Question | Answer |
Sustained positions may be necessary to... | expose a derangement
reduce a derangement or dysfunction |
Interventions | Extension
Flexion
Rotation
Combined movements
Mobilization with Movement
Manipulation |
Purpose of extension interventions | Reduce Posterior Derangement
Expose Anterior Derangement
Remodel Extension Dysfunction
Restore Inferior glide of Facet
Restore function and remodel tissue after anterior derangement |
Purpose of flexion interventions | Reduce anterior derangement
Expose posterior derangement
Remodel flexion dysfunctioin
restore superior glide of facet
Restore function and remodel tissue after reducing posterior derangement |
Purpose of rotation intervention | Reduce posterolateral derangement
Remodel rotation dysfunction
Restore superior glide of contralateral facet or inferior glide of ipsilateral facet |
Exposing and differentiating derangement/dysfunction/postural syndromes with flexion in standing | Repeated movement may expose derangement
Overpressure may expose dysfunction
Sustained may expose postural |
Hypotheses for lesions that respond to manual therapy | Release of entrapped synovial folds or plica
Relaxation of hypertonic muscles by sudden stretching
Disruption of articular or periarticular adhesions
Unbuckling of motion segments that have undergone disproportionate displacements |
Pop or Crack... | Cavitation occurs as dissolved gases in the synovial fluid are released when intracapsular pressure suddenly decreases |
Differentiate mobilization from manipulation | Speed of technique: manipulations are quick short movements |
Contraindications to mobilization/manipulation | lack of diagnosis
lack of pt consent
Bony issues: tumor, infection, metabolic, congenital, iatrogenic, inflammatory, traumatic
Neurologic: cervical myelopathy, cord compression, cauda equina, nerve root compression with increasing neuro deficit
Vascul |
Precautions to mobilization/manipulation | adverse reaction to previous manual therapy
Disc herniation/prolapse
Pregnancy
Spondylolisthesis
Psychological dependence upon manipulative techniques
Ligamentous laxity |
Serious/nonreversible complications of manual therapy | death
CVA
cord compression
cauda equina |
Substantive reversible complications of manual therapy | disc herniation/prolapse
nerve root compression
fracture |
Transient impairment complications of manual therapy | local pain
headache
tiredness
radiating pain
paresthesia
dizziness
fainting
nausea
hot skin |
Causes of complications: incorrect pt selection | lack of diagnosis
lack of awareness of possible complications
inadequate palpation assessments
inappropriate or inadequate progression of forces
lack of pt consent |
causes of complications of manual therapy: poor techniques | excessive force
excessive amplitude
excessive leverage
inappropriate combination of leverage
incorrect plane of thrust
poor pt positioning
poor therapist positioning
lack of pt feedback |
CPR for thoracic manipulation for mechanical neck pain | symptoms less than 30 days
no symptoms distal to shoulder
looking up does not aggravate symptoms
FABQ physical activity subscale less than 12
diminished upper t-spine kyphosis
cervical extension ROM greater than 30 |
Cervicothoracic manipulation for shoulder pain | pain free active shoulder flexion greater than 127
shoulder internal rotation greater than 53
negative neer impingement test
not taking medication for shoulder pain
duration of symptoms less than 90 days |
Characteristics of thoracic vertebrae | 12 thoracic vertebrae
primary kyphotic curve
rotation limitation because of facet orientation and ribs
ribs protect internal organs and provide stability while aiding in breathing |
What are the transitional vertebrae | T1, T11, T12
located at regional junctions
usually possess characteristics common to two regions |
Facet orientation | superior facet faces posterior
inferior facet faces anterior |
Upper T-spine regional motion | limited by rigidity of ribs
frontal plane facet orientation |
lower t-spine regional motion | more flex/ext due to more sagittal facet orientation
motion coupling |
Spinous processes | project inferiorly to level of body of segment below |
