Medical Diagnosis Reference Sheets

The purpose of this exercise is not to improve your skills in transcription but rather it is intended to increase your knowledge and understanding of common pathologies that lead to or are associated with spinal pain and dysfunction. The information needed to complete these pages can be found in a variety of resources that include your textbooks, web resources, journals, medical dictionaries, etc. In general, the information should be consistent across all resources with only minor variations on the same theme.

It is strongly recommended that you utilize at least two resources in completing these pages. They will serve as a future reference for you when you are in the clinic. The first one is completed for you as an example. The diagnostic titles may or may not be consistent across all resources and all may not be found in one resource requiring you to consult other sources.

As you complete these pages, be diligent in your approach and do not procrastinate. Remember the purpose of the task is not to consume ink or lead and kill trees but to facilitate your knowledge, understanding and clinical expertise.

Lumbar Spinal Degenerative Stenosis | Cervical Stenosis | Spondylolysis/Spondylolisthesis | Ankylosing Spondylitis | Fibromyalgia/Chronic Pain | Vertebral Compression Fracture | Adverse Neural Tension/Nerve Entrapment | Degenerative Disc Disease | Facet Sprain | Facet Impingement/Restriction | Piriformis Syndrome/Sciatica | Thoracic Outlet Syndrome | HNP without Nerve Root Impingement | HNP with Nerve Root Impingement | Extension Bias | Flexion Bias | Stabilization | Mobilization




Lumbar Spinal Degenerative Stenosis




Relevant History/Onset of symptoms:
Lumbar spinal stenosis is a degenerative process that leads to a progressive reduction in the canal space that contains neurological tissue. Central canal stenosis leads to a reduction in diameter of the canal that houses and protects the spinal cord. Foraminal stenosis leads to a reduction in the diameter of the intervertebral foramen that houses the nerve roots. This process is usually triggered by severe trauma or a history of spinal abuse through faulty posture and mechanics. The disease progresses before any clinic signs or symptoms are noticed by the patient.

Lumbar stenosis symptoms are often characterized by pain that develops slowly over time and is described as coming and going (instead of continuous pain), as well as pain that occurs with certain activities and is relieved with rest. Lumbar spinal stenosis will also have an affect on the sciatic nerve, causing radiating symptoms into the back of the leg. The compressed nerve can produce the following common symptoms in the lower extremities: tingling, numbness, and weakness. These symptoms are brought on or increased with activities performed in standing or other positions of increased spinal extension.


Tissue Involved: Spinal stenosis can be due to hypertrophy of the spinal ligaments or due to abnormal boney growth. It should be noted that stenosis can occur when there is a reduction in the spaces that house the neural tissues. Non-degenerative causes include HNP, tumors and other space occupying lesions. The pain that is noted by patients is due to compression or encroachment on the neural tissues. There is no pain resulting from the tissues that demonstrate degenerative changes.

Link for video: http://www.spineandscoliosis.com/subject.php?pn=animate-stenosis
https://akron.ithaca.edu/webct/urw/lc5122001.tp0/cobaltMainFrame.dowebct
http://www.youtube.com/watch?v=9sjYXaFyGc4


Impact of process on tissue:
Degenerative changes occur in bones and ligaments as described above. This process is slow and progressive.
external image images?q=tbn:ANd9GcTaWM2tJP-HCsUgGfiTKhweHE91P9_SDMjPG9Uo5ko1Ppcm6s4FXQexternal image images?q=tbn:ANd9GcSWDha6ICECv0ACdMwloG_xLEy2F8WYBGE02Doi6cbXqLk-7KIJ

Examination Findings:
Patients tend to be middle to late age and frequently have other degenerative diagnoses such as peripheral joint DJD. They will frequently have decreased spinal motion. Significant findings include neurological signs especially when the spine is placed in positions that further reduce the spaces that house neurological tissue (ie spinal extension – intervertebral foraminal stenosis) These findings include radicular pain in both lower extremities in the presence of foraminal stenosis and upper motor neuron signs in the presence of canal stenosis. As there is no UMN’s in the lower lumbar spine (cauda equina) these UMN findings may not be present in lumbar stenosis. When radicular symptoms are provoked they are frequently relieved by assuming positions that reverse the closing down of spaces that house neural tissue. This hallmark finding is known as neurogenic claudication and can be confused with intermittent vascular claudication.


Diagnostic testing:
Imaging can reveal the degenerative process long before clinical symptoms bring a patient to therapy. In the case of claudication, radicular symptoms are produced in positions of extension and reduced in positions of flexion. A common test is a treadmill test where a patient walks until symptoms are produced and then sits in flexion and symptoms abolish. When treadmill walking is performed with an incline (produces spinal flexion) symptoms are less irritable or not present. Pedaling a stationery bike in a slouched position is asymptomatic. The individual should not have symptoms when exercising in a flexed position (such as when using a recumbent bike) because this position reduces the stress on the nerves involved. However, if the individual continues to experience symptoms in his/her lower extremities during the exercise, it is most likely caused by intermittent vascular claudication. In this condition, the blocked artery reduces the blood flow and oxygen supply to the muscles involved in the aerobic activity. Therefore, these tests (stationary bike and inclined treadmill walking) can be helpful in differentiating between a vascular condition and neurogenic claudicaiton.

Non-PT Interventions: Anti-inflammatory medications are helpful in reducing neural inflammation. In severe cases foraminotomy procedures can be performed to restore the canal space but are often of minimal long term benefit. In severe cases, surgical removal of portions of the involved facets will be performed to fully decompress the neural tissue. In these severe cases, surgical fusion of the vertebra involved is common to decrease the possibility of spondylolisthesis after decompression. According to spineuniverse.com, 80-90 % postoperative patients have relief of their pain after surgical decompression is performed. An epidural can also be performed as a means of local anesthetic for pain or a direct anti-inflammatory to the area of pain.

The laminectomy and foraminotomy procedures are typically performed in the cervical spine.
Complementary and Alternative Medicine (CAM): acupuncture, massage, etc


PT Interventions:
Patient education in posture and body-mechanics can slow the degenerative process. In late stage cases exercises to bias toward flexed postures can help control neurologic symptoms because flexion will increase the spinal canal space, relieving the compressed neural tissue. This can include pelvic tilting, abdominal strengthening, core training and stability exercises.
Some example exercises are shown here - http://www.spineuniverse.com/conditions/spinal-stenosis/video-series-exercises-spinal-stenosis. Another helpful PT intervention is lumbar/cervical traction to increase the spinal canal space. Link to traction video: http://www.youtube.com/watch?v=XfNa8xhION4
http://www.youtube.com/watch?v=zN1XS_vlUqY&feature=related


Prognosis:
Progressive degenerative process. Presentation worsens, symptomatic control at best. Address compensations that may need to be made and alterations in movement patterns to minimize pain.

Applicable Case Studies
Mary-Lou Whittaker is a 70 y/o woman who arrives in the clinic with complaints of back pain. She states "My back hasn't ever really felt great but now its really becoming a problem." She further illustrates this point stating that she gets more pain and a strange tingle in her legs every time she reaches into her overhead cabinets. She loves cooking for her husband, Hank every day, but states it is really becoming a bother. Afterwords she insists on knitting in her favorite recliner until she falls asleep. When you ask the Mary-Lou to have a seat so you can observe her posture she tries to sit up straight but complains of pain throughout her lower back that spread into her right upper thigh. Medical history includes osteoporosis, for which the patient states she is taking nutritional supplements. Patient states she has been beginning to have pain in her neck when she is knitting and fears that the problem is spreading throughout her body.




