1.  outer 1/3rd of vertebral disc

2.  PLL

3.  Meninges

>> Sensory afferent info from Dorsal

Medial Branch of Posterior Primary Rami -

Afferent info from...

1. Facet Jt

2. Muscle

3. Skin

Also from Dorsal Root

Chronic Dysfunction:

What is the sequence of events?

Irritation>Pain>Local Edema>Local Inflammation>Fibrous Reaction>Fx Disability

Chronic Dysfunction: 

What changes Physically? Emotionally?

Physical Changes: mms shorten, jt restriction, tendon shortens, fascia shortens

Emo Changes: (4 Ds) Drugs,Decondition, Depend., Depression

1.  Cutaneous Innervation (Dermatomes)

2.  Myatomes (MMT)

3.  Reflexes

4.  SLR (testing L4-S3 nerve roots!)

5.  Ely's Test SLR specifically Upper Lumbar (L1-L3)

6.  Compression

7.  Distraction

8.  Facet Compression

SLR: L4-S3 Nerve Root Testing & Tight Hams

Ely's:  L1-L3 Nerve Roots (upper lumbar dysfunction)

Lumbar Mobility Testing-

Anterior Glide Spring Test

pt position: prone with pillow under belly

starting pos: pisiform over lumbar spinous process

mobility test:  take up the slack, spring test in anterior glide direction (slight & quick)

No Give?  Hypomobile

Lumbar Mobility Testing-

Forward Bending

pt posi: sidelying towards PT

starting posi: knee against PT's hip, hold upper leg with caudal hand; cephalic hand, place one finger in interspinous space

mobility test: flex pt's hip & palpate mov't @ interspinous space

>Feel for space to open up (normal)

Lumbar Mobility Testing-

Backward Bending

pt posi:  Sidelying, back to PT

Starting posi: flex knee & hold leg with caudal hand; cephalic hand, one finger in interspinous space

Mobility test: Hyperextend patient's hip & palpate mov't @ interspinous space

> Feeling space close

Lumbar Mobility Testing-

Sidebending

pt posi: prone pillow under abdomen

starting posi: flex knee & hold thigh with caudal hand; cephalic hand, one finger in interspinous space

mob testing: abduct hip and palpate @ interspinous space (feel lower body bump finger)

Lumbar Mobility Testing-

Rotation

pt posi: prone, pillow under belly

starting posi: flex both knees & hold feet with caudal hand; cephalic hand in interspinous space

mob test: rotate hip via feet & palpate movement at interspinous space

>>Understand what's happening @ the spine!! What's opening/closing?  What segments are rotating?  How is the body as a whole moving?

Lumbar Mobility Testing-

Sidebending

pt posi: sidelying facing PT

starting posi: both knees against PT's hip (knees & hip @ 90-degrees), hold legs with caudal hand; cephalic hand, one finger in interspinous space

Mob test: "lean back"/sidebend pt's legs via feet & palpate space

>Feel space close

Lumbar Mobility Testing-

Rotation

pt posi: prone with pillow under belly

starting posi: caudal hand @ ASIS, cephalic finger @interspinous space

mob test: rotate pt via lifting ASIS & palpate at the interspinous space

Lumbosacral Myotomes:

L1-2

L3-4

L4

L5

S1

L1-2: Flex Thigh

L3-4: Extend Leg

L4: Dorsiflex Foot

L5: Extend Hallux

S1: Plantarflex Foot

Reflex:

Patellar

Achilles

Bladder control

Patellar = L4

Achilles = S1

Bladder control = S2-4

iliopsoas

upper thigh

Rectus Femoris (Quads) & Adductors

Upper to Medial Thigh

No Myotome MM

Groin to Inguinal Area

Anterior Tib

Medial Leg to Great Toe

Ext.Hal.Long, Ext.Dig.Long, Ext.Dig.Brev, Post.Tib, Glut Med

Lateral leg & Dorsum of Foot

Peroneus Longus, Peroneus Brevis, Glut Max, Hamstrings, soleus, gastroc

Lateral Foot & Small Toe

Bowel, Bladder, Genitals

Peroneal Area

S: Hx, Interview

O: Initial Obs, Structural Obs, Active Mov't, Neuro Exam, MMT, Palpation, Mobility Testing, Add'l Procedures (ISAN MPM TA)

A: Assessment (what you think is going on?)