ALL | ant/lat surface of vertebral bodies
superficial fibers cross several segments
deep fibers cross 2 segments, blend with annulus
limits extension
2x as strong as PLL |
PLL | in vertebral canal
posterior aspect of body
from C2-sacrum
narrow in L-spine so less support
limits flexion |
Supraspinous lig | tips of spinous processes from C7-sacrum
first to fail with hyperflexion injuries
becomes ligamentum nuchea in c-spine |
Ligamentum flavum | runs in post spinal canal from lamina to lamina C2-sacrum
resists flexion, under some tension in neutral |
costovertebral joint | synovial joint
formed by head of rib, two adjacent vertebral bodies, intervertebral disc
demifacets convex
rib facets are convex, vertebrae are concave
ribs 1, 10, 11, 12 are more mobile because they articulate with only 1 vertebrae |
costotransverse joint | synovial
articulation of costal tubercle of rib with costal facet on transverse process
costotransverse lig--3 portions |
costochondral joint | synchondrosis
no ligamentous support |
chondrosternal joint | synchondrosis/synovial
radiate ligaments |
3 types of ribs | True
False
Floating |
rib motions | pump
bucket handle |
disc height to body height in thoracic vertebrae | 1:5
due to limited mobility |
Fryette's law 1 | segment in neutral--rotation occurs opposite of sidebending |
Fryette's law 2 | segment in full flex or ext--rotation occurs same as sidebending |
Fryette's law 3 | Motion introduced in any plane reduces motion in all other planes |
Clinical considerations of T-spine | 1-2% of spinal problems
lower c-spine can refer to upper t-spine
upper t-spine tends to relate to hypomobility |
systemic sx (red flags) | wt. loss (unexplained), night pain, fever |
systemic causes | pleuropulmonary: pneumonia, emphysema, pleurisy, spontaneous pneumothorax, lung CA
GI: peptic ulcers, pancreatic carcinoma, cholecystitis, esophagitis
pyelonephritis
MI |
Scheuermann's disease presentation | in young
condition of slow growth of ant aspect of vertebrae
leads to kyphosis
no history of pain due to disease but growing kyphosis
findings: incr. kyphosis, if correctable=postural, no pain, incr risk of disc derangement or degeneration stressed ti |
Scheuermann's disease intervention | bracing can reduce curve if still growing
surgery
for those skeletally mature, posture, stabilization exercise, modalities as applicable, bracing to reduce pain |
Thoracic compression fx presentation | osteoporosis
elderly
long term corticosteroid use
trauma if no OP
benign activity if OP
sharp, local pain
constant or intermittant
pain incr with flex
protective mm spasm
better sitting up or standing
best reclined or supine
kyphotic
x-ray=ant |
thoracic compression fx intervention | posture
modalities for pain
meds per physician: pain and anti-inflammatories
activity modification
bracing
kyphoplasty if bracing fails |
Dowager's hump | multiple ant. compression fx
post menopausal osteoporosis, long term corticosteroid use |
Hump back (Gibbus) | localized sharp angulation due to 1-2 level ant. wedging due to fx, infection, congenital anomaly |
Flat back | decreased pelvic inclination, increased kyphosis, mobile t-spine
with nonmobile lumbar and hypermobile thoracic, work on mobility with lumbar and stability with thoracic |
Scoliosis | lateral curvature of t-spine
combined with rotation=rotoscoliosis
points to right=right
75-85% ideopathic
structural=fixed
nonstructural=correctable (rib hump decr in FF)
Adaptive=poor posture, ANR, leg-length, hip contracture |
Cobb Angle | line drawn parallel to superior cortical plate at prox end vert and to inf cortical plate at distal end vert
perpendicular line drawn to each of these
angle at intersection is angle of curvature |
Scoliosis intervention | posture--stretch into curve
education
exercise
muscle balance
manual therapyy
bracing: boston, milwaukee
curves >40 require intervention
curves higher in spine progress more
females more likely to progress |
2 types of breathing | diaphragmatic=deeper---what we want
chest/accessory=shallow
if accessory muscle are overused or overactive they become painful |
Barrel lung | hyperinflation chest deformity
smokers
COPD: emphysema, chronic bronchitis |
Pigeon chest | pectus carinatum