Cervical Stenosis



Relevant History/Onset of symptoms:
Cervical spinal stenosis is a narrowing of the cervical region of the spine; either in the central canal or vertebral foramen. Central canal stenosis involves narrowing of the central canal in one or more vertebrae. Narrowing is typically due to ossification of the inner part of the canal, causing irritation of the spinal cord. Foraminal stenosis can be a result of degenerative disc disease. As a human ages, their vertebral discs tend to lose height due to decreased water retention. As a result, foraminal space is reduced and nerve tissue may become compromised. Foraminal stenosis may also be a result of bone ossification, due to skeletal disorders or increased pressure as described by Wolff's law.


Tissue Involved:
Cervical stensosis involves tissues including vertebrae, intervertebral discs, and nerve tissue. Healthy vertebrae form foramen, or openings, for nerves to pass through. As these spaces are compromised, due to bony abnormalities or disc degeneration, nerve tissue may then become compressed and inflamed. This can lead to neural symptoms related to the level of the spinal cord involved. If canal stenosis is seen from C5-C7, diffuse neurological impairments can be seen at all levels below C5, including thigh and leg symptoms due to the compression of the spinal cord.


Impact of process on tissue:
This process is typically insidious, causing minor irritation of a nerve at first, it may lead to serious neural deficits if not addressed.

Examination Findings (* the key indicators):
Findings are typically related to motions that reduce the size of the intervertebral or central foramen (e.g. extension, sidebending to involved side or rotation to involved side in the cervical region due to its coupled motion). Symptoms are typically insidious, and found in older adults. Patients tend to feel better with motions that decrease neural tension or increase the size of the foramen. In central canal stenosis, flexion may increase symptoms by increasing neural tension of the spinal cord onto the anterior aspect of the central canal, further irritating the tissue. In foraminal stenosis, flexion may relieve symptoms by opening the intervertebral foramen and reducing pressure on the nerve.



Diagnostic testing:
MRIs can show the spinal cord, nerve roots and surrounding spaces to see degenerative changes
X-rays can detect the bone changes and calcification


Non-PT Interventions:
Anti-steroidal drugs to reduce swelling and pain.
Corticosteroid injections help reduce swelling and treat pain that radiates to hips/leg. The pain relief may only be temporary. Patients shouldn't get more than 3 injections in a 6 month period.
Surgery: Laminotomy, Foraminotomy, facectomy, discectomy, corpectomy, laminoplasty.
Complementary and Alternative Medicine (CAM): acupuncture, massage, etc


PT Interventions:
Exercises to build endurance, increase flexibility, and stabilize the spine.
Deep tissue massage, TENS, hot and cold therapies, US to help with pain
Home adaptations to allow pt. to perform ADLs with increased ease.

Prognosis: It is a progressive degenerative process. Presentation will worsen and control symptomatically.






Spondylolysis/Spondylolisthesis




Relevant History/Onset of symptoms:
When one vertebra slips forward over the one beneath it. Most common in low back because of amount of weight bearing and directional forces. Can result from repeated stresses or strains.
Highest mechanical stress at L5 (most common site).
Common in divers, football players, weight lifters, gymnasts (teenage athletes)

The most common symptom of spondylolisthesis is low back pain. This is often worse after exercises especially with extension of the lumbar spine. Other symptoms include tightness of the hamstrings and decreased range of motion of the lower back into the direction of lumbar flexion. Some patients can develop pain, numbness, tingling or weakness in the legs due to nerve compression

Types I and II (Dypslastic/Degenerative or Isthmic)
Isthmic most common in young children (5-7 y.o.)

Factors that increase the likelihood of spondylolysthesis:
  • hypermobility
  • jutter when attempting to touch hands to floor from standing (flexion)
  • atrophy and fat infilitration of multifidi
  • decreased space between facet joints in lumbar region

Tissue Involved:
external image moz-screenshot-3.pngSpondylolisthesis2.jpg
Lumbar Vertebrae - most commonly L4-L5 or L5-S1.
Degenerative Spondylolesthesis: Vertebral joints (facet joints) weaken causing the vertebrae to slip anteriorly.
Isthmic Spondylolesthesis: Vertebrae is fractured (at the pars interarticularis - facet joint connector) , which causes the vertebrade to slip anteriorly.This very thin piece of bone has poor blood supply, which makes it susceptible to stress fractures. The fracture is not likely to cause pain or symptoms, and is not likely caused by trauma, but more likely cumulative stress.
The pars interarticularis (latin for “bridge between two joints”) is the boney connection between the superior and inferior articular processes of the facet joint. It is a very thin piece of bone with a poor blood supply, which makes it susceptible to stress fractures. When it fractures there usually it usually does not cause pain or other symptoms. Trauma is not a common reason for fracturing. The fracture is due to cumulative stress, analogous to taking a paper clip and bending it multiple times. It will eventually break apart after enough stress.
Both conditions may involve either the spinal cord or nerve roots, or in serious cases, both.
external image spondy.jpg

http://www.youtube.com/watch?v=SUSoeLEwvQo


Impact of process on tissue:
Can cause compression on nerve roots, leading to neurological changes (change in sensation, reflexes, muscle tone)

Examination Findings (* the key indicators):
May present with an increased lordosis
Many patients present with no pain associated with this problem. However, symptoms can range from mild to severe in other patients. Symptoms may include:
  • Low back pain and tenderness
  • Buttock pain
  • Thigh and leg pain and/or weakness (one or both)
  • Difficulty controlling bowel and bladder functions (in advanced cases - consider cauda equina)
  • Tight hip flexors
  • Walking resembles waddling movements
  • Swayback (lordosis)
  • Protruding abdomen
Can cause a pt. to walk abnormally.
May c/o back "giving way"
Inc muscle banding across low back at the level of the spondylolisthesis

Graded as I-V slip (depending on degree of displacement)
  • Grade I is a less than 25% slip.
  • Grade II is a 25-49% slip.
  • Grade III is a 50-74% slip.
  • Grade IV is a 75-99% slip.
  • Grade V is for a vertebra that has fallen off the vertebra below it
Grade I & II mostly likely treatable without surgical intervention

Diagnostic testing:
X-rays. Neurological exam.
SLR Test may be painful.

