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128 Cards in this Set
- Front
- Back
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What are the 4 primary altered muscle states?
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-involuntary muscle guarding
-voluntary muscle guarding -chemical muscle holding -adaptive shortening |
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What are the causes of involuntary muscle guarding?
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-joint or ligamentous dysfxn
-disc lesion -instability |
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What are the s/s of involuntary muscle guarding?
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-hypertonicity
-loss of free motion -elevated resting tone -abnormal elastic response to touch |
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Describe the management of involuntary muscle guarding.
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-treat the cause of impairment
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What are the causes of chemical muscle holding?
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-sustained involuntary guarding which restricts blood flow
-unaccustomed overuse |
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What are the s/s of chemical muscle holding?
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-discomfort and fatigue
-restricted and cramped mvmt -muscle tightness -doughiness to touch -not relieved by altered posture |
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Describe the management of chemical muscle holding.
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-heat and massage
-exercise using muscle in proper manner -muscle stretching |
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What are the causes of voluntary muscle guarding?
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-pain/fear of pain
-soft tissue or joint injury -often follows involuntary and chemical guarding |
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What are the s/s of voluntary muscle guarding?
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-pain w/ mvmt
-slow guarded mvmt -fear and anxiety -pt unable/unwilling to move |
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Describe the management of voluntary muscle guarding.
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-rule out serious pathology (tumor/fracture)
-repetitive motion such as McKenzie extension -Gd I & II oscillations |
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What are the causes of adaptive shortening?
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-poor posture
-joint injury -obesity/inactivity -chemical muscle holding |
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What are the s/s of adaptive shortening?
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-minimal symptoms at first
-eventual loss of fxn will lead to discomfort -restricted AROM -free accessory motion |
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Describe the management of adaptive shortening.
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-heat, massage and connective tissue techniques
-myofascial stretching -inhibitive distraction -contract relax |
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What are the five types of facet dysfunction?
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-synovitis/hemarthrosis (strain)
-stiffness -painful entrapment -mechanical block -chronic facet arthrosis |
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What are the causes of synovitis/hemarthrosis?
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-awkward movement or catch
-gross trauma |
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What are the s/s of synovitis/hemarthrosis?
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-good but guarded movement
-involuntary and voluntary muscle guarding |
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Describe the management of synovitis/hemarthrosis.
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-acutely, no stretching or strengthening
-provide support -rest -careful movement |
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What are the causes of facet restriction?
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-resolved synovitis/hemarthrosis
-asymptomatic |
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What are the s/s of facet restriction?
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-no symptoms
-restricted ROM -decreased accessory movements |
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Describe the management of facet restriction.
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-manipulation
-reassessment of motion |
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What are the causes of painful capsular entrapment?
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-awkward movement, possibly in eccentric range
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What are the s/s of painful capsular entrapment?
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-pain increase with downslide/compression of affected facet capsule
-positioned away from downslide |
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If a patient with suspected painful entrapment presents with left torticollis/lateral shift, what is the expected limitation?
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-painful R rotation
-painful R sidebending -painful backward bending |
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Differentiate lateral shift caused by capsular entrapment vs. disc dysfunction
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Capsular = immediate onset, no neurological symptoms, cannot correct lateral shift
Disc = gradual onset, neuro symptoms present, can correct lateral shift |
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Describe the management of painful capsular entrapment.
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-isometric multifidus contraction
-5-10# force -5-10 sec holds -reassess rotation -4 sets |
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What are the causes of a mechanical facet block?
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-idiopathic
-loose body -impaction |
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What are the s/s of a mechanical facet block?
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-sudden onset
-blocked motion -relatively pain free |
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Describe the management of a mechanical facet block.
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-"unhitch" joint surfaces
-Lumbar = rotational manipulation over a bolster -Cervical = strong manual traction with SB away and ROT toward blocked side |
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What are the causes of chronic facet arthrosis?
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-poor posture
-trauma -over use |
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What are the s/s of chronic facet arthrosis?
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-dull ache
-local pain -stiffness |
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In what patient types is chronic facet arthrosis more likely?
