Published on May 8, 2008
Spinal Regions: Spinal Regions Cervical - 7 vertebrae Thoracic - 12 vertebrae Lumbar - 5 vertebrae Sacral - 5 fused vertebrae Coccyx - 4 fused vertebrae Functions of the Spine: Functions of the Spine Spinal cord protection Muscle attachments Curves provide shock absorbing capabilities Movements- flexion, extension, lateral flexion Slide4: The SMS is the basic functional unit of the spine. It consists of the adjacent halves of two (2) vertebrae, the interposed disc and facet joints as well as the supporting ligaments, muscles, blood vessels and neural structures. THE SPINAL MOVEMENT SYSTEM Thoracic Region: Thoracic Region Articulate with ribs Articulating surfaces: facets or demifacets T1- T10 articulate with the tubercles and heads of ribs T11-T12 articulate only with the rib heads Movement is limited Lumbar Region: Lumbar Region The facet angles allow for more flexion – extension movement Bigger stronger vertebrae Sacrum: Sacrum S1-S5 (fused) Female sacrum is shorter, wider, and more curved between S2 and S3 Anterior: 4 transverse lines (mark the joining of the vertebral bodies) Anterior sacral foramina: communicates with the posterior sacral foramina through which nerves and blood vessels pass Parts of Typical Vertebrae: Parts of Typical Vertebrae Body Thick, disk-shaped anterior portion of the vertebrae Weight bearing portion Separated by cartilaginous intervertebral discs Vertebral Arches Formed by the pedicles, laminae Boundaries for the vertebral foramen with the body Surrounds the spinal cord Combined to form the spinal canal Vertebrae cont.: Vertebrae cont. Vertebral Notches Each pedicle has a superior and inferior notch When stacked they form the intervertebral foramen- allows passage of a single spinal nerve Processes 7 arise from the vertebral arch Transverse (2)- serves as muscle attachments Spinous (1)- serves as muscle attachments Superior articular (2)- forms joints with vertebra above Inferior articular (2)- forms joints with vertebra below articulation surfaces are called facets The Disc: The Disc The principle function of the disc is to transmit shock and the load of the spine. Each disk is made up of two parts The hard, tough outer layer is the annulus, which surrounds a mushy, moist center called the nucleus. The outer annulus has approximately 12-16 fiber rings that provide the stability to the disc and keep is resistant to tearing when rotated or pressured from front bending, side bending or extended as in back bending. The disc is water filled and thus is effected by age and weight. The disc compresses slightly when weight bearing and refills with fluid when the load bearing pressures are released. (lying down) The disc has some ability to heal itself if it is not too damaged. However, the healing process is slow, 6 months to 1 year. The nucleus provides a ball bearing type of effect. It is approximately 75% water. Ligaments: Ligaments Provide the CNS with information about body position. (Mechanoreceptors.) The ligaments maintain joint integrity and allow movement. They have poor blood supply and are thus slow healing. Anterior longitudinal ligament - this ligament strengthens the disc anteriorly Posterior longitudinal ligament - strengthens the disc posteriorly Interspinous ligaments tie the spinous processes together. Allow for forward bending. Pars Interarticularis ligament problems are often precursors to disc problems. If you have some laxity in a ligament, then the rotation forces on the disc become to great and a tear of the annulus is likely. Signs and symptoms of a ligamentous problem may include the inability to sit comfortably, aching, deep soreness, no neurological findings and symptoms typically increase with fatigue. Muscles of Thoracic Spine: Muscles of Thoracic Spine Flexion of Thoracic Spine: rectus abdominus, external and internal abdominal oblique Extension of Thoracic Spine: Longissimus thoracis, Interspinalis Rotation and Side flexion of Thoracic Spine: Longissimus thoracis, internal abdominal oblique, external abdominal oblique, transverse abdominis Levator Scapulae Rhomboids Trapezius Serratus anterior, posterior, superior Muscles of Lumbar Spine: Muscles of Lumbar Spine Forward Flexion: psoas major, rectus abdominis, external and internal abdominal oblique Extension: latissimus dorsi, erector spinae, quadratus lumborum, gluteus maximus Side Flexion: latissimus dorsi, erector spinae, quadratus lumborum, psoas major, external abdominal oblique Rotation: transversalis Nerves: Nerves Nerves Cont.: Nerves Cont. Lumbar Plexus: Lumbar Plexus Supplies the anterolateral abdominal wall, external genitals, and part of the lower limb L1- iliohypogastric(muscles of anterolateral abdominal wall; skin of inf. Abdomen and buttock), ilioinguinal L2- genitofemoral(cremaster muscle; skin over middle ant. Surface of thigh, scrotum in male, and labia majora in female) L3- lateral cutaneous nerve of thigh(skin over lateral, anterior, and posterior aspects of thigh) L4- femoral(flexor muscles of thigh and extensor muscles of leg; skin over anterior and medial aspect of thigh and medial side of leg and foot), obturator(adductor muscles of leg; skin over medial aspect of thigh) L5- lumbosacral trunk Sacral and Coccygeal plexuses: Sacral and Coccygeal plexuses