P: STG, LTG, Prognosis

Greater Sciatic Notch

Ala of Sacrum

Intervertebral Foramen

Entire Course of Nerve

Herniated Disc-

Sequence of Events

1.  Disc Protrusion - Local Tension Changes (TBP)

2.  Nonspecific Inflammation

3.  Possible Epidural edema

4.  Adhesion formation of intraneural fibrosis

Herniated Disc -

Sites of Irritation

IV Disc

Vertebral Body

pedicle

Facet joint

capsule

Lig.Flavum

Venous Distension

Piriformis

1.  Sciatica

2.  SLR below 40-degrees

3. 1+ hard neurological signs

4.  CAT scan, MRI, Myelogram confirmation

5.  Failure to respond to conservative tx

LBP Manual Therapy -

Treatment

1.  Relieve Pain

2.  Increase Mobility

3.  Reduce Mobility (Stabilize)

4.  Train & Instruct (Educate)

LBP Manual Therapy -

Schools of Thought

1.  Relieve nerve root pp

2.  Relieve pain

3.  Restore function

LBP Manual Therapy -

Proposed effects of mobilization

1.  Psychological

2.  Neurophysiological

3.  Mechanical

Disc Dysfunction

Plan of Treatment

1. Educate to Proper Back Care
2. Decrease Pain
3. Decrease mm guarding
4. Monitor Neuro signs
5. Increase mobility above and below segment
6. Strengthen trunk and LE mms
7. Improve overall fitness

• FB - full
• BB - lim dev. to R
• RSB - full
• LSB - limited
• RR - limited
• LR - full

• FB - limited deviate to L
• BB - Full
• RSB - Limited
• LSB - Full
• RR - Full
• LR - Limited

• FB - full
• BB - Limited Deviate to L
• RSB - limited
• LSB- Full
• RR - Full
• LR - limited

• FB - limited, deviate to right
• BB - full
• RSB - limited
• LSB - full
• RR - limited
• LR - full

Grading Joint Mobility

1) What are the Grades & what do they indicate?

1) 0: Ankylosed, no PT needs Sx

    0-2: Hypomobile

    3: Normal

    4-6: Hypermobile

    6: Pathologically Unstable, no PT needs sx

Grading Joint Mobility -

2) How do you treat?

2) 0-2 tx: mobilization/mobility exercise/articulate

    3: no treatment

    4-6: postural correction, check for  hypomobilities, ADL/ANL, Taping, collars/corsets, stabilizing exercises, sclerosing injections

1.  In the Thoracic & Lumbar Region, in neutral, sidebending goes with OPPOSITE rotation

2.  In Thoracic & Lumbar in FB & BB and in the Cervical for ALL MOTIONS - SB & Rotation occur in the same direction

3.  If you take up motion in one plane you have less available motion in other planes

1. Increased jt mobility
2. Full general jt mobility
3. Ligamentous tenderness
4. Pain reproduced by prolonged stretch
5. Pain relieved with rest and exercise
6. Pain & stiffness after exercise
7. Predisposed to jt locking
8. Hypomobility elsewhere

1. Reduced mobility at 1+ joints
2. Pain evoked by stretching or compression
3. Local ligamentous tenderness
4. Muscle guarding (acute) & muscle spasm (later)
5. Positional fault
6. Hypermobility elsewhere

Lumbar Mobilization Techniques -

Anterior Glide

pt posi: prone with pillow under abdomen

starting posi: pisiform over lumbar spinous process

mob tech: mob in anterior direction (oscillate <30s)

>> Helps with Extension??? (dc!)

