ATTH 4110 (MSK Assessment - Spinal) Note Compilation PDF

**Topic \#1: Principles of Assessment** Assessments - the basis of all therapy treatment. What does it provide? A base of information from which appropriate decisions/ medical referrals can be made. What must it be? Ongoing!!! Important terminology: - Subjective data -- what cannot be specifi...

**Topic \#1: Principles of Assessment** Assessments - the basis of all therapy treatment. What does it provide? A base of information from which appropriate decisions/ medical referrals can be made. What must it be? Ongoing!!! Important terminology: - Subjective data -- what cannot be specifically verified - Objective data -- what I'm able to visualize - Validity -- a test actually measures what it is supposed to measure and that the results are correct or true - Reliability -- the extent to which comparable results are achieved every time a test is repeated - Inter-rater -- b/w different individuals performing a task - Intra-rater -- one person performing a task, and the result is compared to themselves - Sensitivity -- the probability of a positive test result in someone with the pathology (true positives) - Specificity -- the probability of a negative test result in someone without the pathology (true negatives) - Hardware -- movement restriction/ tissue limitation/ mechanical issue - Software -- movement coordination/ motor control, either the input OR output is flawed - Clinical reasoning -- the process by which a clinician makes clinical-based decision regarding a patient's health, status, and care. - Involves the interaction of 3 knowledge systems: - Professional knowledge -- imperical thinking. What does the data/ textbook tell us? - Personal knowledge -- life experience - Professional craft knowledge -- clinical experience - How many approaches are there? Many different ones. - This makes the difference between novice and expert clinicians. - What does this ultimately result in? Clinical decision making. - Differential diagnosis -- process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient's illness - The comparison of symptoms of similar diseases so that a correct assessment of the client's actual problem can be made - What does it include? All possible diagnoses that have not been excluded by the examination findings. - What are you doing? Picking out the similarities and differences with the case at hand. - What three things do you want to know? - What are the most common pathologies that present this way? - Life-threatening pathologies that may have similar clinical presentations. - Rarer/ unusual pathologies that this may align with. - What are we assuming? That our patient population is coming in with normative data findings - What can we use our clinical reasoning to then come to? Reasonable decision making. - Index of suspicion -- the initial impression of what the injury/ pathology may be - How many of these will you often have by the end of a history? More than 3! - What does a bigger list usually mean? That you're considering not missing something substantial/ serious!!!! - You can add more on, but you cannot "abandon" any of them without rationalizing how you excluded it - Clinical impression -- what you think the presentation is. - How does it come about? After getting there with your clinical reasoning. - What term do we stay away from, and why? Diagnosis, because doctors use that, as it is more exact!!!!!/ exhaustive/ based on a more accurate testing process) - Scope of practice -- the ability to understand the limits of professional knowledge and to utilize the knowledge, skill set and experience of your peers What type of the 2 is more important? Both are valuable! What does data not equal? Knowledge. Informed consent: - 4 general steps: **\"W**isdom **H**ates **R**ebels **A**gainst it\" - What and why you're doing!!!!!!!!!!!!!!!!!!!!! - How you're doing it!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! - The risks and impact of what you're doing!!!! - Reasonable alternatives to what you're doing - It is ongoing and required! - 6 components that it includes: **\"I**ntroduce **P**atients **W**ith **A**nswers **C**ommonly **R**ecorded.\" - Introduction!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! - Patient comfort (ex. body positioning) - What to expect!!!!!!!!!!!!!!!!!!!!!!!!!!!! - Any questions before we begin?????? - Can I proceed????????????????????? - Record what you ask or do!!!!!!!!!!!!!! 7 purposes of documentation: Acronym: **\"L**awyers **C**reate **O**rderly **B**udgets, **O**verseeing **R**esearch for **Q**uality Care.\" Ordetly 1. Legal requirement!!!!!!!!!!!!!!!!!!!!!!! 2. Communication!!!!!!!!!!!!!!!!!!!!!!!!!! 3. Organization!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 4. Billing!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 5. Objective review of progress!!!!!!!!!! 6. Research data!!!!!!!!!!!!!!!!!!!!!!!!!!!! 7. Improve and maintain quality of care 7 documentation requirements: (Acronym: CCASSEL) 1. Chronological and timely -- as soon as the assessment/ treatment has been performed 2. Confidential -- making sure charts aren't left open/ all over the clinic, log off computer every time you step away 3. Accurate 4. Suitable abbreviations 5. Signed/ co-signed!!!!!!!!!! 6. Error correction/ blank spaces 7. Legible and permanent The SOAP format: - Subjective!! - Objective!!! - Assessment - Plan!!!!!!!!! Two aspects of verbal communication - spoken and written language, in this context between the HCP and the patient. 4 other people that it may also include - family members, patient advocates, interpreters and other HCP 1. Speaking and listening 2. Reading and writing Eight aspects of non-verbal communication: 1. Facial expressions 2. Eye contact 3. Posture 4. Positioning 5. Gestures 6. Attitude 7. Tone 8. Distractors 16 steps of an assessment: 1. History 2. IOSs \#1 3. Critical rule-outs 4. Observation 5. IOSs \#2 6. Critical rule-outs 7. Examination (scanning or clearing) 8. IOSs \#3 9. Motion assessment -- AROM + PROM, in the case of spinal replaced by accessory movements 10. Resisted testing (ISOM) 11. IOSs \#4 12. Special tests 13. IOSs \#5 14. Palpation 15. Clinical impression 16. Differential diagnoses 6 things you should do throughout your assessment: (FALLTR) 1. Feel!!!! 2. Assess! 3. Listen!! 4. Look!!! 5. Test!!!! 6. Record How many aspects at a time should your attention be focused on? One at a time. How will this change as you progress to being an expert? You will be focused on more than one aspect at a time. History - a thorough and structured history is imperative to the assessment process - What should you avoid? Leading questions. - What should you do for clarification? Paraphrase. 6 questions important to ask for spinal history taking: (Acronym: MMFFCV) 1. Medications -- linked to back pain and bone health 2. Menstruation/ pregnancy/ menopause -- changes bone health along with many other things 3. Family history of any previously listed chronic illnesses/ diseases 4. Fracture history -- may lead to an increased risk of osteoporosis 5. Chronic illnesses/ diseases - Connective tissue disorders - Rheumatic!!!!!!!! Diseases - - Bone!!!!!!!!!!!!!!! health - Cardiovascular!!!! system - Cancer!!!!!!!!!!!!!! 6. Vertebral basilar insufficiency 20 history red flags: 1. Dizziness/ vertigo 2. Drop attacks/ fainting 3. Dysarthia -- 4. Dysphasia -- difficulty speaking 5. Diplopia -- 6. Difficulty controlling bowels 7. Numbness in the saddle area 8. Numbness/ tingling in both hands and feet 9. Night/ unrelenting pain -- potential cancer 10. History of cancer -- 11. Fever/ chills -- could be a sign of infection 12. Loss of coordination -- includes ataxia -- uncoordinated, unsteady GAIT 13. Long-term corticosteroid use -- impacts tissue health 14. Unexplained weight loss/ gain 15. Unhealing sores/ wounds -- malignancy, pre-cursor to diabetes 16. Osteoporosis/ fragility & compression \#s -- contra-indication for manual therapy, joint play 17. Recent infection - if widespread can have a huge effect 18. Symptoms with exertion, eating/ drinking -- visceral pathology, cranial nerve function, other somatic nerve pathology 19. Thoracic/ abdominal pain -- visceral pathologies 20. Trouble urinating 5 Ds and 3 Ns: 1. Dizziness!!!!!! 