Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Therex final
Lumbar Spine and SI joint (Bob Paul)
| Question | Answer |
|---|---|
| appendicular muscles of the lumbar spine | from the spine to upper and lower extremities |
| how can appendicular mm affect the lumbar spine? | if they are tight, they will pull at their origin or insertion at the lumbar spine and cause pain |
| examples of appendicular mm of the lumbar spine | lats, hamstrings, psoas, iliacus |
| latissimus dorsi origin | spinous process of vertebra T7 to T12, thoraco lumbar fascia, ribs 9-12 and inferior angle of scapula |
| latissimus dorsi insertion | sulcus of humerus between pectoralis major and teres major (" miss between two majors) |
| semitendinosus origin and insertion | origin ischial tuberosity and inserts tibial and pes anserine |
| semimembranosus origin and insertion | origin ischial tuberosity and inserts medial condyle of tibia |
| biceps femoris origin and insertion | •origin ischial tuberosity and sacrotuberous ligament and inserts on fibular head**** |
| There is a posterior diagonal chain between the _____, through the ___ ____ and up to the ____ | hamstrings, gluteus maximus, lats |
| psoas origin and insertion | origin on the bodies of the vertebra and transverse processes T12 to L5 and insertion on the lesser trochanter of femur |
| posterior sling | X formed by diagonal line through hamstrings, glutes, and lats |
| iliacus origin and insertion | origin on the iliac fossa, iliac crest, sacroiliac and iliolumbar ligaments and upper lateral surface of the sacrum |
| psoas and iliacus can reciprocally inhibit what mm when tight? | *gluteus maximus*, multifidus, deep erector spinae, internal oblique & transverse abdominus when tight - extensor mechanism dysfunction |
| function of psoas and iliacus | •Works with erector spinae, multifidus & deep abdominal wall •Works to balance anterior shear forces of lumbar spine |
| what can release of psoas and iliacus help with? | lumbar spine pain |
| function of quadratus lumborum | •Frontal plane stabilizer (lateral) •Works in conjunction with gluteus medius & tensor fascia latae |
| origin and insertion of quad lumborum | Origin-iliac crest and iliolumbar ligament, Insertion- Rib 12, transverse processes of L1 to L4 |
| respiratory mm of the lumbar spine | serratus posterior inferior, serratus posterior superior, many others |
| erector spinae mnemonic | "i like sally" (lateral to medial) |
| function of erector spinae group | - Provide intersegmental stabilization - Eccentrically decelerate trunk flexion & rotation |
| iliocostalis lumborum origin and insertion | origin is the thoracolumbar fascia, iliac crest and posterior sacrum and insertion ribs 6 to 12 |
| longissimus lumborum origin and insertion | origin is iliolumbar fascia, posterior medial lip of iliac crest, lateral crest of sacrum and spinous processes from T11 to L5 and inserts on inferior borders of lower six or seven |
| spinalis origin and insertion | origin spinal processes of lower spinal vertebrae and inserts at the same area as well as base of skull |
| deep mm of the lumbar spine | multifidus - smaller mm include lateral intertransversarius and interspinalis lumborum |
| multifidus origin and insertion | origin from the sacrum and extends up to C2. Multiple insertion points along the spine processes of each vertebra. |
| multifidus function has poor ____ ___ relative to movement production | mechanical advantage |
| multifidus is primarily what type of mm fibers? | Type I muscle fibers with high degree of muscle spindles •Inter/intra-segmental stabilization |
| four layers of abdominal mm | - rectus abdominus and linea alba - external oblique - internal oblique - transvers abdominus |
| function of abdominal mm | - Work to optimize spinal mechanics - Provide sagittal, frontal & transverse plane stabilization - major stabilizer and mover for the spine |
| rectus abdominus origin and insertion | •origin from the crest of the pubic bone and inserts at the costal cartilages of ribs 5 to 7 and ziphoid process of the sternum |
| is rectus abdominus a major intra or intersegmental stabilizer? | no, it is neither |
| linea alba can be damaged from what? | pregnancy |
| intermediate layer of abdominal mm superficial to deep | external oblique, internal oblique, transverse abdominus |
| external oblique origin and insertion | origin ribs 5 to 12 and inserts along anterior aspect of iliac crest •Curves around the anterior and lateral walls of abdomen |
