Therapeutic Exercise II - PTA 1010 - The Spine Part 1 - PDF

4/24/2024 Therapeutic Exercise II PTA 1010 The Spine Part 1 1  4/24/2024 Objectives By the end of this section the student should be able to: Identify major components of sp...

4/24/2024 Therapeutic Exercise II PTA 1010 The Spine Part 1 1  4/24/2024 Objectives By the end of this section the student should be able to: Identify major components of spinal structure and function Understand the most common pathologies experienced in the spine including disc pathology (lesions), degenerative joint disease/ stenosis spondylolisthesis, facet dysfunction, soft tissue disorders, whiplash disorder, cervicogenic headaches and TMJ dysfunction Understand the basic management principles for the above conditions Understand exercise prescription based on directional preferences © Stanbridge University 2024 2 2  4/24/2024 OUTLINE Structure and Common spine function Pathologies © Stanbridge University 2024 3 3  4/24/2024 Review: Structure and function of the spine © Stanbridge University 2024 4 4  4/24/2024 5 Regions of the Spinal Column Anatomage Cervical Vertebrae Thoracic Vertebrae Lumbar Vertebrae Sacral Vertebrae Coccygeal Vertebrae Function: C/S: Serves as sensory system to support and orient the head on thorax and complements respiration, phonation and swallowing T/S and L/S: provide structure and support which to transmit forces from UE and LE and with the rib cage provides protection for the internal organs. © Stanbridge University 2024 5 5  4/24/2024 Review Structure and Function of the Spine 1. Functional components of the spine 2. Motions of the spinal column 3. Structure and function of the intervertebral discs 4. Intervertebral foramina 5. Inert structures: influence on movement and stability 6. Neuromuscular function: dynamic stabilization © Stanbridge University 2024 6 6  4/24/2024 Functional Components of the Spine Anterior Pillar: vertebral bodies and intervertebral discs A: anterior pillar: area in pink weight bearing, shock absorbing portion of the spinal column size of disc influences amount of motion between the two vertebrae B: anterior pillar in white © Stanbridge University 2024 7 7  4/24/2024 Functional Components of the Spine Posterior Pillar: articular processes, facet joints, 2 transverse processes (TPs), and spinous processes (SPs) A: posterior pillar: area in white Facets: provide gliding mechanism for movement Processes (TP & SP): provide muscle attachment sites B: anterior pillar in pink © Stanbridge University 2024 8 8  4/24/2024 Motions of the Spinal Column Functional Unit: 2 vertebrae and the joints in between: 2 facet joints and intervertebral disc Motion at a functional unit (spine) is defined by what motion is occurring at the superior vertebra Kisner & Colby Figure 14.3 © Stanbridge University 2024 9 9  4/24/2024 Arthrokinematics of the Facet Joints Coupled motions: consistent association of one motion about an axis with another motion around a different axis Typically, rotation and side bending Varies depending on the region of the spine, spinal posture, orientation of the facets © Stanbridge University 2024 10 10  4/24/2024 Coupled Motions of the Spine In Flexion and Spinal Region Neutral Facet orientation Extension Side bending and Side bending and Side bending and Upper C/S rotation are coupled to rotation are coupled to rotation are coupled to (C0-C2) the opposite side the opposite side the opposite side Side bending and Side bending and 45 degrees Mid- lower C/S rotation are coupled to rotation are coupled to (C2-C7) the same side the same side Neutral position: Side bending and 60 degrees Rotation, SB to rotation are coupled to Thoracic Spine opposite side the same side Neutral position: Side bending and 90 degrees Lumbar Spine Rotation, SB to rotation are coupled to opposite side the same side © Stanbridge University 2024 11 11  4/24/2024 Arthrokinematics of the Facet Joints Cervical Spine: divided into regions Upper C/S (C0-C2): sub-occipital or craniovertebral region Occipital-Atlantal (OA): C0-1 primary motion: capital flexion and extension (nodding of the head) Atlantal-Axial (AA): primary motion: rotation as atlas pivots around the dens of the axis; approximately 50% of all C/S rotation occurs at C1-2 © Stanbridge University 2024 12 12  4/24/2024 Arthrokinematics of the Facet Joints Mid C/S (C2-C5) Lower C/S (C5-T1) Average facet orientation 45 degrees © Stanbridge University 2024 13 13  4/24/2024 Structure and Function of the Intervertebral Discs Discs are MOBILE structures Annulus Fibrosis: type I collagen Nucleus Pulposus: thin type II collagen, allows for better fluid movement Cartilaginous endplates: each disc has 2 endplates Nutrient delivery and waste removal © Stanbridge University 2024 14 14  4/24/2024 Disc: Annulus fibrosus Outer portion of the disc Made mostly of type I collagen & fibrocartilage Fibers in one layer are parallel and angle around 60-65 degrees to the axis of the spine Next layer at a different angle sciencedirect.com Provides tensile strength to the disc during distraction, rotation, and bending drtonymork.com © Stanbridge University 