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135 Cards in this Set
- Front
- Back
What question do you ask at the first level of triage?
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Is it a mechanical problem?
if not, it's hard to provoke the pain with motions/loading |
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What type(s) of loading predispose the skeleton to early degeneration?
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Excessive and asymmetrical loading
in sagittal (e.g. lumbar lordosis) or frontal (lean to one side) planes |
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What is in the anterior pillar?
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Vertebral body, intervertebral disc, bone-disc-bone interface, anterior longitudinal ligament
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What is in the posterior pillar?
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Pedicles, transverse processes, laminae, spinous processes, facets
Posterior longitudinal ligament, spinal cord, ligamentum flavum |
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Describe the ALL
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anterior longitudinal ligament goes from occiput to sacrum all along the anterior part of the vertebral bodies and discs
Thin superiorly and gets thicker inferiorly |
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Describe the PLL
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posterior longitudinal ligament goes from occiput to sacrum along the posterior part of the vertebral bodies (anterior to spinal cord)
Thick in cervical region and gets thinner toward lumbar |
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What are the three legs of the stool?
How much loading on each? |
front leg - bone disc bone interface
right back - right facet joints left back leg - left facet joints There is finite attenuation ability in each joint, degeneration of one joint affects loading of others Normally, in standing 80% of load is on B-D-B interface, 20% on facets Except in C-spine, where 40% on B-D-B and 60% in facets |
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Explain the chart/graph with the Optimal Loading Zone
How does this relate to practice of PT? |
All tissues have an optimal loading zone
Inactivity creates changes, which shrink the zone for physiologic loading Age, injury, and degenerative changes also narrow the optimal loading zone With degenerative changes and some injuries (such as rotator cuff tendons?), the goal isn't to change the loading zone, but to teach people to adjust to their new zone Train muscular system for attenuating forces |
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What's the significance of degeneration in articular cartilage vs. bone?
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you only get one dose of cartilage
bone has a little more ability to remodel, but once degeneration happens it still has an effect |
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Describe body changes in our "average" patient population
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gain one pound of body weight per year after age 25
Loses 1/2 pound of lean body mass per year after age 25 females can lose 1/3 of skeleton in lifetime Muscle mass loss starts at age 25; by 80, 1/2 of muscle mass is lost Rising obesity trend But, you can slow the descent with exercise! |
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What does SAID stand for?
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Specific Adaptation to Imposed Demand
- training effect and Wolff's law |
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Why is enhancing neuromuscular efficiency so important?
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Increasing muscle insufficiency increases stress on connective tissue of spine
Muscles are major shock absorbing mechanisms of the body (even more than articular cartilage) Carefully prescribed exercises based upon results of physical exam teach patients movement patterns that minimize stress |
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Osteopenia
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loss of bone mass
strength and density of bone influenced by local strain on bone - weightbearing - muscle forces Must cause deformation (a little bending) |
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Sarcopenia
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loss of muscle mass with aging
-starts at approx age 25 by 80, 1/2 is lost - not gender specific Resistance exercises seen to counteract sarcopenia -example of man in Flagstaff who started lifting at 60, and is a badass (picture with bar over head) |
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What is the tent analogy for stability?
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Your body's fascia is like a tent, muscle attach and pull it
Fascial envelope contains muscle tissue, hypertrophy fills envelope and increases stability Not just muscles pulling on ends of tissue, but the health of the muscle within the envelope (pointy tent, vs saggy unstable tent) |
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How does muscle fiber size, force generation, and EMG activity change with training and detraining?
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With training, hypertrophy occurs, particularly in fast twitch muscle, but fiber size decreases with detraining (more quickly in fast twitch)
Force generation increases (but probably plateaus, or at least slows) with training EMG increases at first, but after about 12 weeks it goes down because muscles get more efficient Force decreases with detraining, while EMG first decreases, then increases as muscles get less efficient at generating force |
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Training guidelines for musculoskeletal conditions and improvement of physical heath
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let physical exam dictate exercise prescription limits (positions, loads, etc)
Begin with submaximal load and progress to increased PRE Take time to develop safe movement pattern for each ex and continue resistance ex unti quality of movement changes (reps to substitution) progress to more functional positions vary angles and positions of resistance |
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How does the Clinical spine differ from the anatomical spine?