Non-PT Interventions:
Bracing.
Meds for pain control.
Chiropractic manipulation.
Surgery. ex. spinal fusion. bone grafting with or without hardware which includes fixation with pedicle screws. Most fixation procedures in the cervical spine, including fixation with pedicle screws, are typically performed with an anterior approach.
Epidural injections of lidocaine @ pars interarticularis to reduce inflammation
Complementary and Alternative Medicine (CAM): acupuncture, massage, etc

PT Interventions:
According to Spine Universe A physical therapy program is one of the more effective ways to treat spondylolisthesis for two main reasons: it can help strengthen the muscles that support your spine, and it can teach you how to keep your spine safe and prevent further and future injury. Education to avoid activites that increase hyperextension
If surgical fusion was performed on the patient, allow a period of immobility to enhance the fusion process. Then focus on stabilization, functional mobility and activity. May need to focus on new movement patterns and increasing hip and shoulder flexibility to help compensate.
Passive treatments first to relax and let your body heal. Then progress to active treatments (ther ex) to help strenghten body and prevent recurrence.
Strengthen mm. supporting spine.
directional exercises (Flexion)
  • Pelvic tilts to hold the spine in lumbar flexion
  • Ab Curls
  • Alternating Marching
Deep Tissue Massage to target spasms/tension.
TENS
US
Increase flexibility (esp hamstrings), core stability, ROM
Postural education
Lumbar spine mobilizations/manipulations
Need to focus on strengthening of multifidus and transverse abdominis muscles by doing core exercises. Through research the most effective cue to contract the transverse abdominis is: pull bellybutton up and into the ribcage. Strengthening exercises for the multifidus should incorporate arm and leg movements such as the dead bug exercise and proprioceptive (balance) activities.
link to core exercise videos: http://www.youtube.com/watch?v=D_TzNCUA7uM
http://www.youtube.com/watch?v=SxZOYylKPow&feature=channel


Prognosis:
In young patients with spondylolisthesis, surgical fusion with or without decompression may be curative, and no further intervention may be required. Individuals who have sustained an acute fracture with minimal slippage may completely recover if the fracture heals. Individuals with progressive degenerative changes may continue to have intermittent symptoms. Surgery can be curative, but some individuals may experience only partial or intermittent relief.
Spondylolesthesis very common in the population, but majority of people with it are asymptomatic - only 15-20% have surgical interventions. Most are treatable cases.
Surgery is usually indicated after patient has not seen progress in ~6 months.







Ankylosing Spondylitis


Relevant History/Onset of symptoms: It develops slowly
-family history of AS
-usually first occurs between 15 and 45, average age of 24
-affects white males ~4x as often as females
-in early stages of the disease the SI joints become inflamed and painful
-earliest signs of AS is tenderness around the SI joints and low back pain that may spread down into the buttocks and thighs
-common in patients suffering from frequent GI infections
-Symptoms worse in the morning or after periods of inactivity
-May be accompanied with fatigue, loss of appetite, weight loss, difficulty breathing, bowel inflammation or eye inflammation (causing pain, sensitivity or blurred vision)

Tissue Involved: Joints and ligaments in the back become inflamed and is a form of arthritis. In early stage the sacroiliac joint is painful and inflamed first. As the disease progresses ossification is triggered as a defense mechanism. As the disease progresses, ossification is triggered by the body's defense mechanism. SInce movement is causing pain the body makes new bone to limit movement. This ossification causes new bone to grow between vertebrae, eventually fusing them together and increasing the risk for fracture. When ossification continues it can cause affect ligaments in the spine causing spinal stenosis.

Impact of process on tissue:
Bone formation and vertebral fusions causes stiffness throughout spine and also through ribcage.

Examination Findings (* the key indicators):
Chronic inflammatory disease characterized by pain and progressive stiffness. In the early stages of the disease, the sacroiliac joints become inflamed and painful. One of the earliest signs of AS is tenderness around the sacroiliac joints. Another early symptom is low back pain that may spread down into the buttocks and thighs. Pain varies in intensity and duration, and it is episodic. Stiffness is usually worse in the morning and improves with exercise. Later on it can cause spinal stenosis which can result in neurologic deficit. Other symptoms include limited motion in the lumbar spine that generally moves up to the neck, pain and tenderness in shoulders, hips and knees and inflammation of the intervertebral disc or disc space results in abnormal vertebral motion and pain. Cauda Equina Syndrome may develop. Normal chest expansion may be compromised.
Patients who have developed ossifications often present with increased kyphosis.
Pain levels/symptoms may vary drastically, however almost all patients report "flare ups"
external image images?q=tbn:ANd9GcQ9BfACFVe5k_Eg89xJStYg1nrnmL7Ao6mtBY7qIZDPfsAXrrre
Diagnostic testing:
-Schober test: measures the degree of lumbar forward flexion
-Gaenslen test: stresses the sacroiliac joint, increase pain could be indicative of AS
-Chin Brow measurement: measures the spine's curve in the neck, patients with AS often have necks that angle sharply as the spine stiffens
-chest expansion: measured from deep expiration to full inspiration
-ROM
-Neurologic evaluation (necessary for patients with a spine disorder)
-x-rays

Non-PT Interventions: NSAIDs. Surgery including an Osteotomy, Decompression and Spinal Instrumentation and fusion.
-TLSO (thoracolumbar sacral orthotic)
-halo brace

PT Interventions:
-exercise to help maintain ROM, strengthen back muscles
-improve posture
-increase flexibility
-techniques to enhance breathing
-encourage patients to spend as much time in the prone position as possible to gain more spinal extension

Prognosis: The management of pain and the control of inflammation can reduce the daily symptoms. AS is often chronic but very few people are severely impacted. Maintaining good posture and continuing with an exercise program can also help the individual to control many effects of AS.




Fibromyalgia/Chronic Pain


Relevant History/Onset of symptoms: Fibromyalgia is a chronic pain syndrome characterized by widespread pain and allodynia that can be found all over the body bilaterally. It affects multiple aspects of life: physical, mental and emotional/social.Typically, patients would have had widespread pain in neck, back, and/or UE/LE for more than three months and would present with fatigue, multiple tender points, muscle spasms and weakness, and muscle/joint stiffness. The pain that is associated is often described as a myofascial pain. Fibromyalgia is also often associated with anxiety and depression. It affects wo

Link to Fibromyalgia video: http://www.arthritisresearchuk.org/arthritis_information/arthritis_types__symptoms/fibromyalgia.aspx

Tissue Involved:
There is no known anatomical reason or cause for symptoms. However, many researchers believe it is a problem of central processing with neurotransmitter regulation.
Soft tissues around/near joints; muscular pain.

Impact of process on tissue:

Examination Findings (* the key indicators): Patients tend to have symptoms that may not correlate with typical findings of a mechanical examination of neck and low back pain. The American College of Rheumatology’s criteria for classification of fibromyalgia are bilateral pain above and below waist for more than three months and stimulation of pain in eleven out of eighteen possible “tender points” with 39 Newtons of force (about the amount of force needed to press and make a fingernail nail turn white).The nine paired "tender points" are:


photo of a woman showing the location of the nine paired tender points that comprise the 1990 American College of Rheumatology criteria for fibromyalgia
photo of a woman showing the location of the nine paired tender points that comprise the 1990 American College of Rheumatology criteria for fibromyalgia

Symptoms include: pain(chronic and widespread)*, fatigue that severely affects ADL's and lifestyle, and sleep disturbances.

Diagnostic testing:
Diagnosing Fibromyalgia is very difficult and often involves eliminating several other possible diagnoses which manifest similar symptoms (such as rheumatoid arthritis, lupus, ankylosing spondylitis, and chronic fatigue syndrome).Still, the American College of Rheumatology set specific criteria to allow proper diagnosis of fibromyalgia in 1990. They state that in order for a diagnosis to be fibromyalgia, the patient must have a history of widespread pain (shooting, aching, or burning) for at least in 3 months and experience pain in at least 11 of the 18 tender points. In addition to this, doctors will often order a variety of tests to rule out other condition (e.g. blood count to rule out anemia, Rheumatoid factor test, anti-nuclear antibody test to rule out lupus..etc).

