Musculoskeletal Physical Therapy For Dummies PDF

` Musculoskeletal Physical Therapy For Dummies Overview Upper Quarter Screen Peripheral Joint Scan (with overpressure) 1. Cervical flexion 2. Cervical extension (no overpressure) 3. Cervical rotation...

` Musculoskeletal Physical Therapy For Dummies Overview Upper Quarter Screen Peripheral Joint Scan (with overpressure) 1. Cervical flexion 2. Cervical extension (no overpressure) 3. Cervical rotation 4. Cervical side bending 5. Shoulder ABD 6. Functional ER/IR Myotomes C1-C3 = Cervical rotation C4 = Scapular elevation C5 = Shoulder ABD/IR/ER C6 = Elbow flexion/Wrist extension C7 = Elbow extension/Wrist flexion C8 = Thumb extension T1 = Finger ABD Dermatomes C3 = Side of neck C4 = Supraclavicular C5 = Lateral arm C6 = Thumb  C7 = Digits 2/3 C8 = Ulnar border of hand T1 = Medial arm MSRs C5 = Biceps C6 = Brachioradialis C7 = Triceps Key Muscles Muscle Origin Insertion Innervation Relevance MMT/Stretch Deep Neck Vertebral TPs (anterior) Cervical Weak with Pressure Flexors bodies primary rami head forward biofeedback posture method Suboccipitals SPs/TPs of Occiput C1 dorsal rami Restrict OA Suboccipital C1/C2 flex. release Cervicogenic (TED) headaches Levator TPs C1-C4 Sup/med Dorsal Restrict N/A Scapulae scapula scapular n. contralateral (C5) AA rot. C1-C4 stuck closed Trapezius Med ⅓ sup. Acromion, CN XI, C3, C4 C5-T1 stuck Upper Trap: nuchal line, spine of closed MMT: nuchal lig, SPs scapula, lat ⅓ seated/prone T1-C7 clavicle shoulder shrug TED: flex, contralateral rotation and ipsilateral side bending Middle Trap: prone, ABD to 90, push humerus/lateral scapula Lower Trap: prone, ABD 140, push humerus SCM Sternum, med. Mastoid CN XI, C2, C3 Restrict OA Chin tuck, ⅓ clavicle process flexion contralateral Torticollis side bend, ipsilateral rotation Scalenes TPs C3-C7 1st rib Spinal n. Stuck open N/A C3-C8 (esp C3-C6) Latissimus Inf 3-4 ribs, Floor of Thoracodorsal Thoracic spine MMT: Dorsi SPs T6-T12, intertubercular n. (C6-C8) stuck open prone with arms post iliac crest, groove at side, side TL fascia, inf bend and resist angle of scapula Stretch: Supine, knees to chest and apply force R/L (TED) Serratus Lat ribs 1-8 Anterior Long thoracic Muscle Seated, flex to Anterior medial (C5-C7) imbalance with 130, push scapula flexion humerus restriction Multifidus Superior SPs Inferior TPS Dorsal rami Thoracic spine Flexion and stuck closed contralateral rotation (TED) Rhomboid SPs C7-T5 Medial Dorsal prone, flex Major/Minor Scapula Scapular (C5) elbow, extend shoulder with force at humerus Teres Major Lateral Medial lip of Lower N/A Scapula intertubercular subscapular groove (C5-C6) Teres Minor Superior Inferior facet Axillary N/A lateral scapula of greater (C5-C6) tubercle Pectoralis Ribs 3-5 Coracoid Medial Tight with N/A Minor process pectoral TOS/head (C8-T1) forward posture Pectoralis Sternal: costal Lateral lip of Lateral Tight with supine/at table Major cartilage intertubercular pectoral TOS/head horizontally ADD Clavicular: groove (C5-C7) forward and resist pull medial ½ Medial posture At table for 0-2 clavicle Pectoral (C8-T1) Supraspinatus Supraspinous Superior facet Suprascapular Sit, flex into fossa of greater (C5-C6) scaption (use tubercle HHD) Infraspinatus Infraspinous Middle facet of Suprascapular Seated or prone fossa greater (C5-C6) resist IR (2 tubercle fingers) Hang off table for 0-2 (Use HHD) Deltoid Acromion, Deltoid Axillary Anterior spine of tuberosity (C5-C6) Flex and push at scapula, lateral humerus (use ⅓ clavicle HHD) Middle ABD to 90 and push at humerus (use HHD) Posterior prone, ABD to 90, push humerus/lateral scapula Subscapularis Subscapular Lesser Upper and Prone resist ER fossa tubercle lower with 2 fingers subscapular Hang off table (C5-C6) for 0-2 (Use HHD) Biceps Brachii Long head: Radial Musculo- Seated resisted supraglenoid tuberosity cutaneous elbow flexion tubercle (C5-C6) with supination Short head: At table for 0-2 coracoid (Use HHD) process Resist pronation at 90 degrees elbow flexion Brachialis Distal ½ Coranoid Musculo- Seated resisted anterior process and cutaneous elbow flexion humerus ulnar (C5-C6) with pronation tuberosity At table for 0-2 Brachioradialis Lateral Radial styloid Radial Seated resisted supracondylar process (C5-C7) elbow flexion line with neutral forearm At table for 0-2 Triceps Brachii Long head: Olecranon Radial Prone with arm  infraglenoid (C6-C8) ABD to 90 tubercle At table for 0-2 Lateral head: (use HHD) posterior humerus above radial groove Medial head: posterior humerus below radial groove Pronator Teres Medial Mid shaft of Median Resist supracondylar radius (C6-C7) supination with line and elbow flexed to coranoid 90 process Supinator Lateral Wrap around Deep Radial Resist pronation epicondyle and proximal ⅓ of (C7-C8 at end range posterior ulna radius elbow flexion Pronator Distal ¼ ulna