Strengthen what is long and weak; Stretch what is short and tight Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 25 Upper and Lower Crossed Syndromes These syndromes feature a cross-pattern arrangement with anterior muscles that are weak diagonally correlated with posterior muscles that are also weak, and anterior muscles that are tight diagonally correlated with posterior muscles that are also tight, so the alignment of weak and tight muscles forms a cross, or an X-shape through the sagittal plane of the body This arrangement additionally demonstrates a tight muscle on one side of the body aligned directly across from a weak muscle on the opposite side Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 26 Upper Crossed Syndrome The typical posture of a person with upper crossed syndrome includes a forward head with upper cervical lordosis, thoracic kyphosis, protracted and winged scapulae and internally rotated or abducted shoulders This posture may range from mild to severe, depending on the severity of the person’s pathology Headaches, neck pain, thoracic outlet syndrome and shoulder impingement may result from upper crossed syndrome Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 27 Lower Crossed Syndrome This imbalance of muscles in the region results in excessive anterior pelvic tilt that is identified as an exaggerated lumbar lordosis Associated with this pelvic tilt and lordosis is hyperextension of the knees Hip flexor tightness pulls the lumbar spine anteriorly to exaggerate the lumbar lordosis Unfortunately, weakness in the abdominal and gluteal muscles provides insufficient strength to counteract this pull from the hypertonic muscles The anterior pelvic tilt moves the hips into flexion, which results in the body’s centre of mass moving forward of the knees This alignment of the body’s line of gravity causes the knees to hyperextend, further lengthening and weakening the hamstrings Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 28 Lower Crossed Syndrome It is not surprising that injuries commonly associated with this pathology include Low-back pain Facet dysfunction Sacroiliac dysfunction Anterior knee pain Hamstring strains Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 29 Upper and Lower Crossed Syndrome Treatment Unfortunately, people with upper or lower crossed syndrome often have both conditions You must be aware of these crossed syndromes and the impact they have not only on muscles, but also on fascia, neural facilitation, joints and bones Elements of the therapeutic exercise program include Patient education Postural changes Soft-tissue treatments Correction of muscle imbalances with flexibility and strengthening exercises Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 30 Upper and Lower Crossed Syndrome Treatment Instructing patients to change posture often throughout the day and to avoid prolonged postures, especially for those who normally perform tasks in prolonged positions, helps to reduce muscle stress Until muscle imbalances are corrected, muscles endurance improves and poor postural habits change, patients will find that they can tolerate the proper posture for only short periods, after which they will resort to their previous poor posture – be supportive as patients make slow gains Myofascial release of tight fascia restricting muscles and joints is often needed to help make flexibility and mobility gains – eg. foam rolling / lacrosse ball. Before strength is restored to the weakened muscles, tightness must first be corrected. If strengthening is addressed before tightness, the treatment’s effectiveness will be minimal Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 31 Upper and Lower Crossed Syndrome Treatment Clinic or home flexibility exercises may include the use of foam rollers in addition to exercises that may be performed through the day while in school or at work Once the goals of the program are achieved, you should create a maintenance program for patients Flexibility exercises for the formerly tight muscles with a strength- maintenance program for the formerly weak muscles performed 2 or 3 days per week is often sufficient to maintain good posture Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 32 Sprains and Strains Sprains and strains are among the most common back injuries Signs and symptoms Tenderness on palpation Painful during contraction (eg. back extension) Painful under stretch Program considerations Resolve pain and muscle spasm (PRICE and light stretching) Soft-tissue mobilisation Correct posture and biomechanics Muscle strength progression A progression of strength exercises Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 33 Sprains and Strains A progression of strength exercises should begin once the pain and spasm have diminished sufficiently enough to allow active exercises The muscles requiring the greatest