Non-PT Interventions:
Muscle relaxants and opiates are often prescribed to help control symptoms. Acupuncture has been shown to help manage symptoms. Other treatments include herbal supplements, and yoga, in addition to other alternative therapy treatments.

PT Interventions: Aquatic therapy can help relax muscle tension and reduce fatigue. Manual therapy and massage can also help reduce myofascial pain and tension. Research shows that patients with fibromyalgia who participate in aquatic exercise programs can break the cycle of inactivity and manage their symptoms better. Aerobic exercise, in land and aquatic based therapy, is found to be extremely beneficial for patients with fibromyalgia.

Prognosis:
There is no cure for fibromyalgia. But symptoms can be managed with medication and physical therapy to better tolerate ADL's.






Vertebral Compression Fracture


Relevant History/Onset of symptoms:
Implies a crush/wedge injury (fall, picking up heavy weight). Result of some form of trauma
Ranges frommild to severe. A mild compression fracture causes minimal pain and deformity, and is treated with time and activity modification.
A severe compression fracture may involve the SC or n. roots (neurologic injury rare with compression fracture--degree of neurologic injury is usually due to amount of force present at time of injury; can cause weakness, sensory changes and reflex changes). Severe pain results, as well as a kyphosis.
Risk for spinal compression fractures increases with age. Osteoporosis is a common risk factor d/t the weakening of bones.

Patient over the age of 60 with acute onset of LBP
Difficult to diagnosis because the fracture is hard to see on an x-ray and often ruled out.
Estimated only 1/3 of compression fractures are diagnosed.

Tissue Involved:
Vertebral body

Impact of process on tissue:
external image compression.jpg
Examination Findings (* the key indicators):

Tenderness and sensitivity over specific vertebrate near the area of pain.
Mild kyphotic deformity (ex. Sudden angulation forward or hunched appearance)
external image 9499.jpg
Diagnostic testing:

Plain X-Ray
CAT scan, to differentiate between a compression fracture (front part of vertebral body is crushed, forming a wedge shape) and a burst fracture (when entire vertebral body breaks)
MRI, to rule out disc herniation and pathological fracture
BMD density scan to check for osteoporosis

Non-PT Interventions:
Rest

Bracing / Immobilization
Medication – Analgesics for pain management

Surgery
- Balloon Kyphoplasty
external image BalloonKyphoplasty2.jpg
- Vertebroplasty

PT Interventions:
Back extension exercises, core stabilization exercises
Weight bearing exercises

Prognosis: Most compression fractures from trauma will heal in 8-10 weeks with rest, bracing, and pain medication. If surgery is neccessary, the recovery time will be longer. Fractures that are due to osteoporosis, usually become less painful with rest and pain medication. In some individuals with osteoporosis, this may cause chronic pain and disability. Medication to prevent future fractures in patients with osteoporosis is available. Compression fractures caused by tumors have variable outcomes. The outcome is dependent on the type of tumor involved. Some common tumors that may involve the spine include: Breast Cancer, Lung Cancer, Lymphoma, & Prostate Cancer. Some complications in recovering from compression fractures includes: failure of the bones to fuse (if surgery is neccessary), kyphosis, & spinal cord or nerve root compression.







Adverse Neural Tension/Nerve Entrapment


Relevant History/Onset of symptoms:
Adverse Neural Tension is excessive n. tightness or sticking. This can be caused by a disc bulge, spine changes, or scar tissue.
Often involved in UE and LE conditions such as hamstring strains/tightness or CTS/wrist pain (sciatic and median nn.)
Nerve entrapment refers to a nerve getting "trapped" or having sustained pressure against it due to a tight muscle or postural stress.

Tissue Involved:
Nerve
Piriformis syndrome is caused by entrapment of the sciatic n. as it leaves the greater sciatic notch in the gluteal region.
Common Points of Entrapment
Ulnar Nerve
  • Cubital Tunnel: Symptoms include ache /pain at the medial elbow radiating into the hand and parasthesia along the medial surface of the hand. Functional losses commonly associated with entrapment distal to the cubital tunnel can also be found.
  • Guyon’s Canal: Symptoms include; parasthesia throughout the medial hand but not proximal to it, weakness of hypothenar muscles and decreased grip / finger opposition strength, and the inability to adduct the 5th digit which is known as Wartenburg’s Sign.
Median Nerve
  • Pronator Teres- Pain increases with pressure from flexion and pronation. Patients present with weakness of the FDS, FDP, FPL, and PQ
  • Branching to the anterior interosseous nerve- Patients present with pain in the proximal forearm which increases with activity and weakness of the; FPL, FDP, PQ and lumbricals.
  • Transverse Carpal Ligament or the Carpal Tunnel- Patients present with insidious onset of pain, including nocturnal radiating pain. Patients with CTS will complain of a comparable sign with prolonged pressure on the carpal tunnel through end range wrist flexion.
Radial Nerve
  • Anterior to the head of the radius at the elbow


· Tendinous margin of ECRB
· Proximal edge of Supinator
· Patients present with pain/parasthesia distal to the point of entrapment and with decreased motor function in extension and resisted supination


Impact of process on tissue:
Inflammation around nerve. Compromised n. elasticity.

Examination Findings (* the key indicators):
recreation of symptoms during ULTT/LLTT

Diagnostic testing:
Neural tension testing.
  • Ulnar n.-Scapular Depression, Glenohumeral abd. & ext. rot., wrist and finger ext., forearm pronation, elbow flex (hand to ear), contralateral cervical sidebend.
  • Median n.- Scapular depression, GH abd. & ext rot., Forearm SUP, elbow EXT, contralat. cervical SB.
  • Radial n.- Scapular depression, ~10 degrees GH abd& int rot, forearm pronation, wrist flexion w/ ulnar deviation, contralat. cervical SB.
Nerve conduction studies.
Special tests designated for involved n.
ULTT/LLTT
ULTT examples on Youtube

Non-PT Interventions:
Chiropractic manipulation
Surgical: Removal of structure causing the entrapment, example: soft tissue.

PT Interventions:
Provide patient with exercises to do on their own that will mobilize and stretch the affected n. such as nerve gliding/nerve flossing
If a n. is entrapped as a result of m. spasm or tightness, stretching exercises should be implemented to lengthen that m. and relieve the nerve.
If symptoms are resulting from a disc bulge or spine structural changes, mobilization or manipulation may be required. Exercises can also be introduced in that case to address a bulging disc.
Massage therapy/US to address m. tightness or spasm.
Postural education
PT Manipulation

Prognosis:



Degenerative Disc Disease


Relevant History/Onset of symptoms:
Degenerative Disc Disease is a progressive disease most commonly with an insidious onset. The intervertebral disc is prone to the degenerative changes due to wear and tear, and aging; the disc becomes thinner and stiffer. It is most common in the lumbar and cervical spine. Smoking increases the risk of developing DDD as it decreases the amount of water in the disc. Additionally, a history of heavy lifting is common in patients with DDD.

degenerative-spine.gif

Link for video: http://www.spineandscoliosis.com/subject.php?pn=animate-ddd
Tissue Involved:
Nucleus pulposus and annulus fibrosus. Later in the process the facet joints can also be affected as a secondarfy effect.