2024 15 15  4/24/2024 Disc: Nucleus Pulposus Central portion of the disc Gelatinous mass Anatomage table Distributes pressure Nucleus imbibes (absorbs) water when pressure is reduced on the disc (supine lying, traction) Nucleus squeezes water out under compressive loads © Stanbridge University 2024 16 16  4/24/2024 Disc: Nucleus Pulposus During flexion of a vertebral segment: anterior portion of disc is compressed posterior portion is distracted NP moves away from compression Dutton Figure 19.2 © Stanbridge University 2024 17 17  4/24/2024 Disc: Nucleus Pulposus During extension of a vertebral segment: posterior portion of disc is compressed anterior portion is distracted NP moves away from compression Dutton Figure 19.3 © Stanbridge University 2024 18 18  4/24/2024 Intervertebral Foramina An opening Located in the posterior pillar Motor and sensory nerve exits the spinal canal via the foramen Blood vessels, meningeal or sinu-vertebral nerves exit via the foramen Anatomage table © Stanbridge University 2024 19 19  4/24/2024 Intervertebral Foramina CLOSING OPENING backpainexplained.com LARGER during flexion, contralateral side bending SMALLER during extension, ipsilateral side bending © Stanbridge University 2024 20 20  4/24/2024 Review What are the components of the spine? Describe the intervertebral discs’ components What spinal motions open and close the intervertebral foramina? What are the coupled motions of the spine? © Stanbridge University 2024 21 21  4/24/2024 OUTLINE Structure and Common spine function Pathologies © Stanbridge University 2024 22 22  4/24/2024 Pathologies within the spine: Disc pathology (lesions) Degenerative joint disease/ stenosis Spondylolisthesis Facet dysfunction Soft tissue disorders Whiplash disorder Cervicogenic headaches Tempomandibular joint dysfunction © Stanbridge University 2024 23 23  4/24/2024 Disc Lesions © Stanbridge University 2024 24 24  4/24/2024 Back Pain Prevalence The Lumbar Spine Mechanical Diagnosis and Therapy Volume one Robin McKenzie, 2003 Between ½ and ¾ of the population will experience back pain in their lifetime 40% of people will have at least one episode of back pain in any one year 80-90% of back pain recovers within 6 weeks Strongest risk factor for developing back pain is a previous episode Reoccurrence of back pain after a first episode is 50% © Stanbridge University 2024 25 25  4/24/2024 Disc pathology: Epidemiology orthobullets.com 95% of disc problems are at L4/5 or L5/S1 Only 5% of disc herniations become symptomatic 3:1 male to female ratio © Stanbridge University 2024 26 26  4/24/2024 ainsworthinstitute.com © Stanbridge University 2024 27 27  4/24/2024 Disc Injuries HNP: herniated nucleus pulposus Any change in the shape of the annulus that causes it to bulge beyond its normal perimeter Kisner Figure 15.1 © Stanbridge University 2024 28 28  4/24/2024 Disc Injuries Protrusion: nuclear material is contained by the outer layers of the annulus and supporting ligaments © Stanbridge University 2024 29 29  4/24/2024 Disc Injuries Prolapse: frank rupture of the nuclear material into the vertebral canal © Stanbridge University 2024 30 30  4/24/2024 Disc Injuries Prolapse Extrusion: extension of nuclear material beyond the confines of the PLL or the disc space, but still in contact with the disc © Stanbridge University 2024 31 31  4/24/2024 Disc Injuries Prolapse Free sequestration: extruded nucleus has separated from the disc and moved away from the prolapsed area © Stanbridge University 2024 32 32  4/24/2024 Disc Lesions slideshare.net https://westcoastsci.com © Stanbridge University 2024 33 33  4/24/2024 INTERVERTEBRAL DISC HNP: Fatigue Breakdown Fatigue breakdown: Most common etiology repeated overloading of the spine in flexion ex: sitting, bending, stooped postures especially with rotation Callahan et a; Clin Biomech 2010 Most common in the posterolateral corner opposite to the direction of rotation (weakest region) Radial fissures develop in annulus Outer layers rupture, allowing the nuclear material to herniate through the fissures (prolapse) © Stanbridge University 2024 34 34  4/24/2024 INTERVERTEBRAL DISC HNP: Traumatic Rupture Usually from hyper-flexion with rotation Can be a one-time event (rare) Gradual breakdown of the annular rings (most common) Theory: fatigue breakdown had already occurred, but no symptoms felt until “traumatic” event occurred © Stanbridge University 2024 35 35  4/24/2024 Intervertebral Disc Axial Overload Compression of Spine End plate damage or vertebral body fracture usually prior to damage to annulus fibrosis Scheuermann’s Disease: nucleus migrates superiorly or inferiorly through a cracked end-plate © Stanbridge University 2024 36 36  4/24/2024 INTERVERTEBRAL DISC HNP: Typical Age of Onset 30-45 years old most common (20-55) Discs naturally begin to degenerate in the 40s Once herniated: nucleus still able to imbibe water, but may protrude through the tears or fissures in the annulus Large amounts of imbibed water can be the cause for extreme pain in the morning after antigravity position all night (larger bulge) © Stanbridge University 2024 37 37  4/24/2024 Intervertebral Disc Injury: Effects on spinal mechanics Early Stages: Hyper-mobility of affected segments Leads to abnormal forces on facets and supporting structures Treatment begins with repeated movements Tx progression to stability exercises Late Stages: may lead to DJD, etc.