Lumbar Mobilization Techniques -

Forward Bending

pt posi: Sidelying

starting posi: knee against PT's hip; wrap caudal forearm around butt and place fingers over inferior spinous process; place cephalic finger inferior to superior spinous process (to block)

mob tech: flex pt's hip while distracting inferior sp. process with fingers and forearm and resist mov't of superior segment

>> open up spinal canal posteriorly

Lumbar Mobilization Techniques -

Posterior Glide

pt posi: sidelying

starting posi: knee against PT's hip; caudal hand hold leg; cephalic finger over posterior surface of superior spinous process

mob tech: flex pt's hip until mov't palpated at respective jt; push femur posteriorly with therapist's hip for posterior glide & resist movement of superior segment

>> for BB???

Lumbar Mobilization Techniques -

Sidebending

pt posi: prone, pillow under ab

starting posi: flex knee & hold thigh with caudal hand; thumb or 2nd cephalic finger against superior spinous process on ipsilateral side

mob tech: abduct pt's hip and resist mov't of superior segment

 (see notes)

Lumbar Mobilization Techniques -

Rotation

pt posi: prone, pillow under ab

starting posi: flex both knees & hold feet with caudal hand; 2nd finger of cephalic hand block superior spinous process

mob tech: rotate pt's hip via feet & resist mov't of superior segment

Lumbar Mobilization Techniques -

Rotation (2)

pt posi: prone with pillow under ab

starting posi: caudal hand under ASIS (contralateral side), 2nd cephalic finger against sup. spinous process (ipsilateral side)

mobilization techniques: rotate pt by lifting ASIS and resist movement of superior segment

Lumbar Mobilization Techniques -

Positional Distraction

posi pt: sidelying over a bolster

starting posi: flex pt's hip until mov't is initiated at respective interspace; cephalic hand grabs inferior arm & rotates trunk until mov't occurs at respective interspace

>> See notes for indications! KNOW!!!

Disc Treatment Theories -

Flexion

Extension

Peripheralization vs Centralization

Tx of...

1.  Protruded Disc

2.  Sequestrated Disc

Why would you use Extension to treat a LHD?

(3 syndromes)

Disc Dysfunction-

Clinical Findings

Disc Dysfunction -

Plan of TX

Nerve Roots for...

Isthmic Spondylolisthesis?

Degenerative?

L5

L4

Grade 1-2: PT - Flexion Bias, bracing >Stability

Grade 3-4: Spinal Fusion

To Normalize Height of Vertebral bodies

1) Vertebroplasty Sx - inject cement

2)  Kyphoplasty - insert balloon, then inject cement

>> no mobilizations post-sx; focus instead on transfers, posture, lengthen pectoralis mm

Stretching Muscles of LB

*** p. 57-59 ***

Be able to describe your and pt's position

Erector Spinae

2 Leg Erector Spinae

Butt

Hams

Piriformis

Adductors

Calf

Quadratus Lumborum

Iliopsoas

Rectus Femoris

TFL/IT Band

Abdominal Exercises

p. 60 

Post. Pelvic Tilt

Lower Abdominals

Curl-Up

Curl-Up with Rotation

Trunk Extensor Exercises

p. 61

** be able to describe pt's position and action** 

Trunk Extension

Bridging

Trunk Extension with Scapular Retraction

Hip Anti-Gravity Exercises -

 p. 62

** be able to describe pt's position and action** 

Flexion

Extension

Adduction

Abduction

Ligamentous.

>> We "normalize" the alignment to take stress off the structure.

Structural Exam

Active Trunk Movements

Sacral Spring Test

Innominate Mobility Test

Palpation (3)

Muscle Flexibility Tests (3)

SIJ Exam -

Structural Exam

SIJ Exam -

Palpation

Pubic Symphysis

Baer's Point

Gluteal Region 

SIJ Examination -

Muscle Flexibility Tests

Piriformis

Rectus Femoris (Quads)

Hamstrings

Palpate:

Sacral Sulcus, Lateral Inferior Angle, BB (prone push-up)

Supine-Sit/Leg Length Test

Anterior & Posterior Innominate Rotation Tests

Anterior SI Ligament Gap Test

Posterior SI Ligament Gap Test

SI Mobility Testing -

Sacral Spring Test

Innominate mobility testing 

Same as (1) but now pt props self on elbows - for both (1) & (2) can also perform by palpating at the Lateral Inferior Angle of Sacrum since these correlate in same movements

Determines Innominate Rotatory Dysfunction -

P.S.Su

(Posterior Shorter in Supine)

Posterior Innominate Rotation = shorter in supine, longer in sitting

Anterior Innominate Rotation = shorter in sitting, longer in supine

* Be able to reason out!