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Anatomical - 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal
Clinical 1. upper cervical (occiput, 1st and 2nd C-spine) 2. Cervical Spine 3. Cervicothoracic Jct (transition point) 4. Thoracic spine (not too many things go wrong there) 5. ribs/spine interface (potential for problems, but easy to detect with breathing) 6. Thoracolumbar Jct 7. Lumbar spine 8. Lumbosacral joint 9. Sacroiliac (controversy, can provoke pain) 10. Pubic symphysis (not many sprains, strains) Exam is usually of cervicothoracic spine or lumbopelvic spine (not 10 diff exams) |
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What components are in the cervicothoracic spine? (clinical designation)
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Clinical
1. upper cervical (occiput, 1st and 2nd C-spine) 2. Cervical Spine 3. Cervicothoracic Jct (transition point) 4. Thoracic spine (not too many things go wrong there) 5. ribs/spine interface (potential for problems, but easy to detect with breathing) 6. Thoracolumbar Jct |
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What components are in the lumbopelvic spine? (clinical designation)
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7. Lumbar spine
8. Lumbosacral joint 9. Sacroiliac (controversy, can provoke pain) 10. Pubic symphysis (not many sprains, strains) |
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Clinically significant differences in cervical spine
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holes through transverse processes - transverse foramen. For vertebral arteries (which merge on brainstem and form the basilar artery).
Careful during manipulation - HVT should have high velocity and low amplitude, patient can't stop the manip, so safety is in the small amplitude A tear in the vertebral artery can lead to death spasm would limit O2 to the brain and could cause permanent damage Spinous processes are smaller Facets oriented in transverse plane |
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Risk of manipulations, and how do clinicians decide when to do them
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Cervical manipulation could damage the vertebral arteries if done improperly
Clinican makes decision once they put their hands on the patient and assess, move through range, end feel (not bone-on-bone or muscle guarding) Manips are a fast easy way to decrease pain, acute (not chronic) pain is an indication BTW, no evidence that spine gets "out of place" Manipulation is low risk - NSAIDs and treadmills are more risky statistically |
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Clinically significant differences in thoracic spine
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articulation for ribs on transverse processes and vertebral body
Facets oriented in frontal plane |
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Clinically significant differences in lumbar spine
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Nerve roots (not spinal cord) after L1 or L2 in central canal
Facets oriented in saggital plane |
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What is the lateral recess
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area in the spine where roots are exiting
inner part of peduncles (medial aspect of intervertebral foramen) Lateral recess stenoisis can be caused by disc pathology or facet spurs and can cause compromise of nerve roots |
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What is a lot of the force attenuation in the spine due to?
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as a result of moveable spinal curves
spine can dissapate loads more effectively 10x more resistant to compression |
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Why are shear forces dangerous and how are they prevented?
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shear forces change the architecture of the intervertebral foramen (which nerves pass through)
Support elements include ALL, PLL, capsule Losing health of passive support tissues leads to more movement, as does degeneration of the discs anterior shear created in bending is usually prevented by tissues |
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What are the grades of spondylolisthesis?
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Grade I: 25% or less slipped (20% of the class would probably be diagnosed)
Grade II: 25-50% 3: 50-75% 4. >75% |
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Describe the ligamentum flavum
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goes from the inferior aspect of the lamina above to the superior aspect of the lamina below
So, it covers the posterior part of the spinal cord in between each vertebra |
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Understand the vertebrae and relationship to neural structures - see slide
Where are the rami, roots, and spinal nerve located? |
Roots branch out of anterior and posterior (ventral and dorsal) horns of the spinal cord and join in the intervertebral foramen (in between the bones) to form
a mixed spinal nerve the spinal nerve then splits into a larger anterior ramus, which goes to the extremities and anterior trunk, and a smaller posterior ramus, which supplies the posterior trunk (back) |
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What are the ligaments in the spine and where do they go?
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Supraspinous ligament runs the whole way
(where is it?) Interspinous ligament - inbetween spinous processes |
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What happens if you have a hypertrophic ligamentum flavum?
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can get stenosis of the spinal canal (sounds crazy!)
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Three intervertebral disc components (in clinical anatomy)
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cartilaginous endplate
annulus fibrosus nucleus pulposus |
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What determines the type and amount of motion in the spine?
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facets determine type
ligaments (annulus) determine amount not a lot of distortion at each segment ~25 degrees motion occurs close to the axis of rotation and there are many segments to make up the overall motion |
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How do nutrients get to the disc without vasculature?