2. Drop attacks!! 3. Diplopia!!!!!!! - 4. Dysarthia!!!!!! -- slurred speech 5. Dysphagia!!!!! -- difficulty swallowing 6. Ataxia of GAIT -- 7. Nausea!!!!!!!! -- 8. Numbness!!!!! -- 9. Nystagmus!!!!! -- difficulty tracking eyes/ googly eyes What should the therapist have following a comprehensive subjective assessment? An index of suspicion How many of these are you expected to state at the end of a history? Three What 3 things do you gain information on during an observation? (Acronym: FAV) 1. F 2. A 3. V 4. Functional deficits 5. Abnormalities of alignment and movement 6. Visible!!!!! defects The observation begins on first sight of the patient and continues throughout the physical tests of the examination With what eye do you observe? The dominant one Appropriate exposure must occur for an observation-- at minimum, do this for the injury site. 13 new aspects of observation for spinal: (Acronym: WASPSKICKeDRIBSC) 1. Weight -- COG may need to be corrected when you're assessing to get a proper view of plumb 2. Are the knees relaxed or locked in extension? 3. Scapulae 4. Pottenger's saucer -- a loss of kyphotic curve that has been correlated with digestive disorders 5. Skin conditions: - Presence of wounds - Thick skin - Areas of vascularity 6. Knee alignment 7. line 8. Chest deformities 9. Knee alignment (genu valgum/ varum) 10. Dynamic observations: - GAIT - Functional tests 11. Rotation 12. Inverted T - Where does the person line up? - Can the person maintain that position when they squat? 13. Breathing -- looking for: - Chest vs abdomen - Anterior -- lateral -- posterior 14. Shingles -- an adult form of chicken pox. - What pattern does it typically follow? A dermatomal one. - How high is you risk of contacting it, and what does this mean? High, and that you should terminate the assessment. 15. Calcanei 8 factors influencing posture: (Acronym: \"Hyper, Hypo, Leg, Lack, Pain, Neuro, Muscle, Density, Bone.\") 1. Hypermobile joints (ex. genu recurvatum) 2. Hypomobile! joints (ex. flexion contracture) 3. Leg-length!!!! discrepancies (ex. functional scoliosis) 4. Lack of postural awareness (ex. acquired bad habits, like slouching in a chair) 5. Pain!!!!!!!!!!! (ex. antalgic posture) 6. Neurological pathology (ex. winging of the scapula secondary to the inhibition of the long thoracic nerve) 7. Muscle!!!!!!!! imbalances (ex. increased pelvic angles secondary to weak abdominal muscles) 8. Decreased muscle extensibility (ex. decreased pelvic angles secondary to tightness of the hamstring muscles) 9. Bony!!!!!!!!!!! abnormalities (ex. toe-in or toe-out posture secondary to tightness of the hamstring muscles) **[CLEARING VS SCANNING]** Scanning - sometimes confusing (has been described as poorly named) - can be called \"screening\" Described by the quadrant/ half of the body that is being targeted (ex. if someone comes in with knee pain and we are doing a scanning exam, we would be examining the lower quadrant of the body - L spine and inferior to that, wrist pain - UQ involving C spine and everything distal to that) \"The noisy victim may be some distance away from a silent culprit\" With chronic injuries/ insidious onset, we have to look more broadly 6 cases where a scanning exam is indicated: (Acronym: DIALReScue) 1. Diffuse/ non-specific MOI -- could be referred from somewhere else, include several joins/ body parts being involved 2. Insidious onset 3. Altered sensation 4. Long track signs/ symptoms -- things associated with the spinal cord, particularly upper motor neuron pathologies: - Hyperreflexia - Ataxia - Balance difficulties - Patients presenting with abnormal patterns - Suspected psychogenic pain 5. Several joints/ body parts involved 6. Radicular signs/ symptoms Clearing - looking at joint above and below (at a minimum) Just because you\'ve done one of these exams, it doesn\'t mean that you\'ve eliminated all the causes for an injury outside of a joint Regional interdependence -- the concept that a patient's primary musculoskeletal symptoms may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s). - What is the mechanism behind it likely? Multifactorial, and can occur irrespective of the proximity of the structures to one another [5 steps of an upper quadrant scanning exam:] 1. T-spine PACVPs!! 2. Peripheral joints a. TMJ -- open, close, side-to-side! b. Shoulder AROM + OP!!!!!!!!!!!! c. Elbow AROM + OP of FLEX/ EXT d. Wrist AROM + OP of FLEX/ EXT! 3. UQ myotomes!! e. C3 -- f. C4 -- g. C5 -- h. C6 -- i. C7 -- j. C8 -- k. T1 - 4. UQ dermatomes l. C1 -- top of head/ forehead m. C2 -- back of head n. C3 -- neck/ upper shoudler o. C4 -- shoulder p. C5 -- anterior arm q. C6 -- lateral upper arm r. C7 -- lateral forearm s. C8 -- digits 4-5 t. T1 -- medial forearm u. T2 -- medial upper arm 5. UQ reflexes!!!!!! v. C4 -- deltoid w. C5 -- biceps x. C6 -- brachioradialis y. C7 - triceps [5 steps of a lower quadrant scanning exam:] 1. T-spine PACVPs!! 2. Peripheral joints a. SI joint -- Gillet's!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! b. Hip AROM + OP (FLEX, EXT, IR, ER, ABD, ADD) c. Knee AROM + OP of FLEX/ EXT!!!!!!!!!!!!!!!!!! d. Ankle AROM + OP of PF/ DF!!!!!!!!!!!!!!!!!!!!! 3. LQ myotomes!! e. L1 -- upper thigh f. L2 -- the thigh g. L3 -- the knee h. L4 -- the inner lower leg i. L5 -- the outer lower leg + toes 1-3 j. S1 -- toe 4-5 and heel k. S2 - hamstring 4. LQ dermatomes l. L1 -- L2 -- hip flexion m. L3 -- knee extension n. L4 -- ankle dorsiflexion o. L5 -- 1^st^ toe dorsiflexion p. S1 -- ankle plantarflexion q. S2 -- knee flexion 5. LQ reflexes!!!!!! r. L4 -- patellar!!!!!!!!!!!! s. L5 -- achilles!!!!!!!!!!!! t. S1 -- medial hamstring u. S2 -- lateral hamstring Since pain is very frequently referred from proximal to distal, and since joints which are situated in areas to which pain of spinal origin is commonly referred often develop secondary dysfunction which contributes to the total picture of signs and symptoms, all examinations should proceed invariably from the spine to the distal body parts. With scanning and clearing, what is it hardly wrong to do? Be more thorough. **[EXAMINATION]** What are tests influenced by? The history and observation. 7 examination considerations: 1. Patient positioning -- for their comfort and gravity (working with or against it), functional positions, dynamic tests 2. Therapist positioning -- good body mechanics, making sure we're not stressing ourselves 3. Hand positioning 4. What side should you test first? Normal side. 5. What movements would you want to test first? Non-painful. 6. What movements would you want to test last? Painful, because we may not be able to complete all tests we want to if we do the most painful ones first 7. How do you know what movements/ tests are appropriate today? Because of the info found, and indices of suspicion at that point of the exam 8 roles of the non-injured limb in the examination process (summary -- provides a reference) 1. [Inspection] -- provides a reference for symmetry, alignment, and color of the superficial tissues 2. [Joint and muscle function] -- provides a reference to identify impairments relating to available ROM, strength, and pain with movement 3. [Joint stability test] -- provides a reference for end-feel, hypermobility or hypomobility, and pain 4. [Selective tissue tests] -- provides a reference for pathology of individual ligaments, joint capsules, and musculotendinous units, as well as the body's organs 5. [Neurological test] -- provides a reference for sensory, reflex, and motor function 6. [Vascular screening] -- provides a reference for blood circulation to and from the involved extremity 7. [Palpation] -- provides a reference for the symmetry of bones, alignment, tissue temperature, tissue density, or other deformity, as well as the presence of increased tenderness **[Motion/ strength]** Range of motion -- the full movement which is possible at a joint. What are you comparing it to? What is normally expected in a joint Anatomical vs physiological barriers **Barrier type** **Anatomical** **Physiological** ------------------------------------------- ------------------------------------------------ -------------------------------------------- [ROM type associated with it] AROM PROM [Definition] What the patient is able to reach on their own How far the joint is actually able to move [How it is achieved] Using their own muscle power By an external force  What is the difference between the two barriers called? The elastic barrier AROM -- combines tests of: 1. Patient's willingness to perform movement 2. Joint range 3. Joint control 4. Muscle power What 2 types of tissues does it test? 1. Inert!!!!!!! 