SI Mobilization Techniques -

Sacral Anterior Glide

Same as Sacral Spring Test but with mobilizations

--> Use when anterior ligament tightness/hypomobile

(PROMOTING posterior rotation of innom.)

pt posi: sidelying

starting posi: place knee against therapists' hip & flex pt's hip to 90-degrees; caudal hand over ischial tub; ceph hand over ASIS

mob. tech:resist pt's contraction in direction of hip ext.(ant. rot); pt stops contraction, mob innom in direction of posterior rot.  

* indicated for pt too much in anterior innom. rot.

(promoting ANTERIOR innom rotation - stretching out hip flexors & adductors!)

pt posi: prone, pillow under abdomen

starting posi: near leg flexed @ hip and foot flat on floor/stool; cephalic hand on top of opp. PSIS, caudal hand opposite-underneath inferior thigh 

mob tech: therapist hyperextends+add opposite leg, resist pt's contraction in direction of hip flexion; pt stops contraction, mob innom in anterior rotation

(to treat upslip, promote downslip - stretch QUADRATUS LUMBORUM)

pt posi: prone with pillow under abdomen

starting posi:PT grabs near leg from above ankle

mob tech: PT hyperextends, IR, abducts near leg; resist pt's hip hiking contraction, pt stops contraction; mob innom via pulling near leg DISTALLY

* Alt. Tx? sidelying, pp down iliac crest with hip hike

(treat downslip, promote upslip)

pt posi: sidelying

starting posi: one hand over ischial tub; other hand over ASIS

mob tech:pt contract hip hike; CONCURRENTLY assist innominate in direction of hip hike (not resisting with this one)

(promote inferior glide, tx upslip by using adductors to pull pubis down)

pt posi: supine

starting posi: PT grabs near leg's inferior thigh from medial side

mob tech: PT abducts near leg; resist pt's contraction in direction of adduction 

(Tx downslip by promoting superior glide via rectus abdominis)

pt posi: supine with hip & knees flexed

starting posi: PT places one hand over near side chest wall

mob tech: resist pt's contraction in direction of sit-up 

Indicated for:

Left Sacral Torsion over Left Oblique Axis

pt posi: LEFT sidelying with trunk LEFT rotated

starting posi: place knees against PT's hip & hold legs with caudal hand (pt's arm behind back)

mob tech: flex pt's hips, rotate legs in direction of floor; resist pt's upward rotation of legs

*Palpate @ sacral sulcus can feel multifidus contract

(Left piriformis working)

Indicated for:

Left Sacral Torsion over Right Oblique Axis

pt posi: RIGHT sidelying, LEFT trunk rotation

starting posi: knees against PT's hip & hold leg with caudal hand (pt's arm in front)

mob tech:  flex pt's hips, rotate legs in direction of ceiling; resist contraction downward rotation

(Left piriformis working)

Indicated for:

Right Sacral Torsion over Right Oblique Axis

pt posi: RIGHT sidelying, trunk rotated to RIGHT

starting posi: knees against PT's hip & caudal hand holds legs (arm behind pt's back)

mob tech: flex pt's hips, rotate legs in direction of floor, resist pt's contraction in direction of upward rot of legs

Indicated for:

Right Sacral Torsion over Left Oblique Axis

pt posi: LEFT sidelying, trunk rotated to RIGHT

starting posi: knees against PT's hip, caudal hand hold legs

mob tech: flex pt's hip, rotate legs in direction of ceiling; resist downward rotation of legs

SI Dysfunction -

Clinical Findings

Pain @ PSIS or across PSIS (@ or below belt line)

Can have radiating pain

Worse with Standing

Discomfort with Rising to standing

Tender Butt

Lumbar MM Guarding/spasticity

Sacral Dysfunction

Innominate Dysfunction

Decreased Hip MM Flexibility

SI Dysfunction -

Plan of Tx