Wvsom Fom 9-4-14

Front 1

[Vertebral Biomechanics & Fryette's Law]

1. Compare & Contrast motions caused or limited by the intrinsic back muscles, Ligaments, and vertebrae.

Back 1

PVS - determines range of motion

AVS - load bearing

IV DIsc - cushions & distributes stress

Intrinsic muscles - splenius, erector spinae, Transversospinalis, Intertransversarii

Ligaments - Posterior longitudinal lig., Costotransverse lig., Supraspinous lig., Interspinous lig., Ligamentum flavum., Nuchal lig., Iliolumbar lig., Posterior Sacrococcygeal lig.

Front 2

[Vertebral Biomechanics & Fryette's Law]

1. Detail the active functions of the intrinsic back muscles.

Back 2

Splenius - Extension

Erector Spinae - (BI) Extension, (UNI) side-bending and lateral flexion

Transversospinalis - Rotation & extension

Intertransversarii - Proprioception

Front 3

[Vertebral Biomechanics & Fryette's Law]

2. Describe the innervation of the structures of the vertebral column

Back 3

Zygophophyseal joints are innervated by branches of the spinal nerve.

Posterior rami from two spinal nerves innervate each joint

Front 4

[Vertebral Biomechanics & Fryette's Law]

3. Compare and contrast the deformation of the IV disc with various movements of the back.

Back 4

Compression - puts pressure on the nucleus pulposus, causing deformation.

Lateral Flexion deforms the IV disc into a wedge shape.

Flexion of the back pushes the nucleus pulposus posteriorly.

Extension pushes the nucleus pulposus anteriorly.

Front 5

[Vertebral Biomechanics & Fryette's Law]

4. Compare & contrast the effects of a herniated IV disc on spinal nerves.

Back 5

The nucleus pulposus can herniate through the anulus fibrosus. This herniation will impinge either the spinal cord or nerve roots of the vertebrae below the disc, e.g. a herniated L4-L5 IV disc will affect the L5 spinal nerve.

This is common in the L5 to sacral region. The impingement of the nerve roots will cause motor & sensory symptoms.

Front 6

[Vertebral Biomechanics & Fryette's Law]

4. Define Radiculopathy

Back 6

Pain radiating along a dermatome

Front 7

[Vertebral Biomechanics & Fryette's Law]

5. Describe the appropriate terminology for vertebral curvatures & spinal nerve-opathies (radiculopathy)

Back 7

Curvatures include: Kyphosis, Lordosis, and Scoliosis

Opathies include: disc herniation, degeneration, and spondylosis

Front 8

[Vertebral Biomechanics & Fryette's Law]

6. Define the vertebral unit.

Back 8

Two adjacent vertebrae with their associated intervertebral disk, arthrodial, ligamentous, muscular, vascular, lymphatic, and neural elements.

The lumbar and thoracic spines couple side-bending and rotation together, they cannot occur independently.

Front 9

[Vertebral Biomechanics & Fryette's Law]

Describe Fryette's three laws.

Back 9

Law #1 is where the spine is in neutral position, include a group of vertebrae where side-bending and rotation occur in opposite directions.

-Rotation occurs towards the convexity,

-Side-bending away from the convexity.

Law #2 applies to the spine in flexion or extension with side-bending and rotation occuring in the same direction and applies to a single vertebra.

Law #3 doesn't apply right now, check back later

Front 10

[Vertebral Biomechanics & Fryette's Law]

8. Explain the biomechanics of the vertebral column.

Back 10

Consider this as a REGION based mechanics.