Impact of process on tissue:
Over time the collagen in the annulus weakens and the water content of the disc decreases causing the disc not to be able to handle mechanical stress.The disc loses it's "sponginess" and becomes thinner, decreasing the space between the vertebra. This change in the height of the disc also affects the facet joints. As a result, the facet joints actually can be HYPERmobile due to cartilage wearing which can lead to a secondary diagnosis of spinal stenosis (through osteophyte production and a narrowing of the intervertebral foramen).

Examination Findings (* the key indicators):
-Chronic neck or low back pain (may be acute flare ups)
-Pain from inflammation or from the annulus breaking down and not being able to resist motion of the spine.
-Back pain increases in sitting, bending, lifting and twisting
-Less pain with walking, running, or lying down
-Less pain with frequent position changes

Diagnostic testing:
-X-Ray, CT, Discogram, Myelogram--Not entirely reliable

Non-PT Interventions:
-Spinal fusion
-New treatment of artificial disc replacement, interbody fusion with/without hardware. Including fusion with fusion cage or bone graft.
Complementary and Alternative Medicine (CAM): acupuncture, massage, etc

PT Interventions:
-Disease Process Education
-Postural education
Link to exercises for DDD: http://www.spineuniverse.com/conditions/degenerative-disc/video-series-exercises-lumbar-degenerative-disc

Prognosis:
It is a progressive disease. Symptoms will continue to worsen. PT can treat symptoms but cannot cure disease.



Facet Sprain


Relevant History/Onset of symptoms:
Acute injury-can be with lifting, twisting, or excessive bending.
History of back pain; contracture has formed over time (Scar tissue shortening)
Poor posture (Adaptive shortening secondary to disuse)
Patients with a facet joint sprain may experience a sudden onset of back pain during the causative activity. However, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning. Symptoms are typically felt on one side of the spine and muscle spasm may be experienced around the affected joint. Occasionally pain may be referred into the buttocks or lower limb on the affected side. Symptoms are generally exacerbated with activities that involve twisting, lifting, arching backwards, bending forwards or sideways or sitting for prolonged periods of time.

Factors that may contribute to development of facet sprain:
  • poor posture
  • lumbar spine stiffness
  • a sedentary lifestyle
  • poor core stability
  • muscle weakness or tightness
  • inappropriate lifting technique
  • being overweight
  • a lifestyle involving large amounts of sitting, bending or lifting


Tissue Involved:
Facet Joint - bone and surrounding soft tissue - mostly ligaments
external image Facet-Joint.gif

Impact of process on tissue:

Examination Findings (* the key indicators):
Pain (localized)-in the acute stage; sx are similiar to a sprain elsewhere in the body
Guarding and muscle spasms
Swelling (in acute stage)
Decreased ROM-usually because one is hesitant to move after injury(disuse) or due to scar tissue adhesions limiting movement
Quality of movement - fribrus adhesions if seen in a chronic stage may drastically limit movement at the involved segment.

Diagnostic testing:
MRI-can detect ligament damage

Non-PT Interventions:
-rest from activity that increases pain

PT Interventions:
Want to move/direct treatment in the direction of pain to break painful adhesions and restore ROM
exercise-->
1. rotation in supine
Lumbar Rotation in Lying
Lumbar Rotation in Lying

2. prop on elbows in prone
Prone on Elbows
Prone on Elbows


- AROM for patients in sitting/standing can be a good initial HEP if the patient exhibits good posture during exercise in the clinic.
- PIVM with oscillation or sustained mobilizations to gently stretch and relieve pain in the involved segment.
- Grade 5 mobilizations used if prominent adhesions are noticed due to improper healing of a chronic sprain.


Prognosis:
-varies patient to patient depending on how soon they begin treatment after initial injury and compliance to the program
-typically takes 2-3 weeks if treatment starts soon after injury
-if patient seeks treatment in the chronic stage after adhesions have formed, therapy generally is lengthened


Facet Impingement/Restriction


Relevant History/Onset of symptoms:
Facet Restriction: Insidious, poor posture, history of trauma


Tissue Involved:

The meniscoid of a facet capsule may be entrapped, impinged, or stressed, which causes pain and muscle guarding. Overtime, stress is placed on the contralateral joint and on disk, which eventually lead to issues in these structures.

Impact of process on tissue:
History of whiplash will cause scar tissue to form which may restrict the facet joint
Poor posture can lead to adaptive shortening causing facet restriction

Examination Findings (* the key indicators):
-Limited range of motion depending on the direction and side of restriction
-Pain is localized and does not radiate.
- Loss of ROM and attempted movement induces pain.
- No pain at rest.
If you suspect lumbar facet upglide or opening restriction some special tests that should be performed to help you make your diagnosis is to first perform PA pressure to assess what segment/level is restricted, next facet upglide or opening PIVM to assess interspinous space (the amount of seperation should be relatively the same for each level; if a particular level does not separate when flexing the leg this indicated upglide or opening restriction at that level), and also the upglide or opening PIVM to assess transverse process movement (normally transverse process should remain level as both facets upglide; if on transverse process becomes more superficial this indicated an upglide or opening restriction on that side).
If you suspect a facet downglide or closing restrtiction some special tests you should perform to help you make your diagnosis is to first perform PA pressure to assess what segment/level is restricted, next facet downglide or closing PIVM to assess interspinous space (the amount of approximation should be relatively the same for each level; if a particular level does not approximate when extending the leg this indicates a downglide or closing restriction at that level), and also the facet downglide or closing PIVM to assess transverse process movement (normally transverse process should remain level as both facets downglide; if one transverse process becomes more superficial this indicates a downglide or closing restriction on the opposite side).
Diagnostic testing:
-x-ray
-CT to show surrounding tissues
-can use facet joint injection of x-ray contrast, anesthetic, cortisone; if pain is relieved there is facet joint involvment

Non-PT Interventions:
-anti-inflammatory medication
-neck collar or nighttime pillow
-bone fusion
-facet rhizotomy which destroys the innervation to facet joints also referred to as a medial branch block or rhizotomy

PT Interventions:
-hot/cold packs
-postural education
-TENS
-cervical or lumbar traction
-Lumbar manipulation if patient present with 4 or more of these predictive rules there is a 95% likelihood of dramatic outcomes. The predictive rules are: recent onset of less than 16 days, low FABQ < 19, no symptoms below the knee, lumbar hypomobility, and hip IR >35 degrees.
-Thoracic manipulation if patient present with 3 or more of these predictive rules there is a 86% likelihood do dramatic improvement. The predictive rules are: recent onset less than 30 days, low FABQ score <11, no symptoms distal to the shoulder, looking up does not increase symptoms, cervical extension <30 degrees, flat thoracic spine at T3-T5.
Lumbar spine manipulation link: http://www.youtube.com/watch?v=qqXcQ2KOkCY
Thoracic spine manipulation link: http://www.youtube.com/watch?v=qbS8kOmJ7_k