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Diffuse through cartilaginous end-plate (above and below) and then through disc
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What is the structure of the annulus like? what happens with degeneration?
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Layers - about 14-20 concentric rings (could peel like an onion... or an ogre). About 3 types of collagen
Delamination of degeneration process - spaces between rings (injury is not just stretching or tearing) Diagrams give you the idea that the nucleus pulposus is very distinct from the annulus but there is actually a gradual change and they look very similar Annulus is like a big ligament, also so bulky that it helps absorb compressive loads |
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Where is the cartilaginous end plate?
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Only on central part of the disc, serves as roof and floor for nucleus pulposus
vertebral bodies are concave and end-plate fits within |
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Why is the term "collagen" very generic?
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There are about 10-12 different types of collagen and they have subclasses
about 3 types in annulus |
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What is the annulus fibrosus composed of? (substances from most to least)
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collagen
elastin (small) hydrated proteoglycan gell (protein sugar that sucks up water) Annulus is the major "ligament" of the spine can tear or overstretch |
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What happens to collagen with aging?
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Turns on some aspects of collagen and turns off others. Stiffness is from different composition of collagen, aging changes the profile
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What makes the annulus such a strong "ligament"?
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Layers of collagen are oriented perpendicular to each other, so there's no motion that doesn't create tension in some aspect of the annulus
criss-crossing allows it to "check" motions bending and twisting... (anterior cruciate ligament of back most likely. not sure what that note meant, maybe injury most likely then?) |
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Functions of the annulus fibrosus
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encase nucleus pulposus
restrict and regulate movement absorb compression loads - bulky, so tolerates and attenuates loads |
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What is the nucleus pulposus composed of (in order of proportion)?
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mostly hydrated gel of proteoglycans consisting of sulfated glycosaminoglycans
-chondroitin sulfate -keratan sulfate Collagen (least represented in pulposus, unlike in annulus!) Nucleus is mostly water - binds itself to protein-sugar molecules One sulfate loves H20 more than the other. the composition changes with age, which makes nucleus less water-filled Proteoglycancs absorb more water at night. |
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What are Schmorl's nodes?
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nucleus projects through endplate up into spinal segment
blatant disruption in endplate (weak link in compression - not annulus or nucleus) |
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What is special about the outside of the annulus?
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Outer third is the only part with vascularity
Also, only the outer aspect is "innervated" and can act as pain source proprioceptive receptors as well |
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Why is there some controversy over disc surgery where they remove part of the nucleus?
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Normally, as the nucleus absorbs water it exerts a pushing force
Tension on the annular rings creates stability Without part of the nucleus there's less push and less tension, which creates some instability between segments |
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What are the functions of the nucleus pulposus?
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Force dissipation via hydrophilic proteoglycans
maintenance of -disc height -capsular tension Needs to be intact to have these properties -facet alignment |
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Why and how is a discogram done?
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Done to evaluate and increase disc pressure to see if that reproduces the person's pain
Injection of dye, so it's not radio-opaque Needle into L4/L5 interspace Compare discs (in picture) - L4/L5 nucleus kinda broken down |
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What are the influences on intradiscal pressure?
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Muscle contraction - by far the #1 cause of increasing pressure (as well as causing extension or lateral side bending, causes compression)
Ligamentous prestress - ligaments aren't loose and floppy, have some elasticity, but not a whole lot, slightly squeeze vertebrae together Superincumbent Body weight (trunk load) - not a huge influence Ground Reaction Force |
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How does intraiscal pressure change in various postures?
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Lowest in supine
Then standing - dissipate forces through legs, rest on hip ligaments Leaning forward - muscle contraction! Sitting Bending and picking something up |
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What is the innervation of the disc?
What does discogenic pain come from? |
Primary nerve is sinuvertebral (recurrent) nerve
small nerve fillaments from spinal nerve come back into the canal, supply ligaments, annulus, etc. Nerves register increased pressure of disc, send info about tension, modulate Some people w/ back pain are "motor morons" - lost sensory receptors, decreased control of muscles So, while nerves can be source of pain, they are also important for sensory, mechano receptor input |
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What happens with contraction of spinal muscles?
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Increased spine contraction -> increased disc pressure -> increased annular tension -> stability
unless someone has a bad disc |
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Where is the axis of motion in the spine?