=Hypomobility Tx focus- stretching activities © Stanbridge University 2024 38 38  4/24/2024 Signs & Symptoms of Disc Lesions Only the outer 1/3 of annulus has nerve innervation→ therefore, not all disc injuries are symptomatic sciencedirect.com © Stanbridge University 2024 39 39  4/24/2024 Signs & Symptoms of Disc Lesions and Fluid Stasis Discogenic pain: pain coming from the disc pressure of a swollen disc or swollen tissues against pain- sensitive structures (ligaments, dura mater, blood vessels around nerve roots) chemical irritants of inflammation if there is herniated disc material © Stanbridge University 2024 40 40  4/24/2024 Signs & Symptoms of L/S Disc Lesions Neurological Signs & Symptoms: From pressure against spinal cord or nerve roots Myotome specific muscle weakness Dermatome specific sensory changes respectively Increased myoelectric activity in the hamstrings (cramps are common) Positive straight leg raise test esp. cross straight leg raise test Depressed deep tendon reflexes (hyporeflexia 0 or 1+) © Stanbridge University 2024 41 41  4/24/2024 Disc verses Nerve Root location © Stanbridge University 2024 orthobullets.com 42 42  4/24/2024 Lumbar disc herniation location orthobullets.com © Stanbridge University 2024 43 43  4/24/2024 Disc Herniation Location Classification Central: directly posterior, back pain only not likely radiating as nerve root is not involved if lower could cause cauda equina Posterior lateral (also named paracentral): most common: 90-95% of herniations where the disc annulus and Posterior longitudinal ligament is weakness affects the lower nerve root- example L4-5 disc would affect L5 nerve root Foraminal: far lateral less common (5-10% of herniations) affects the upper nerve root- example L4-5 disc affects L4 nerve root © Stanbridge University 2024 44 44  4/24/2024 Lumbar HNP Central: Low back only Nerve root not affected Posterolateral: *most common Affects lower nerve root Foraminal: (far lateral) Affects upper nerve root © Stanbridge University 2024 45 45  4/24/2024 Signs & Symptoms: Thoracis Spine Disc Lesions T/S disc lesions are rare: small disc to vertebrae ratio stable osseous anatomy T11/12 most common level When they occur the are more severe → disc herniates posteriorly leading to increased risk of spinal cord compression © Stanbridge University 2024 46 46  4/24/2024 Signs & Symptoms of Disc Lesions Variability in Symptoms: depend on the direction of the protrusion, degree of the protrusion, spinal level of the lesion Posterior or posterolateral HNP: possible pressure against the PLL or dura mater, spinal cord signs, cervical myelopathy (MOST COMMON) EXTENSION BIAS Anterior HNP: possible pressure against the ALL leading to back pain, NO RADICULAR PAIN possible, may have referred pain FLEXION BIAS © Stanbridge University 2024 47 47  4/24/2024 Signs & Symptoms: Disc Lesions Onset of symptoms often occurs after: Repetitive bending, bending and lifting Attempting to stand up after having been in a prolonged recumbent, sitting, or forward-bent posture Pain increases with inactivity i.e., prolonged sitting, prolonged flexion posture or after night’s rest © Stanbridge University 2024 48 48  4/24/2024 Signs & Symptoms: Disc Lesions Pain behavior: Aggravated by activities that increase intradiscal pressure: Sitting, bending, coughing, straining, moving from sit → stand after being in a flexed position, crunches Peripheralization of symptoms down the limb(s) with aggravation Symptoms may shift side to side if annular wall is still intact (protrusion) Symptoms can often be alleviated by walking © Stanbridge University 2024 49 49  4/24/2024 Signs & Symptoms: Disc Lesions Neurological Signs: Anesthesia total or partial loss of sensation & muscle weakness are not noted unless there is nerve root, spinal cord, or cauda equina compression Paresthesia: abnormal sensations i.e., pins and needles © Stanbridge University 2024 50 50  4/24/2024 Common Objective Findings Associated with a Lumbar Disc Lesions Posterior-lateral, Posterior Protrusions: Pain, muscle guarding, preference for standing & walking May present with a flexion posture May present with a lateral shift: deviation away from symptomatic side- called a Neurological symptoms: dermatome an/or myotome pattern of the affected nerve root © Stanbridge University 2024 51 51  4/24/2024 Peripheralization vs. Centralization Peripheralization: (worsening) Symptoms are traveling further down the leg Into the “periphery” Centralization: (improving) Symptoms recede up to leg, or become localized to the back Closer to the “center” © Stanbridge University 2024 52 52  4/24/2024 Peripheralization vs. Centralization Kisner Figure 15.2 © Stanbridge University 2024 53 53  4/24/2024 Centralization Describes the progressive reduction and abolition of distal pain in response to therapeutic loading strategies (directional preferences) Definition: In response to therapeutic loading strategies, pain is progressively abolished in a distal to proximal direction with each progressive abolition being retained over time until all symptoms are abolished. The word abolish means to put an end to, get rid of, so in this case it means the pain is completely gone © Stanbridge University 2024 54 54  4/24/2024 Characteristics of centralization: Lasting abolition of peripheral and radiating pain Relief occurs sequentially from distal to proximal May occur rapidly or gradually Occurs in response to loading strategies May be accompanied by increase in spinal pain Usually, a rapid change in pain over a few sessions Occurs in choric and acute patients Indicates good prognosis Always a LASTING change in pain reduction Occurs most commonly with extension Failure to achieve indicates poor prognosis Accompanied by improvements in mechanics presentation (increased ROM, decreased neural symptoms, increased myotomal strength, decreased neural tension) The Lumbar Spine Mechanical Diagnosis and Therapy Volume one Robin McKenzie, 2003 © Stanbridge University 2024 55 55  4/24/2024 Peripherialization: Distal symptoms are produced and remain or Distal symptoms are made worse in response to loading strategies (repeated movements, sustained postures) Occurs in sequential pattern © Stanbridge University 2024 56 56  4/24/2024 Research Findings If centralization or peripheralization occurs the probability of discogenic pain is 72% If pain remains unchanged the probability of non-discogenic pain is 87% Donelson et al. 1997 © Stanbridge University 2024 57 57  4/24/2024 Common Objective Findings Associated with a Lumbar Disc Lesions Posterior-lateral, Posterior Protrusions: Initially extension is limited due to compression of bulging disc material Repeated backward bending, symptoms centralize (if outer layers of annulus are intact) LATERAL SHIFT must be corrected BEFORE extension exercises or symptoms can increase © Stanbridge University 2024 58 58  4/24/2024 Disc Pathology: Lateral Shift A Lateral Shift to the Right Lateral Shift Correction Described by superior movement of vertebra on bottom © Stanbridge University 2024 59 59  4/24/2024 Disc Pathology: Acute Lumbar Kyphosis A patient might not be able to stand up straight after the initial event This is described as “acute lumbar kyphosis” Likely from a large posterior HNP Will need to address this postural deviation before any other treatment Will lay the patient prone over pillows to accommodate the posture, and gradually remove pillows until flat in prone (LAB) Process may take 45-60 minutes © Stanbridge University 2024 60 60  4/24/2024 Interventions for Posterior HNP Correct any postural deviation (lateral shift or acute lumbar kyphosis) Assess response to different positions of extension (each patient will respond differently) Can be static postures or repeated movement Positions are progressed as such: Prone lying → Prone on elbows → REIL (press ups) → REIS (standing extension) Perform the alleviating exercise frequently Educate patient regarding ADL’s and positions to avoid Correct sitting posture © Stanbridge University 2024 61 61  4/24/2024 Extension Bias Approach A Lying Prone www.spineone.com © Stanbridge University 2024 62 62  4/24/2024 Extension Bias Approach A Prone Press Up or Prone on Elbows REIL: Repeated extension in lying Can be done as repetitions or sustained holds Typically, 2-3 sets of 10 every 2 hours © Stanbridge University 2024 63 63  4/24/2024 A Extension Bias Approach Kisner Figure 15.7 2-3 sets of10 x every 2-3 hours awake © Stanbridge University 2024 64 64  4/24/2024 Disc verses Nerve Root location orthobullets.com © Stanbridge University 2024 65 65  4/24/2024 Intervertebral Disc HNP: C/S C5 and C6 are most common for causing radicular pain C6/7 disc affecting the C7 nerve root C5/6 disc affecting the C6 nerve root © Stanbridge University 2024 66 66  4/24/2024 Common Objective Findings Associated with Cervical Disc Lesions Symptoms in respective dermatome & myotome patterns of the cervical nerve roots May present with faulty forward head posture, hold head in side-bent or rotation away from the affected side Peripheralization: may occur with C/S flexion Centralization: can occur with C/S extension, traction Nerve mobility impairments (+ULTT) © Stanbridge University 2024 67 67  4/24/2024 Common Objective Findings Associated with Cervical Disc Lesions Severe Cases: (B) upper extremity involvement Cervical myelopathy: Any narrowing of the spinal canal leading to cord dysfunction Congenital Spondylosis HNP Cord compression can cause -Gait abnormalities -Upper motor neuron sxs/signs -Leg weakness/paresthesia's ssrehab.com © Stanbridge University 2024 68 68  4/24/2024 Treatment of Posterior Cervical HNP Correct sitting posture (forward head posture) Repeated movements will also reduce symptoms in cervical spine There are more options to do this in the cervical spine Extension loads include cervical retractions, retraction with extension Unilateral symptoms might respond to IL rotation or Side bending In lab we will learn the