Distal ¼ AIN (C8-T1) Resist Quadratus radius supination with elbow at end range ROMs Cervical Spine Flexion ○ Goniometer = 45 degrees ○ Inclinometer (x2) = 50 degrees Extension ○ Goniometer = 45 degrees ○ Inclinometer (x2) = 60 degrees Lateral flexion ○ Goniometer = 45 degrees ○ Inclinometer (x2) = 45 degrees Rotation ○ Goniometer = 60 degrees  ○ Inclinometer = 80 degrees Thoracic Spine Flexion ○ Inclinometer (x2) = 60 degrees Extension ○ Inclinometer (x2) = 10 degrees Shoulder Flexion = 180 degrees (120 degrees for GH only) Extension = 60 degrees (40 degrees for GH only) Abduction = 180 degrees (120 degrees for GH only) Internal Rotation = 70 degrees (total arc of 160 degrees) External Rotation = 90 degrees (total arc of 160 degrees) Elbow Flexion = 150 degrees Extension = 0-10 degrees of hyperextension Pronation = 80 degrees Supination = 80 degrees Mobilization Key Points Mobilize in the direction of restriction! Grades ○ Grade I = small amplitude, short of R1 Primarily used for pain ○ Grade II = large amplitude, short of R1 Primarily used for pain ○ Grade III = large amplitude, 50% R1-R2 Primarily used to increase ROM ○ Grade IV = small amplitude, 50% R1-R2 Primarily used to increase ROM ○ Grade V = small amplitude, high velocity at R2 and beyond (thrust/manipulation)  Primarily used to increase ROM Effects of Joint Mobilizations ○ Neurophysiological Effects (Grades I-V) Firing of mechanoreceptors/proprioceptors Firing of cutaneous and muscular receptors Altered nociception ○ Mechanical Effects (Grades (III-V) Stretching of joint restrictions Breaking of adhesions Alter positional relationships Diminish/eliminate barriers to normal motion ○ Psychological Effects (Grades I-V) Confidence gained through improvement Positive effects from manual contact Response to joint sounds Mulligan Mobilizations with Movement ○ Rules Must be pain free Must be weight-bearing ○ Techniques Blocking SNAG (sustained natural apophyseal glide) Exercise Key Points Training Goal Goal % 1RM Sets Reps Rest Strength > 84% 2-6 11 < 31 sec General Fitness 65-80% 2 8-15 Estimating 1RM ○ 50% = 25 reps ○ 60% = 17 reps ○ 70% = 12 reps ○ 80% = 8 reps ○ 90% = 5 reps ○ 100% = 1 rep Rate of Perceived Exertion vs Reps in Reserve RPE RIR 10 Maximal, 0 reps left 0 9 Near Maximal, 1 rep left 1 8 Very Hard, 2 more reps 2 7 Hard, 3 more reps 3 6 Moderate-hard, 4 more reps 4 5 Moderate, 5 more reps 5 4 Moderate, 6 more reps 6 3 Light-moderate, 7 more reps 7 2 Light, 8 more reps 8 1 Very light, 9 more reps 9 0 No effort, 10 more reps 10 TMJ Biomechanics Articulation Synovial, bilateral, moving hinge joint Articulation of mandibular condyle and temporal bone (both are CONVEX) Divided by disc  ○ Upper joint = gliding ○ Lower joint = hinge Disc Covered with fibrocartilage Held in place by medial/lateral poles of condyle Biconcave ○ Increase joint congruency ○ Self centering mechanism ○ Thin portion (contact point) is not innervated Attachments ○ Anterior → capsule and superior head of lateral pterygoid ○ Posterior → bilaminar retrodiscal pad ○ Laminal bands Superior laminal band (elastic and assists with repositioning) Inferior laminal band (tether limiting forward translation) Motion Mandibular Depression (opening) ○ Phases Initial opening = hinge ONLY Translation phase = hinge AND glide ○ Primary mover = digastric ○ Normal ROM = 35-55 mm Mandibular Elevation (closing) ○ Muscles Termoralis, masseter and medial pterygoid Eccentric contraction of superior lateral pterygoid Mandibular Protrusion ○ Bilateral action of masseter, medial pterygoid and lateral pterygoids Lateral Deviation ○ Muscles medial and lateral pterygoids (opposite side) Temporalis (ipsilateral side) **Exception = lateral pterygoid and temporalis on same side (spin disc) Normal ROM = 8-11 mm Assessment Hypomobility (< 35 mm) Characteristics ○ C curve toward hyomobile side ○ Does not break midline ○ JMD Causes ○ Disc displacement Reciprocal Click Disc is displaced anterior 1st click with opening (disc reduces on top of condyle) ○ Later occurring = increased severity 2nd click with closing (dislocates) ○ Joint degeneration (OA) 80-90% of population over 60 Usually unilateral Caused by microtrauma or loss of posterior teeth Sx = pain with translation phase, flattened condyle, narrow joint space ○ Muscle spasm Temporalis → headaches, tenderness, visual sx Masseter Medial/lateral pterygoids Longus colli → sore throat SCM Scalenes → sx radiating to UEs ○ Soft tissue contractures/adhesions/tight capsule Bleeding → scarring → connective tissue disorganization Hypermobility (> 50 mm) Characteristics ○ S curve ○ Breaks midline ○ SMCD/muscular imbalance Causes = habits!  ○ Bottle feeding, gum chewing, nail biting, mouth breathing, nocturnal bruxing Treatment Inflammation Protected motion (soft foods) Modalities (ultrasound!) Prevent irritation (pain free ROM, education Joint Hypomobility Mobilization Active/passive ROM Strengthening/re-education exercises ○ Isometrics! Evaluate cervical spine Cervical Spine Safety Tests 1) Ligamentous Stability Sx of cervical instability ○ Neck pain, headaches, decreased cervical ROM, UMN Sx, lower cranial n. palsies, respiratory Sx, quadriplegia, “heavy head”, 5 Ds/3Ns Anterior Shear/Sagittal Stress Test ○ Position in supine with neutral spine ○ Apply anterior force through posterior arch of C1 and/or SPs C2-C7 ○ Looking for tissue stretch end feel ○ (+) = soft end feel, 5 Ds/3Ns, “lump” in throat Alar Ligament Testing ○ Lateral Flexion Alar Ligament Test Position in sitting or supine Stabilize C2 SP and passively side bend head, looking for strong capsular end feel  (+) = soft end feel and excessive side bending ○ Rotational Alar Ligament Stress Test Position in sitting or supine Stabilize C2 SP and passively rotate head R/L (+) = >20-30 degrees without movement of C2 or excessive mobility Sharp Purser Test ○ One hand on forehead, one on C2 SP ○ Pt. slowly flexes head and examiner pushes posteriorly on forehead ○ (+) = backward slide/ “clunk” or Sx relief Transverse Ligament Stress Test ○ Position in supine with head in hands with fingers on posterior arch of C1 ○ Lift anteriorly and hold 10-20 seconds ○ (+) = soft end feel, 5Ds/3Ns, “lump” in throat, muscle spasm 2) Vascular Clearing Looking for 5 Ds/3Ns ○ Dysphagia, Dysarthria, Dizziness, Diplopia, Drop Attacks, Nystagmus, Nausea, Numbness Minimal Testing ○ Sustained end range cervical rotation to L/R (>45 degrees), hold for 10 sec ○ Provocative position Static Vertebral Artery Test ○ Can be done sitting or supine ○ Hold each position 10-30 second and stop if Sx occur Distraction (supine) R/L rotation Extension R/L rotation with extension Cervical Quadrant Test ○ Position in supine ○ Passively extend, side bend and ipsilaterally rotate head and hold for 30 seconds Relevant Red Flag: Cervical Myelopathy Symptoms ○ Motor: spastic paresthesis, stiffness/heaviness, scuff toe, weakness/fatigue, hyperreflexia, pathological reflexes, drop foot, UMN and LMN involvement, atrophy ○ Sensory: headache, neck/eye/ear/throat pain, hoarseness, vertigo, tinnitus synchronous, occulovisual changes, autonomic disturbances, numbness, dysphagia, dysarthria, hiccups Tests ○ Romberg Test Pt. stands with eyes closed for 20-30 sec (+) = excessive swaying/loss of balance ○ Lhermitte’s Sign Pt. long sits Examiner passively flexes neck (can also flex hip simultaneously) (+) = sharp pain/electric shock into extremities Imagining Canadian C-Spine Rules Imagining is indicated with trauma unless ○ No posterior midline tenderness ○ No intoxication/normal alertness ○ No neurological deficits ○ No painful distracting injuries 1. Is there a high risk factor? > 65 years old Dangerous MOI Paresthesias in extremities 2. Is there a low risk factor allowing safe assessment of ROM? Simple rear end MVC Ambulatory anytime after injury Delayed onset of pain Absence of cervical spine tenderness  3. Can pt. rotate neck 45 degrees L/R Plain FIlm Radiography Key Observations ○ Alignment ○ Wedging/Displacement/Subluxation ○ Fractures/Osteophytes ○ Disc Space ○ Spinal Canal Diameter Standard Views for Cervical Spine ○ Anteroposterior (AP) View ○ Lateral View ○ Open Mouth/Odontoid View (especially with trauma) For Osteoarthritis ○ AP View ○ Lateral View ○ Oblique View (Joints of Lushka, subluxation/spondylosis, facet joints/foramen) Computed Tomography (CT) Bone (fragments, defects in vertebral bodies/neural arches) MRI Disc protrusions/herniations N. roots, spinal cord, thecal sac MRA → blood vessels (vertebral artery) Weighted Sequences ○ T1 = anatomy (bone/soft tissue) ○ T2 = inflammation (fluid, herniation, compression) Upper C Spine OA Joint Biomechanics Convex Concave!!  Primary Motion = flexion/extension (nodding) Note: With cervical rotation, OA joint side bends in opposite direction to maintain vertical plane of head SFMA Findings and Movement Assessment Fail Cervical Flexion → DN, DN, DN/DP/FP To assess: rotate to end range and nod chin (looking for 20 degrees) ○ Assesses ipsilateral side of rotation With Unilateral Restriction ○ Extension: chin deviates TOWARD restricted side ○ Flexion: chin deviates AWAY from restricted side Treatment Subcranial Occipitoatlantal Distraction Accessory with Physiologic Motion (Hold-Relax) Technique Self Mobilization (Chin Tuck) Suboccipital Release Stretch SCM AA Joint Biomechanics Primary Motion = rotation (50 degrees R/L) Note: With side bending, AA joint rotates opposite direction to maintain forward gaze ○ If AA joint is restricted, side bending increases with ipsilateral rotation SFMA Findings/Movement Assessment Fail cervical rotation → DN, DN, DN/DP/FP To asses: Cervical Flexion Rotation Test ○ Passively flex cervical spine with pt in supine ○ Rotate L/R (looking for 40 degrees bilaterally) Biomechanical