2. Contractile What 3 things should you evaluate? 1. Quality!!! of movement 2. Quantity of movement 3. When and where onset of pain occurs and ceases 5 considerations with AROM: 1. Adaptive strategies by the patient -- are they used? 2. Posture and positioning -- correct patient on this before you begin 3. Repetition and sustainability -- ex. if they don't get pain until they work out for half an hour 4. Motion in other planes -- which one do we tend to test in? Frontal. Which movements may be more functional? Side bending and rotation. 5. Movement at varying speeds PROM -- follows testing of AROM. 1. Should you expect more or less ROM than with AROM? More ROM! 2. What does it test? Inert tissue. 3. What must the patient be? Relaxed. 4. 3 things you should evaluate: - Range of movement - When and where onset of pain occurs - Quality of end feel 5. PPIVMS! 6. 3 types of normal end feel: - Hard/ bone-to-bone - Soft/ soft tissue approximation - Firm/ tissue stretch 7. 5 types of abnormal end feel: - Hard - Soft - Firm - Spasm - Empty Which one is the most difficult to understand? Empty, because the patient may not let you do so -- it is patient limited AROM vs PROM: AROM PROM Impression ------------ ------------ -------------------------------------------------------------------------------------------------------------- Normal Normal Cleared!!!!!!!!!! Restricted Normal Software issue! -- when we took the person's contributions out of the problem, there was no longer a problem Restricted Restricted Hardware issue -- ex. a bony block. Osteophyte mechanically limiting the ROM In what 3 circumstances may passive movements be unnecessary? If: 1. AROM is full and pain free 2. Overpressure does not produce symptoms 3. End feel is normal How is ISOM performed? In a neutral/ static position What tissues does ISOM test? Contractile and nervous. What is it used to obtain? A gross measure of the muscle's ability to produce force. Cue -- "don't let me move you" Grading scale: 1. 0/5 -- gone -- no contraction is felt 2. 1/5 -- trace - the patient cannot produce movement, but a muscle contraction is palpable 3. 2/5 -- poor!!! -- the patient can move the body part in a gravity-eliminated position through the full ROM. 4. 3/5 -- fair!!!!! -- the patient can move the body part against gravity through the full range of motion 5. 4/5 -- good!!! -- the patient can resist against moderate pressure 6. 5/5 -- normal -- the patient can resist against maximal pressure. The examiner is unable to break the patient's resistance. 7 considerations with ISOM testing: (Acronym: WADAHCP) 1. What should you watch for? Adaptive strategies. 2. Avoid crossing joints with hands placement 3. Direction of force 4. Amount of force -- gradually build to a max resistance over 3 to 5 seconds 5. Hands 6. Comfortable grip/ position 7. Patient & therapist body positioning **[SPECIAL TESTS]** 5 things that special tests are designed to evaluate: (Acronym: FANSI) 1. Function of specific muscles in ROM (MMT) 2. Arthrokinematics 3. Neurological function 4. Selective tissues 5. Integrity of ligaments and joint capsules 2 things they used for: 1. To confirm a tentative clinical impression 2. To unravel difficult signs and symptoms Considerations with joint play: 1. Accessory motions/ arthrokinematics 2. Inert structures, primarily capsular integrity 3. 3 motions: - Roll!! - Glide - Spin! 4. Preform if ROM not full!!!!!, and if injury not acute!!!!!!! 5. How often is it included in spinal assessment? Almost always!!!!! 6. What position would they be tested in? Resting/ relaxed 7. 3 most common directions of movement: - Longitudinal!!!!!!! - Anterior posterior - Posterior-anterior 8. Where is it also used in? Rehabilitation 4 types of outcomes in a joint stability test: 1. Hypermobility 2. Hypomobility 3. Laxity 4. Instability 3 components of neurological testing: 1. Sensory - Dermatomes -- area of skin innervated by a single nerve root - 3 things you're evaluating for: 1. Anaesthesia -- absence of sensation 2. Paresthesia -- different (usually less) sensation 3. Hyperesthesia -- increased touch perception - If it is positive, what is required? More detailed examination -- for us this is sharp and dull discrimination - Alternative -- do hot and cold sensation, but this is less feasible 2. Motor - What is the method for testing this? Myotomes. - How many sides are you testing at a time? Just one. - What shouldn't you do if you're re-testing? Take a break between the 1^st^ and 2^nd^ test! - How long should you hold each for? 5-7 secs. - What are you watching for? Fatiguability. 3. Reflex - 3 types: 4. Deep tendon 3. What type of reflex arc? Simple 4. How many times do we perform them? 3 to 5 5. What must the patient be? Relaxed 6. Do the Jendrassik's maneuver -- distraction technique for doing only lower extremity reflexes 1. If you engage it for 1 reflex, how many others must you engage it for? All others, because you may get an exaggerated response with it. 7. How are they graded? On a scale of 0 to 4: 2. 0/4 -- no response 3. ¼!! - hypo reflexive -- indicates a compressed nerve 4. 2/4 -- normal 5. ¾!! - hyper reflexive 6. 4/4 -- clonus -- indicates an upper motor neuron lesion -- a lesion proximal to the anterior horn of the spinal cord that results in paralysis, loss of voluntary movement, spasticity, etc. 5. Superficial -- indicates upper motor neuron lesions (Acronym: CAAP) 8. Cremasteric/ Geigel 9. Abdominal 10. Anal 11. Plantar 6. Pathological -- reflexes that are normally not present 12. Hoffman's 13. Babinski 14. Chaddock's 15. Openheim 16. Clonus 2 circumstances when it'd be preformed: 1. In a scanning examination 2. When you suspect neurological involvement Vascular screening -- a gross assessment of blood flow to and from the extremities: Includes: 1. Capillary refill 2. Pulses: - Lower extremity 1. Femoral 2. Posterior tibial 3. Dorsal pedal - Upper extremity 4. Brachial 5. Radial 6. Ulnar - Systemic 7. Carotid Palpation -- to examine or explore by touching, the application of the fingers to the surface of the skin or other tissues, using varying amounts of pressure to selectively determine the condition of the parts beneath - When is it performed? After other tests, because it can irritate the tissues and cause inaccurate findings - Should be distal to proximal from the primary injury site - 3 main principles: 8. Move slowly 9. Avoid excessive pressure (progressive) 10. Focus on what you're feeling - What side first? The normal side - 7 Ts of palpation that describe what you're feeling: 11. Texture 12. Tenderness 13. Temperature 14. Tissue tension 15. Thickness 16. Tremors - Tissue texture abnormality -- a palpable change in tissues from skin to periarticular structures that represent any combination of the following signs: 17. Vasodilation 18. Edema 19. Flaccidity 20. Hypertonicity 21. Contracture 22. Fibrosis 23. Itching 24. Pain 25. Tenderness 26. Paresthesias - Types of TTAs: 27. Bogginess 28. Thickening 29. Stringiness 30. Ropiness 31. Firmness 32. Increased/ decreased temperature 33. Increased/ decreased moisture - Areas of: 34. Tenderness 35. Spasm 36. Crepitus 37. Nodules 38. Scar tissue 39. Swelling - Important comparative descriptors: 40. Superficial/ deep 41. Compressible/ rigid 42. Warm/ cold 43. Moist/ dry 44. Painful/ pain free 45. Local/ diffuse 46. Relaxed/ tense 47. Hypertonic/ hypotonic 48. Normal/ abnormal Functional testing -- very important in determining day-day impact, causation, kinetic chain dysfunctions, etc. - What would you do with something aggravating? Save it until the end of the assessment! - Examples: 49. Gripping, pinching 50. Standing to/ from sitting 51. Squatting 52. Hopping 53. Balancing 54. Dexterity tasks What will you provide at the end of an assessment? Your clinical impression, and a minimum of 2 differential diagnoses (IOSs that you haven't been able to screen/ rule out) 6 more considerations: 1. Are there any further details necessary? 