Nachemson's Disc Pressure Studies: Nachemson's Disc Pressure Studies Supine - 25% of standing Standing - 100 % Forward bending - 150% Forward bending with a weight - (10lbs) - 220% Sitting - 140% Sitting and lifting a weight - 185% Sit ups - 210% Supine with legs supported - 35% Most patients with a disc would rather stand than sit. Sitting puts an axial load on the spine and thus loads the disc more than standing. Slide27: Reflexes L3-4 patellar tendon L4-5 muscle test, extensor hallucis longus, anterior tibialis L5-S1 Achilles tendon reflex S2-3-4 are the bowel and bladder control nerves Slide28: L4 Muscle - anterior tibialis Reflex - patellar reflex Sensation - medial side of the leg and foot L5 Muscle - Extensor hallucis longus Reflex - None Sensation - top of the foot S1 Muscle - peroneus longus and brevis Reflex - Achilles Sensation - lateral leg and foot Slide29: Injuries and Syndromes of the Spine Facet dysfunction Myofascial sites SI joint dysfunction Ligamentous weakness Instability Disc Dysfunction Spondylolisthesis Spondylosis Slide30: Fractures Acute Stress Compression Stenosis Elevated first rib Thoracic outlet syndrome Scoliosis Slide31: Normal curves When using a plumb line, the ear, ac joint, greater trochanter of the hip, anterior knee, and lateral malleolus should line up vertically. When these structures line up it creates natural curves in the spine, the cervical area curves in, the thoracic area curves out, the lumbar area curves back in and the sacral area curves out again. An increased thoracic or sacral curve is called kyphosis. An increased cervical or lumbar curve is called lordosis. Abnormal Curvatures: Abnormal Curvatures Scoliosis- abnormal lateral curvature Kyphosis- “hunchback”; abnormal thoracic curvature Lordosis- “swayback”; abnormal lumbar curvature Slide33: Abnormalities Scoliosis is a lateral curvature of the spine which usually has a childhood onset. It can be corrected by strengthening the convex musculature (if the curvature is not too severe.) Stretching the concave muscles and using muscle stimulation at night. Activity if fine as long as the patient is asymptomatic and the angular curves are not progressing. Slide34: Spondylosis Is a fracture of the Pars articularis in the lumbar spine which does create some instability and pain. Specific exercise can help, sports can be continued with modifications of exercises, specifically weight training. ( elimination of squats and power cleans, hitting the sled, etc. any exercises that cause hyper extension of the back and pain.) Confirmation via x-ray is necessary, oblique views in which a "Scotty Dog" is present are necessary. If the dog has a band or collar on, this represents a fracture of the Pars. Slide35: Spondylolisthesis This is a progressive form of spondylosis where the lumbar vertebrae displaces on the one below it, this normally occurs at L4/5. This condition can cause pressure on the lumbar nerve roots and heavy physical labor or athletics may be contraindicated. The body will slide forward on the inferior disc and vertebral body. This causes strain / sprain on the ligamentous tissues as well as closing the neural foraminal spaces. Slide37: A herniated disc is a bulging disc, which can impinge on the spinal nerves. Depending upon the degree of herniation, the patient may be pulled from activity until therapy and exercises can slowly advance the patient to an activity level that they can tolerate. Avoid any activities that aggregate neuro symptoms. A ruptured disc usually is very painful with associated paresthesia and paralysis and requires surgery. Back surgery patients may take from 6 to 18 months to rehab and some never fully recover to their pre op form. Slide39: Arthritic changes in the facets and vertebrae can be disabling and painful. The swelling is secondary to the arthritis but it can impinge nerves and stretch ligaments. Long term changes include degenerative changes and exostoses. Soft tissue problems in the muscles and ligaments of the spine are treated like those in other areas, but the need to rest the muscles of the low back may have greater need than resting the muscles of the leg. The muscles of the back almost never rest whether the patient is sitting, lying down, or standing. Muscle injuries were previously thought to stand alone, however, recent research has shown that often the muscle spasm is a sequela to ligamentous and or disc trauma. Slide40: Ligament Injury Slide41: Back Evaluation Tests Kernig / Brudzinski Test The patient is lying supine with their hands cupped behind the head. The practitioner is standing next to the patient. The patient is asked to flex the C-Spine by lifting the head. Each hip is flexed separately to less than 90 degrees. The opposite leg remains on the table. Pain that radiates into the lower extremity with neck and hip flexion is deemed a positive finding. The pain is usually relieved when the knee is flexed. The origin of the pain is nerve root irritation, meningeal irritation and dural irritation that is increased as a result of stretching the spinal cord. Slide42: Distraction test Pull the vertebrae apart, increased pain indicates tight muscles, tendons or ligaments. Compression test Push the vertebrae together, increased pain or radiating pain implies a possible