Screening PAIVM Treatment PA glide AA Contract-Relax Self Mobilization  Stretch Levator Scapulae Upper Cervical Therapeutic Exercises Strength and Control of Deep Neck Flexors and Extensors Pneumatic Pressure Device Isometric and Eccentric Progression Perturbations (Contraction under unpredictable patterns) Upper/middle/lower trapezius strength Prone and upright rows “Ts”/ “Ys” Side lying GH ER, Flexion Military Press Lateral Raises Repositioning Acuity Headlight and Wall Target Oculomotor Control (VOR) “Skywriting” Maintain Gaze with weight shifting, trunk rotation or head movements Move eyes between targets Postural Stability Relevant Clinical Point: Cervicogenic Headaches Referred pain arising from cervical structures innervated by spinal nerves C1, C2, and C3 ○ ie: OA, AA and facet joints, ligaments, disc, muscles Unilateral headache without side-shift with an occipital or suboccipital component Neck involvement ○ pain triggered by neck movement or sustained posture ○ external pressure in the posterior neck or occipital region; Ipsilateral neck, shoulder, and arm pain Reduced range of motion (especially OA) Autonomic sx (dizziness, photophobia, phonophobia, or blurred vision in the ipsilateral eye) Middle/Lower Cervical Spine Biomechanics Characteristics ○ Resting Position = midway between flexion and extension ○ Closed Packed Position = full extension ○ Capsular Pattern = side bending and rotation equally, extension Unique Features ○ Highly mobile (lax soft tissue and little bony stability) C5/C6 = most mobile, most likely to degrade ○ Facet Joints are angled superior and anterior ○ Rotation and ipsilateral side bending are coupled ○ Joints of Luschka between uncinate processes Motions of Cervical Spine Flexion ○ ROM = 45/50 degrees ○ Bilateral upglide of facets ○ Ventral compression/posterior distraction of disk Extension ○ ROM = 45/60 degrees ○ Bilateral downglide of facets ○ Posterior compression/ventral distraction of disk Rotation/Side bending ○ ROM Rotation = 60/80 degrees Side bending = 45 degrees ○ Ipsilateral facet “closes” (slides back into extension) ○ Contralateral facet “opens” (slides open into flexion) SFMA Findings/Movement Assessment Cervical Flexion (bony contact of chin to sternum) ○ Breakouts: Active Supine Cervical Flexion Passive Supine Cervical Flexion  Active Supine OA flexion (20 degree) ○ DN/DP/FP, DN/DP/FP, FN = JMD or TED of middle/lower cervical spine Cervical Extension (within 10 degrees parallel to ceiling) ○ Breakouts: Supine Passive Cervical Extension ○ DN/DP/FP = JMD/TED of cervical spine Cervical Rotation (Chin over midpoint of clavicle) ○ Breakouts Active Supine Cervical Rotation (80 degrees) Passive Supine Cervical Rotation (80 degrees) C1-C2 Cervical Rotation Test (40 degrees) ○ DN/DP/FP, DN/DP, FN = JMD or TED of middle/lower cervical spine Biomechanical Screening Position Testing ○ Palpate depth of TPs in neutral, flexion and extension If extension increases asymmetry → stuck OPEN/flexion positional fault/extension restricted If flexion increases asymmetry → stuck CLOSED/extension positional fault/flexion restricted PPIVM ○ Assess intervertebral movement while passively moving the head ○ Lateral glides in neutral, flexion and extension Palpate for ROM, muscle guarding and end feel If restricted, motion is restricted by facet joints Restricted in flexion = stuck CLOSED Restricted in extension = stuck OPEN ○ Help ID restrictions and direct arthrokinematic testing (PAIVM) PAIVM ○ Determine if hypomobility is articular (JMD) or extraarticular (TED) based on joint end feel Central PA Pressure (force on SP) Unilateral PA Pressure (force on TP/Facet) Manual Therapy JMD Stuck open ○ UPAS (on restricted side, facet of bottom partner) ○ Lateral Glides (toward contralateral side, restricted side is side bends) ○ Blocks (block bottom TP on ipsilateral side with ipsilateral rotation/side bending) Stuck Closed ○ UPAS (on restricted side, facet of bottom partner) ○ Lateral Glide (toward ipsilateral side, uninvolved side side bends) ○ SNAG (snap facet of top partner on restricted side with contralateral rotation/side bending) TED Stuck Open ○ Stretch Anterior/Middle Scalene Stabilize first rib/clavicle Grasp under neck with shoulder on forehead Translate head toward the floor (chin tuck), side bend to contralateral side and rotate to ipsilateral side Stuck Closed ○ For C1-C4 → stretch Levator Scapulae Depress, upwardly rotate and posterior tilt scapula Flex, contralateral side bend and rotate neck ○ For middle/lower cervical → stretch Upper Trapezius Depress scapula Flex, contralateral side bend and ipsilaterally rotate neck Tuck chin/flex upper cervical spine ○ stretch Multifidus Flex and contralaterally rotate neck SMCD/Therapeutic Exercise Assessing Strength ○ Pressure Biofeedback Method for Deep Neck Flexors Inflate pressure cuff to 20 mmHg Flex (chin tuck) to