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-older population
-those with DJD |
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Describe the management of chronic facet arthrosis.
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-decompress joint surfaces
-postural education -abdominal strengthening -flexion exercises -mobilize adjacent areas if needed |
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What are the causes of ligamentous weakness?
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-repeated minor strains
-obesity -poor posture -vibration |
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What are the s/s of ligamentous weakness?
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-pain on assuming fixed position
-pain relief w/ position change -pain relief w/ "cracking" -ligament tenderness |
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Describe the management of early stage ligamentous weakness.
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-stabilization exercise
-back school |
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Describe the management of late stage ligamentous weakness (pre-discal).
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-rest/controlled activity
-supportive device -first aid education |
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What first aid information should be provided to a patient regarding potential disc injury?
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-approximate annulus fibrosus via extension to prevent fluid imbibition
-outer annulus will heal due to vascularity |
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Define instability.
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-osseo-ligamentous strucures and neuromuscular control insufficient to maintain neutral spine and prevent buckling, slippage and shear
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Define hypermobility.
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-range of motion believed to be excessive but not unstable due to superb neuromuscular control
-hypermobility may become unstable if muscles fatigue -hypermobility may be present surrounding hypomobile segments (i.e. from fusion) |
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What are the characteristics of normal motion?
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-smooth regardless speed
-adequate antagonist relaxation -full ROM for body type -pain free -normal muscle strength -PROM > AROM |
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What are the characteristics of dysfunction?
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-limited ROM
-unwillingness to move -painful arc -compensation -crepitus -signs of instability -juddering -end ROM pain -PROM = AROM -muscle dysfxn |
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Describe the presentation of a myofascial pattern.
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-limited AROM opposite tight muscle
-normal accessory ROM -EX: normal SB, ROT, BB, FB limited; decreased lumbar lordosis; normal accROM; no neuro s/s = tight lumbar myofascia |
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Describe the facet capsular pattern of the lumbar spine. (Left facet)
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FB = left deviation
SB = right limitation ROT = left limitation |
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Describe the facet capsular pattern of the cervical spine. (Left facet)
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FB = left deviation
SB = right limitation ROT = right limitation |
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What are the causes of instability?
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-ligament stress/strain from sports or poor posture
-lack of NM training and control -surgical and medical complications |
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Describe potential history and structural appearance of an instability patient.
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-h/o catches, twinges, sudden pain, pain w/ prolonged sitting
-obese -poor posture -spondylolisthesis -involuntary muscle guarding -step in stand disappears in lying |
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Describe the active movements seen with instability.
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-uneven, slipping, juddering
-pain at end ROM -poor balance and NM control |
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Describe the treatment principles of instability management.
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-lifestyle education
-exercise -manual therapy |
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What are the components of lifestyle education to be addressed with an instability patient?
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-muscle endurance, not strength
-improve motor control -diet and nutrition -frequent rest for disc health -educate on stability and overload, mvmt and exercise -ADL/ANL training |
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What are the exercise components of instability management?
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-abdominal setting
-multifidus strengthening -QL training -quads, abs and glut strengthening |
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How is manual therapy used to address instability?
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-treat IMPAIRMENTS
-manipulate surrounding stiff joints and myofascia -increase HS length if needed |
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Describe the 2 types of disc protrusion according to McNab.
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BULGING ANNULUS
Type I - localized annular bulge Type II - diffuse annular bulge |
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Describe the 3 types of disc herniation according to McNab.
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TORN ANNULUS
Type I - prolapsed nucleus Type II - extruded nucleus Type III - sequestrated nucleus (free body) |
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Describe the history of a pre-prolapse disc patient.
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-dull muscle ache in sitting
-perhaps h/o self cracking -low back pain radiating to buttock -no frank neuro signs |
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Describe the physical presentation of a pre-prolapse disc patient.
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-demonstrates many signs of instability
-grade 5 or 6 PIVM |
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Describe the management of a pre-prolapse disc patient.
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-stabilization, focus on endurance
-back school -manipulation to stiff joints and myofascia -instruct in disc first aid |
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Describe the history of a patient with an annular tear or strain.