2. Communication with other HCP 3. Referrals 4. What care will you provide today? 5. Identify your role in recovery, develop treatment plan (if appropriate) 6. Allow opportunity for questions and clarification, and give an opportunity to absorb the info the patient has received Knowledge trimming and speeding up of procedure follows naturally in time, as the worker gains clinical experience, but the informed and responsible use of short-cuts rests on competence, and the beginner's obligation is to steadily acquire this by orderly self-discipline and dedicated practice. Is taking short-cuts the expectation in this course? No!!!!!!!!!! What do you have to do until you can demonstrate that you have the knowledge base to skip particular steps? Be thorough. What do you have to do this with, which is a part of my practical experience? Acknowledging how/ why you get to do that. What 2 things can reduce the number of steps performed? 1. Information and results from the history 2. Early inspection To do this, use best evidence! It makes the examination: 1. Efficient!!!!!!!! 2. More accurate What is the most undervalued/ overlooked ROM? PROM. What is the most often skipped/ skimmed part of the assessment? Palpation! **Topic \#2: Spinal anatomy** How many vertebrae are there in the spine? 33 3 regions of the spine: 1. Cervical 2. Thoracic 3. Lumbar 2 types of spinal curves: 1. Primary!!! - the natural curves of the spine that are present at birth. 2. Secondary - develop after birth as a result of growth and movement, usually in response to various activities such as lifting the head, sitting, and walking. Neutral spine 2 functions of the spine - provides: 1. Mobility for functional movement of the human body 2. Stability required for vertical support of the torso 1. 2 spine mobility zones: - C spine - L spine 2. 3 spine stability zones: - T spine - S spine - Pelvis!! **[BONES]** 1. Body 2. Spinous process 3. Transverse process 4. Lamina 5. Pedicle 6. Superior articular process 7. Inferior articular process **[Intervertebral discs]** 1. What % of the length of the spinal cord are they? 25%. 2. 3 functions: (Acronym: PAPS) - Protects spine - Absorbs force - Provides tensile strength 3. How many are there in total? 23. 4. What region of the spine is it absent from? C0-C1. 5. Two parts: - Annulus fibrosus -- outer layer 1. In what part is it weakest? Posteriorly. 2. Vertebral end plate 3. Neovascularization - Nucleus pulposus -- center core of disc, slightly posterior 4. What part of it is H2O? 70-80%. 5. What happens to it with age? It degenerates. 6. What does its herniation cause? The AF to take more load. **[Vasculature]** 1. Carotid artery splits at the C4 into external/ internal  for head/ neck. 2. Jugular veins drain into the brachial cephalic behind the clavicle. 3. The vertebral arteries -- the most clinically relevant: - What structure do they travel superiorly through? The transverse foramina. - What do they merge to form? The basilar artery.  - What is its point of re-entry? C6. 4. The basilar artery - How much blood flow to the brain does it supply? 10-20%. - To what part of the brain? The deep parts. - What is it the extension of? The vertebral arteries. 5. Aorta  - What does it bifurcate into? Left and right common iliac. - At what point does this occur? The L4.  6. Vena cava. 7. Common iliac artery/ vein  - What do they merge into? The IVC The articulations: 1. Zygapophyseal/ facet joints - What are they covered in? Hyaline cartilage. - Their orientation: (Acronym: OAT) 1. Cervical -- oblique plane 2. Thoracic -- away from the midline 3. Lumbar -- towards midline. 2. Cervical - Uncovertebral - small synovial joints located in the cervical spine. 4. They form between the uncinate processes of the vertebrae and the lateral aspects of the adjacent vertebrae above them. Specifically, these joints are found between: 3. Cervical Vertebrae: The uncovertebral joints typically develop between the bodies of the cervical vertebrae, particularly from C3 to C7. 4. Uncinate Processes: These are bony projections on the lateral borders of the upper surfaces of the cervical vertebral bodies that articulate with the vertebra above. 5. These joints help stabilize the cervical spine and allow for limited motion, such as flexion and lateral bending, while also playing a role in limiting excessive movement that could lead to injury. Additionally, they can be involved in degenerative changes or conditions like cervical spondylosis. - Atlanto-occipital  - Atlanto-axial - Intervertebral 3. Thoracic - Costovertebral  - Costotransverse  - Joints of head of rib 6. Costochondral 7. Costosternal 8. Sternoclavicular 9. Manubriosternal/ xiphisternal What part of the spine carries the most load? L4-5 and L5-S1 Which way does the superior articular process face? Posteromedial. Which way does the inferior articular process face? Anterolaterally. Nerves - Where does the spinal terminate? The cauda equina. - What area is this structure located in? L1-L2. - Spinal nerves/ nerve roots 10. Anterior posterior and their functions: 5. Anterior -- motor!! 6. Posterior -- sensory 7. Why are the functions different? Because they have different types of neurons. 8. What do they divide into? The root at the IVF. - Cervical nerves/ nerve roots 11. Where does the C1 nerve pass? Superior to the arch of the C1 vertebra. 12. Where do the C2-C7 nerves pass? Through the IVF superior to the corresponding vertebra.  13. Where does the C8 nerve pass through? The IVF between C7 + T1 vertebrae. 14. Where do the thoracic nerves pass through? The IVF inferior to the corresponding vertebrae.  15. Where do the lumbar nerves pass through? The IVF inferior to the corresponding vertebrae. 16. The L2-4 nerve roots are pinched by what disc? The same level. At what aspect of the disc? The superior-lateral. 17. The L5 nerve root is pinched by what disc? L4 disc. At what aspect of the disc? The inferior-lateral. Bony anatomy - How many ribs and vertebrae should there be? 18. Supernumerary -- more ribs/ vertebrae 19. Sub numerary!! -- less ribs/ vertebrae - Sacralization -- when the L5 is fused to the sacrum, and is acting as a sacral vertebra - Lumbarization -- when the S1 is not fused and acts like an extra vertebra. The same number of bones, but the sacrum has an extra disc.  - Hyoid bone -- anterior, is suspended by muscles. What should it be level with at rest? The C3 vertebral body. - What 3 structures does the spinal nerve run through? (Acronym: AAV) 20. Adjacent pedicle!!!!!!!!!!!!!!!!!!!!!!! 21. Anterior aspect of articular process 22. Vertebral body!!!!!!!!!!!!!!!!!!!!!!!!! 4.  - In this picture: 23. Vertebral body 24. Spinous process 25. Vertebral foramen 9. What is it formed by? 1. The posterior aspect of the vertebral body 2. Adjacent pedicle 3. Anterior aspect of articular process 26. Transverse process 27. Superior articular facet 28. Costotransverse facet 29. Transverse foramen **Ligament** **Description** **What movement it limits** **Continuous** **Paired** **Picture** ------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- ---------------- ------------ ------------------------ Anterior longitudinal Primary stabilizer, base of skull to sacrum. Extension Yes No Intertransverse Connect TPs of adjoining vertebrae, upper border TP to lower border TP below. Lat flex Yes Yes Interspinous Connect spines of adjacent vertebrae Restricts separation of SP No Yes Supraspinous Connects tips of SPs from C7 to sacrum Flexion Yes No  Ligamentum flavum Stretched lig base of skull to pelvis Hyperflexion Yes No Posterior longitudinal Prevents disc herniation, post surfaces of vertebral bodies in vertebral canal Hyperflexion Yes No  Joint capsules (facet) Provide stability to spine in neutral, limit movement of motion segment No No Transverse (cruciate) Runs between medial aspect of adjacent lateral masses, attaches post to dens Displacement of dens No No Alar Runs between dens & occipital condyles Rotation, side flex, ext No No  Apical Tip of dens to anterior margin of foramen magnum, not a significant stabilizer Hyperflexion No No Ligamentum nuchae Continuation of supraspinous ligament, attachment for muscles Hyperflexion Yes No  Tectorial membrane Continuation of PLL, attaches to inside of foramen magnum, stabilizes upper spine Flexion / rotation Yes No Atlanto-axial occipital Maintain support/stability of atlanto-occipital joint, reduce excess movement No No  Costotransverse Runs between ribs & TPs Excessive movement at ribs No 3/s Inter articular Divides costovertebral joint, attaches to disc, stabilizes joint Yes No Radiate Main ligament of costovertebral joint, joins ant aspect of head of rib radiating Yes No  Iliolumbar Attach medially on TPs of 5th lumbar vertebrae, laterally on inner lip of iliac\... Flexion / extension Yes Yes Thoracolumbar fascia Provides support to spine and abdominal structures, helps w/ friction, allows effective load transfer between spine, pelvis, and legs \- Yes No    - Continuous ligaments: 30. Anterior longitudinal 31. Supraspinous 32. Posterior longitudinal 33. Ligamentum nuchae - Non-continuous ligaments: 34. Intertransverse 35. Intraspinous 36. Ligamentum flavym 37. Transverse 38. Alar 39. Apical 40. Iliolumbar - Paired ligaments: 41. Intertransverse 42. Ligamentum flavum 43. Iliolumbar - Non-paired ligaments: 44. Anterior longitudinal 45. Interspinous 46. Supraspinous 47. Posterior longitudinal. 48. Transverse 49. Alar 50. Apical Visceral innervations/ pain referrals: (Acronym: Hearts Love Every Special Little Gift, Sending Positive Kindness & Compassion) +-----------------------------------+-----------------------------------+ | **Organ** | **Innervation** | +===================================+===================================+ | Heart!!!!!! | C8-T4 | +-----------------------------------+-----------------------------------+ | Lungs!!!!!! | T2-T5 | +-----------------------------------+-----------------------------------+ | Esophagus | T4-T5 | +-----------------------------------+-----------------------------------+ | Spleen!!!!! | T6-T8 | +-----------------------------------+-----------------------------------+ | Liver!!!!!!!! | T6-T9 | | | | | Gall bladder | | | | | | Stomach!!! | | | | | | Pancreas!!! | | +-----------------------------------+-----------------------------------+ | Kidneys!!!! | T10-T11 | +-----------------------------------+-----------------------------------+ | Small intestine | T8-T12 | +-----------------------------------+-----------------------------------+ | Colon!!!!!!! | T8-T12, L2, S2, L4 | +-----------------------------------+-----------------------------------+ | | | +-----------------------------------+-----------------------------------+ - -  Rule of 3s: 1. T1-3 -- SP is at the same level as the TPs 2. T4-6 -- SP is ½ vertebral level below the TPs 3. T7-9 -- SP is one full vertebral level below the TPs 4. T10 -- SP is one full vertebral level below the TPs 5. T11 -- SP is ½ vertebral level below the TPs 6. T12 - SP is at the same level as the TPs **Topic \#3: Spinal motion assessment** Review precautions in POA! When should they be obtained? During a detailed history. 4 main factors we\'re looking at: 1. Bone health 2. Ligament status/ instability 3. Blood flow 4. Vulnerability of the spinal cord **What must you establish before proceeding with motion assessment?** That everything is safe What must you do with fractures? Screen/ refer before any further assessment REVIEW CANADIAN C-SPINE RULES! Three critical rule-outs: 1. Fractures - particularly those of cranio-vertebral/ cranio-sacral region, the primary stabilizers of which are: - Alar ligament!!!!!!! - Transverse ligament 2. Ligaments - are a concern for any motion assessment, particularly segmental motion assessment 3. Vertebral artery/ internal carotid artery (cervical spine) Next, what must you determine? Whether it is appropriate to proceed with motion assessment. This includes 2 considerations: 1. Are you doing active and/ or passive movement? 2. Are you doing all or some movements? Don't underestimate the significance of patient positioning and/ or load/ strain on assessment of motion. There are 3 main reasons for this: 1. Convenience/ efficiency 2. Patient comfort 3. Trying to maximize/ limit the impact of gravity **Movement of the vertebral column** 1. What 2 things does it vary according to? - Spinal region - The individual 2. At each segment, it is small, but together can produce large movements. 3. Movement at a motion segment involves the more superior vertebral body moving on the more inferior vertebral body. This is the case regardless of which vertebra is actually moving. (ex. if patient was lying prone and lifted their shoulder off the table, T8 is described as rotating left on T9. If the individual lifted their right pelvis off of the table, that motion would still be described the same way, though now T9 is rotating on T8) 4. How else is motion described? Using the anterior surface of the vertebral body. 5. What regions of the spine is ROM greatest in? Cervical and lumbar. 6. How else does vertebral motion occur? Sequentially. (ex. movement starts at T2, T2 rotates left on T3 until end range. Now, rotation of T3 beginning on T4, and moves down the spine one motion segment at a time). 7. 6 degrees of freedom in the spine: (Acronym: FLLARD) - Flexion/ extension/ hyperextension - Lateral flexion!!!!!!!!!!!!!!!!!!!!!!!!!! - Lateral translation!!!!!!!!!!!!!!!!!!!!! - Anterior/ posterior translation!!!!!! - Rotation!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! - Distraction/ compression!!!!!!!!!!!! Motions of the spine: FLEX EXT ----------------------------------------------------------------------------------------------------------------------- ----------------------- ------------------------------------------ How does the superior vertebra rotate around the horizontal axis? Anteriorly Posteriorly. How does the superior vertebra translates along the sagittal axis? Somewhat forward. Somewhat backward How do the TSPs of the superior segment move? More anteriorly More posteriorly How does the inferior facet of the superior vertebra move in relation to the superior facet of the inferior vertebra? Superiorly. Inferiorly. SB movement occurring ROT movement occurring Around sagittal axis Rotation!! depends on vertebral segment involvement Around the horizontal axis Translation depends on vertebral segment involvement Around the longitudinal axis Rotation!!! Rotation Keynote: rotation is always a component of side bending, with the exception of what joint? Atlantoaxial. Coupled motion -- motion around one axis is consistently associated with motion around another axis (ex. if you SB to the left, some rotation must occur with that as well) 1. How does a spinal segment do this ipsilaterally or contralaterally? No one really knows. 