emphasis are the pelvic stabilisers, the abdominals, especially the obliques and lower abdominals, the trunk extensors and the gluteal muscles Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 34 Spondylosis, Spondylolysis and Spondylolisthesis Spondylosis – Degenerative age-related wear and tear to the IVDs and facet joints, often leading to the formation of bony spurs Spondylolysis – A pars interarticularis (bone between the inferior and superior articular processes of the vertebrae) defect or stress fracture Spondylolisthesis (Anterolisthesis) – Vertebra slips forward relative to the one below it Retrolisthesis – Involves the vertebra slipping backwards relative to the one above it (less common) Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 35 Spondylosis, Spondylolysis and Spondylolisthesis Although these three conditions differ from one another, they all usually involve the lower lumbar spine that becomes irritated with extension movements The two most important factors with patients who have any of these conditions are that the person should be taught to maintain a posterior pelvic tilt and that they should avoid hyperextension movements as much as possible A therapeutic exercise program for these patients involves the same exercises and progressions as for other back patients. The important difference, however, is that their pelvic neutral is not neutral but in a posterior pelvic tilt position. The least degree of posterior pelvic tilt that the person achieves without pain is the position they should maintain during activities Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 36 Disc Lesions and Radiculopathy A protruding or herniated disc can be a serious problem and often causes radiculopathy down one or both extremities, depending on the location of the protrusion The annulus fibrosis degenerates over time, increasing susceptibility to disc injury The mere presence of pain or symptoms down the leg does not mean that there is a disc herniation, but you should consider this a possibility until it has been ruled out Other conditions such as facet injuries, muscle spasm and myofascial pain can also refer down the lower extremity Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 37 Disc Lesions and Radiculopathy Patients diagnosed with disc lesions should avoid those positions and motions that aggravate or reproduce the patient’s radicular symptoms. These motions are most commonly those that increase disc pressure Forward flexion Trunk flexion and rotation Patients who have disc lesions must learn to find and maintain pelvic neutral and must strengthen the abdominals, obliques, back extensors and gluteal muscle groups Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 38 Disc Lesions and Radiculopathy Although not all authorities agree on its importance, some advocate the centralisation of pain for disc lesions. That is, if the treatment is appropriate and effective, the patient will experience a gradual and progressive retreat of the radicular symptoms from distally to proximally until the only pain remaining is localised to the back. Typically, the use of extension exercises, flexibility, strengthening exercises and pelvic-neutral exercises will accomplish this If the pain recedes with treatment, the progression of exercises can continue; if the radicular symptoms worsen, you must re-evaluate the current exercises, first for how the patient performs them and secondly for appropriateness Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 39 Disc Lesions and Radiculopathy L4/5 IVD L5/S1 IVD Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 40 Facet Injuries Facet injuries can be difficult to identify and you often need to use your investigative skills in order to identify them Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 41 Facet Impingement and Positional Dysfunction Facet restriction can occur from an impingement following a traumatic event where the facet surfaces on one side suffer an injury A facet can be restricted in either flexion or extension, and this determines whether the motion restriction is to the same side or to the side opposite the site of injury The position the facet is in is called positional dysfunction A motion restriction is what the facet cannot do A positional dysfunction will always be opposite to the direction of its restricted motion A facet joint in flexion is open since the two facet surfaces of the joint are apart; the upper facet surface cannot drop down into extension so the two joint surfaces are ‘open’ Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 42 Facet Impingement and Positional Dysfunction A facet joint in extension is closed; the upper facet surface cannot move upward and forward into flexion, so the two joint surfaces are ‘closed’ If a facet is restricted in its ability to open (flexing), the facet is stuck in extension and