disc, swelling, or facet problems. Valsalva test As the patient to hold their breath and then bear down as if attempting to move their bowels. A space-occupying lesion (disc) will cause pain at the site of protrusion. Slide43: Thomas test This tests for hip flexor tightness. Have the patient draw both knees to the chest while laying down, then drop one leg to the table, the hamstring of the dropped leg should reach the table, if it does not, the hip flexor muscles are too tight and are effecting the biomechanics of the back by pulling the pelvis forward an increasing the lordosis. Slide44: Gaenslen test Is performed the same way that the Thomas test is except that the extended leg is allowed to fall off of the exam table. This forces the pelvis to rotate and compress the si joint on the dropped side. Pain is indicative of SI problems. Slide45: Pelvic compression and distraction Tests the SI joint. The test is performed by applying pressure to the ASIS to distract the SI joints or by pushing on the ASIS to compress the SI joint. Figure 4 or Fabere test Tests for SI joint compression. Have the patient drag one heel up the opposite leg and then let the bent leg fall into abduction and external rotation. Pain on the same side indicates a sensitive SI joint. Slide46: One Leg Standing (stork) Tests for lumbar segmental rotation and places stress on the Pars interarticularis thus testing for a spondylosis resulting from an acute or stress fracture. This test has significant clinical correlation. Slide47: Straight Leg raise test (Hoover Test) Tests the flexibility of the hamstring muscles and the possibility of sciatica. Have the patient dorsiflex their foot, straighten his knee and lift his leg as far as possible. Pain in the hamstrings is indicative of tightness; pain in the buttocks indicates sciatica (sciatic nerve pain). Pain on the opposite side of the SLR indicates a space-occupying lesion. (Disc) The inability to raise the leg may be indicative of weakness due to a neuromuscular weakness. A positive test is noted if the practitioner does not feel pressure under the non raised leg. Slide48: Ober's test This test checks the length of the tensor fascia latae or the I.T. band. Have the patient lie on the side, stabilize his pelvis, bend the top knee and have him touch the table behind him, if the leg floats and does not go down to the table, the tensor fascia is tight. Slide49: Slump Test The patient is seated on the edge of a table with the legs supported. The first segment is to have the patient slump the shoulders and back into thoracic and lumbar flexion. The head and neck are not flexed at this time. The head and neck are then flexed and the legs extended. Pain and or discomfort should be expected in the areas behind the knees and in the mid back, however, if pain or symptoms are noted at any time during the segmented testing, the examiner does not need to progress to the next level. (Magee, 9-40) Slide50: Trendelenburg Test The patient is standing supported on both legs. Have them raise one leg thus standing on one foot. Slide51: Range of motion Test the ROM in all three  planes of motion. You should record the rom, strength, and quality of these movements. Also note any guarding that may take place. Look to Detect any abnormal movements or structural findings such as kyphosis, lordosis, or scoliosis. Slide52: Manual muscle tests There is a specific test for all the muscles in the abdomen and low back. Test all the muscles of the upper thigh and hip also. Perform all of the tests and then repeat several of them on the major muscle groups to see if increased repetitions and thus fatigue are indicated. Take a detailed history of past painful patterns, medication, and any special tests performed by the physicians in the past. Check the patient's posture and leg length. Check the posture from the front, side, and back. Check the leg length. Slide53: True leg length - measured from the ASIS to the medial malleolus. Apparent or functional leg length - measured from the umbilicus to the medial malleolus. If apparent leg length is off and true leg length is ok, then there is an imbalance in the pelvis area. Slide54: Gait analysis Bad gait patterns and posture can lead to back problems. Make sure that walking patterns are not aggravating the back problem. Lifestyle changes Do not be afraid to tell your patient that they may have to change some of there habits or lose weight in an effort to help their back. Consult with their physician before sharing such "news" so that the entire health care team is on the same page. Patients with back pain do not sleep on their stomachs. If side sleeping, they should put a pillow between their legs to maintain a level pelvis. Slide55: Weight Room and Lifting Mechanics Spondylosis / spondylolisthesis patients should not squat and or power clean in the weight room. Hamstring curl machines should have a bend back surface to eliminate the lower back from those lifts. Rules Maintain an anterior curve in the spine. (head up position) Do not twist while lifting Use legs. Not back to lift. Keep objects close to the body. There is no evidence that lifting belts prevent injury. They may help a patient return from injury. They do however help to promote proper lifting techniques due to their width.