The Thoracic's primary motion is rotation

The Lumbar's primary motion is flex/extend

individual units:

Thoracic - coronal facets

Lumbar - parasagittal facets

Front 11

[Vertebral Biomechanics & Fryette's Law]

Discuss the restrictive barriers & ease of motions that occur with Fryette type 1 somatic dysfunctions & locked open & locked closed facets

Back 11

Type 1:

-Neutral; sidebending & rotation - opposite sides

-Terminology: NS(R)R(L) or NS(L)R(R)

-Facets not engaged

-Multiple segments, long curves

-Compensatory, adaptive

-Rotation towards convexity, out from under the load

-Smooth Curves

-Treat last after type 2, if necessay

Front 12

[Vertebral Biomechanics & Fryette's Law]

Discuss the restrictive barriers & ease of motions that occur with Fryette type 2 somatic dysfunctions & locked open & locked closed facets

Back 12

Type 2:

-flexion or extension; sidebending & rotation to same side

-Terminology: FR(R)S(R) or ER(R)S(R), FR(L)S(L) or ER(L)S(L)

-Facets engaged

-single segments

-traumatic/primary/viscerosomatic

-rotation towards the concavity, into the load

-apices (apex) & crossovers, viscerosomatic reflexes

-treat first

Front 13

[Vertebral Biomechanics & Fryette's Law]

10. Discuss the restrictive barriers & ease of motions that occur with dysfunctional facets that are locked open or closed.

Back 13

Position of ease is the direction of ease.

The restrictive barrier is the direction that the joint won't go to easily.

Front 14

[Vertebral Biomechanics & Fryette's Law]

Diagnose a somatic dysfunction by vertebral motion testing.

Back 14

Palpate for the posterior transverse processes in either the prone or seated position. These may feel like a firmness or a resistance to pressure.

If multiple segments are noted, the dx is Type 1.

-NSxRy or Restricted SyRx

If a single segment, retest in flexion & extension, the dx is type 2.

-F or ERSx or Restricted E or FRSy

Front 15

[Vertebral Biomechanics & Fryette's Law]

Describe the "rule of 3's" as it pertains to the thoracic spine.

Back 15

-T1-3 SP is directly over the same vertebral body

-T4-6 SP is halfway between that body and the one inferior.

-T7-9 SP is directly over the body of the next inferior vertebrae.

-T10-12 SP is directly over the same vertebral body

Front 16

[Somatic Dysfunction of the T & L spine]

1. Identify the planes, axes, & directions of vertebral motion.

Back 16

Horizontal - rotation around a vertical axis

Sagittal - flexion/extension around transverse axis

Coronal - sidebending around anterior-posterior axis

Front 17

[Somatic Dysfunction of the T & L spine]

3. Diagnose type 1 or 2 thoracic & lumbar somatic dysfunctions by position of ease or direction of restriction.

Back 17

Type 1 - Neutral position.

-Posterior right transverse processes T8-L2

-Somatic dysfunction diagnosis: -T8-L2 NSLRR or T8-L2 restricted SRRL

Type 2 – Non-Neutral

Posterior left transverse process T11

Less prominent in extension, more prominent in flexion

Somatic dysfunction diagnosis: T11 ERLSR or T11 restricted FRRSL

Front 18

[Somatic Dysfunction of the T & L spine]

5. Determine positions for indirect and direct treatments of thoracic and lumbar somatic dysfunction

Back 18

Indirect is counterstrain & myofascial release: always towards the position of ease.

Direct is always towards the restricted direction, myofascial release, muscle energy, thrust

Front 19

[DS Low Back Pain]

1. Describe the common H&P findings of patients with low back pain.

Back 19

-Trauma history may be illusive, search for specific traumatic events, continuous muscle stress, or poor lifting mechanics.

-Pain localized to the lumbar or lumbosacralk area with no radiation to the extremities but may radiate to the buttocks.

-Pain will increase with activity but be relieved by rest.

-Any motion contracting injured muscles reproduces back pain.

Front 20

[DS Low Back Pain]

2. Describe strains:

Back 20

Stains - defined as tears, either partial or complete, of the muscle-tendon unit.

First degree strains include microscopic muscle fiber tears.

Second degree strains include macroscopic muscle fiber tears.

Third degree strains include complete disruption with joint instability.