has motion restriction (it cannot move) in flexion; therefore, extension is the positional dysfunction and flexing is the restricted motion Since rotation and side bending are coupled with each other, they will also have motion restrictions in positional dysfunctions. In other words, if motion is restricted in rotation, side bending (side flexion) is also restricted since these motions occur together When there is a positional dysfunction of (stuck in) extension, rotation and side flexion are limited to the side opposite to the problem facet In a positional dysfunction of (stuck in) flexion, side flexion and rotation are limited on the same side as the problem facet Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 43 Facet Impingement and Positional Dysfunction If a left facet has a positional dysfunction of (stuck in) extension, left rotation and left side flexion, the motion restriction will be flexion, right rotation and right side flexion; the problem causing this situation is that the left facet will not open into flexion. The patient will be unable to move the spine into normal flexion, rotation to the right and side flexion to the right, but movement into extension, left rotation and left side flexion will not be impeded and will appear normal Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 44 Facet Impingement and Positional Dysfunction On the other hand, if the positional dysfunction of (stuck in) flexion is present, restricted motion in side flexion and rotation will be ipsilateral to the problem facet For example, if a patient has a positional dysfunction of (stuck in) flexion because the right facet will not close, the stuck position (positional dysfunction will be flexion, left rotation and left side flexion with motion restricted in extension, right rotation and right side flexion; the patient will be unable to move the spine into normal extension, right rotation and right side flexion, but movement into flexion, left rotation and left side flexion will not be impeded and will appear normal Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 45 Facet Impingement and Positional Dysfunction Other signs of facet impingement and positional dysfunction include radiating pain mimicking a dermatomal distribution, tenderness of the spinous processes and reflex muscle spasm Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 46 Facet Sprains Sprains to the facet joint result in more trauma than impingement, so tissue injury is also greater. A more conservative treatment approach is needed An acute facet joint sprain is typically caused by flexion and rotation whilst lifting (same mechanism as many disc protrusions) Chronically, facet joint sprains may be caused by repeated stress over time, particularly in extension activities Characterised by localised, deep pain that is lateral to the spinous processes Extension and lateral flexion provoke pain Flexion movements typically relieve pain by unloading the facets Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 47 Facet Sprains Gentle ROM in pain-free movements can relieve muscle spasm, pain and oedema As rehabilitation continues, flexibility exercises and strengthening are added to the therapeutic exercise program Initially, extension activities may be painful, so these are approached as the patient tolerates them Core strengthening may be necessary if deficiencies were noted during the patient’s examination If the patient fails to progress and pain persists, referral to a Physician for injection (corticosteroid) into the facet joint may be necessary to relieve the pain and subsequently allow the patient to complete the rehabilitation program Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 48 Scheuermann’s Disease Occurs during adolescent growth (10-15 yrs) – pain in thoracic spine Characterised by excessive kyphosis due to wedge-shaped vertebrae Presents in adulthood as excessive thoracic kyphosis & lumbar lordosis Program considerations: Prevent progression of postural deformity Improve thoracic extension & reduce lumbar lordosis Identify tight/shortened structures & long/weakened muscles Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 49 Thoracic Outlet Syndrome (TOS) Thoracic outlet syndrome (TOS) can be classified as either a cervical injury or a shoulder injury Compression of the neurovascular bundle caused by postural defects (forward head, rounded shoulders) Tight scalene & pectoralis muscles Weak serratus anterior & lower trapezius Signs & symptoms: Pain in neck or shoulder Numbness or tingling along arm, possible weakness Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 50 Thoracic Outlet Syndrome (TOS) Although the diagnosis of TOS can be difficult to make and the signs and symptoms are complex, the treatment program is usually quite simple Symptom control is the first goal; accomplishing this goal includes the use of