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in the center of the disc - tension on one side, compression on the other
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Describe intervertebral disc degeneration
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asymptomatic, irreversible progression with age
disc space narrows water content decreases (because you manufacture different proteoglycans) nucleus pulposus migrates through annular fissures |
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Describe pathogenesis sequence of intervertebral disc
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Dessication of nucleus
-age related changes - portal from cartilaginous endplate defects (that breakdown happens before coming through window of annulus) Viscoelasticity of annulus exceeded Ring stiffness lost Annulus yields easily to pressure Annular buckle results Nucleus is avascular. Blood can seep through imperfect cracks in end plate. Foreign interaction - nucleus as low-grade inflammatory reaction, helps start dessication Normally, cartilaginous endplate actively filters nutrients |
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"midlife crisis" of intervertebral disc
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Nucleus still able to exert pressure (good H20 content)
Annulus has tears and fissures - age related changes - cumulative stresses - injury High level of activity persists - occupational stresses - social/sporting |
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Where can nerve root compromise occur?
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at the intervertebral foramen or central canal
and Lateral recess (inner part of foramen) once they come together, it's not a nerve root issue |
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Describe what happens with disc herniation
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dessication
nuclear material pushes on weakened annulus probably not clinically painful (only outer annulus innervated) picture shows a little bit of nucleus blumping out |
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Describe disc protrusion
treatments? |
more material has dessicated
distorting annulus tension may be creating pain Picture shows nucleus sticking into annulus and annulus having a bulge IDET - intra-discal electrothermal treatment - stick needle into "corner" electric probe goes in and around, intent to heat collagen to make it shrink, also cauterize the nerve-endings Chymopapain injection papaya enzyme (tenderize?) break-down collagen proteins But, also starts dissolving annulus if there's defects, also degenerate nerve in canal |
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Describe sequestered nucleus
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nuclear material is presenting in spinal canal
more common to actually present in clinic with pain Surgery - scoop out crab meat picture shows pieces of nucleus sticking through the annulus |
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Describe nuclear extrusion
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Happens because something makes the nuclear material dessicate and stresses to annulus make it less resistant to pressure
2nd pain scenario where disc material ends up in spinal canal (how is this different from sequestered nucleus, the stresses?) |
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What are the different types of disc issues?
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disc herniation
disc protrusion sequestered nucleus nuclear extrusion |
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What's the most common spinal surgery
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microdiscectomy
cut window out of ligamentum flavum and push nerve root aside get into canal and move nerves to see and remove herniation |
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how can you tell what is the superior articulating process and what is inferior on a slice?
facets in axial view |
inferior process is medial to superior
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What are the pathophysiologic findings with compression to a nerve root form an intervertebral disc
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intraneural edema and ishemia
nerve root goes over "hill" - greater excursion -> tension Also blood vessels when damaged/compressed -> unhealthy environment -> angry nerve root usually easy to provoke pain and predict it's a nerve root problem |
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How does a nerve get nutrients?
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blood flow
and passive diffusion through CSF keep things healthy pathology compromises arterial flow and CSF environment (thicker, like pea soup) Coverings, vascular and nervi nervorum |
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What prevents avulsion of nerve roots?
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dura mater ends as "blind sack" or A-frame tent
can't pull nerve root away because Dura plugs up foramen good system usually, but watch out for waterskiing and football |
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What is necessary in order to have nerve root symptoms?
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must have inflammation of nerve root!
root isn't mechanically sensitive unless it's inflammed compress the nerve roots on a regular basis but it doesn't hurt so, inflammatory process can resolve -> no pain One person's clinical scenario may affect different rootlets than another The 15% of people who you can identify anatomical tissue at fault are these people |
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Non-mechanical effect: neurotoxicity
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Nuclear material itself is an inflammatory component
swelling/inflammation from interaction Cytokines related to nucleus pulposus or associated granulation tissue -tumor necrosis factor - alpha (TNF - a) - INterleukin - Interferon Analyze specific cytokines to figure out specific anti-inflammatories Predict that by taking a sample of nerve root fluid it'll become easier to target drugs to diminish inflammation (see cytokines) |
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The disc and the pro-inflammatory response
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nucleus pulposus is biologically active tissue capable of responding to pro-inflammatory stimulus
principle mediators of inflammatory response are IL-6, IL-8, PGE2 TNF - alpha site of production probably in granulation tissue forming around disc herniation or in nerve root sheath rather than in herniated NP (what does this mean!) Enormous chemical change going on associated with nerve root, makes it sensitive to provokation |
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Effect of TNF-alpha on nerve root
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increased spontaneous discharges of
-wide dynamic range (WDR) and nociceptive specific (NS) neurons in dorsal horn of cord at involved nerve root level Enhanced nociceptive responses of WDR neurons lasting hours Interstitial edema of dorsal root ganglion -> sensitization of dorsal horn neurons -> inflamed/compressed nerve roots increase sensitivity to mechanical stimulation |
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Pathomechanics of nerve root injury
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mechanical compression + inflammation around the nerve root induces more nerve root injury than each factor alone
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Describe chart showing how nucleus pulposus present in spinal canal leads to pain
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nucleus pulposus within spinal canal causes direct compression to nerve roots which causes neuropraxia
AND causes release of pathogenic substances (cytokines) which (along with compression) cause inflammatory and immunochemical reactions which cause enhanced responses of dorsal horn neurons which induces prolonged excitation in pain-producing neurons That whole right side of the chart (with cytokines) was unknown until recently (last decade) |
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What's an important question to ask patients, which might indicate whether they're surgical candidates?