result of childhood respiratory illness
forward, downward projection of sternum
incr a/p diameter |
Pectus excavatum | funnel chest
marfan's syndrome
post. projecting sternum due to outgrowth of ribs |
what to look for with t-spine assessment | quantity (asymmetrical movement)
quality (compensatory movement)
provocation (pain/symptom reproduction)
end feel |
Flexion | normal 20-45
seated so no pelvic motion or hamstrings |
Extension | 15-20 normal |
Measuring methods | inclinometer at T1 and T12
subtract T12 from T1
measure distance between T7 and T12
2.5 cm difference from neutral to ext normal |
Rotation | 35-50 normal
20 functional |
Sidebending | 25-40 normal |
Passive neck flexion | seated, fully flex neck
stretches dura of cerv and thor region
may indicate dural irritation or dural meningitis |
passive scapular approximation | T1-T2 dural stretch
pt. seated protracts & retracts shoulders
PT overpressure
retraction pulls on thoracic extent of dura mater
if positive suspect upper thoracic space occupying lesion (HNP, tumor) |
Scalene mm length test | contralat neck lat flex and ipsilat rotation limited |
pec major mm length test | limited horiz abd and lat rot
lower portion=flex and abd limited |
pec minor mm length test | depressed coracoid fwd and downward |
lat mm length test | limits arm flex & abd, depresses shoulder girdle downward and forward |
Functional testing includes... | deep inhilation, exhilation, cough
posture correction--achieve & maintain
active flex, ext, sb, rot of trunk
shoulder flex, horiz add, abd, scap retrac/protrac
gait observation |
palpation includes... | spinous processes
pinch test
transverse processes
accessory joint glides
costo-vertebral palpation
ribs, costal cartilages, intercostal spaces of ribs 2-10
mm/soft tissue--spasm, pain atrophy
abdomen-tenderness, distention, rebound tenderness |
Visceral pain presents as... | dull, vague, may be accompanied by nausea or sweating, can refer to different areas of thorax |
Acute Facet Dysfunction | pain local or referred, unilateral
acute onset, insidious, pain with lifting, reaching, bending
limitation > in one direction than other
limited ext/SB toward or flex/SB away, pain PA mobs, unilat mobs pain on one side, mm spasm
dx: neg except facet |
Acute Facet Dysfunction intervention | prognosis good if isolated lesion
posture, body mechanics, exercise, mobilization/manipulation |
Thoracic derangement | acute or chronic, constant or intermittent, know what makes better, occupation with repeated movement or sustained flex, flex or rot produces, incr, periph pain; ext or opp rot central, reduces, abolishes pain
x-ray neg, MRI pos or neg |
Thoracic derangement intervention | posture, exercise into direction of preference, body mechanics/ergonomics, mobilization/manipulation |
Thoracic dysfunction | some hx of trauma/surgery, 6-8 wks min
intermittant, localized pain unless ANR
ERP
ROM limitation?
consistent will not change quickly
diagnostics neg
prognosis good if follow recommendations
treatment stretch tissue |
Postural syndrome | pain with sustained postures/positions
local, intermittant pain
negative exam findings except sustained positions
diagnostics neg
prognosis excellent
tx: posture, ergonomics |
differentiating rib and t-spine | rule out c-spine
if flex is limited have pt take deep breath and hold then flex until pain is felt
if able to flex further after exhaling, suggests rib involvement
rib springing while blocking thoracic motion |
costal sprains | local pain, usually history of trauma, will hurt with thoracic movement, breathing , rib springing
treat inflammation, activity modification, brace/girdle, stretching as tolerated to prevent dysfunction |
First rib syndrome | local or diffuse neck or shoulder pain
tenderness over first rib, spasm and pain over local mm, rib feel elevated vs other
loss of neck ROM or provocation of neuro/vascular sx may occur with certain positions of neck
treat with rib and soft tissue mobs |
Rib dysfunctions | pain 3-4 cm from midline in region of CV jt
often secondary to trauma
painful with inspiration or expiration
hypermobility: posture, breathing, exercise, brace, avoid agg factors
hypomobility: mobilize, stretch |