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-sudden unguarded motion resulting in acute deep pain
-usually a flexion injury perhaps with a torque |
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Describe the s/s of an annular tear/strain.
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-sudden, deep pain
-guarded motion -pain referral to buttock -neuro signs may be exaggerated -DO not test FB and rotation |
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Describe the management of an annulus tear/strain.
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-goal = heal annulus
-maintain lordosis if not too late for 4 weeks (corset) -stabilization exercises -manipulation to stiff joints after 3 weeks -myofascial techniques |
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Describe acute management of a disc prolapse.
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day 1 to 4
-minimal bed rest to prevent disc swelling -attempt BB, likely too late -palliative medical measures -education, encourage movement, avoid prolonged rest |
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Describe subacute management of a disc prolapse.
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day 4 and improving
-initiate movement -myofascia manipulation -corset -stabilization |
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Describe the settled management of a disc prolapse.
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week 2 to 4
-positional distraction -stabilization -possible neural mobilization -back school, lifestyle education -mechanical traction (viti) |
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Describe the likely history of a chronic disc patient.
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-serious debilitating back pain
-h/o neuro signs -possible failed surgery or remission following successful surgery |
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Describe the physical presentation of a chronic disc patient.
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-possible medication for depression
-ROM restriction due to pain -PIVM combinations of restriction and instability -myofascia restrictions -poor tone/conditioning |
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Describe management of a chronic disc patient.
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-lifestyle education
-stabilization -positional distraction if neuro signs -careful neural mobilization -manipulate stiff joints and myofascia -fitness/work hardening |
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What are the 3 types of spondylolisthesis?
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-fatigue fracture of pars
-degenerative facet arthrosis and tropism -isthmic spondylolisthesis |
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What are the causes of fatigue fracture spondylolisthesis?
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-repeated overload
-prevalent in weight lifters, gymnasts, and divers -combination of torque with extension and rotation |
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What are the s/s of fatigue fracture spondylolisthesis?
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-step above level in standing, disappears in lying if unstable
-hypertonicity at affected level -ligamentous dull ache -rotational component if unilateral |
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Describe the management of a fatigue fracture spondylolisthesis.
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-stabilization exercise
-manipulate stiff joints above -myofascial techniques -CT scan if pt not healing, will require brace |
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What are the causes of degenerative spondylolisthesis?
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-congenital tropism = alteration of facet planes from coronal to sagittal
-facet arthrosis -overload |
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What are the s/s of degenerative spondylolisthesis?
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-step at level of slip
-step in standing does not show on Xray (no fx) -Xray must be taken in standing at end of day |
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Describe the management of a degenerative spondylolisthesis.
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-stabilization exercise
-manipulation of stiff joints above -myofascial techniques (usually psoas) |
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What are the causes of isthmic spondylolisthesis?
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-pars interarticularis lengthens allowing vertebrae to slip
-childhood obesity is precipitating factor |
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What are the s/s of isthmic spondylolisthesis?
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-Xray shows elongated isthmus
-Xray may show fracture of pars, masking initial cause |
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Describe management of isthmic spondylolisthesis.
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-stabilization exercises
-manipulation of stiff joints -myofascial techniques -weight control |
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What are the s/s of an unstable spondylolisthesis?
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-dull ligamentous ache at end of day
-step on standing disappears in lying -muscle guarding in standing, disappears in lying -rotational fault if unilateral |
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Describe management of an unstable spondylolisthesis.
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-stabilization exercise
-manipulate stiff joints -myofascial techniques -education to reduce loading and extension activities -surgery if stabilization unsuccessful and neuro signs presenting |
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What are the causes of lumbar central spine stenosis?
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-degeneration
-wear and tear, poor posture -tight psoas, lumbar spine myofascia -increased lordosis -disc protrusion/prolapse |
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What are the s/s of lumbar central spine stenosis?
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-chronic dull low back pain
-leg pain on walking any distance (neurogenic claudication) |
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Describe the management of lumbar central spine stenosis.