cervical nod and retraction only, additional training can be done with the Makenzie Institute USA © Stanbridge University 2024 69 69  4/24/2024 Intervertebral DISC HNP: Healing Healing of Disc: poor and slow poor circulation in the disc endplates feed nutrition may get fibrous repair, but is weaker than normal & takes a long time due to the relative avascular status of the disc © Stanbridge University 2024 70 70  4/24/2024 Pathomechanical Relationships of the Intervertebral Disc and Facet Joints The three-joint complex: Disc height diminishes from bulge or degeneration More stress on facet joints DJD of spinal segment © Stanbridge University 2024 71 71  4/24/2024 Degenerative Disc Disease (DDD) Decrease in water content & disc height Vertebral bodies approximate Intervertebral foramen & spinal canal narrow→ stenosis © Stanbridge University 2024 72 72  4/24/2024 Intervertebral DISC: Degenerative Changes- DDD Strong genetic component Loss of integrity of disc from: infection, disease, herniation, end plate defect Smoking, heavy lifting (less correlation) Lynnavillanovamd.com © Stanbridge University 2024 73 73  4/24/2024 Intervertebral Disc: Degenerative Changes DDD Structural changes Progressive fibrous changes in nucleus: loses ability to imbibe fluid → decreased size of nucleus Loss of organization of the rings of the annulus Loss of cartilaginous end-plates Anatomage table © Stanbridge University 2024 74 74  4/24/2024 Stenosis & Radiculopathy © Stanbridge University 2024 75 75  4/24/2024 Stenosis Narrowing of a passage or opening by: -disc protrusion -fibrotic scars -swelling -osteophytes -spondylolisthesis -faulty posture Progression results in neurological symptoms Symptoms worsened in extension © Stanbridge University 2024 76 76  4/24/2024 Stenosis Although the true definition of stenosis is “narrowing”, and we have presented many reasons or causes for the narrowing it has become a common industry standard to use the diagnosis of stenosis as referring specifically to narrowing due to DJD or bony changes In this program when we say stenosis, we will state stenosis/DJD to indicate that we are referring to narrowing due to anatomical bony changes to assist in determining proper interventions © Stanbridge University 2024 77 77  4/24/2024 Stenosis Central stenosis: narrowing of spinal canal Lateral stenosis: narrowing of the nerve root canal, intervertebral foramen © Stanbridge University 2024 78 78  4/24/2024 Stenosis Typically, patients with stenosis feel better with FLEXION biased exercises to increase foraminal volume and relieve pressure on the facets. Exception is narrowing caused by HNP: extension bias Flexion exercises combined with manual therapy, nerve mobilization, C strengthening exercises and progressive walking should be considered Clinicians should consider repeated movement exercises based on A patient preference and centralization of symptoms © Stanbridge University 2024 79 79  4/24/2024 Radiculopathy A pinched nerve (root), refers to a set of conditions in which one or more nerves are affected and do not work properly. Symptoms can be radicular pain, weakness, numbness, or difficulty controlling specific muscles © Stanbridge University 2024 80 80  4/24/2024 Radiculopathy Causes: Pressure from disc against the spinal cord or nerve roots DDD (degenerative disc disease) DJD: osteophytes on facets or vertebral bodies that decreases the size of the spinal canal or intervertebral foramen Instability, spondylolisthesis: excessive translation of vertebra causing decreased foraminal space and nerve root impingement Inflammatory response: trauma, degeneration, etc. Scarring or adhesion formation after injury or surgery © Stanbridge University 2024 81 81  4/24/2024 Radiculopathy Tx activities should focus on centralization and decrease of signs and symptoms A Manual therapy (thrust and non thrust manipulation) should be considered in patients with radiculopathy. A Repeated, patient directional preference movements that create centralization of symptoms should be considered. © Stanbridge University 2024 82 82  4/24/2024 Spondylolisthesis Hypermobility of spine or spinal segments Anterolisthesis: Anterior slippage of one vertebrae on the one directly below it Retrolisthesis: Posterior slippage of one vertebrae on the one directly below it Causes: congenital malformation of pars interarticularis, traumatic fracture of the intervertebral arch, degenerative changes (OA) © Stanbridge University 2024 83 83  4/24/2024 Spondylolithesis- Types Retrolisthesis: RARE Extension Bias Exercises © Stanbridge University 2024 84 84  4/24/2024 Spondylolithesis- Types Anterolisthesis: Flexion Bias Exercises braceability.com spinehealth.com © Stanbridge University 2024 85 85  4/24/2024 Treatment for Flexion Bias Diagnosis’ DJD/Stenosis or Anterior Spondylolisthesis Follows similar positional progressions with creating flexion of the lumbar spine Most common exercise is supine DKTC or RFIL → must pulls knees to chest to create the posterior pelvic movement and associated lumbar flexion Performed frequently throughout the day with repetitions © Stanbridge University 2024 86 86  