modalities as needed and instructing the patient about positions that can relieve the tension or compression on the brachial plexus The sleeping position that best relives TOS is a supine position with the scapula in protraction and elevation and the shoulder in internal rotation and adduction In severe cases, it may be necessary for the patient to wear an arm sling during the day. In less severe cases, the patient can obtain relief during the day by placing his or her hand in a front pant pocket or in the waistband when standing and by supporting the arm when sitting Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 51 Thoracic Outlet Syndrome (TOS) Correction for posture and body mechanics is vital to correcting and preventing a recurrence of TOS A typical posture held by persons with TOS is a forward-head, round- shoulder posture Once the inflammation phase has subsided, flexibility and strengthening exercises begin The brachial plexus should be stretched. These stretches are performed to the point of pain, but not beyond, because pushing into the pain may re-irritate the nerve bundle Flexibility exercises for the cervical and thoracic spine should also be included Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 52 Thoracic Outlet Syndrome (TOS) Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 53 Thoracic Outlet Syndrome (TOS) Strength exercises are designed to restore the correct muscle balance in the neck and upper back so that the patient can have normal movement of the brachial plexus and related soft tissue and less stress on the tissues It is common for patients with TOS to breathe primarily with the upper respiratory muscles, the sternocleidomastoid and scalenes. These patients should be taught how to do diaphragmatic breathing, or belly breathing, in addition to using a combination of upper and lower respiratory muscles Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 54 Cauda Equina Syndrome Clinical Red Flag – Seek urgent medical attention Cauda equina – lower 10 pairs of nerve roots Aetiology: Compressive (herniated disc, spinal stenosis, spinal neoplasm/tumor, vertebral fracture) or non-compressive (ischemia, infection, inflammation) Signs and symptoms: Severe LBP Loss of bladder & bowel function Sensory & motor deficits in LL Severe sciatica Sexual dysfunction Saddle anaesthesia Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 55 Functional Anatomy and Rehabilitation of the Vertebral Column SPECIFIC MOVEMENT CONSIDERATIONS Flexion Exercises Flexion exercises reduce the lumbar lordosis 1. Sit-ups 2. Posterior pelvic tilt 3. Single/double knee to chest 4. Sit & reach 5. Lunge stretch 6. Deep squat Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 57 Flexion Exercises Indications: Lx pain reduced with sitting Lx pain increased with lying or standing Trunk flexion eases pain Patient’s lordosis remains during trunk flexion End-range of lumbar extension causes pain Poor abdominal strength Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 58 Flexion Exercises Mechanisms: Reduce facet joint stress Stretch thoraco-lumbar fascia & erector spinae Open intervertebral foramen & relieve stenosis of spinal canal Improve abdominal strength & increase intra-abdominal pressure to provide spinal stabilisation Contraindicated in acute disc pathology Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 59 Extension Exercises Extension exercises relieve disc pressure 1. Prone lying 2. Prone on elbows 3. Press-up from prone lying 4. Standing extension 5. Cat-cow in sitting 6. Double knee to chest alt. L & R Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 60 Extension Exercises Indications: Lx pain reduced with lying down Lx pain increased with sitting Trunk flexion is limited & increases pain or area of referred pain increases in size or severity Pain is reduced with back extension movements Mechanisms: Reduce neural tension Reduce disc load & therefore disc pressure Increase strength & endurance of the back extensors Contraindicated in facet joint degeneration, spondylosis or spondylolisthesis Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 61 Functional Anatomy and Rehabilitation of the Vertebral Column SPECIAL TESTS AND TREATMENT TECHNIQUES IN RADICULOPATHY Special Tests in Lumbar Spine Assessment Straight Leg Raise (Lasegue’s Sign) A neurodynamic test Assesses for compression of the lumbosacral nerve roots Positive if the radicular symptoms are reproduced in a dermatomal pattern at between 35⁰ and 70⁰ of hip flexion Watch how the test is performed below: https://www.youtube.com/watch?v=LdAD9GNv8FI Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 63 Special Tests in Lumbar Spine Assessment The Slump Test A neurodynamic test Assesses for compression of the lumbar nerve roots Positive if the radicular symptoms are reproduced during the movement Watch how the test is performed