2. Is coupling motion different at different positions? Yes, it is - if you were flexed, coupling motion would be different than if you weren\'t -- by: - Region - Segmentally within a region 6 variables that determine the amount of motion available at each region of the spine (Acronym: CADDDD is a G): 1. Compliance of the fibrocartilage 2. Age 3. Disc-vertebral height ratio 4. Disease 5. Dimensions and shape of the adjacent vertebral end plates 6. Gender 4 other factors not mentioned by Dutton (Acronym: WRIP): 1. Willingness to go through ROM 2. Resistance of muscles and ligaments 3. Individual strength 4. Presence of pain What is the type of motion available in the spine governed by? 1. Shape and orientation of the articulations 2. The size and location of its articulating processes 3. The ligaments and muscles of the segment Articular surfaces in: 1. [Lower C spine] -- shape is flat and oval, lie in an oblique plane 2. [T spine] - project almost vertically 3. [L spine] - marked upwards and downwards projection...all of them move into FLEX + EXT + SFLEX + ROT...with the exception of what spinal segment and movement? L spine and rotation Upper cervical spine:   B/w occiput and C1 - [Articular surfaces] - ellipsoidal - [Plane] - horizontal - [Facilitate] - a substantial amount of FLEX + EXT, and small amount of SFLEX + ROT   Lateral articular surfaces b/w C1 and C2 - [Plane] - also in the horizontal plane and along the median atlantoaxial joint - [Facilitate] - a substantial amount of ROT in C spine, with small amounts of FLEX, EXT, SFLEX Two types of motion in the spine: 1. [Osteo kinematic] - occurs when muscles contract, or gravity causes the position of a bone to change in relation to the other bone (ex. AROM, PROM, PPIVMs) - What is it necessary to achieve? Full, pain-free osteokinematic motion - When can't it be usually done? In isolation voluntarily, because other osteokinematic motions have to occur alongside it for this to take place. 2. [Arthro kinematic] - movement between two articulating surfaces without reference to external forces being applied to that joint (ex. PAIVMs) 2 regions that the C spine is subcategorized into mechanically: Cervicocephalic/ upper C spine Cervico 1. Cervicoencephalic/ upper cervical 2. Cervicobrachial/ lower cervical Spine region Resting position Close-packed position Capsular pattern of restriction -------------- ------------------ ----------------------- ---------------------------------------------------------------------------------- Cervical Not described Not described side bend and rotation are equally limited, and FLEX is less limited than EXT!!! Thoracic Not described Not described Difficult to determine Lumbar Not described Not described Difficult to determine SUMMARY OF TABLE -- all are unknown except for C spine capsular pattern! What 5 movements are considered and assessed in the spine? 1. FLEX!!!!!!!!!!!!!!!!!!!!! 2. EXT!!!!!!!!!!!!!!!!!!!!!! 3. SB!!!!!!!!!!!!!!!!!!!!!!!! 4. ROT!!!!!!!!!!!!!!!!!!!!!! 5. Combos of the above What 3 tools may be used to measure physiological motion? 1. Inclinometers!!! 2. Goniometers!!!! 3. Measuring tapes...but most frequently, we eyeball. What are the inherent issues with the last measurement? 1. Reliability 2. Accuracy!! Why are we sometimes required to use another measurement? For legal reports. 4 aspects of a ROM recording legend: 1. \-\-\-- - pain-free ROM 2. X, \ - pain provocation reported with ROM 3. ↑, ↓ - radicular symptoms 6 grades of measuring osteokinematic and arthrokinematic mobility: +-----------------------+-----------------------+-----------------------+ | **Grade** | **Description** | **Treatment** | +=======================+=======================+=======================+ | | Ankylosis or no | None | | | detectable movement | | +-----------------------+-----------------------+-----------------------+ | | Considerable | Mobilization | | | limitation in | | | | movement | Manipulation | +-----------------------+-----------------------+-----------------------+ | | Slight limitation in | Mobilization | | | movement | | | | | Manipulation | +-----------------------+-----------------------+-----------------------+ | | Normal | No treatment | +-----------------------+-----------------------+-----------------------+ | | Slight increase in | No treatment | | | movement | | | | | No stabilization | | | | exercises | +-----------------------+-----------------------+-----------------------+ | | Considerable increase | Stabilization | | | in movement | exercises | | | | | | | | Treatment of | | | | neighboring | | | | hypomobility | +-----------------------+-----------------------+-----------------------+ | | Unstable | Stabilization | | | | exercises | | | | | | | | Treatment of | | | | neighboring | | | | hypomobility | | | | | | | | External support | | | | | | | | Fusion | +-----------------------+-----------------------+-----------------------+ 3 more simplistic ways to quantify arthrokinematic mobility: 1. Hypomobile 2. Normal!!!!!! 3. Hypermobile 5 things you should state for AROM: (Acronym: PPORC must be eaten actively) 1. Pain!!!!!!!!!! 2. Palpate!!!!!! 3. Observe!!!!! 4. ROM!!!!!!!!! 5. Cue/ correct 4 things you should state for PROM: 1. Patient relaxed 2. Pain!!!!!!!!!!!!!! 3. ROM!!!!!!!!!!!!! 4. End feel!!!!!!!!!!! 3 things you should state for PPIVMs, PAIVMs, PACVPs, PAUVPs, TVPs, side glides: 1. Pain!!!!!! 2. Mobility! 3. End feel! What region of the spine are side glides performed in? The cervical spine **ROM table \#1 -- AROM** +-----------------+-----------------+-----------------+-----------------+ | | **C spine** | **T spine** | **L spine** | +=================+=================+=================+=================+ | [FLEX]{.underli | What should you | Hands -- on | What position | | ne} | cue? Head tilt/ | shoulders | is it done in? | | | nod forward, as | | Standing | | | opposed to | Elbows -- | | | | bending head | up!!!!!!!!! | | | | and neck moving | | | | | forward. | Back -- rounded | | | | | | | | | What should you | Elbows -- | | | | make note of, | towards hip/ | | | | because it may | groin | | | | be indicative | | | | | of upper | Arms -- in same | | | | cervical | position | | | | instability? | | | | | The prominence | | | | | of C2 in C | | | | | spine flexion. | | | | | | | | | | In what | | | | | circumstance | | | | | would this not | | | | | have to be | | | | | done? If we did | | | | | our critical | | | | | rule-outs ahead | | | | | of time. | | | | | | | | | | The | | | | | intervertebral | | | | | foramen space | | | | | b/w any given | | | | | vertebra is | | | | | said to | | | | | increase by | | | | | 20-30%. as | | | | | people flex. If | | | | | they had any | | | | | spinal nerve | | | | | root | | | | | compression, | | | | | they may feel | | | | | some relief | | | | | from that | | | | | because of the | | | | | increase in the | | | | | space of the | | | | | intervertebral | | | | | foramen. | | | | | | | | | | What should you | | | | | ensure? That | | | | | the mount | | | | | doesn't open. | | | | | You can use | | | | | bottom of chin | | | | | to chest as an | | | | | informal | | | | | measurement, | | | | | with 2 fingers | | | | | being the | | | | | normal range | | | | | for cervical | | | | | flexion for | | | | | this. | | | +-----------------+-----------------+-----------------+-----------------+ | [EXT]{.underlin | | Arms -- resting | Cue patient to | | e} | | on shoudlers | place their | | | | | hands over | | | | Shoulders -- | their | | | | flexed to 90 | buttcheeks/ | | | | | over the iliac | | | | Instruct | crest | | | | patient to | | | | | stick chest | Let the head go | | | | forward, extent | back if the | | | | in T spine | person doesn\'t | | | | using elbow to | have any | | | | pull back, but | dizziness | | | | still | issues | | | | maintaining the | | | | | same position | May pick up | | | | | clinical | | | | What happens to | instability | | | | the neck? It's | here - looking | | | | brought along | for poor | | | | with the | quality of | | | | movement (let | motion in | | | | it flex and | regard to this/ | | | | extend along | aberrant | | | | with the other | motions (sudden | | | | regions of the | accelerations | | | | spine) | or | | | | | decelerations | | | | Try to lock | of movement, or | | | | down/ limit | motions that | | | | lumbar spine | occur outside | | | | through pelvic | of the) | | | | positioning (so | | | | | that the | | | | | movement isn\'t | | | | | occurring in | | | | | the L spine as | | | | | opposed to the | | | | | T spine) | | +-----------------+-----------------+-----------------+-----------------+ | [SB]{.underline | Ensure | | Standing or | | } | shoulders do | | sitting? | | | not elevate or | | Standing | | | protract | | | | | | | | | | Why may you | | | | | want to repeat | | | | | the movements? | | | | | To assess the | | | | | influence of a | | | | | myofascial | | | | | restriction | | | +-----------------+-----------------+-----------------+-----------------+ | [ROT]{.underlin | | | Standing or | | e} | | | sitting? | | | | | Sitting!!! | +-----------------+-----------------+-----------------+-----------------+ | [Protraction]{. | Results in | | | | underline} | flexion!!!!!! | | | | | of lower C | | | | | spine, and | | | | | extension of | | | | | upper C spine | | | +-----------------+-----------------+-----------------+-----------------+ | [Retraction]{.u | Results in | | | | nderline} | extension of | | | | | lower C spine, | | | | | and | | | | | flexion!!!!!!!! | | | | | of upper C | | | | | spine | | | +-----------------+-----------------+-----------------+-----------------+ **ROM table \#2 -- PROM** What is critical with PROM of the spine? Patient positioning! +-----------------+-----------------+-----------------+-----------------+ | | **C spine** | **T spine** | **L spine** | +=================+=================+=================+=================+ | [FLEX]{.underli | | To call these | | | ne} | | movements truly | | | | | passive is | | | | | generous - | | | | | they\'re more | | | | | active assisted | | | | | than truly | | | | | passive (in | | | | | order to stay | | | | | seated, the | | | | | person has to | | | | | utilize their | | | | | back muscles) | | | | | | | | | | If you wanted | | | | | to make it | | | | | truly passive | | | | | in the lower T | | | | | spine - side | | | | | lying position | | | | | and flexing | | | | | their hips | | | | | towards their | | | | | chest. | | | | | | | | | | For extension - | | | | | moving the | | | | | person\'s heels | | | | | towards their | | | | | bum. | | +-----------------+-----------------+-----------------+-----------------+ | [EXT]{.underlin | | | | | e} | | | | +-----------------+-----------------+-----------------+-----------------+ | [SB]{.underline | Practitioner's | Instead of | | | } | hands -- | moving the | | | | cupping the | thorax, | | | | back of the | practitioners | | | | head | move the | | | | | shoulders | | | | Sometimes, | | | | | there is some | | | | | benefit to | | | | | having the | | | | | person\'s head | | | | | off the edge of | | | | | the bed because | | | | | this will | | | | | impede the ROM | | | | | less. You must | | | | | be able to hold | | | | | the head, and | | | | | they must trust | | | | | that you\'re | | | | | doing so. | | | +-----------------+-----------------+-----------------+-----------------+ | [ROT]{.underlin | | Arms - crossed | | | e} | | across the | | | | | chest | | | | | | | | | | One shoulder | | | | | and one elbow | | | | | are used to | | | | | press a person | | | | | into position | | | | | | | | | | What should you | | | | | make sure of | | | | | before pressing | | | | | on that area? | | | | | That the person | | | | | doesn't have a | | | | | GH instability! | | +-----------------+-----------------+-----------------+-----------------+ | [Protraction]{. | How often is it | | | | underline} | done? Almost | | | | | never! | | | +-----------------+-----------------+-----------------+-----------------+ | [Retraction]{.u | Lying supine | | | | nderline} | with head on | | | | | bed | | | | | | | | | | Would use | | | | | webbing b/w | | | | | thumb and | | | | | forefinger to | | | | | go over | | | | | forehead and | | | | | glide A-P the | | | | | head into the | | | | | table (would | | | | | have wanted to | | | | | have done the | | | | | necessary | | | | | critical | | | | | rule-outs | | | | | before doing | | | | | that!) | | | +-----------------+-----------------+-----------------+-----------------+ PPIVM guidelines **ROM table \#3 -- ISOM** With spinal flexion, what can the presence of shooting pain down the spine be an indicator of? An upper motor neuron pathology. What would a \"swipe\" to one side, or chin and nose are not tracking in a straight line throughout C spine FLEX + ETX indicate? A facet dysfunction. What 2 things should you observe for with AROM of spine? 1. Smoothness 2. Compensation Only when would you cue proper spine ROM? After the patient is able to do it on their own PPIVM -- motion palpation to assess segmental physiological motion - What does positioning vary by? By region. - Passively flex while placing a fingertip on the interspace between the segment you are evaluating. - 2 criteria by which the joint can be considered normal with a PPIVM assessment: 1. Normal range!!! 2. Normal end-feel - 3 circumstances in which PPIVMs would be indicated: 3. Pain with flexion!!!!!!! 4. Hinging points present 5. A poor curvature!!!!!!! - What is the biggest issue with PPIVMs? Their inter-rater reliability! - 2 aspects of patient positioning: 6. Relaxed and well-supported 7. Spinal position - neutral - 3 aspects of therapist positioning: 8. Good body mechanics with table at an appropriate height 9. As close to patient as possible 10. Firm and professional contact - 4 aspects of the technique performance: 11. Slow, rhythmic, relaxing movements 12. Relax palpating hand 13. Palpate for, do not create or block, movements 14. Consider starting away from restricted and painful segments **PPIVMs** +-----------------+-----------------+-----------------+-----------------+ | | **C spine** | **T spine** | **L spine** | +=================+=================+=================+=================+ | [FLEX]{.underli | Supine | As we get lower | Done side-lying | | ne} | | in the T spine, | | | | Shoulders at | it will become | Clinician moves | | | edge of bed, | increasingly | both legs. Some | | | head is being | more difficult | people will do | | | fully | to take a | top leg only. | | | | movement to end | However, when | | | Patient is | range | there\'s | | | supine | | someone much | | | | Only when we | bigger than | | | Patients are | get to the L | you, it may be | | | positioned with | spine or lower | better to do | | | shoulders at | T spine, | one leg to not | | | the edge of the | patient is side | injure yourself | | | bed, their head | lying | and preserve | | | is being fully | | proper | | | supported by | | biomechanics. | | | the clinician. | | | | | | | | | | You are | | | | | cradling the | | | | | occiput w/ at | | | | | least 1, if not | | | | | more, fingers | | | | | in your hand | | | | | with the | | | | | midline on and | | | | | between the | | | | | spinous | | | | | processes, so | | | | | that as the | | | | | person flexes, | | | | | you\'re feeling | | | | | for the | | | | | movement of the | | | | | SPs away from | | | | | one another | | | | | | | | | | Ex. if we were | | | | | assessing C3, | | | | | we would be | | | | | feeling for the | | | | | movement of C3 | | | | | into FLEX away | | | | | from C4 - | | | | | gapping | | | | | | | | | | Some people may | | | | | struggle with | | | | | feeling an | | | | | opening | | | | | initially but | | | | | as you return | | | | | to your | | | | | starting | | | | | position, you | | | | | may feel that. | | | | | If you\'re | | | | | lucky, you will | | | | | feel both! | | | +-----------------+-----------------+-----------------+-----------------+ | [EXT]{.underlin | Common mistake | | | | e} | - people don\'t | | | | | move into | | | | | extension, | | | | | they\'re just | | | | | returning from | | | | | flexion to | | | | | neutral. | | | | | | | | | | We want to make | | | | | sure that we | | | | | are moving | | | | | beyond neutral | | | | | position/ into | | | | | hyperextension | | | | | | | | | | We must adjust | | | | | our positioning | | | | | as we move from | | | | | one vertebral | | | | | segment to the | | | | | next, we have | | | | | to adjust the | | | | | overall | | | | | position of the | | | | | neck in order | | | | | to actually | | | | | feel movement | | | | | of that segment | | | | | | | | | | In the case of | | | | | the C spine, we | | | | | must consider | | | | | when we flex | | | | | them (ex. | | | | | feeling | | | | | movement on C3 | | | | | to C4 as | | | | | opposed to C6 | | | | | to C7), we | | | | | can\'t just | | | | | keep moving | | | | | them back and | | | | | forth and | | | | | expect to feel | | | | | end feels of | | | | | both of those | | | | | segments. End | | | | | feel of C6 is | | | | | in a different | | | | | position than | | | | | C3 - applies | | | | | for FLEX, EXT, | | | | | SFLEX, ROT | | | +-----------------+-----------------+-----------------+-----------------+ | [SB]{.underline | Where you feel | Generally done | Inevitably the | | } | will be | seated | technique will | | | variable - | | assess what | | | right between | Can likely | other Rom along | | | SPs, off to the | assess these | with side | | | side of SPs, | PPIVMs easier | bending? | | | opening which | because we\'re | Rotation. | | | would occur on | doing smaller | | | | the left side | movements. | | | | (when you RSB, | | | | | left side will | Again, smaller | | | | gap, and | muscles are | | | | clinician will | still involved | | | | put their | | | | | finger in | Arms - are | | | | between the SPs | crossed | | | | on the left | | | | | side), or | We will slide | | | | closing (would | our arm between | | | | be on right | those of the | | | | side of SPs to | patient\'s | | | | feel that). | | | | | | | | | | If you\'re | | | | | returning to | | | | | neutral, these | | | | | switches - | | | | | opening right | | | | | side will gap, | | | | | and clinicians | | | | | will put their | | | | | finger in | | | | | between SPs on | | | | | the right side) | | | | | or closing | | | | | (would be on | | | | | left side of | | | | | SPs to feel | | | | | that). | | | | | | | | | | Would be more | | | | | typical that | | | | | you\'d feel C3 | | | | | on the right | | | | | side, then on | | | | | the left, then | | | | | move down to C4 | | | | | on the right | | | | | side, and on | | | | | the left, etc. | | | | | as opposed to | | | | | feeling C3, C4 | | | | | on the right | | | | | side, and then | | | | | moving on to | | | | | the left side | | | | | | | | | | \- We\'re doing | | | | | 1 vertebral | | | | | segment at a | | | | | time, we may | | | | | also feel | | | | | multiple | | | | | segments at a | | | | | time (that\'s | | | | | how Mark does | | | | | it) - putting | | | | | your index | | | | | finger on C3, | | | | | 4th digit on | | | | | C4, etc. | | | | | | | | | | This is one of | | | | | the harder | | | | | skills that | | | | | we\'ll work on | | | | | - one section | | | | | is enough! | | | +-----------------+-----------------+-----------------+-----------------+ | [ROT]{.underlin | | | For the most | | e} | | | part, why is | | | | | this more | | | | | challenging? | | | | | Because it is | | | | | harder to home | | | | | in one | | | | | vertebral | | | | | segment. | | | | | | | | | | How are | | | | | mobilization | | | | | and | | | | | manipulation | | | | | recognized by | | | | | the literature? | | | | | Heavily | | | | | challenged - it | | | | | may look cool | | | | | doing it, but | | | | | whether it\'s | | | | | reliable and | | | | | specific | | | | | (specificity) | | | | | is something | | | | | that must be | | | | | established. | +-----------------+-----------------+-----------------+-----------------+ | [Protraction]{. | | | | | underline} | | | | +-----------------+-----------------+-----------------+-----------------+ | [Retraction]{.u | | | | | nderline} | | | | +-----------------+-----------------+-----------------+-----------------+ Four types of PAIVMs: 1. PACVP -- posterior to anterior central vertebral pressure. Pushing into midline of SP. Starting from posterior aspect of vertebra and gliding it anteriorly with that pressure 2. Side glides -- moving the vertebra laterally. a. Most common in C spine, can be performed in L spine, though it\'s arguably not as discrete in movement (segment by segment just like in the C spine b. It can be performed by pushing on TSPs. In many cases, because of sensitivity issues (scalenes attach there), people will use the articular pillars behind the TSPs for a side glide. c. Are not done in the T spine. 3. TVP -- transverse vertebral pressure d. What type of PAIVM do they often get mixed up with? PAUVPs! e. Finding the SPs and off a bit to the side (done on left + right), would be pushing on SP away from you (also assessing rotation in a truer sense - more in one plane rather than the anterior glide w/ PAUVPs) 4. PAUVP -- What do all PAIVMs replicate? Instability tests for spine. Hence, if someone had instability, these tests would aggravate it. I must be cautious with it. Which type is most well-known? posterior to anterior central vertebral pressure. In what position must PACVPs and PAUVPs be done in for T and L spine? Prone!!!!!!!!!!!! How about the C spine? Supine or prone **PAIVMs** +-----------------+-----------------+-----------------+-----------------+ | | **C spine** | **T spine** | **L spine** | +=================+=================+=================+=================+ | [PACVP]{.underl | Patient | Patient | Patient | | ine} | positioning -- | positioning -- | positioning - | | | supine or prone | prone!!!!!!!!!! | prone!!!!!!!!!! | | | | !!! | !!! | | | Hand | | | | | positioning -- | What 2 parts of | What is the | | | thumb on thumb, | the hand can be | consideration | | | because this | used to apply | that is | | | will preserve | pressure? | specific for | | | us as | | the L spine? | | | clinicians | Medial border | Because of the | | | | of 5th MC. | lordotic curve, | | | | | we may have to | | | | Pisiform. | change our | | | | | angle slightly | | | | What part are | to account for | | | | you landmarking | the position of | | | | with? In the | the vertebra. | | | | mid-shaft of | | | | | MC. | Inclination on | | | | | L1-L3 -- not | | | | Interlacing | big | | | | webbing between | | | | | the thumb and | Inclination on | | | | forefinger. | L4-L5 -- | | | | Most accessory | bigger! | | | | motions in the | | | | | spine, you are | | | | | \"walking\" the | | | | | upper body and | | | | | leaning your | | | | | body weight in. | | | | | | | | | | Generally, when | | | | | learning a | | | | | skill, you | | | | | (clinician) | | | | | will have a | | | | | much easier | | | | | time picking up | | | | | the amount of | | | | | motion and | | | | | feeling end | | | | | feel using | | | | | thumb-related | | | | | techniques as | | | | | opposed to | | | | | ulnar border of | | | | | hand. But for | | | | | patients, ulnar | | | | | border is | | | | | generally much | | | | | more | | | | | comfortable. | | +-----------------+-----------------+-----------------+-----------------+ | [PAUVP]{.underl | Patient | Patient | Patient | | ine} | positioning -- | positioning - | positioning - | | | supine or prone | prone!!!!!!!!!! | prone!!!!!!!!!! | | | | !!! | !!! | | | | | | | | | 2 methods of | How deep are | | | | applying | the TSPs in L | | | | pressure: | spine from | | | | | posterior | | | | 1. Thumb | aspect of back? | | | | | One inch. | | | | 2. Pisiform | | | | | over | When we\'re | | | | fingertips | \"palpating\" | | | | | the TSPs, | | | | Pushing on | we\'re | | | | either TSP or | palpating | | | | the articular | through a bunch | | | | pillar | of stuff, but | | | | | to say that | | |