4/24/2024 Facet Joint Dysfunction/Pathology © Stanbridge University 2024 87 87  4/24/2024 Facet Joint Pathology Synovial joint Has a meniscoid-like structures in the joint Entrapment of the structures lead to pain and limited mobility regenexx.com arthriticchick.com © Stanbridge University 2024 88 88  4/24/2024 Facet Motion Opens with Closes with Flexion Extension Contralateral side flexion Ipsilateral side flexion Ipsilateral rotation Contralateral rotation © Stanbridge University 2024 89 89  4/24/2024 Facet Movement- Example Referring to the RIGHT facet Opening of facets: flexion, left side bend and right rotation spineuniverse.com Closing of facets: Extension, right side bend and left rotation *see spine model* Backpainexplained.net © Stanbridge University 2024 90 90  4/24/2024 Facet Joint Pathologies Facet Sprain/Joint Capsule injury: trauma leads to effusion, limited ROM, muscle guarding Spondylosis, OA, and DJD: degeneration of the disc and facet joints Spondylosis- umbrella term for age related spinal changes Early DJD: hypermobility → altered mechanics Late DJD: hypomobility→ osteophytes, pain, neural impingement © Stanbridge University 2024 91 91  4/24/2024 Facet Spondylosis laserspineinstitute.com © Stanbridge University 2024 92 92  4/24/2024 Facet Joint Impingement Sudden or unusual movement: meniscoid tissue of the facet can become entrapped leading to pain and muscle guarding Loss of a specific movement No pain at rest No neurological signs May have referred pain in dermatome © Stanbridge University 2024 93 93  4/24/2024 Facet Joint Pathology Typically, patients with facet joint pathology feel better with decreased loading of the facets Based on L/S guidelines C FLEXION exercises combined with manual therapy, nerve mobilization, strengthening exercises and progressive walking should be considered. A Clinicians should consider repeated movement exercises based on patient preference and centralization of symptoms. © Stanbridge University 2024 94 94  4/24/2024 Soft Tissue Injury © Stanbridge University 2024 95 95  4/24/2024 Pathology of Muscle and Soft Tissue Injuries: Strains, Tears, and Contusions General symptoms from trauma: Pain & muscle guarding: initially due to protection of the affected area, but then becomes a source of pain Pain with contraction or stretch of the affected muscle Interference with ADL’s i.e., transfers, sitting, standing, walking © Stanbridge University 2024 96 96  4/24/2024 Pathology of Muscle and Soft Tissue Injuries: Strains, Tears, and Contusions Common sites of strain - C/S Acceleration/deceleration Injuries “whiplash” Postural strain: To muscles of the posterior C/S, and scapular and upper T/S muscles due to sustained postures in a sitting position, etc. Emotional stress: Often expressed as increased tension in the posterior C/S or L/S region © Stanbridge University 2024 97 97  4/24/2024 Pathology of Muscle and Soft Tissue Injuries: Strains, Tears, and Contusions Impairments Interventions Impaired muscle performance Strengthening and endurance exercises Impaired mobility Stretching exercises Impaired spinal control and stabilization Stabilization exercises exercises Impaired postural awareness Pt education- Kinesthetic Awareness Limited ADLs Functional Activities © Stanbridge University 2024 98 98  4/24/2024 Whiplash-Associated Disorder (WAD) Acceleration/deceleration injury rehabmypatient.com Common Method of injury: Hit from behind causing a hyperextension injury with a rebound affect causing a hyperflexion injury Can also occur from diving into shallow water Injury to ligaments and sometimes fracture © Stanbridge University 2024 99 99  4/24/2024 Headaches (HA’s) Most common categories of Headaches: 1. Vascular: migraines or cluster HA’s 2. Inflammatory: tumors or disease of the eyes, nose, throat 3. HA’s resulting from muscle tension, cervical spine impairments, TMJ dysfunction Headaches in the third category can be treated with physical therapy © Stanbridge University 2024 100 100  4/24/2024 Signs and Symptoms Impairments Headache reproduced with provocation of the involved C/S segments Limited cervical ROM Restricted upper cervical (C0-2) segmental mobility Strength and endurance deficits of the deep neck flexor muscles © Stanbridge University 2024 101 101  4/24/2024 Cervicogenic Headaches : Etiology Tissue ischemia due to: Soft tissue injury Faulty or sustained postures Greater occipital nerve irritation or impingement (muscle guarding) Sustained muscle contractions due to emotional tension or temporomandibular dysfunction (TMJ) © Stanbridge University 2024 102 102  4/24/2024 Cervicogenic Headaches: Common Associated Findings Faulty T/S joint mobility (usually upper T/S) Faulty posture (forward head, protracted shoulder posture) Trauma, DJD, sedentary lifestyle, etc. Restricted upper C/S joint mobility Impaired muscle endurance of the postural stabilizers (deep cervical flexors, suboccipitals, scapular muscles) Impaired lumbar posture, muscle imbalances © Stanbridge University 2024 103 103  4/24/2024 Neck Pain with Headache Interventions Impairments Interventions Headache reproduced with provocation of the