Prognosis:




Piriformis Syndrome/Sciatica


Relevant History/Onset of symptoms: insidious onset, overuse/repetitive motion injury, seen often in runners and most common in women.

external image piriformis.gif
Video link about Sciatica: hhttp:www.spine-health.com/video/sciatica-causes-and-treatments-video


Tissue Involved: tightness of the pirifomis muscle (actions: external rotation of the hip, balance on ipsilateral LE, and
stability for the pelvic region) The sciatic nerve runs under the piriformis muscle, so muscle spasms can compress the sciatic nerve

Impact of process on tissue:

  • piriformis tightness
  • pain at lateral hip jt
  • pain in central of buttocks*
  • sciatica*
*MAY be included in symptoms

Examination Findings (* the key indicators):
1. pain in and around the lateral hip jt
2. muscle tightness in piriformis
3. decreased ROM and guarding secondary to pain/tightness
4. increased tension in joint (could lead to bursitis)

Sciatica Symptoms:
Pain that travels from the low back, through the buttocks, downward into the leg, and sometimes into the foot. Numbness and tingling down leg.Leg weakness or numbness.Pain in the buttock or leg that is worse when sitting .A shooting pain that makes it difficult to stand up, and for some makes it difficult to walk

Diagnostic testing: Limited hip external rotation strength due to symptoms produced with contraction, limited internal rotation at the hip due to symptoms produced at end range and tenderness at the piriformis m.

Non-PT Interventions:
rest to prevent overuse! It is important to determine the cause of the piriformis muscle tightness/adaptive shortening or spasm and address those factors. After resting, restoring normal length and strength is critical.
Complementary and Alternative Medicine (CAM): acupuncture, massage, etc

PT Interventions:

  • modalities
  • massage
  • stretch
  • avoid repetitive motions
  • Pt education on positions to avoid, especially in sleeping (won't want to sleep in sidelying fetal position as will put muscle on a tensed position all night)
Prognosis: Pts heal following rest and treatment well and can return to activity





Thoracic Outlet Syndrome

Relevant History/Onset of symptoms: Insidious onset. Commonly seen in runners, students with heavy backpacks, poor postural habits (tight pec minor)

external image TOS_scalenes.JPG

Tissue Involved: Compression of the subclavian artery and/or brachial plexus

Impact of process on tissue:
The neurovascular bundle can be compressed in a number of areas. It could be compressed between the scalenes in the cervical region. Patients with this compression may have increased symptoms during heavy breathing when accessory muscles are needed to elevate the rib cage. The bundle may also be compressed between the clavicle and first rib. Often, these patients may have a cervical or shadow rib (an extra rib above C1) that predisposes them to compression of the neurovascular bundle in this region. Patients with this compression may c/o increased symptoms while carrying a back pack or heavy other heavy items on their shoulders. Also, the neurovascular bundle could be compressed due to tightness from the pec minor.

Examination Findings (* the key indicators): Symptoms may be neurogenic or vascular in origin. Parasthesia and "aching" pain over the whole arm. Symptoms are aggravated by carrying, lifting, or engaging in activities. Also, activities that cause increased respiration may increase symptoms. When present, muscle atrophy usually affects all the intrinsic muscles of the hand.

The patient may experience their pain limited to specific parts of their arm that follows the distribution of a specific nerve. The patient may have positive ULTT (ulnar n, radial n, or median n). Additionally, a patient may present with increased muscle tension in the scalenes, SCM and Levator. Increased tension/tightness especially of the scalenes can lead to the compression.

Key features in vascular compromise: Coldness, aching in the muscles, and loss of muscle strength.

Diagnostic testing:

Wright's test/maneuver: The examiner flexes the patient's elbow to 90 degrees while the shoulder is extended horizontally and rotated laterally. The patient then rotates the head away from the test side and the examiner checks the radial pulse. If the radial pulse disappears when the head is rotated away from the test side, then it is positive for TOS. Common for compression between the pec minor.

Costoclavicular syndrome: Examiner palpates the radial pulse and then brings the patient's shoulder down and back while the patient sits up straight looking forward. This is a positive test if the radial pulse dissipates. Common for compression between the clavicle and the first rib.

Adson Maneuver: Examiner finds the radial pulse and then rotates the patient's head to face the testing arm. The examiner laterally rotates and extends the patients shoulder while palpating the radial pulse. If the pulse disappears then this test is positive for TOS. Common for compression between the scalenes.
external image 0.jpg

Roo's Test: Patient sits up straight with both arms abducted to 90 degrees and externally rotated to 90 degrees so hands are point straight towards ceiling. The patient then repeated opens and closes their hand (like the talking gesture!) for 3 minutes. If the patient has a reproduction of their symptoms, severe fatigue, or loss of position then this is a positive sign for TOS.
external image picture%203.jpg
X-Ray of the area which may reveal an extra cervical rib. MRI (These images can help your doctor determine the location and cause of compressions of the brachial plexus nerves or the subclavian artery. The scans may also reveal any congenital anomalies — such as a fibrous band connecting your spine to your rib or a cervical rib — that may be the cause of your symptoms.) Electromyography and/or Nerve conduction velocity testing to evaluate the nerves of the thoracic outlet and the related muscles.

Non-PT Interventions:
Removal of cervical rib.

PT Interventions: Increasing the space of the thoracic outlet by improving the posture, correcting the muscle imbalance, and modifying the occupational, recreational, and sleeping habits that affect the posture of the head, neck, and upper back.

Self stretching exercises to relieve tightness in the scalenes, SCM, pec major/minor and neck extensors.

Manual therapy/soft tissue/deep tissue massage to scalenes, SCM, levator scapula and suboccipitals may help to improve extensibility of muscles and decrease pain.

Strengthening of the scapular stabilizers, particularly the lower trap and middle trap, to improve posture and prevent compensatory strategies by the Upper trapezius.

Nerve gliding (both by therapist and for HEP) of the Ulnar, radial, and/or median n.

Prognosis: The prognosis for TOS is good as long as the patient conducts their self stretching exercises on a routinely basis. Cooperation by the patient is crucial to their outcome.





HNP without Nerve Root Impingement

Relevant History/Onset of symptoms:
Age: 20-55 y.o. History of repeated motion or poor posture (if posterior derangement then history of flexion, if anterior derangement then history of repeated extension, etc).

Tissue Involved:
Outer annulus and/or dural sleeve (stimulation)
Progressing from outer annulus and encroaching on dura to evolve and compress nerve root
Disc may be categorized as an intradiscal displacement and protrusion (if no neurlogical/referred symptoms).

Impact of process on tissue:
Progresses to include the nerve root in damage. With highly innervated annulus, the pain is referred distally to UE/LE, causing the "nerve root symptoms".