increase by 10 mmHg Hold for 10 seconds for 10 repetitions  ○ Scapular Retraction Test for Lower Scapular Stabilizers Prone or seated with arms at side Hold at end range scapular retraction for 10 seconds for 10 repetitions Assess Rolling ○ Prone-Supine Upper Body Rolling https://www.youtube.com/watch?v=YOWgYIhUa20 ○ Supine-Prone Upper Body Rolling https://www.youtube.com/watch?v=MFChXttYC5Q 4 x 4 Matrix Feedback No load Supported Supine cervical flexion w/ Supine active cervical A pressure biofeedback ROM h p Active cervical Rolling a flexion/rotation with horizontal/diagonal band pull in supine Supported rolling Suspended Active cervical ROM in Active cervical ROM in R quadruped with feedback quadruped q (palpation or band a around arms) Stacked Active cervical ROM with Active cervical ROM in R horizontal/diagonal band sitting/kneeling k pull in kneeling k Standing Active cervical ROM with Active cervical ROM in R horizontal/diagonal band standing s pull in standing Upper/middle/lower trapezius strength ○ Prone and upright rows  ○ “Ts”/ “Ys” ○ Side lying GH ER, Flexion ○ Military Press ○ Lateral Raises Repositioning Acuity ○ Headlight and Wall Target Oculomotor Control (VOR) ○ “Skywriting” ○ Maintain Gaze with weight shifting, trunk rotation or head movements ○ Move eyes between targets Postural Stability Clinical Points Cervical Radiculopathy Cluster Involved Side Cervical Rotation 65 years old Pain in Stenosis Unilateral OR bilateral Multi-dermatomal Relief with rest Pain increases with extension Slow Onset Disc Herniation Thoracic Spine Overview Characteristics Resting position = midway between flexion and extension Closed pack position = full extension Capsular pattern = side bending and rotation equally, extension’ Biomechanics Rule of 3s Motion ○ Flexion = 20-45 degrees (with inclinometers 60 degrees) ○ Extension 25-45 degrees (with inclinometers 10 degrees) ○ Sidebending 20-40 degrees ○ Rotation 35-50 degrees Deformities Imaging Indications Trauma ○ Flexion force → traumatic compression fracture ○ Anterior compression fracture = most common spinal injury detected on radiographs Arthropathy Infection (especially vertebral bodies) Neoplasms Metabolic disorders Congenital/acquired disorders Surgical/procedural planning Postoperative evaluation Plain Film Radiology Standard Views ○ Anterior Posterior (AP) View Best view of costovertebral joints Key abnormalities  Wedging Rotation “Bamboo spine” → ankylosing spondylitis Scoliosis Malposition of heart and lungs Pneumothorax Asymmetry of ribs AP → posterior ribs vs. PA → anterior ribs ○ Lateral View Includes ribs and sternum Key abnormalities Structural kyphosis/wedging Schmorl’s Nodes (disc bulges into superior/inferior vertebral body) ○ Sheurmann’s Disease Osteophytes ○ Swimmer’s View Lateral with arms overhead Better view of inferior cervical/superior thoracic vertebrae ○ Oblique View Lateral/Posterior oblique → good view of sternum/SC joint Anterior/Posterior oblique → axillary ribs Computed Tomography (CT) ○ Detailed depiction of bone Bony fragments Defects in vertebral bodies/neural arches MRI ○ Differentiate bone and soft tissue Disc protrusions/herniations ○ MRA (angiography) Examine blood vessels with dye in bloodstream Often done with thoracic outlet syndrome Scoliosis ○ Measurement of spinal curvature Cobb Method (AP View)  Draw lines perpendicular to superior plate at top of curve and plate at the bottom of the curve and assess angle Groups ○ 1 = 0-12 degrees ○ 2 = 21-30 degrees ○ 3 = 31-50 degrees ○ 4 = 51-75 degrees ○ 5 = 76-100 degrees ○ 6 = 101-125 deges ○ 7 = > 125 degrees Pedicle Method 0 = no rotation + = pedicle moved slightly toward midline ++ = pedicle ⅔ of way to midline +++ = pedicle in midline ++++ = pedicle beyond midline ○ Structural vs. Nonstructural Use erect side bending views Structural = cobb angle of 25 degrees or greater with an ipsilateral side bend ○ Risser Sign Assess skeletal maturity Indicated by the appearance of apophyses of the iliac crest First appear at ASIS and progress posteromedially to PSIS Grades 1+ = excursion over 25% of crest 2+ = 50% of the crest is capped 3+ = 75% of the crest is capped 4 + = 100% of the crest is capped 5+ = osseous fusion is complete and progression of scoliotic curve is strongly inhibited Cervicothoracic Junction and First/Second Ribs SFMA/Movement Assessment Fail top tier cervical flexion, extension and/or rotation ○ Cervical Flexion → DN, DN, FN ○ Cervical Extension → DN/DP/FP ○ Cervical Rotation → DN, DN, FN Biomechanical Examination Positional Testing Similar to cervical Assess symmetry of pairs of TPs and depth relative to the segment above/below Test in neutral, flexion and extension (only need to move head/neck!) PPIVM Palpate between SPs of adjacent vertebra and assess intervertebral motion with passive flexion and extension of head/neck ○ Can be done seated (WB) or