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ask if they're having trouble with control of bowel and bladder
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What are the features of nerve root irritation?
(vs. nerve root compression) Big question - memorize this! |
- extremity pain greater than spine pain (radicular -> arm or leg pain)
- quality of pain differs from referred pain (intense burning, aggravating, changes relationships and work, want surgery to take it away, referred is more of an ache, very precise, can outline where pain is occuring - Clear demarcation of pain pattern in extremity - Proximal pain and distal paresthesias (prox - shoulder hurts, distal - ants running up and down, tingling, vibration, etc.) usually vague onset, gradually becomes radicular - Neural tension testing reproduces extremity pain (SLR produces leg pain, not back pain) - Gentle spinal motions result in excessive irradiation (ROM and compression - zing) |
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What is seen in clinics more than nerve root compression, and what question should be asked at the front desk?
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nerve root irritation!
front desk should ask whether back pain or leg pain is worse Leg > back gets quicker appointment, more likely surgical ask question in several ways to make sure |
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How do referred and radicular pain differ?
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referred pain is not radicular, tissues of same embriological origin
more peripheralization with more problems at source referred more of a vague ache while radicular is intense and precise |
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Features of nerve root compression
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muscle wasting
muscle weakness sensory impairment quality of reflexes altered Mechanical distortion so great it blocks neural communication -action potentials can't pass wasting - no input sensory - dorsal roots textbooks tend to talk about compression, but about 10% of patients we'll see (often need surgery) surgeons explain they're going to take away leg pain with discectomy, not back pain |
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Like any synovial joint, facet joints...
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Are innervated
Are a pain source Have a degenerative process |
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How much weight is usually born in facet joints?
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Facets are not big weight-bearing structures - normally carry about 15-20% of load, 30-40% is above physiological capacity, pain and accellerated breakdown
brings up question of whether procedures that alter loading (such as discectomy) are worth it in the long run |
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What is the purpose of doing a supine/prone back exam?
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to substantiate the findings from upright antigravity posture (see if motions mimic the way it hurts )
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What's one of the purposes of the facet joints in the lumbar spine?
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Facets help attenuate shear - there is an obligatory shear force in the spine because gravity is always trying to slide the vertebrae (component of force vector creates shear)
People with posterior column pain tuck their tailbones to shift weight anteriorly and decrease compression and shear |
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How do the articulating processes of the facet joints interact with each other?
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inferior articulating processes lie medial to superior
on cross section, superior facet is concave and inferior is convex |
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What sports have the highest incidence of back pain?
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golf
and bowling repetitive unilateral motion (increases compressive load between facets) |
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Clinically, you see most back problems with positions that
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increase compressive loading
liability of facet articulations is compression |
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What are the motions of the lumbar spine at each segmental level?
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Flexion and extension mainly: ~ 20 degrees at one segment
Rotation and lateral bending: very little rotation (1-2 degrees), pretty much just from compression of cartilage |
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What does pars mean?
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body
pars interarticularis is between superior and inferior articulating process stress on pars with extension |
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What is the significance of the gymnast with tight hamstrings?
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She has injury to central core from compression and bending, tight hamstrings shift weight anteriorly (flexion), muscle guarding to unload the spine
So, tight muscles are usually not cause of problem, but protective |
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sporting activities with increased risk of pars fatigue fracture are those with _____, such as __
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high rates of flexion extension cycles, such as gymnastics, diving, weightlifting, football (offensive line)
(in order of most risk to least) repetition, rather than degrees of movement, is most dangerous |
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What should PTs do with athletes who have increased risk of pars fatigue fracture because of their activities?