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-myofascial manipulation and stretching
-increase physical fitness -mobilize spine -strengthen abdominals -flexion exercises -surgical intervention (laminectomy) |
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What are the causes of cervical central spine stenosis?
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-forward head posture
-decreased disc height causing narrowing of canal and enfolding of ligamentum flavum -bosses and bars |
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What are contributing factors to cervical central spine stenosis?
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-poor posture
-cervical stress/strain, MVA -hypermobility due to UT kyphosis -C2/3; C5/6 instability |
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What are the s/s of cervical central spine stenosis?
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-bilateral UE symptoms
-vague, transient neuro signs in UE and LE -test for UMN signs (babinski and clonus) |
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Describe the management of cervical central spine stenosis.
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-posture; axial extension
-stabilization via longus coli and longus capitis -avoid BB -manipulate stiff UT region -address neuro complications (balance, proprio) |
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What are the causes of lumbar lateral foraminal stenosis?
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-lateral disc protrusion
-loss of disc height -degenerative changes to facets and lig. flavum |
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What are the s/s of lumbar lateral foraminal stenosis?
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-pain, numbness
-decreased neurological responses -true neuro signs: paresis > skin sensation > reflexes > neural tension |
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Describe management of lumbar lateral foraminal stenosis.
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-posture education
-stabilization -positional distraction -mechanical traction (viti) -manipulate stiff joints |
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What are bosses and bars?
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-osteophytes on the posterior aspect of cervical spinal column
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What are the causes and contributing factors of cervical lateral foraminal stenosis?
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-degeneration
-Von Lushka osteophytes -lig. flavum thickening -facet arthrosis -UT slouch and stiffness causes MC hypermobility |
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What are the s/s of cervical lateral foraminal stenosis?
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-neck and UE pain and parasthesias
-frank neuro signs = paresis, decreased sensation, decreased reflexes -pain relief with cervical distraction |
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Describe the management of cervical lateral foraminal stenosis.
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-manipulate stiff joints
-myofascial techniques -posture -positional distraction -surgical = foraminectomy |
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Differentiate common patient presentation of lumbar and cervical related neurological signs.
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LUMBAR
-discogenic; younger pts (28-50); M>F CERVICAL -lat foraminal stenosis from degenerative arthrosis; older patients (>50); F>M |
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What are the causes of acceleration/deceleration injuries?
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-MVA
-fall down stairs -being struck by a yacht boom |
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What are the s/s of acceleration/deceleration injuries?
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-unreliable s/s
-initially minimal -potentially bizarre -sympathetic involvement |
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Describe the management of acceleration/deceleration injuries.
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-2 weeks rigid immobilization, minimal movement
-plastic collar @ 1 week if symptom free -soft collar @ 4 weeks if symptom free, no exercise -NO TRACTION EVER until after 8 weeks, no resistance exercise until after 8 weeks |
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Define thoracic outlet syndrome.
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-compromise of the neurovascular structures of the upper extremity
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List the functional causes of TOS.
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-anterior scalene hypertrophy or adaptive shortening
-1st rib elevation/hypermobility -subclavius hypertrophy -pec minor adaptive shortening |
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List the congenital causes of TOS.
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-broad anterior scalene insertion
-fibrous slip connecting anterior to middle scalene -cervical rib/fibrous band from C7 |
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Describe the symptoms of TOS.
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-UE pain and parasthesia
-ill defined aching -intermittent claudication -Raynaud's -dorsal scapula pain -vein engorgement, intermittent edema |
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Describe the management of TOS.
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-treatment differs depending on tissue specific impairments
-manipulate restricted joints and myofascia -postural re-education -diaphragmatic breathing -HEP of stretching and self-mobilization |
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What is Baastrups Disease? (kissing spinous processes)
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-artificial joint between lumbar spinous processes
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What causes Baastrups disease?
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-spinous processes rub in posterior mid line
-inflammatory rxn is source of pain |
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What factors contribute to Baastrups?
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-poor posture
-pot belly w/ excessive lordosis -short stocky males |
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Describe the management of Baastrups.