side lying (NWB) Palpate TPs between adjacent vertebra with passive sidebending and rotation of head/neck ○ Can be done seated (WB) or side lying (NWB) Palpate 1st ribs for tenderness and assess depth PAIVM Determine if hypomobility is articular (JMD) or extraarticular (TED) based on joint end feel ○ Central PA Pressure over SP ○ Unilateral PA Pressure over facet joint ○ Transverse vertebral pressure (SP from lateral aspect) ○ Caudal Glide of first and second ribs Can be done seated (WB) or supine (NWB) In seated, can ABD arm on thigh or table Passively side bend to ipsilateral side Spring first rib from anterior and posterior aspect Manual Therapy JMD Elevated first rib ○ Caudal glide (WB or NWB) Stuck Open (Extension/Closing Restriction) ○ UPA (on restricted side, facet of bottom partner)  ○ Transverse vertebral pressure (on SP of top partner, rotating towards direction of restriction) ○ Thoracic Upglide/Scoop Pt. is seated with forehead placed on folded arms Weave hands through Pts arms and place fingers on facet joints and induce extension Can bias extension to L/R ○ Blocks Block bottom partner SP and induce extension Block bottom partner of problem side and rotate or side bend towards the problem side Self Blocking ○ SNAGs Rotate or side bend toward the side of the problem with pressure on the top partner of the opposite side ○ Upper/Mid-Thoracic Distraction High-Velocity Thrust Pt. is seated with legs hanging over edge of table and fingers interlocked between head at base of neck and elbows relaxed Weave through pts arms and rest hands below pts fingers Start to lift and slightly extend to point of resistance then quickly extend knees to deliver thrust ○ Prone High Velocity CTJ Thrust Stuck Closed (Flexion/Opening Restriction) ○ UPA (on restricted side, facet of bottom partner) ○ Transverse vertebral pressure (on SP of top partner, rotating towards direction of restriction) ○ Blocks Block bottom partner SP and induce flexion Block bottom partner of problem side and rotate towards the problem side Block bottom partner of problem side and side bend away from problem side Self Blocking ○ SNAGs  Rotate toward the side of the problem with pressure on the top partner of the opposite side Side bend away from the side of the problem with pressure on the top partner of the problem side ○ Upper/Mid-Thoracic Distraction High-Velocity Thrust ○ Prone High Velocity CTJ Thrust TED Stuck Open (Extension/Closing Restriction) ○ Stretch Upper Trapezius Stuck Closed (Flexion/Opening Restriction) ○ Stretch Multifidus Flexion and ipsilateral rotation Self Stretch: Floor press up/neck flexion Middle/Lower Thoracic Spine SFMA/Movement Assessment Multisegmental Flexion Criteria ○ Touch toes with straight knees and uniform spinal curve ○ > 70 degrees sacral angle ○ Normal effort/motor control ○ Close eyes → look for drift Drift toward hypomobile side ○ Look for structural scoliosis Breakouts ○ Long sitting test 80 degree sacral angle If FN → weight bearing SMCD ○ Active SLR (> 70 degrees) Any FN following this breakout → prone rocking!  ○ Stabilized SLR (>70 degrees) Engage core/posterior tilt ○ Passive SLR (>80 degrees) ○ Supine knees to chest (120 degrees) Keep knees together and sacrum to floor ○ Prone rocking All fours, rock back on heels and assess spinal curve Alternate posture = bend over in chair If FN → weight bearing spine flexion SMCD Spine Flexion MD (prone rocking is final test) ○ DN, FN, DN ○ DN, DN, FN (core SMCD), DN ○ DN, DN, DN, FN (active hip flexion SMCD), DN ○ DN, DN, DN, DN, DN (possible active hip flexion SNCD), DN ○ DN, DN, DN, DN, DN, DN (hip flexion MD), DN Multisegmental Extension Criteria ○ > 170 degrees shoulder flexion ○ Spine of scapula posterior to heels ○ ASIS anterior to toes ○ Uniform spinal curve Breakouts ○ Press Up test Prone lifting trunk with hands ASIS may life 2 in off table If FN → assess shoulder ○ Active Lumbar Locked (IR) Extension/Rotation Test (50 degrees) Prone rock with elbow down at midline and rotate Eliminates lumbar spine ○ Passive Lumbar Locked (IR) Extension/Rotation Test (50 degrees) ○ Active Prone on Elbow Extension/Rotation Test (30 degrees) Rule out lumbar spine ○ Passive Prone on Elbow Extension/Rotation Test (30 degrees) ○ Active prone shoulder girdle flexion test (170 degrees)  ○ Passive prone shoulder girdle flexion test (170 degrees) *** Always assess shoulder and always rule out lumbar spine Spine MDs ○ DN, DN, DN = thoracic extension/rotation MD Rule out shoulder ○ DN, FN (thorax SMCD), DN, DN = lumbar extension/rotation MD Rule out shoulder Multisegmental Rotation Criteria ○ Pelvis rotation > 50 degrees ○ Shoulder rotation > 50 degrees ○ Maintain posture (no pelvis/spine deviation ○ Maintain foot position Breakouts ○ Seated Torso Rotation Test (50 degrees) Cross legs with feet on floor Dowel behind neck ○ Active Lumbar Locked (IR) Extension/Rotation