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Go through workout plan with person and make adjustments, monitor amount of flex/extension cycles
Work on that and "tightness" goes away |
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How does ligamentum flavum become hypertrophic?
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it is the anterior wall of the facet joint
Driving the inferior facet down beats the heck out of Ligamentum Flavum (what makes inferior facet get particularly "beat"y?) |
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What are lifting recommendations?
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Lift symmetrically
avoid jerking motion (use smooth motions) Use moderate lifting speed Keep COG of object as low as possible Maneuver object as close to body as possible Maintain symmetric relatively upright posture |
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What is the incidence/prevalence of disc problems as compared to degenerative back pain?
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Age for disc problems is bell curve peaking at 28-45 years old
Degenerative back pain is increasing slope that starts actually rising around 50-60 Healthy disc has lots of water and can create pressure, less pressure as collagen type changes (dessicates) Changes to disc change loading on facets, increase contact pressure |
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Definition of mobilization/manipulation in guide to PT Practice
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"A manual therapy technique comprised of a continuum of skilled passive movements to joins and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement"
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Who is documented as first using traction?
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Hippocrates (460-355 B.C.)
wrote "on settting joints by leverage Had a traction couch reduced dislocated shoulders |
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Who founded osteopathy, and what are the founding principles?
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Andrew Still in 1874
1st school in 1896 "Rule of the artery" - diminished blood flow has adverse effects, restore position with manipulation to relieve pressure on vasculature Licensed to practice in all states, but not many osteopaths now manipulate the spine they saw void in family practice and filled it, more traditional, rather than manual medicine now D.O. and M.D. degrees basically the same now |
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When was chiropractics founded and what to they do?
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founded in 1895 by D.D. Palmer (1845-1913)
"Chiropractors do not manipulate; they do not use the process of manipulating; they adjust" Idea of putting vertebrae back in alignment D.D applied an adjustment to T4 vertebra that resulted in restoration of lost hearing Concept of subluxation as causal factor in disease and the revelation that adjustments can restore the body's innate healing abilities Beyond solving skeletal alignment problems, good for all kinds of diseases, focal regions for each condition (T4 - liver) Palmer school of chiropractic founded in 1897 |
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Chiropractic PHilosophy
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belief in body's innate ability to heal itself
presence of a "subtle" energy within the organism "The law of the nerve" adjust spinal subluxations to restore nerve flow and facilitate the body's innate healing ability Schools are more independent, don't have oversight of curriculum So, don't have role in hospital, less insurance coverage Big into marketing themselves |
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Who was the "are you a world champion?" guy?
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Freddy Kaltenborn
advanced practice of manipulation in PT Wrote The Spine in 1961 Nordic approach first to relate manipulation to arthokinematics Dr. DeRosa says he was 6'6" and 280 lb, but his hands formed to a body like they were born on you |
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How did Geoffrey Maitland influence the practice of manipulation?
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Wrote "Vertebral Manipulation" in 1964
Treats "reproducible signs" Described grades of oscillatory technique - I-IV and V Grade I: "just enough to make the fly's knees bend" |
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How did Stanley Paris advance the practice of manipulation?
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Wrote "Spinal Lesion" in 1965
Educated PT's in US n manual therapy Founding member of AAOMPT and first president of Orthopaedic section Founder of U of St. Augustine Maitland, Kaltenborn, and Paris established long term Manual Therapy education programs for PTs in US and abroad Paris was a CSM. Avid sailor - just attempted solo mission. |
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Current History and the Future of manipulation/mobilization in PT
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Evidence Based Practice
PTs are the leaders in the diagnosis and management of "movement" disorders - evidence shows that manipulation and exercise are PTs most useful tools Professional Associations promote and protect scope of practice |
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What is some evidence that manipulation is not dangerous to patients?
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Maginnis and Associates liability insurance carrier has provided a letter to the APTA stating that there is no evidence of higher claims losses due to PTs utilizing manipulative procedures
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What red flags to PTs screen for prior to manipulation treatment (and refer for further diagnostic testing)
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Significant trauma
Weight loss History of cancer Fever Intravenous drug use Steroid use Patient over 50 years severe, unremitting night-time pain pain that gets worse when lying down pretty much common sense is it mechanical? find out in the history |
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What are the risks of serious complications from lumbar TJM?