| what other mm does external oblique meet with? | Meets anteriorly with other external oblique to form the linea alba |
| Where does the linea alba extend from? | from xiphoid process to pubic symphysis |
| internal oblique origin and insertion | •origin is thoracolumbar fascia, inguinal ligament and anterior 2/3 of iliac crest and inserts at ribs 9 to 12 •Lies below the external oblique and just above the transverse abdominus. -, |
| transverse abdominus function | •Works in concert with the multifidus and the pelvic floor musculature for spinal control and stability |
| transverse abdominus origin and insertion | •orgin is the inguinal ligament, iliac crest, thoraco lumbar fascia and ribs 7 to 12 and inserts on pubic crest along with aperneurosis of internal oblique as well as the linea alba |
| layers of abdominal mm from superficial to deep | - linea alba and rectus abdominus - external oblique - internal oblique - transverse abdominus |
| diaphragm origin and insertion | •Diaphragm origin is the xiphoid process, inner surface of lower six costal cartilages and L1 to L5 vertebrae. •Insertion is the central aponeurotic tendon |
| how does diaphragm relate to LBP? | •Patients with LBP had an abnormally positioned diaprham compared to subjects without LBP (JOSPT) |
| what issues is the diaphragm implicated in? | scoliosis, lumbar, thoracic, and cervical spine dysfunction, respiration, rib mobility |
| what makes up the core? | - pelvic floor mm - diaphragm - glute med and max - psoas and iliacus |
| what can be sources of pain the back other than mm? | discs, joints, nerves, organs |
| Superior facets are _____ and articulate with the____ facets. (look at skeleton) | concave, adjacent inferior convex |
| Lumbar spine facets transition from a _____ plane to_____ plane orientation | sagittal, frontal |
| tropism | abnormally oriented joints especially at L5S1 |
| disc and end plate orientation | disc, end plate, adjacent vertebra |
| what makes up disc? | •Annulus fibrosus •Nucleus polposus |
| Nucleus is oriented to the ____ surface of the disc in lumbar spine | posterior |
| what makes up the disc? | end plates, annulus fibrosus, nucleus pulposus |
| annulus fibrosis | outer portion of disc layers of type I collagen fibers |
| Fibers of any layer of annulus are oriented ____ degrees to axis of spine | 60 to 65 |
| Fibers of annulus _____ in successive layers | alternate |
| what do fibers of annulus allow? | tensile strength to the disc with all motions of spine |
| what is annulus attached to? | adjacent vertebra |
| nucleus pulposus | central part of disc made up loosely aligned type II collagen fibers - great affinity for water |
| where is lumbar spine nucleus pulposus located? | closer to posterior border than the anterior border of the annulus |
| ___ ___ allow distribution of pressure evenly throughout the disc under loading | fluid mechanics |
| Nucleus imbibes water when pressure is ____ and squeezed out water under ____ | reduced, compression |
| Nucleus may distort with____ | flexion |
| end plates | •cartilaginous and cover the nucleus and lie between the nucleus and the vertebral bodies |
| how does disc get nutrition? | •Nutrition diffuses from the marrow of vertebral bodies to the disc via the end plate |
| are end plates vascualrized? | yes |
| end plate fx | - very painful - not routinely looked for - difficult tx |
| sciatic nerve | largest nerve in body, often involved in lumbar spine dysfunction |
| what does sciatic nerve branch into? | fibularis and tibial nerve |
| where can sciatic nerve be compressed? | - intervertebral foramen - piriformis region - in the periphery |
| what can femoral nerve cause? | anterior LE pain, will not allow complete extension if tight |
| lateral femoral cutaneous nerve | •Travels under the inguinal ligament •Sensory nerve for anterior thigh |
| what can lateral femoral cutaneous nerve cause? | •Meralgia Paraesthetica |
| obturator nerve | •Descends within the psoas major muscle •Passes into pelvis •Supplies medial area of thigh |
| what mm tightness can affect the obturator nerve? | psoas |
| organs that can mimic lumbar spine and SI joint pain | kidney, liver, prostate, uterus, stomach |
| evaluation red flags | - night pain (tumor) - saddle anesthesia - systemic disease or visceral disease - bilateral or quadrilateral paresthesia - loss of B&B control - pain with cough or sneeze |
