arthokin mobil path Flashcards
What is a vertebral motor segment?
two continuous vertebral bodies and their common disc
What components of the motion segment dictate the amount and direction of motion?
- disc dictates amount of motion
2. facets dictate direction of motion
What is the muscle activation pattern for upright lumbar flexion?
- pelvis is stabilized by glut maximus, glut medius and hamstrings
- erector spinae eccentrically low trunk
- passive restraints take over in full flexion and the dynamic restraints shut off
What is the IAR of the lumbar motion segment during flexion?
- multiple locations are given including White, Panjabi Rolander in the anterior portion of the disc; Calve in the center of the disc; and Reichman level of the disc but in front of the disc
- as you flex it tends to move down and forward into the end plate or body
What is the muscle activation pattern of the lumbar spine with extenstion?
- Erector spinae active in beginning and end range
2. abdominals slowly increase through the ROM
What is the IAR of the lumbar disc with extension?
multiple theories are given including White and Panjabi posterior to annulus, Calve center of disc, Rolatner anterior disc and Reichman level of disc but anterior and outside the disc
What is the IAR of lumbar side bending?
- Panjabi contralateral side of the center of the disc
2. Grimsby ipsalateral facet
What is the muscle activation pattern for lumbar rotation?
contralteral multifidus, ipsalateral erector spinae, abdominals with multifidus counter acting the flexion moment
What is the IAR of the lumbar rotation?
- Panjabi puts it at the central of the subjacent end plate and slightly contralateral
- Grimsby indicates that it slowly migrates towards the closed pack facet
- before it reaches the closed pack position must shift into the spinal canal to prevent cord compression
How does the IAR change in the lumbar spine with a loss of disc height?
- flexion it moves anterior and superior out side the vertebral body
- extension it moves posterior and inferior
- rotation it moves inferiorly and laterally
How are the facets of the lumbar spine oriented and why is this important?
- upper lumbar have greater sagital orientation and lower lumbar become more transverse
- lower lumbar helps with anterior displacement of the segment
How does disc pathology effect the IAR?
- results in much larger movement in the IAR
- decreased height results in decreased tension of the connective tissues
- greater available ROM results in greater tension on the connective tissues
- greater tension on the connective tissues leads to MTL and further degeneration
What are the weight bearing roles of the disc, facet and UV joint?
- in the cervical spine the weight is transmitted primarily through the UV and facet joints
- in the thoracic and lumbar spine the weight shifts anteriorly into the disc and vertebral bodies
- L5 the weight bearing is in both the disc and facets
What are the coupled motions of the spine?
- cervical spine side bending and rotation the same reguardless of spien position
- L1-L3 side bending and rotation opposition in neutral same in flexed spine
- L5 same as cervical
- L4 is a transition zone and can go either way
What is the ratio of SB to rotation with coupled spine motions?
3 degree side bend for 2 degree rotation
What are the relative rotation segmental ROM of the lumbar spine?
increases distally from 2 to 5 degrees
What are the relative segmental SB ROM of the lumbar spine?
greatest in the middle and least at the bottom from 3 to 8 degrees
What are the relative segmental ROM for flexion of the lumbar spine?
increases distally from 12 to 17 degrees
What is the best way to determine mobility deficits?
relative segmental motion with an awareness of expected ROM
What is a normal of amount of sagital plane motion for the lower lumbar spine?
about 2mm of shear is relatively normal for the lower lumbar spine
How does disc pressure change with changes in posture?
- greatest with standing flexion
- least with supine position
- sitting and slumped posture both increase pressure on the disc
Why might painful end range trunk flexion indicate segmental instability?
as you flexion forward you reach of point where the posterior musculature turns off because and the ligaments and fascia provide the only support for the spine
What the clinical signs of hypomobilities of the spine?
- reduced mobility
- pain with stretch or compression
- local ligamentous tenderness
- acute muscle guarding
What are the clinical of hypermobilities of the spine?
- increased joint mobility
- full ROM
- ligamentous tenderness
- pain with prolonged stretch
- pain relieved with rest and exercise
- pain and stiffness after exercise
- joint locking and catching
- a.m. that improves once they get up and start moving around
How can hypermobility reproduce segmental symptoms?
- With rotation the contralateral facet reaches closed pack position the axis of motion shifts out of the spinal canal and can facilitate a stenotic vertebral canal
- Like wise with flexion you can have excessive forward displacement and narrowing of the vertebral canal
How do connective tissues become ossified?
- abnormal stress to a ligament triggers increases levels of fibronectin
- you also have an decrease in the number of fibroblasts, increased chodrocytes and a change in proteoglycan levels
- Hypermobilities contribute to ossification of the ligaments, for example orientation of the TL junction facet dictates ossification levels in that the greater the rotation ROM the greater the ossification
In the lumbar spine why does neuro testing provide the level of segmental dysfunction?
- The orientation of the roots sleeves can cause the segments above the segemental distribution to interfere with the nerve roots
- sinovertebral and PBPPR travel up and down several segments
- Therefore segmental mobility testing is necessary to determine level of dysfunction
What is far out syndrome?
entrapment of the anterior primary rami between the sacrum and L5
What nerve is responsible sensing meniscoid entrapments and why is this important?
- Medial branch of the posterior primary rami
2. each facet can have multiple segmental innervations and requires manual assessment to determine to involved segment
Pain with cough in most likely explained by what?