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Haldeman and Rubenstein reviewed the literature over 77 year period in "The Spine" 1992
Ten episodes of Cauda Equina syndrome following manipulation reported (none from PTs) Estimated risk: <1 per 10 million manipulations Compare to risk from exercise (1/1,500,000 - sudden death), NSAIDS (1-3/100 - GI bleed), Epidural Steroid Injection (8-11/100 Intravascular injection), Disc Surgery (1.6-17/10,000 - vascular perforations and 3.8/10,000 visceral injuries), Fusion (17/100 varied), and discectomy, laminectory +/- fusion (.2-.3/100 - death) |
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Summary on safety of TJM
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Benefits > risks as long as clinical decision making is based on thorough examination and evidence-based impairment-based approach
-screen for red flags - consider contraindications - modify techniques when appropriate More risk with other common medical and surgical procedures PTs clinical decision-making philosophy facilitates safe practice |
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what do clinical practice guidelines for low back pain say about manipulation?
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AHCPR ('94) - Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms (strength of evidence - B)
first major clinical guideline to recommend using TJM for LBP Medicare commisioned a group to look at evidence Chiropractors bought ads saying chiropractic manipulation is the "best" treatment for back problems |
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What's the ratio of chiropractors to PTs in AZ?
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3,000 PTs, 800 chiropractors
But, they are strong lobby-ers - "loud" and good at putting out message |
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What profession provided the manipulation in the referenced Randomized Controlled Trials?
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Physical Therapy!
Totals for all reports cited by either AHCPR or RAND treatment guidelines that support manipulation Chiropractors - 5 (18%) MD 10 Osteopath 3 PT 12 (40%) |
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History and exam factors predicting success with manipulations
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Duration of symptoms < 16 days
Symptoms not distal to the knee Fear Avoidance Belief Questionnaire work subscale <19 (psychosocial component, history should start to give information about that) At least one hip internal rotation of 35 degrees or more (don't know biomechanical rational of that one) Hypomobility at one or more lumbar levels with spring testing (do in lab!) |
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How did manipulation fare in the validation study by Childs et al.?
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Spinal manipulation seemed to offer a 'slam dunk" if patients met certain criteria
-Deyo's editorial in Annals of Internal medicine |
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What conclusions did the Cochrane Collaboration 2004 systematic review on Manipulation/mobilization come to?
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Strong evidence supporting thrust manipulation plus exercise to improve short and long-term outcomes of care for patients with neck pain disorders
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Summary on the evidence for mob/manip
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Greater evidence for spinal manip than most other PT interventions
- strong evidence for thrust manipulations for subgroup of patients with acute LBP -strong evidence for mob/manip combined with exercise for subgroup of patients with neck pain Clinical prediction rules (CPR) have been developed by PTs to help guide clinical decision-making in use of TJM CPRs should be integrated with an impairment-based approach |
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What do PTs do while assessing motion and deciding whether to use mob/manip?
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See if there's pain before tissue resistance, synchronous with resistance, or after resistance (over-pressure)
Let's you know how aggressive you can be with treatment Passive tests are what make PTs different Pain is not always with stretch, can be compression or shear, etc. |
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Notes on the sacroiliac - iliosacral articulation
Controversy? |
Discussions are even more controversial than manipulation conversations (is it the root of all problems? Does it not move?)
Iliac portion of innominate bone Forces also imparted at pubic symphysis, but logs of give there, so not involved In lab - push sacrum anterior and/or pull ilium posterior to create shear |
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What is the clinical importance of the SI joint?
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Source of LBP
good provocational injection studies - irritate joint and map discomfort referred pain in groin and posterior hip wouldn't expect patient to say leg pain > back pain (or specific, more diffuse) |
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What can be identified on CAT scan at SI joint showing cross sectional view?
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Thick cartilage on sacrum (sacrum looks like elephant)
thin fibrous cartilage on ilium hills and valleys match - stability From posterior to anterior: Multifidus muscles, posterior SI ligament, interosseus ligament (spans whole length, strongest in human body), joint space (with synovial fluid), anterior SI ligament Post-partum tear of anterior SI ligament can leak synovial fluid from joint space and cause back pain Fusion with age - gap filled with more fibrous tissue Multiparus women with history of difficult childbirth - suspect sprain of ligament (right?) |
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How do you palpate swelling at the SI joint?