Test (50 degrees) Prone rock with elbow down at midline and rotate Eliminate lumbar spine ○ Passive Lumbar Locked (IR) Extension/Rotation Test (50 degrees) ○ Active Prone on Elbow Extension/Rotation Test (30 degrees) Rule out lumbar spine ○ Passive Prone on Elbow Extension/Rotation Test (30 degrees) Spine MDs ○ DN, DN, DN = thoracic extension/rotation MD ○ DN, DN, FN (thoracic SMCD), DN, DN = lumbar extension/rotation MD ○ DN, FN, DN, DN = lumbar extension/rotation MD Biomechanical Examination Position Testing Palpate asymmetry between TPs in neutral, flexion and extension Deeper side = Problem side PPIVM Palpate between SPs of adjacent vertebra and assess intervertebral motion with passive flexion and extension ○ Can be done seated (WB) or side lying (NWB) Palpate TPs between adjacent vertebra with passive sidebending and rotation ○ Can be done seated (WB) or side lying (NWB) PAIVM Spring Testing ○ Regional testing with PA pressure over TPs ○ Require additional testing to ID segmental level Central PA pressure (over SP or a pair of TPs simultaneously) Unilateral PA pressure (over facet joint) Alternative level PA pressure (“Rule of the Lower Finger”) ○ Lower finger (index) on bottom partner of problem side to create gapping ○ Upper finger (middle) on top partner of opposite side to create rotation toward problem side Transverse vertebral pressure (SP from lateral aspect) Manual Therapy JMD Flexion Restriction (Stuck Closed) Bilateral ○ Supine longitudinal distraction Palpate interspinous space with lateral MCP of index finger Flex/extend dysfunctional segment ○ Seated longitudinal distraction Rock patient forward/backward For mid/lower segments Place a towel at SP of caudal vertebra Lift and rock patient up and backwards ○ Central PA pressure (over SP or a pair of TPs simultaneously) ○ Accessory Motion with Physiologic Motion Techniques (SNAGS) Pressure with ulnar border over SP of top partner with flexion Unilateral  Unilateral PA pressure (over facet joint) Alternative level PA pressure (“Rule of the Lower Finger”) Transverse vertebral pressure Accessory Motion Techniques Central PA pressure (over SP or a pair of TPs simultaneously) Unilateral PA pressure (over facet joint) Alternative level PA pressure (“Rule of the Lower Finger” Accessory Motion with Physiologic Motion Techniques (SNAGS) Physiologic Movement with Finger Blocking (Blocks) Extension Restriction (Stuck Closed) Bilateral ○ Central PA pressure (over SP or a pair of TPs simultaneously) ○ Accessory Motion with Physiologic Motion Techniques (SNAGS) Pressure with ulnar border over SP of bottom partner with extension Unilateral ○ Unilateral PA pressure (over facet joint) ○ Alternative level PA pressure (“Rule of the Lower Finger”) ○ Transverse vertebral pressure ○ Self Mobilization Use foam roller, back of chair or floor induce extension Thoracic Anterior Glide with Rotation High Velocity Thrust Thoracic Anterior Glide with Rotation “Pistol” High Velocity Thrust TED Flexion Restriction (stuck closed) Serratus Anterior ○ Assessment Wall push-ups observing for scapular winging ○ Re-education Wall pushups focusing on separating scapula Progress by performing unilaterally Push shoulder blades apart in quadruped Multifidus ○ Flexion and ipsilateral rotation ○ Self Strtech: Floor press up Extension Restriction (stuck open) Latissimus Dorsi ○ Assess Length  Flex and ER shoulders overhead in supine Flex knees and observe if arms elevate from the table ○ Stretch In supine, flex hips, knees and lumbar spine and apply stretch R/L Self Stretch: prayer stretch SMCD/Therapeutic Exercise Stabilization ○ Key Muscles Deep Stabilizers = rotatores and multifidus Local Stabilizers = multifidus, rotatores and intercostals ○ Assessment Prone Arm Lift Note pain or differences in effort to lift right vs left arm Observe/palpate scapular movement (should remain stable against chest wall) Thorax should not rotate, side bend, flex or extend Repeat test with compression (approximate ribs toward midline) Seated Arm Lift Assess Rolling ○ Prone-Supine Upper Body Rolling https://www.youtube.com/watch?v=YOWgYIhUa20 ○ Supine-Prone Upper Body Rolling https://www.youtube.com/watch?v=MFChXttYC5Q Isolated contraction of deep segmental muscles ○ Palpate for tension of segmental measures and recruitment of global muscles Scapular muscles should remain relaxed ○ Progress from supported positions to functional positions ○ Goal = 10 second holds for 10 repetitions with normal breathing 4x4 Matrix Feedback No load Supported Supported rolling Rolling S  - Spine Flexion Spine Flexion w -Sagittal/oblique curl ups -Sagittal/oblique curl ups with band S -Knees to chest - -Supine knees to chest b with horizontal band pull Spine Extension -crocodile/full press up S Spine Extension - -Supine lifts with band -half rolling c le Spine Rotation Spine Rotation -Supine lifts and chops -Supine