below: https://www.youtube.com/watch?v=HFGfP84uwEo Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 64 Special Tests in Lumbar Spine Assessment Kemp’s Test A non-specific provocation test for facet injuries and spinal stenosis Watch how the test is performed below: https://www.youtube.com/watch?v=4GBjhAcwh90 Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 65 Special Tests in Cervical Spine Assessment Spurling’s Test A neurodynamic test Assesses for compression of the cervical nerve roots Positive if the radicular symptoms are reproduced during the movement Watch how the test is performed below: https://www.youtube.com/watch?v=3ZSNdv0o0yk Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 66 Special Tests in Cervical Spine Assessment Shoulder Abduction Sign A neurodynamic test Assesses for compression of the cervical nerve roots Positive if the radicular symptoms disappear during the movement Watch how the test is performed below: https://www.youtube.com/watch?v=8_AHkiiPYS8 Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 67 Special Tests in Cervical Spine Assessment Upper Limb Tension Tests Neurodynamic movements Assesses for compression of various cervical nerve roots and peripheral nerves in the upper limb Positive if the radicular symptoms are provoked by the movement/s Watch how the test is performed below: https://www.youtube.com/watch?v=rir6x6Iiqc4 Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 68 Neurodynamic Treatment Techniques for Lower Limb Radiculopathy Designed to assist in the ‘sliding and gliding’ of lower limb neural structures Watch how the these are performed below: https://www.youtube.com/watch?v=WXzf8gxYQ2o Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 69 Neurodynamic Treatment Techniques for Upper Limb Radiculopathy Designed to assist in the ‘sliding and gliding’ of upper limb neural structures Watch how the these are performed below: https://www.youtube.com/watch?v=Fv_EJV8q2E0 Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 70 Functional Anatomy and Rehabilitation of the Vertebral Column SURGICAL INTERVENTION Corticosteroid Injection Known as an epidural steroid injection (ESI), it is a minimally invasive procedure Injection of a powerful steroid anti-inflammatory to a site in the vertebral column Often U/S or CT-guided Designed to reduce inflammation and subsequent pain, particularly from nerve root compression Highly variable results Can last days or months Can provide no benefit whatsoever Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 72 Microdiscectomy A procedure to remove part of an IVD that is compressing a nerve root Those patients who have undergone microdiscectomies follow a course of treatment similar to that of patients who have disc pathology without surgical correction Watch how a microdiscectomy is performed below: https://www.youtube.com/watch?v=i5xZrmoamsA Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 73 Foraminotomy A procedure to remove bony spurs that narrow the intervertebral foramen and therefore contribute to nerve root compression Those patients who have undergone foraminotomy follow a course of treatment similar to that of patients who have disc pathology without surgical correction Watch how a foraminotomy is performed below: https://www.youtube.com/watch?v=5ILE-2z0Ey4 Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 74 Laminotomy / Laminectomy A procedure to remove part of the lamina that can contribute to spinal stenosis Typically performed for spinal stenosis Patients have a reduction in trunk stability post-operatively Watch how a laminotomy is performed below: https://www.youtube.com/watch?v=5_hETUNrkBs Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 75 Artificial Disc Replacement A very invasive procedure designed to maintain intervertebral disc height and lumbar spine range of motion The entire IVD is removed and replaced by an artificial disc A fairly uncommon procedure Given the hardware involved, each surgeon will provide their own post- operative treatment guidelines Watch how an artificial disc replacement is performed below: https://www.youtube.com/watch?v=uWignI-e2zI Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 76 Fusion A very invasive procedure designed to eliminate all movement at the affected level Typically used as a ‘last resort’ The procedure is usually reserved for people with unstable spines, severe of multi-level disc degeneration or spondylolisthesis After surgery, the patient’s range of motion is restricted to allow the fusion to heal. Accordingly, the patient should avoid excessive loading or rotation of the spine Given the hardware involved, each surgeon will provide their own post- operative treatment guidelines Watch how a fusion is performed below: https://www.youtube.com/watch?v=WID1p_UJZIM Week 5 - Functional Anatomy and Rehabilitation of the Vertebral Column 77