Pt education, kinesthetic awareness involved C/S segments Limited cervical ROM Stretching Restricted upper cervical (C0-2) segmental Cervical mobilization/manipulation mobility Strength and endurance deficits of the deep Coordination, strength and endurance exercises neck flexor muscles © Stanbridge University 2024 104 104  4/24/2024 Cervicogenic HA’s: Potential Interventions A Cervical spine joint mobilization C Upper T/S joint mobilizations Soft tissue mobilization/myofascial Release suboccipitals A Stabilization and endurance exercises O’Leary et al. JOSPT, 2007 -Cervical spine, scapular stabilizers, lumbar stabilizers A Patient education: non -provocative activities, reassurance of good prognosis can full recovery is common Childs et al. JOSPT 2008 © Stanbridge University 2024 105 105  4/24/2024 Cervicogenic HA’s: Potential Interventions A Postural training; relaxation training C Flexibility exercises (to improve T/S rotation and extension, OA flexion, decrease protracted shoulder posture, to improve C/S ROM, etc.) Childs et al. JOSPT 2008 Psychosocial management: stress management and cognitive behavior therapy © Stanbridge University 2024 106 106  4/24/2024 Temporomandibular Joint Dysfunction (TMJ) © Stanbridge University 2024 107 107  4/24/2024 Temporomandibular Joint: Structure and Function Mandibular condyle articulates with the temporomandibular disc and the glenoid fossa of the temporal bone Necessary to chew, talk, yawn, etc. Motions: ✓Mandibular depression and elevation (mouth opening and closing) ✓Lateral deviation ✓Protrusion/retraction © Stanbridge University 2024 108 108  4/24/2024 Temporomandibular Joint Motions https://medical-dictionary.thefreedictionary.com © Stanbridge University 2024 109 109  4/24/2024 TMJ- Muscles and Action Kisner Figure 15.18 © Stanbridge University 2024 110 110  4/24/2024 As jaw opens the disc and condyle slide anterior on the articular eminence Kisner & Colby 7th edition © Stanbridge University 2024 111 111  4/24/2024 TMJ Dysfunction: Etiology 3 most common causes of dysfunction are: 1.Trauma 2.Poor posture 3.Faulty movement patterns Additional causes: Poor oral hygiene Gum chewing, Open mouth breathing Heavy kissing Bruxism (grinding the teeth) Smoking Rheumatoid arthritis or other inflammatory conditions © Stanbridge University 2024 112 112  4/24/2024 TMJ Dysfunction Signs and Symptoms Primary Signs: Pain in the TMJ that is affected by movement Joint noise during movement Restrictions or limitations of jaw movement © Stanbridge University 2024 113 113  4/24/2024 TMJ dysfunction: sources of pain Pain in the vascularized retro-discal pad Pain from muscle spasm- masseter, temporalis, medial pterygoid, lateral pterygoid Tension in cervical muscles can create irritation of the greater occipital nerve © Stanbridge University 2024 114 114  4/24/2024 TMJ Assessment Subjective assessment: DOI, mechanism of injury (MOI), healing phase Functional assessment: abnormal breathing, tongue on floor of mouth, tongue or jaw thrust during speech or swallowing Opening and closing pattern “S curve of opening Without pain= muscle imbalance or incoordination With pain= involvement of disc or capsule “C” curve= capsular pattern Intra and extraoral examination AROM measures © Stanbridge University 2024 115 115  4/24/2024 AROM of TMJ- depression or opening Normal mouth opening Abnormal mouth opening lateral deviation left Norkin & White, 4th edition © Stanbridge University 2024 116 116  4/24/2024 AROM of TMJ- Normative values Norkin & White, 4th edition © Stanbridge University 2024 117 117  4/24/2024 Jaw opening AROM assessment Norkin & White, 4th edition © Stanbridge University 2024 118 118  4/24/2024 TMJ AROM- depression or opening Measure the bottom of upper incisor to the top of the lower incisor Functional mouth opening: two or three flexed proximal interphalangeal joints within the opening Adult functional ROM opening averages 35 mm - 50 mm Opening of only 25 mm to 35 mm is needed for normal activities Norkin & White, 4th edition © Stanbridge University 2024 119 119  4/24/2024 TMJ AROM- protrusion Distance between the lower central incisor and the upper central incisor teeth with a tape measure or ruler Norkin & White, 4th edition © Stanbridge University 2024 120 120  4/24/2024 TMJ AROM- lateral deviation Measure the lateral distance between the center of the lower incisors and the center of the upper central incisors with a millimeter ruler Norkin & White, 4th edition © Stanbridge University 2024 121 121  4/24/2024 TMJ AROM Normative values © Stanbridge University 2024 122 122  4/24/2024 TMJ Dysfunction: Principles of Management Relaxation and breathing training Soft tissue & joint mobilization and modalities (per POC) Postural correction (kinesthetic awareness) Extra and Intra articular soft tissue techniques (masseter, pterygoid, temporalis, suboccipital muscles) Eat soft foods (soup, pasta, mashed potatoes, fish, cooked vegetables, etc.) Chew on uninvolved side until symptoms improve Avoid items requiring large degree of mouth opening or crunchy items (apples, corn on the cob, bagels, chips) NO GUM © Stanbridge University 