Examination Findings (* the key indicators):
Pain Location: UE/LE symptoms that are radiating - Back, buttock, thigh, leg, foot, neck, shoulder arm, hand
Pain Behavior: Dynamic/Changing (better or worse with certain activities)---Centralization/Peripherilization
Decreased ROM - usually into ext if bulge is post/lat, and sidebending to ipsilateral side of bulge
Possible positive Centralization test

Diagnostic testing:
Cautious with MRI: Many false positives
Pain Location: Radiating - Back, buttock
, thigh, leg, foot, neck, shoulder arm, hand
Pain Behavior: Dynamic/Changing (better or worse with certain activities)

Non-PT Interventions:
Although at this stage, surgery is not likely indicated procedures may include laminectomy, discectomy, disc replacements. Pain management through epidural steroidal injections
Complementary and Alternative Medicine (CAM): acupuncture, massage, etc

PT Interventions:
Move into direction of limited range/pain in order to achieve centralization. Continue with this direction until patient is able to move into Opposite direction painfree (ie, if patient has a posterior herniation, begin with extension and continue until flexion is painfree). Then begin controlled movement into this opposite direction (ie, in posterior derangement, begin into flexion) in order to strengthen the annulus scar tissue to prevent future re-injury. Continue with a balance between flexion and extension. An example of exercise that could be used for a patient with a posterior herniation of lumbar spine would be:
Press Up
B4B7A82356F5D50ED361DA1A4A3F.jpg
Patient education is critical. Topics should include postural education in all positions, body mechanics, ergonomics and pain management. Patients should also be educated regarding the recurrent and progressive nature of disc related spinal pain.

Prognosis:
If only intradiscal displacement or protrusion, prognosis is good--patient can recover without surgery. If not treated early and properly, this patient can progress to have nerve root impingement and possibly extrusion or sequestration which may eventually require surgery.





HNP with Nerve Root Impingement

Relevant History/Onset of symptoms:
Age: 20-50 y.o.
MOI: repeated flexion activities, prolonged sitting, gradual/insidious onset. Patient is usually unsure when/why pain started. Typically related to posture.

external image pinched_nerve.gif external image herniated+disc.jpg

Tissue Involved:
-Nucleus Pulposus and Annulus Fibrosis. Nerve Root and dural sleeve.

Impact of process on tissue:
-The nucleus pulposus is displaced either within the annulus (intradiscal displacement or protrusion) or is pushed all the way through the annulus (extrusion or sequestration). The annulus undergoes microtears and fissures in which the cartilaginous rings of the annulus also separate. This separation between the rings makes it more difficult to relocate the nucleus. The nerve root is compressed/agitated by the displaced nucleus. This compression leads to nerve root findings in a neurological screening.

Examination Findings (* the key indicators):
Pain Location: UE/LE symptoms that are radiating - Back, buttock, thigh, leg, foot, neck, shoulder arm, hand
Pain Behavior: Dynamic/Changing (better or worse with certain activities)--Centralization/peripheralization
Decreased ROM - usually into ext if bulge is post/lat, and sidebending to ipsilateral side of bulge

Diagnostic testing:
Cautious with MRI: Many false positives
Pain Location: Radiating - Back, buttock, thigh, leg, foot, neck, shoulder arm, hand
Pain Behavior: Dynamic/Changing (better or worse with certain activities)
Possible positive SLR, Sitting Slump, and Centralization tests
Check myotome/dermatome/reflexes at suspected nerve root level
Diagnostic Discogram identifies contained vs complete annular rupture

Non-PT Interventions:
If inc pain: treat with rest and anti-inflammatory meds
Steroid injections - variable duration relief
Discectomy - partial or complete
Epidural with anesthetic or anti-inflammatory

PT Interventions:
Move into direction of limited range/pain in order to achieve centralization. Continue with this direction until patient is able to move into Opposite direction painfree (ie, if patient has a posterior herniation, begin with extension and continue until flexion is painfree). Then begin controlled movement into this opposite direction (ie, in posterior derangement, begin into flexion) in order to strengthen the annulus scar tissue to prevent future re-injury. Continue with a balance between flexion and extension.

Static traction in neutral position and sustained up to 15-20 minutes shows decrease in pain. In the lumbar spine, the amount of force should be at least half of the body weight.

Patient education is critical. Topics should include postural education in all positions, body mechanics, ergonomics and pain management. Patients should also be educated regarding the recurrent and progressive nature of disc related spinal pain.

Prognosis:
Better prognosis if annulus is intact (intradiscal displacement/protrusion) versus a ruptured annular wall (extrusion/sequestration). Better prognosis if centralization occurs





Extension Bias


Relevant History/Onset of symptoms: Indicates that the preferred position of the patient's spine has decreased lordosis in the lower back and neck. Herniated discs and injury to the posterior longitudinal ligament are two conditions with extension bias. May be due to an intervertebral disc lesion, fluid stasis, a flexion injury, or muscle imbalances from a flexed posture.


Tissue Involved: Flexed postures or repetitive flexion motions loads the disc anteriorly and facet joints which causes fluid redistribution from the compressed areas and swelling. Thus, extension motions will relieve symptoms by moving the fluid away from the compressed areas.

Impact of process on tissue: Pt. may have dec. lordosis due to tight hamstrings or abdominals. Hip flexors and back extensors may be long/weak.

Examination Findings (* the key indicators):

Extension tests decrease or centralize symptoms.
Flexion movements increase or peripheralize symptoms.

Diagnostic testing:
Active and/or passive range of motion tests that show centralization of symptoms when patient moves into extension.

Non-PT Interventions:

PT Interventions: Patients benefit from early interventions that emphasize extension(such as prone press-ups), postural education, pelvic tilt exercises, and traction of the intervertebral disc.
external image press_up.jpg
Prognosis:

Depends on severity of impairment.



Flexion Bias

Relevant History/Onset of symptoms: Flexion Bias is when a patient prefers for their low back to be in a state of flexion. These patients may be more comfortable sitting than standing and tend to lean forward onto something when they do stand or walk. Patients may present with intervertebral foramen or spinal canal stenosis, anterior disc displacement, spondylosis, and spondylolisthesis. Patient present with increase lordosis.

Tissue Involved: Flexion bias could occur as a result of facet down glide restriction, disk displacement, or muscular imbalances.

Impact of process on tissue:
Examination Findings (* the key indicators):

Patients prefer flexion to relieve pain
Often patient present with anterior pelvic tilt
Extension tests exacerbate or peripheralize symptoms
flexion test centralize symptoms


Diagnostic testing: Observe posture. Active and/or passive range of motion tests that show centralization of symptoms when patient moves into flexion.

Non-PT Interventions:

PT Interventions: Patients with flexion biased low back pain often benefit from core strengthening, postural training, and ergonomic assessment. It seems that flexion bias would be easier to treat if the physical therapist knew the cause. Exercises include single knee to chest, double knee to chest, and posterior pelvic tilts.

SKTC
SKTC

DKTC
DKTC


Prognosis:
Depends on severity of impairment




Stabilization

Relevant History/Onset of symptoms:
Excessive or repeated stresses, genetic factors, or compensatory joint changes, poor posture
Signs and sx: giving way, or descriptors such as tiring, aching, or stabbing are possible indicators of instability.

Tissue Involved:
Inter-working of three subsystems: passive, active and neural. Passive- comprised of vertebrae, discs, and ligaments. Active- muscles and tendons surrounding the spinal column. Neural//- monitor and coordinate the passive and active subsystems.

Impact of process on tissue:
Inability to provide necessary contraction of muscle (active) stabilizers may lead to injury of passive structures as a result of the spine "buckling" with activity.