| four basic types of lumbar spine dysfunctions | - disc - stenosis - instability - facet joint dysfunction |
| disc problems | •Disc protrusion •Ruptured disc •Degenerative Disc Disease (DDD) |
| stenosis | •Narrowing of the central canal or foramen |
| what can cause stenosis | •Bulging disc, osteophytes, trophic changes in ligaments.capsule |
| what can cause instabilities | •Pregnancy, hypermobility, DDD, arthritis, spondylolisthesis |
| what can cause facet joint dysfunction | Subluxed facet, Sprained ligaments, Hypomobile facet, Arthritic facet |
| what can cause mechanical back pain? | mm sprains, herniated discs, compressed nerve roots, DDD or DJD |
| what can cause non mechanical back pain | Tumors, infections, referred pain from organs, (kidneys, aortic aneurism etc...) |
| pt population for disc problems | many times younger pts |
| signs and symptoms of disc problems? | - can't sit for long time, flexion cause pain, like to walk, radicular pn in LE, decreased reflexes, dermatomal changes |
| protruded disc | nuclear material is still contained in annulus, but is starting to shift |
| prolapsed disc | nuclear material is breaking through the annulus but is not outside yet |
| extruded disc | nuclear material has broken all the way through the nucleus |
| sequestrated disc | nuclear material of disc spills out and completely separates from disc |
| disc pathology tx | pain and inflammation control, positions of rest (avoid flex), pt education, extension therex, walk, manual therapy for disc and facet joint, core stabilization |
| why do we want to encourage extension? | helps centralize sx |
| symptoms of central or lateral stenosis | •Bilateral or unilateral leg signs and symptoms, love to sit, aggravated by walking and standing, older, flexion relieves, extension aggravate |
| treatment of spinal stenosis | avoid extension with ADL's, flexion positioning, aerobic conditioning, traction, severe causes may be surgical |
| causes of instability | progressed from hypermobile joint, DDD, arthritis, pregnancy, disease process |
| what spinal dysfunction is most difficult to tx? | instabilities, will need extensive core training |
| signs and symptoms of spinal instabilities | •Inconsistent •Constantly changing position to relieve signs and symptoms •Signs and symptoms can be found in early part of AROM •Hypermobile facets •Instability tests positive |
| spondylolisthesis | •anterior slippage •Can be unstable posterior or anterior or both •Core training in neutral if both |
| causes of facet joint dysfunction | hypomobile joints, DJD, injuries causing capsular or joint dysfunction |
| acute with inflammation phase | constant pain or position of comfort. Use medications. |
| acute without inflammation | symptoms are intermittent and related to mechanical deformation. |
| tx during acute phase without inflammation | •Educate especially position of comfort and posture •Teach awareness of movement- pelvic tilt, anterior tilt, neutral zone •Initiate neuromuscular activation- deep segmental muscle activation |
| subacute phase tx | •Self management training- ergonomics and posture •Increase motion in restricted tissues- muscle, joint, fascia and nerve |
| what can you do to increase motion in restricted tissues? | •Mobilization or manipulation (careful) •Isolated positional traction •Mobilization with movement •Peripheral nerve mobilization •SCS or other inhibition techniques for guarding muscle •Muscle energy technique |
| what therex can you do in the subacute stage? | •Progress stabilization exercises- think core •Body mechanics ( push/pull, lifting, vacuuming, reaching, carrying etc....) •Aerobic exercises •May start extremity work at this time •Increased muscle endurance •Must have excellent NM control |
| when can you talk about the neuroscience of pain? | subacute and chronic stage |
| chronic stage | •patient should have minimal functional or range of motion impairments that prevent ADLs |
| chronic stage tx | •This phase is concentrating on conditioning and spinal control during high intensity or repetitive activities •Advancement of the subacute activities •Talk about the neuroscience of pain |
| examination findings for extension syndrome | pain increase with forward bend and decrease with backward bend |
| interventions for extension syndrome | •Extension exercises •Restrict flexion activities |
| extension syndrome exercises | •Extension in prone with and without resistance •Standing extension with tubing •Extension over a ball or roll (advanced) |