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-pelvic tilt exercises
-stretch psoas and myofascia -weight loss -healthy back living -surgical intervention (excision, denervation, phenol to deaden nerve) |
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What is Thoraco-Lumbar Syndrome? (Maigne syndrome)
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-pain over the lateral thigh and occasional giving away of the leg
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What causes thoraco-lumbar syndrome?
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-T/L junction instability involving the lateral femoral cutaneous nerve
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What are the s/s of thoraco lumbar syndrome?
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-lateral thigh pain
-spontaneous giving way of leg -tenderness over lateral iliac crest |
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Describe the management of thoraco-lumbar syndrome.
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-stabilization of T/L junction via multifidus exercises
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What are potential disease causes of SI pain?
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-ankylosing spondylitis
-paget's disease -tuberculosis -female reproductive disorders -GI disorders |
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What are potential dysfunctional causes of SI pain?
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-torsional stress/joint strain
-laxity -displacement (positional faults) |
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List 3 SI joint syndromes.
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-strain/sprain
-hypermobility/instability -displacement |
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What are potential causes of an SI joint strain?
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-fall on ischial tuberosity
-bumping down the stairs -awkward twist and reach |
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What are the s/s of an SI joint strain?
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-localized pain, unilateral
-pain w/ provocation tests -ligament tenderness -ipsilateral tenderness w/ multifidus, erector spinae, QL, and piriformis resistance -pain altered by torsion |
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Describe the management of an SI joint strain.
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-multifidus exercises
-IFC and heat over tender area -body mechanics training -stretch associated muscle tightness |
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What are potential causes of SI joint instability/hypermobility?
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-repetitive minor trauma
-one legged standing -intercourse strains -childbirth |
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What are the s/s of SI joint instability?
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-dull ache on backward torsion such as with standing
-posterior leg pain -lowered iliac crest in standing -hypermobile symphysis pubis -positive spring test |
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Describe the management of SI joint instability.
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-supportive device 6-12 weeks, must be worn in standing
-posture/biomechanics education -hip manipulation if restricted -therex to include bridging, HL ER with theraband and prone hip extension -possible surgery |
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What are the potential causes of SI joint displacement?
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-hypermobile joint overrides articular prominences
-severe force to joint -possible symphysis pubis rupture |
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What are the s/s of SI displacemnt?
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-constant low grade pain, even with bed rest
-raised/lowered iliac crest -restricted passive motion -positive supine to sit test |
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Describe the management of SI joint displacement.
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-manipulative reduction
-examine to determine possible hypermobility and treat accordingly |
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Describe the anatomy of the coccyx.
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-two synovial joints
-attachments: sacrospinous ligament, glut max, coccygeus, sphinctor ani, levator ani |
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What are potential causes of coccygeal dysfunction?
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-direct trauma resulting in sprain
-fracture -hypermobile SI joint via sacrotuberous ligament -disc pressure on dura mater causing pull from filum terminale to 2nd piece of coccyx |
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What are common subjective aspects of coccygeal dysfunction?
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-history of trauma
-pain with sitting and defecation -localized pain and tenderness |
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What objective findings are common with coccygeal dysfunction?
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-tenderness with direct pressure and passive motion
-restricted mobility -pain w/ indirect stress such as glut max resistance -possible radiological evidence of fx/displacement |
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Describe standard management of coccygeal dysfunction.
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-stress reduction via pillow/pads
-avoid climbing stairs, sling chairs -use pillow w/ cut out for coccyx, not ring pillow |
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What are the causes of chronic discomfort with coccygeal dysfunction? What is the recommended rx for each?
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-adhesions = manipulation
-periostitis = stress reduction treatment |
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Describe management of coccygeal dysfunction using manipulation.
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-4 visits
-use gloves and lube -1 finger into rectum, used thumb of other hand exteriorly as counterpressure -pull along long axis of coccyx, repeat 3 to 5 times |
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List the principal indicators of headaches that we can treat.
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-pain begins in C/T spine
-headache affected by change in posture -history of trauma -physical or emotional stress brings on headache |