Front 21

[DS Low Back Pain]

2. Describe sprains:

Back 21

Sprains are ligamentous tears.

These are caused by a sudden, violent contraction, sudden torsion, severe direct blows, or a forceful straightening from a crouched position. All major ligaments can sustain sprains, however the posterior ligaments are more prone to injury.

Front 22

[DS Low Back Pain]

3. Differentiate between lumbar strain/sprains, lumbosacral radiculopathy, and cauda equina syndrome.

Back 22

Lumbar strains/sprains can occur together, symptoms include pain & spasms localized over that posterior lumbar spinal muscle that typically worsens with movement and improves with rest.

Lumbosacral radiculopathy results from nerve root impingement or inflammation that has progressed enough to cause neurologic symptoms such as pain, numbness, tingling or weakness in the areas that are supplied by the affected nerve. Sciatic pain or parasthesias to foot, symptoms worsen with valsalva, abnormal CT or MRI, and positive neurological s/sx.

Cauda Equina syndrome.... yeah, call a neurosurgeon :)

Front 23

[DS Low Back Pain]

4. Describe Piriformis syndrome

Back 23

Piriformis is the irritation of the sciatic nerve (sometimes through pressure, but not always). Nerve compression usually causes impairment or loss of conduction. Sciatic pain/parasthesias usually stops at the knee, has no increased pain with valsalva, noted tenderness over the belly of the piriformis muscle, restricted ROM in internal rotation of the hip, and may cause dyspareunia via pelvic diaphragm irritation.

NO NEUROLOGICAL DEFICITS IN PIRIFORMIS SYNDROME.

Front 24

[DS Low Back Pain]

4. Describe Iliopsoas syndrome

Back 24

The iliopsoas is a muscle that connects from the lumbar vertebrae to the lesser trochanter of the femur. Patients are usually flexed at the time of the injury, the sciatic pain usually does not extend past the knee. They usually present with a c/o new onset of scoliosis with key somatic dysfunctions on L1 or L2 type 2. The pelvis will shift to the opposite side of the iliopsoas spasm while the piriformis muscle will spasm on the opposite side as the troublesome iliopsoas.

Front 25

[DS Low Back Pain]

4. Describe Iliolumbar syndrome.

Back 25

Iliolumbar syndrome involves the ligaments extending to the iliac crest from L4 & L5. This injury occurs when the iliolumbar ligaments are strained or stressed. Pain in multifidus triangle that includes pain in the sacroiliac, posterior thigh, and/or inguinal regions that mimics an inguinal hernia.

Front 26

[DS Low Back Pain]

5. Discuss degenerative disc disease and discogenic pain.

Back 26

Degenerative disc disease is a natural part of aging as well as a consequence of smoking, poor nutrition, atherosclerosis, occupational, or genetics. This degeneration begins in the second decade of life with a (usually) gradual onset of neck stiffness with or without pain.

Discogenic pain without nerve root involvement is typically vague, diffuse, and distributed axially with activities that increase intradiscal pressure intensifying the s/sx. Vibration stress from driving also exacerbates this. Disc herniation may coexist.

Front 27

[DS Low Back Pain]

6. Discuss why imaging the back is not always helpful in patients with low back pain.

Back 27

1. 52 % of the subjects had a bulge in at least one level
2. 27 percent had a protrusion
3. 1 % had an extrusion
4. 38 % had an abnormality of more than one intervertebral disk
5. The prevalence of bulges, but not protrusions, increased with age
6. Therefore your MRI must correlate with your physical findings

Front 28

[DS Low Back Pain]

7. Discuss the conservative treatment of low back pain.

Back 28

Relief of discomfort for mechanical low back pain can be accomplished safely with nonprescriptive medications and/or OMT. Patients are encouraged to return to work/ADLs as soon as possible.

Medications include NSAIDS, muscle relaxants, opioids, oral corticosteroids, and pain modifiers.