| flexion syndrome examination findings | pain increase with backward bending and decrease with forward bending |
| interventions for flexion syndrome | •Flexion exercises •Restrict extension activities |
| what may be causing flexion syndrome? | •Facet dysfunction •Intervertebral foramen •Spinal canal •Stenosis •Spondylosis •Spondylolisthesis |
| flexion exercises | - curl up and down, diagonal - Bilateral SL raise or lower (advanced) - double knees to chest |
| lumbar syndrome examination findings | •Local, unilateral LBP •Patterned LOM |
| interventions for lumbar syndrome | •Mobilization •Manipulation |
| immobilization syndrome exam findings | •Frequent episodes of LBP •Pain ↑ static postures |
| interventions for immobilization syndrome | •Avoid sustained posture •Trunk strengthening |
| traction syndrome exam findings | •Radicular symptoms •Pain ↑ with lumbar AROM |
| interventions for traction syndrome | •Mechanical traction |
| traction lateral shift syndrome exam findings | •Lateral shift present •Unilateral SB limitation •Pain ↑ lateral shift correction & extension |
| interventions for traction lateral shift syndrome | •Mechanical traction •Correct lateral shift |
| who does flexion positioning work well for? | - many pts - stenotic pts - all pts as long as not symptomatic |
| who does extension positioning work well for? | - acute and subacute disc pts - some jt dysfn - may not work well for stenosis |
| aston patterning | "stacking" the spine - we did in lab |
| how to stretch to increase spine flexion | knees to chest, quadruped(cat) and child's pose |
| how to stretch to increase spine extension | press up, quadruped (cow) and standing extension |
| how to stretch to increase spine sidebending | side bend with arms over head, prone using legs to side bend or side lying with towel under spine |
| what is the core? | •Lumbo- pelvic -hip complex •Where all motion begins •Natural back brace |
| •Core _____ may be more important than core _____-greater chance of injury to the spine when stabilizing muscles fatigue | endurance, strength |
| train the core from ____to ____ | inside, outside |
| Must have a ____ and ____ core- neutral position with the ability to active deep muscles | neutral, strong |
| what core mm are anticipatory? | transverse abdominus and multifidus |
| when does normal core fire prior to UE and LE? | UE- 30 ms prior LE- 110 ms prior |
| when does dysfunctional core fire with movement? | •Fires 450 ms after the movement- puts joints at risk |
| how long does it take multifidus to atrophy after back injury? | 24 hrs |
| Will the multifidus return on its own? | no, it needs to be retrained |
| poor recruitment of multifidus is specific to | level of dysfunction |
| 5 steps for core training | 1. train pt to recruit rectus 2. Train patient to recruit pelvic floor 3. Then train patient recruit multifidus with transverse abdominus 4. Work core with all therapeutic exercises 5. Work core with all therapeutic functional training |
| Why is core training important? | - Must correct the abnormal stresses being place on spine - Can relieve much of a patient's pain - Has to be implemented and maintained by patient for long term recovery |
| progression for deep segmental mm training (transverse abdominus and multifidus) | Find and train neuromuscular Incorporate the upper and lower extremities. Maintain control and start to move actively |
| where can you palpate TrA? | distal to ASIS and lateral to rectus abdominus |
| cues for TrA | draw belly button in and up |
| cues for multifidus | "Swell" muscle out against my digits |
| how long should pt hold TrA contraction? | 10 sec 10X |
| how can you add slight resistance for multifidus? | side-lying, add trunk rotation at the pelvis or ribs |
| emphasize _____ with core bracing and stabilization exercises | endurance - need to have before can add weights or bands |
| how to progress abdominal mm exercises | • add external resistance- bands, weights or pullies • add position changes- supine-sit-kneel-standing • use functional positions • add unstable surfaces |
| Research indicates increase cross section of multifidus when using a ____ | ball |
| Once able to activate ___ ____muscles , all exercises need to be performed in neutral , drawn in maneuver and maintained | deep segmental |
| exercises for progressive limb loading | •Bent knee fall out |