lifts and chops with band Suspended Spine Flexion Spine Flexion S -Quadruped cats and -Quadruped cats and - dogs with band dogs a a -Reachunders with band Spine Extension -Lumbar-lock IR - Spine Extension reachbacks in w -Lumbar-lock IR quadruped reachbacks in quadruped S with band around legs Spine Rotation - -Lumbar-lock IR re Spine Rotation reachbacks in w -Lumbar-lock IR quadruped reachbacks in quadruped S with band around legs -Reachunders in - quadruped re -Reachunders in w quadruped with band around legs - q a Stacked Spine Flexion Spine Flexion S -Long sit pelvic tilt with -Kneeling pelvic tilt - band around legs s -Half- kneeling w -Half- kneeling sagittal/oblique curls sagittal/oblique curls with S band Spine Extension - -Kneeling lifts w Spine Extension -Kneeling lifts with band -Rotational kneeling lifts - to pull or around legs k Spine Rotation p -Rotational kneeling lifts -Half kneeling chops and with band to pull or lifts with rotation S around legs - p Spine Rotation a -Half-kneeling push and  pulls with band -Half- kneeling oblique curls with band -Rotational kneeling lifts with band to pull or around legs Standing Spine Flexion Spine Flexion S -Standing/split stance -Standing/split stance - chops with band to pull or chops c around legs re -Rotational standing/split a -Rotational standing/split stance chops stance chops with band - to pull or around legs -Standing trunk curls s in -Standing trunk curls with Spine Extension b band -Square/split stance lifts - Spine Extension -Rotational square/split c -Square/split stance lifts stance lifts le with band to pull or around legs Spine Rotation S -Square/split stance - -Rotational square/split chops and lifts w stance lifts with band to a pull or around legs - Spine Rotation s -Split stance re pulling/pushing with band a S - s b Ribs Biomechanics Rib motion ○ 1-6 = pump handle ○ 7-10 = bucket handle ○ 11-12 = caliper Rib movements with breath  ○ Inhale: ribs expand, move posterior and ER (up and back) ○ Exhale: ribs return, move anterior and IR (down and forward) **Note: breathing can be used to self mobilize! Dysfunction → pain with deep breathing, rotation, sneezing or coughing ○ Structural = subluxations with force ○ Torsional = held in position of IR or ER ○ Respiratory = poor posture Deformities ○ Pigeon Chest ○ Funnel Chest ○ Barrel Chest Assessment Respiration Screening Observation ○ Rib flare ○ Lateral mobility of rib cage ○ Prominent accessory muscles (SCM/scalenes) Breath Hold Test ○ Functional residual capacity = after a normal exhale (> 25 sec) ○ Total lung capacity = after a full inhale (> 35 sec) Hi-Lo Test ○ Palpate and assess movement of sternum and upper abdomen while patient breathes ○ Look for paradoxical breathing MARM Assessment ○ From behind palpate and assess lower rib cage/abdomen with breathing Costovertebral Expansion ○ Measure expansion with inhale following a full exhale (normal = 3-7 cm) T4 (spine of scapula) Axilla T8 T10 Biomechanical Assessment Can be palpated posteriorly, anteriorly and laterally Assess relative size of intercostal spaces  Assess relative depth Note tenderness of intercostal muscles or iliocostalis Rib Motion and Thoracic Excursion ○ Palpate and assess relative motion between TP and rib with flexion/extension Rib Spring ○ Spread thumb and webspace over rib and apply PA pressure ○ Repeat mobilization while blocking TPs of the opposite side Pain with the repeated PA glide indicates a rib problem If pain is not provoked a facet problem is indicated Rib Maneuver for Costal Sprain ○ Laterally flex away from painful side ○ Raise and hold the arm of the painful side over head ○ Perform both caudal and cranial glides on the rib being assessed ○ With a costal strain Pain will increase with stretch Pain will decrease with compression Manual Therapy Rib Elevation (Inhalation) Mobilization (stuck DEPRESSED) Accessory Motion Technique ○ Pt. is side lying and rib is mobilized upwards during inhale ○ Can also be done bilaterally in supine Accessory with Physiologic Motion Technique ○ Rib is mobilized upwards with side bending to opposite side and inhale Self Mobilization ○ Side bend on foam roller and reach overhead (with inhale) RIb Depression (Exhalation) Mobilization (stuck ELEVATED) Accessory Motion Technique ○ Pt. is side lying and rib is mobilized down during exhale ○ Can also be done bilaterally in supine Accessory with Physiologic Motion Technique ○ Rib is mobilized downward with side bending to ipsilateral side and exhale Rib Posterior Mobilization (stuck ANTERIOR) Accessory Motion Technique ○ Rib is mobilized up and back with inhale and  Accessory with Physiologic Motion Technique with Blocking ○ Caudal rib is blocked and Rib Anterior Mobilization (stuck POSTERIOR) Accessory Motion Technique Accessory with Physiologic Motion Technique with Blocking Accessory Motion (NWB)/Roll Down Manipulation