2024 123 123  4/24/2024 TMJ Dysfunction: Principles of Management Control of Jaw Musculature: Teach proper jaw resting position (should be maintained throughout the day): lips closed, teeth slightly apart, tongue resting lightly on hard palate behind the front teeth Teach breathing in/out of nose, diaphragmatic breathing Tongue controlled mouth opening exercise: Practice opening mouth keeping chin in midline and tongue on roof of mouth (in front of mirror) 6 reps 6 times/day; speed increases with increased control Isometric TMJ exercises- for control (not strength)10 reps x 10 sec © Stanbridge University 2024 124 124  4/24/2024 TMJ Principles of Management: Isometrics Tongue on roof of Mandibular depression lateral deviation mouth 6 reps, 6x/day drjeffreytucker.com © Stanbridge University 2024 125 125  4/24/2024 TMJ Dysfunction: Principles of Management Stretching for restricted jaw opening: Place layered tongue depressors in between teeth Increase # of tongue depressors until opening is such that the knuckles of the index and middle fingers can fit between the central incisors Youtube.com © Stanbridge University 2024 126 126  4/24/2024 TMJ Dysfunction: Principles of Management Joint mobilization See pictures next slide Correct upper quarter muscle imbalances: identify strength, endurance, and ROM/flexibility deficits © Stanbridge University 2024 127 127  4/24/2024 TMJ: Joint mobilization techniques Unilateral mobilization Bilateral distraction Dutton, 2nd edition © Stanbridge University 2024 128 128  4/24/2024 A Consider Addressing the Faulty posture loading the TMJ Joint healthclues.net Poor resting Posture Chin tuck/ retraction © Stanbridge University 2024 129 129  4/24/2024 Did we meet these Objectives? By the end of this section the student should be able to: Identify major components of spinal structure and function Understand the most common pathologies experienced in the spine including disc pathology (lesions), degenerative joint disease/ stenosis spondylolisthesis, facet dysfunction, soft tissue dysfunction, whiplash disorder, cervicogenic headaches and tempomandibular joint dysfunction Understand the basic management principles for the above conditions Understand exercise prescription based on directional preferences © Stanbridge University 2024 130 130  4/24/2024 References Stuart M McGill, Sylvian Genier, Natasa Kavcic and Jacek Cholewicki, Coordination of muscle activity to assure stability of lumbar spine. Journal of Electromyography and Kinesiology 2003; 13: 353-359 Simon Wang and Stuart M McGill, Links between the mechanics of ventilation and spine stability, Journal of Applied Biomechanics, 2008; 24:166-174 Shaun O’Leary PT, PhD, Deborah Falla, PT, PhD, James M. Elliott, PT, PhD, Gwendolen Jull, PT, PhD, Muscle dysfunction in cervical spine pain, JOSPT 2009; 39(5): 324-333 Callahan JP and McGill SM, Intervertebral disc herniation: Studies on porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinic Biomech 2001: 16: 28-37 Muhammad Alrwaily, Michael Timko, Michael Schneider, Joel Stevans, Christopher Bise, Karthik Hariharan, Anthony Delitto, Treatment- Based Classification System for Low Back Pain: Revision and Update, Physical Therapy 2016, 96 (X): 1-10 Johan W.S. Vlaeyan and Steven J Linton. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of art. Pain 2000; 85: 317-332 Jo Armour Smith and Kornelia Kulig, Altered multifidus recruitment during walking in young asymptomatic individuals with a history of low back pain. Physical Therapy 2016; 46(5): 365-374 © Stanbridge University 2024 131 131  4/24/2024 References John D Childs, Joshua Cleland, James M Elliott, Deydre S teyhen, Robert S Wainner, Julie M Whitman, Bernard J Sopky, Joseph J Godges, Timothy W Flynn, Neck Pain: Clinical Practice Guidelines linked to the international classification of functioning, disability, and health from the Orthopedic Section of the American Physical Therapy Association, JOSPT 2008, 38(9): A1-A34 Anthony Delitto, Steven A George, Linda Van Dillen, Julie M Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R Derringer, Joseph J Godges, Low back pain: Clinical Practice Guidelines linked to the international classification of functioning, disability, and health from the Orthopedic Section of the American Physical Therapy Association, JOSPT 2012; 42(4):A1-A57 Shaun O’Leary, Deborah Falla, James M Elliott, Gwendolen Jull, Muscle dysfunction in cervical spine pain: Implications for assessment and management. JOSPT 2009; 39(5): 324-333 Yu Okubo, Koji Kaneoka, Atsushi Imai, Itsuo Shina, Masaki Tatsumura, Shumpei Miyakawa, Electromyographic analysis of Transverse Abdominis and Lumbar Multifidus using wire electrodes during lumbar stabilization exercises, JOSPT 2010, 40(11): 743-750 Peter Blanpied, Anita Gross, James Elliott, Laurie Devaney, Derek Clewley, David Walton, Cheryl Sparks, Eric Robertson, Neck Pain: Revision 2017 Clinical Practice Guidelines linked to the international classification of functioning, disability and health from the orthopedic section of the American Physical Therapy Association, JOSPT 2017, A1-A83 © Stanbridge University 2024 132 132