| many exercises heavily recruit the rectus abdominus and other superficial mm, what does the pt need to do to make sure the deep segmental mm are working? | need to make sure pt is using the draw in manuever |
| how to progress spine extensor exercises | •Patient is quadruped or prone •Lift one arm •Lift one leg •Combine arm and contralateral leg •In prone: lift one leg, both legs and then head, arms and legs |
| Trunk extensor/flexor ratio study reveals that there was an increase with incidence of LBP with patients who had less ____strength than____ strength | extensor, flexor |
| you need to incorporate ____ with extensor exercises | rotation |
| what group should you be cautious about rotation with? | disc pathology |
| quadratus lumborum function | •Important stabilizer in frontal and transverse plane |
| how can we train quadratus lumborum | side plank position |
| centralization | symptoms moving to mid- line |
| peripheralization | symptoms in the lower extremity. |
| As symptoms begin to abate, one should see _____ of symptoms | centralization |
| what causes a lateral shift | the disc is impacting the exiting nerve so patient may shift toward or away from the bulging disc |
| how to correct lateral shift | can be done in standing or prone, go directly into extension when shift is corrected |
| McKenzie self treatment protocol for prone | 5 min every two hours Press up-10 reps every two hours |
| McKenzie self treatment protocol for standing | 10 reps every two hours |
| neural mobilization | •Straight leg raise and slump stretching are equally effective in reducing pain in patients with low back pain with adverse neural tension |
| types of neural mobilization | sliders and tensioners |
| neural sliders | moving neural tissues both distal and proximal in a sliding fashion |
| neural tensioners | moving tissues proximal and distal in a tensioning fashion |
| what should neural slides or tensioners feel like? | Should elicit gentle pain or tension- avoid too much pain |
| what do neural tensioners and sliders mobilize? | the exiting spinal nerve and peripheral nerves of the extremities |
| ____ and ____ stretching are equally effective in reducing pain in patients with low back pain with adverse neural tension | Straight leg raise, slump |
| Oscillatory movement like straight leg stretching, there is elongation and shortening of the nerve which temporarily increases the ___ ____ pressure followed by a period of relaxation in between | intra neural |
| how do oscillatory movements decrease pain? | pumping action increase dispersal of local inflammatory products= alleviate hypoxia and reduce pain |
| effect of neural mobilization | high analgesic effects based on the finding that the resting muscle tone decreased post neural mobilization |
| neurodynamic technique | consist of short oscillatory movements and was sufficient to disperse the edema, thus alleviating the hypoxia and reducing the associated symptoms |
| effect of traction | - paraspinal relaxation = stretch - spinal and facet capsule creep - vertebral body distraction = reduce IVD pressure = reduce bulging disc |
| lumbar spine traction contraindications | •Acute LBP or trauma, Loss of spinal integrity, Hypermobility or instability, Hiatal or abdominal hernia, myelopathy, pregnancy, aortic aneurysm, claustrophobia, elderly, spinal surgery, obesity, resp dysfn, HTN |
| positioning for lumbar traction with stenosis or facet dysfn | supine |
| positioning for lumbar traction with disc dysfunction | prone |
| Lumbar traction parameters review | •½ body weight to overcome friction •60 - 100 lbs. typical •80 - 120 lbs. usual to distract vertebrae •Split table decreases effect of friction |
| lumbar traction duration review | •8 - 10 min. IVD •15 - 25 min. DJD |
| what is Enzymatic Intradiscal Therapy used for? | a contained prolapase |
| how does Enzymatic Intradiscal Therapy work? | •Reduces ability of disc's water absorbing ability •Ultimately decreases disc pressure |
| Most commonly performed lumbar surgical intervention | discectomy |
| what type of discectomy for herniated disc? | posterior |
| Percutaneous diskectomy | •minimally invasive procedure using a probe for aspiration of the nucleus polposus |
| microdiscectomy | •removal of disc material that is compressing the nerve root. Some studies report 90% success rates |
| laser discectomy | laser used to remove disc tissue. Low success |
| laminectomy | •Removal of the lamina. •May also include decompression- may also include a partial facetectomy, canal enlargement, pediculectomy •May also include removal of spinous process and ligamentum flavum |