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not possible
can palpate multifidus/musculature |
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Anatomy of SI joint
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morphology changes with age
- flat until puberty (lots of give) - by 30 bony ridges on the ilium side - by fourth decade ridges on both sides It varies greatly in size, shape, contour from side to side and between individuals The synovial cleft narrows with age; partially fuses -1-2 mm in individuals 50-70 - 0-1 in over 70 group |
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What creates loading at SI joint?
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Trunk forces
Ground reaction forces Torque to pelvis as a result of hip motion Muscle forces Converging forces - keystone part - trunk load coming down, legs up Spongy cartilage attenuates loads |
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SI joint stability: form and force closure
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Increasing compression between joint surfaces to increase friction
Form closure - bony congruencies Force closure - muscle, ligamentous, or external forces (such as bracing). bones squeezed together, increased friction - decreased aberrant motion, even with smooth surfaces in childhood it is quite stable |
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What are the forces (loads) over the sacroiliac articulation
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Torque - because femur meets ilium more anterior, creates opposite torque on ileum (toward anterior tilt?)
Shear - wants to slide up and down (sacrum down and innominate up) Ground forces up through femur - counter-clockwise rotation (sacrum clockwise, ilium counter-clockwise) Posterior nutation of sacrum? ASK SOMEONE ABOUT THIS! |
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What do you call motion of sacrum within the ilium?
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Nutation or counter nutation
flex - nutation force |
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What's the difference between torsion and nutation?
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nutation is motion of sacrum within ilium
Torsion is motion of ilium (one side) Not the same as tilt (whole thing - 2 innominate and 1 sacrum) Can have anterior or posterior torsion of ilium on sacrum |
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Restraints to sacral nutation and iliac torsion
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Sacrotuberous ligament
Sacrospinous ligament Interosseus ligament Ligaments provide stability Interosseous has corkscrew shape - gets tighter with forces Joint so stable you'll fracture bones before dislocating |
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What forces are on the pelvis in a kneeling lunge with right leg forward?
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Left - significant anterior torsional stress
R = posterior torsional force Females who delivered a few months ago and are breastfeeding probably don't realize position is intense end-range loading |
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Muscle energy in the pelvis
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muscle activity over pelvis through stabilization of femur (reversing origin and insertion) - abdominal obliques or hip flexors
Stabilize femur and get strong contraction of hip flexors - anterior torsion Too heavy of a leg press - too much muscle force - stress on joint |
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How much motion occurs at the sacroiliac joint?
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Movement vs. force attenuation: movement is mostly cartilage deformation
Studies vary - 1,4,<3.7, 2, 2 degrees, <2mm, <1.6 mm amount of motion is very small |
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What's happening to SI joint in picture of asymmetrical loading with left pelvic tilt?
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right side is higher - shear
left - compression |
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What's going on in the picture traced off an x-ray with right pelvic tilt
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asymmetrical loads - left facets more compressed, decreased IVF on left
- more tension on right - more shear on left SI Article showed frontal plane asymmetries contribute to needing THA Adducted hip has more compressive load (left side) Have person stand with foot on a lift, then on the floor, then lift, then floor etc. Will have relief with block 99% of time it's a skeletal asymmetry, not muscle issue if they're equally weight bearing |
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What is the liability of the sacroiliac joint?
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joint shear
extrinsic/intrinsic ligamentous tension |
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Sacroiliac articulation: history and physical exam
What is the evidence for methods of diagnosis? |
Some evidence: pain pattern, mechanism of injury
Evidence worth consideration: provocational stresses (load SI joint) Still searching for evidence: palpation for bone position, palpation for joint movement |
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Anatomical influences to management of SI joint
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modulate pain - use of muscle activity (muscle energy) to put controlled forces through pelvis, an active mobilization technique
Control of loads through region - crutches to control weightbearing through region - SI supports - Avoid hip endrange positions with ADL, sport, work (star by that point!) - exercise precautions - avoid loads approaching hip muscle isometric, too much torque |
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What type of sacroiliac support should one get?
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A support that tightens from the back
Front tighteners compress ilia and create torque the patent is currently up on Dr. DeRosa's support |
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Management of SI joint - dynamic stability of joint - "force closure"
What creates it? |
Latissium/gluteus maximus linkage (looks like "X" on back)
Abdominal mechanism/pelvic floor Hamstrings Spinal extensors |