Examination Findings (* the key indicators):
Hypermobility of vertebrae
Weakness in local (those muscles having a direct attachment to the spine and having the greatest impact on segmental stabilization: transverse abdominis, multifidus, and posterior fibers of the internal oblique) and global (transverse abdominis, internal and external obliques, erector spinae, and a portion of the quadratus lumborum) muscle stabilizers.

Diagnostic testing:
Palpation, lumbar PIVM testing, PA Spring Test

Non-PT Interventions:
Surgery to repair passive structures

PT Interventions:Lumbar stabilization exercise program includes a range of exercises that typically progress from beginning to more advanced for example, static to dynamic or gravity minimized positions to against gravity positions. During all exercises a neutral spine position is maintained. Some examples of exercises are:
  • Transverse Abdominis training: a gentle drawing in or hallowing of the lumbar area. Quantitative assessment of TA control may be measured with biofeedback or pressure biofeedback mechanisms. Cue: Draw belly button in and up towards rib cage.
  • Hamstring Stretches: A passive exercise. Lay supine on the floor with knees bent and feet on the floor. Find the neutral spine position and maintain it while slowly straightening one leg and lifting the heel toward the ceiling while supporting the back of the thigh with both hands. Hold for 10 to 30 seconds and repeat with other leg. Do 3 repetitions. Can make the leg muscles static too by using a wall to straighten the leg while resting the leg muscle.
  • http://www.topendsports.com/medicine/images/hamstring-supine.gif
    http://www.topendsports.com/medicine/images/hamstring-supine.gif
  • Pelvic Tilt exercises: Active exercise from one position, where the abdominal muscles are isolated and used to move the spine. Lay supine on the floor with knees bent and feet flat on the floor. For anterior pelvic tilt, cue patient to arch back. For posterior pelvic tilt, cue patient to round out back by pushing into the table. Hold for 10 seconds. Do 3 to 5 repetitions.
  • Arm/Leg Raises:A more dynamic exercise introduces movement of the arms and/or legs to challenge the neutral spine; this exercise is for the hip abductors. Lie on one side with lower arm bent under head and upper arm resting with hand on floor near chest. Bend both knees and flex hips and find neutral spine position. Slowly raise upper leg 8 to 10 inches and lower. Do 5 to 10 repetitions and repeat on opposite side.
  • http://img.wonderhowto.com/screengrabs/633501061806250000.jpg
    http://img.wonderhowto.com/screengrabs/633501061806250000.jpg
  • Exercise Ball Bridges:An advanced stabilization exercise that introduces unpredictable movement that must be responded to (the movement of the ball). Lay supine on floor with both feet propped up on the exercise ball with legs straight and arms relaxed to the sides. Find the neutral spine position and hold while slowly tightening the buttock muscle to lift the buttocks off the floor 2-3 inches.
  • http://www.istockphoto.com/file_thumbview_approve/3523364/2/istockphoto_3523364-bridge-with-extended-legs-on-exercise-ball.jpg
    http://www.istockphoto.com/file_thumbview_approve/3523364/2/istockphoto_3523364-bridge-with-extended-legs-on-exercise-ball.jpg
  • http://www.spine-health.com/wellness/exercise/lumbar-stabilization-exercises-lower-back-pain
Additional core stabilization exercises that have shown to be effective are:

Bridging

Begin this core exercise lying on your back in the position demonstrated.Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds and then return to the starting position. Perform 1 - 3 sets of 10 repetitions provided the exercise is pain free. Maintain activation of your transversus abdominis muscle throughout the exercise.
1.png

Four Point Kneeling Opposite Arm & Leg Raises

Begin this core exercise in Four Point Kneeling as demonstrated. Maintain good posture and activation of your transversus abdominis muscle throughout the exercise. Raise one arm and the opposite leg and then return to the starting position. Keep your spine and pelvis still throughout the exercise and breathe normally. Perform 1 - 3 sets of 10 repetitions, provided the exercise is pain free, alternating between sides.
2.png

Side Holds

Begin this core exercise propped up on one elbow and foot with your back straight as demonstrated. Maintain activation of your transversus abdominis muscle throughout the exercise. Hold the position for as long as possible provided it is pain free and you are maintaining good posture. Repeat 3 times on each side.
3.png

Prognosis:
Good with continuation of exercises. Instability is prevented with increasing stiffness of passive structures and increasing activity of stabilizing muscles.





Mobilization


Relevant History/Onset of symptoms:
- poor posture, trauma, spinal disease, or congenital problems, facet restrictions, HNP

Tissue Involved:
- facet joints, and/or the costovertebral articulations (thoracic spine and ribs). Joint restrictions or hypomobility can lead to muscle tightness/spasm, pain or fatigue.

Impact of process on tissue:
The goal of mobilization is to restore normal joint movement, including surrounding soft tissue. The focus is each restricted motion segment and releasing painful adhesions that are causing the patients pain or limiting his/her movement.

Examination Findings (* the key indicators):
Hypomobility of vertebrae. During initial examination of lumbar and thoracic spine, spinous process gaping will appear to skip a segment, highlighting the involved area. In the cervical spine, first noting a pain or a ROM loss, side gliding in neutral will be limited on the involved side in comparison to the good/healthy side. To highlight an up glide, bring the neck into flexion, a down glide - extension.

Diagnostic testing:
- central P/A (extension mobilization)
- unilateral P/A mobilization
- neutral gapping mobilization
- cervical lateral mobilization
- SIJ gapping / compression
-Lumbar, Thoracic, Cervical PIVM
-Tranverse Process tracking during flexion and extension

Non-PT Interventions:

PT Interventions:
treat in a way similiar to how you assessed it
- central P/A (extension mobilization)
- unilateral P/A mobilization
- neutral gapping mobilization
- cervical lateral mobilization
- cervical up glide mobilization
- cervical down glide mobilization
- SIJ mobilizations
-Stretching
-Manipulation
- Static Traction (sustained force for up to 15-20 minutes): This is an effective treatment for a patient presenting with a herniated disc
- Intermittent Traction: This is an effective treatment for joint stiffness and muscle spasms.

Predictiors for Identifying Patient with LBP who will improve with spinal manipulation:
Symptoms present for less than 16 days
No symptoms below the knee
FABQ <19
Lumbar Hypomobility
Hip IR >35 degrees.
If four or more factors are present, there is a 95% likelihood of dramatic outcome

Predictors for Identifying Patient with cervical pain who will improve with thoracic spine thrust manipulation:
Symptoms present for less than 30 days
FABQ > 11
No symptoms distal to the shoulder
Looking up does not aggravate symptoms
Cervical Extension < 30 degrees
Flat T3-T5
If three or more factors are present, there is a 86% likelihood of dramatic outcome

The effects of spinal traction are: separation of vertebral bodies, gliding of facet joints, tensing of ligamentous structures, opening of the intervertebral foramen, and stretching/straightening of the spinal musculature.

neckr.jpg
services_clip_image008_0000.jpg
Contraindications to Traction: Osteoporosis, infection, tumor, RA, vertebral fractures, hypermobility, ruptured disc, acute sprain/strain

Prognosis:
Good. May need to be combined with other interventions. Use as part of an intervention program