| lumbar spine fusion | - anterior or posterior - helps preserve discal space and decompress intradiscal space - much hardware used |
| what is lumbar spine fusion often accompanied by? | interbody grafts, cages or dowels |
| lumbar spine surgical precuations | - specific to surgeon •Preserve and restrict motion of operated area until at least four weeks |
| tx goals after lumbar spine surgery | •Restore motion of thoracic spine and hip/pelvic region •Balance training Cardio training- bike, walk etc |
| Total Disc Replacement (TDR) | - remove pn sensitive material - insert prosthetic with two end plates of metal and articulation |
| Non constrained center of mobility TDR | •mobile core articulating with end plates |
| semi constrained center of mobility DTR | ball and socket" fixed center of rotation |
| rehab after lumbar spine surgery | •Restore motion- lumbar spine, Assume some restrictions on flexion and rotation, Start with TrA and multifidus, Follow the same program as any lumbar spine patient |
| TDR lumbar spine rehab | •MUST BE SPECIFIC TO THE SURGEON, May have motion restrictions for post surgical period, Restore all areas above and below the area, Motion restoration, Muscle and neuromuscular rehab as any other lumbar patient |
| Mulligan's mobilizations-with movement (MWM) | novel manual therapy techniques to improve joint ROM by combining physiological and accessory joint movements. |
| MWM techniques incorporate a sustained accessory joint glide to correct the ___ ____ while a physiological motion that usually caused the pain is performed actively or passively | "positional fault" |
| What does SNAG stand for? | sustained natural apophyseal glide |
| how should SNAG procedure feel? | should not be painful, loss of motion should be restored |
| what motions can be addressed with SNAG procedure? | •flexion, extension and side bending. |
| what is only mm that attaches to anterior portion of sacrum? | pirifomis |
| what do L4 and L5 move in synchrony with? | the sacrum |
| how many joints make up pelvic girdle? | 11 |
| joints of pelvic girdle | •Two SI joints, Four lumbar facets- L4L5 and L5S1, Two hip joints, One pubic symphysis,Two intervertebral discs |
| intrinsic ligaments of pelvic girdle | •Anterior SI joint ligaments, Short posterior SI ligaments*, Long posterior SI joint ligaments* |
| All positional faults of ilium cause irritation of these ligaments: | •Short posterior SI ligaments, Long posterior SI joint ligaments |
| extrinsic ligaments of pelvic girdle | •Sacrotuberous -attached to the biceps femoris, Sacrospinous, Iliolumbar |
| posterior mm of the pelvic girdle | Latissimus dorsi, Erector spinae, Multifidus, Quadratus lumborum, Gluteus maximus, Hamstrings |
| anterior mm of the pelvic girdle | Rectus abdominus, TrA, internal and external oblique, Iliacus, Psoas major and minor, Rectus femoris, TFL, Sartorius, **Piriformis** |
| Piriformis origin and insertion | Origin: Anterior surface of sacrum S2 to S4 plus Sacro tuberous lig Insertion: Greater trochanter of femur |
| lateral mm of pelvic girdle | •Gluteus medius, Gluteus minimus, TFL/ IT Band |
| medial mm of pelvic girdle | gracilis and adductors (longus, brevis, magnus) |
| what movements are possible at the ilium on the sacrum? | anterior and posterior rotation, inflare and outflare, upslip |
| upslip is always accompanied by what? | rotation (anterior or posterior) |
| what movements are possible at the sacrum on the ilium? | L and R rotation, sacral flexion (nutation) or sacral extension (counternutation) |
| what is sacral flexion or nutation always accompanied by? | lumbar extension |
| what is sacral extension or counternutation always accompanied by? | lumbar flexion |
| what movements can occur at the pubic symphysis? | superior and inferior translation, rotation anterior or posterior |
| how should you choose intervention for SI joint? | Use intervention that the patient appreciates and likes, Use intervention that is easy to apply, no one fix all solution |
| where should you go back to if the SI joint won't clear? | lumbar spine |
| what might central symptoms indicate? | •Disc, Unlikely unilateral structure |
| what might unilateral symptoms indicate? | •Unilateral or central structure, Stenosis |
| what might bilateral symptoms indicate? | •Spondylolisthesis,Stenosis, Disc, Neoplasm |
Created by:
bdavis53102
Popular Physical Therapy sets