- mechanical pain from muscle contraction
- distention of the blood vessels with increase with increased intrabdominal blood pressure
- NOT increased intradiscal pressure
What is the primary cause of stenosis?
segmental instability and progressive spondylosis
What structures primarily contribute to spinal stenosis?
- degenerative disc (62%)
- hypertrophy of facets (25%)
- thickened ligamentum flavum (12%)
- spondylosisthesis (11%)
What functional activities tend to exacerbate lumbar spine stenosis?
- standing
2. walking down stairs or hills due to the increased lumbar etension
What is Van Geldrin’s test
test to differentiate claudication and stenosis when person bike until onset of pain then leans forward while continuing to bike to see if this will change the symptoms
What is cyclic sciatica?
With endometriosis menstruation will cause the uterus to compress the sciatic nerve
Is scoleosis a structural or mobility problem?
it frequently starts as a mobility problems turns into a structural problem
What part of the scoleosic curve is least mobile and why?
apex because all of the slack is taken up
Why so you avoid heel lifts with child who have scoleosis?
- Growth plates respond to pressure
- the long leg will force the body over the short leg increasing the pressure on that leg
- monitor for up to two years to for changes
Before providing a heel lift to normalize scoleotic changes what must you do first?
you must restore the axis of motion because you accentuate the problem if the persons spine lacks to mobility to compensate for the heel lift
What are the primary objectives when treating scoleosis?
- restore motion at the hypomobile segments
- stabilize motion at the hypermobile segments
- normalize soft tissues around the curves
What is the osteopathic lesion?
- Andrew still thought of it as the musculoskeletal dysfunction without disease
- Stoddard thought of it as impaired segmental mobility adn found that most common clinical signs inclued hypomobility, positional faults, pain and tenderness, muscular tension, reflex changines in skin and muscle
- Acute locked back or menisciod entrapment
What are the most prevalent theories of the cause of the osteopathic lesion?
- Kos and Wolf- coupling reversal
- Bogduk and Twomey- the fibroadipose meniscus doesn’t go back between the joint surface, but gets balled up inside the capsular space distending the capsule.
- Bogduk and Twomey- They also proposed things other than the meniscus can become entrapped such as a loose body of fat pad
What is Kos and Wolf’s theory on entrapments?
- Reverse of couple motion.
- As you lean forward and reach with one arm you have segmental SB and rotation gapping the ispalateral side
- as you stand back up the coupling reverses potentially entrapping the meniscoid
What are the five diagnositic criteria of Maigne’s syndrome
- the iliac crest point sign-
- skin rolling- gluteal and illiac crest, in his book he identifies this area as the trigger point region for the upper lumbar region
- positive segmental mobility testing in the upper lumbar spine
- facet tenderness
- pain inhibiting injection
What is ankylosing spondylitis?
- the disease attacks the synovial, enthesis and cartiliage of the axilla skeleton
- the disease under goes a process of inflammation and hypermobility
- as it progresses the effected joints undergo hypobility and ankylosing
What is the clinical profile of an ankylosing spondylitis patient?
- primary white
- 4:1 males to females
- onset usually late teens or early 20s, rarely after 40
- progression is over a 10-15 year period
What are the common subjective reports of an ankylosing spondylitis patient?
- insidious onset
- no neuro signs
- difficult to localize
- dull pain
- loss of mobility
- morning stiffness improving as they get and move
What are the classic AS radiological signs?
- (B) sacrolitis
2. A/P trolley track sign from ossification of the intraspinous ligaments and facet capsules
What findings will you have with AS blood work?
- erthroctye sedimentation during inflammation
2. HLA-B27 as inflammation subsides
What is the differential for episacroiliac lipoma?
- tender to sustained pressure
2. is not always incapsulated
What are the pain complaints, DTR changes, motor deficits, sensory deficits, trigger points and cellulagic zone for …
L2
anterior lateral upper thight ilioposas, hip adductors DTR none sensory dermatome mid thigh tirgger points0 pectineus, sartorius, adductor longus lateral tight cellulagic zone
What are the pain complaints, DTR changes, motor deficits, sensory deficits, trigger points and cellulagic zone for L3
anterior thigh and knee motor changes iliopoas and quad DTR patellar sensory distal thigh and knee as femoral nerve tension trigger points in quad medial thigh cellulalgic zone
What are the pain complaints, DTR changes, motor deficits, sensory deficits, trigger points and cellulagic zone for L4
lateral thigh and medial shin muscles: tibialis anterior and quad DTR: quad sensory: lateral thigh and medial shin trigger point: quad, TFL, tibialis anterior medial knee cellulagic zone
What are the pain complaints, DTR changes, motor deficits, sensory deficits, trigger points and cellulagic zone for L5
pain complaints in buttock, posterior thigh, lateral calf, medial foot
motor changes in extensor hallucis longus, extensor digitorum brevis
sensory change lateral calf and medial foot
DTR reflex
trigger points glut medius, semimebranousus, semitendonosus
cellulagic zone in lateral shin
What are the pain complaints, DTR changes, motor deficits, sensory deficits, trigger points and cellulagic zone for S1
pain buttock, poterior thigh, posterior calf, posterior heel, lateral foot, lateral toes
motor- fibilaris longus and brevis, gastroc and soleus
sensory changes lateral ankle, lateral foot, plantar foot
DTR achilles
trigger point- glut max, biceps femoris, semitendenosis, medial gastroc, soleus
cellulagic zone posterior calf
