exsc 460 FINAL Flashcards
Trunk Posture Posterior View: plumb line dropped from ________ should bisect ________
occipital protuberance
vertebral spinous processes
angle formed by the direction the spinous process and the frontal plane- should be 90d
angle of protuberance
most prominent spinous process
C7 or T1
should be symmetrical
ribs
arm to body distance
muscular development (no evidence of spasm or atrophy)
Trunk Posture Anterior View: should be symmetrical
muscular development
ribs
body countour
Lateral View: curves
cervical-anterior
thoracic-posterior’
lumbar- anterior
sacral- posterior
development
cephalocaudal
primary curves are:
thoracic and sacrum
secondary curves are:
cervical and lumbar
at birth:
whole spine is concave
at 3 months:
child begins raising head and cervical curve develops
at 6-8 months:
child begins to sit up and lumbar curve begins to develop
abdominal tonus
lack of protrusion
functions of abdominal wall
protection support of viscera elimination forced expiration trunk flexion and rotation pelvic tilit stabilization of trunk and pelvis (most important stabilization muscles)
relationship of abdominal muscles to curves of spine
pelvic tilit
lordosis
abdominal ptosis
a pathological weakness or absence of the abdominal wall
beevors sign
determines integrity of segmental innervation of rectus abdominus and corresponding paraspinal muscles
how beevors sign test is performed
patient does 1/4 sit up with arms folded on chest, umbilicus drawn to the stronger or uninvolved side, away from the weakness
Deepest layer of the spine
multifidus- rotation toward opposite side and extension
rotatores- same as above
interspinalis- extend vertebrae
intertransversarii- lateral flexion
intermediate layer
erector spinae:
spinalis
longissimus
iliocostalis
superficial layer
latissimus dorsi
gluteus maximus
vertebrae of lumbar spine
large and massive w/ short thick and strong pedicles
facet joints absorb shear and rotational forces in the spine
thicker and narrower in the thoracic than in the cervical and lumbar regions
limits hyperextension of spine and forward displacement of one vertebra on another
anterior longitudinal ligament
thicker in thoracic than in cervical and lumbar regions
posterior lateral corners of intervertebral discs are poorly covered
posterior longitudinal ligament
connects laminae of adjacent vertebrae from axis to sacrum
ligamentum flavum
connects tips of spinous processes of adjacent vertebrae from 7th cervical to sacrum
supraspinous ligaments
connects the adjoining spinous processes from their tips to their roots
interspinous ligament
connects transverse processes of adjacent vertebrae
intertransverse ligament
what covers the superior and inferior surfaces of vertebral bodies?
hyaline cartilage
intervertebral fibrocartilages (discs) are made up of how much water?
85-90%
how much nerve supply does the disc have?
minmal, peripheral posterior aspect of the annulus fibrosus may be innervated by a few nerve fibers from the sinuvertebral nerve
what 3 distinct tissues make up the intervertebral disc?
annulus fibrosus
nucleus pulposos
vertebral endplate
what is the annulus fibrosus?
outer circumfrence of disc made of 10-20 concentric rings of type 1 collagen fibers that criss cross at an angle of 30-60degrees to the spinal axis
is the annulus fibrosus vascular?
only the periphery of the disc is vascular
what is the nucleus pulposus?
central portion of the disc
loose collagen fibril network contained within an extensive gelatinous matrix (type II collagen)
at birth the nucleus pulposus:
contains a high portion of mucopolysaccharides which cause the disc to resist deformation.
these mucopolysaccharides decrease with age.
what is the function of the nucleus pulposus?
transmit vertical loading (compression) to radially directed tensile forces in the annulus
is the nucleus pulposus vascular?
no, avascular
How does the nucleus pulposus receive nutrition?
passive diffusion from the periphery of the annulus fibrosus and the vertebral bodies
what is the vertebral endplate?
thin layers of hyaline cartilage that cover the superior and inferior surfaces of the vertebral bodies.
endplates are 1 mm thick and allow nutrient transport in and out of discs via passive diffusion
condition characterized by an abnormal anterior convexity of the lumbar spine
lumbar lordosis
most common postural deviation seen
Etiology of lumbar lordosis
mal posture muscle imbalance overweight or pregnant compensation due to kyphosis fashion-high heels
X-ray evalutaion of lumbar lordosis shows:
pelvic angle and sacral angle increase from 30d to 40d
lumbosacral angle decreases from 140
anterior distance between vertebral bodies is greater than normal
clinical evaluation of lumbar lordosis
increased pelvic inclination/anterior tilt
lack of pain, edema, or discoloration
pathological changes
posture changes: accompanying kyphosis
internal rotation of hips
What muscle and Ligament changes accompany lumbar lordosis
abdominals stretched/weakened
low back extensors shortened
hip flexors tight
hip extensors weakened/stretched
sporting activities that aggravate lordosis
football lineman
gymnastics
equestrian events
Basic 5 exercises for Lumbar Lordosis
pelvic roll strengthen abdominals strengthen hip extensors stretch low back extensors stretch hip flexors
how to establish good postural practice:
encourage regular physical fitness program
provide knowledge base
provide motivation
Low Back Pain: Nociceptors detect pain through what 3 changes?
mechanical changes
chemical changes
temperature changes
What are mechanical changes?
over stimulation of mechanoreceptors
severe deformation of a tissue=perception of pain
What are Chemical changes?
presence of various chemicals such as hydrogen ions, potassium ions, or polypeptides from break down of proteins and acetylcholine. deficiency of blood or oxygen.
longer lasting
What are temperature changes?
thermoreceptors produce the perception of pain when extremes in temperature occur.
How much of all people will experience back pain during their life?
80%
the annual incidence of back pain ranges from:
15-45%
vast majority of low back pain takes how long to resolve?
2-3 weeks
_____ of patients experience improvement in _____
90%
6-12 weeks
recurrence rate:
58-90%
what ages are most commonly affected
35-55
difficulty in treatment lies with:
ability to achieve a definitive diagnosis
3 predisposing factors to etiology of low back pain
poor sitting posture
loss of extension
frequency of flexion
low back pain shows a fluctuation of symptoms depending on:
patients activities and postural positions
certain positions _____ the pain while others ____ the pain
aggravate
relieve
what must be done to determine the movements that are therapeutic to each patient?
mechanical evaluation
patient performs series of end-range spinal movements
What is postural syndrome?
soft tissues surrounding the vertebrae are subjected to prolonged periods of mechanical stress. (bending finger back)
characteristics of postural syndrome:
pain always intermittent in nature
pain is strictly positional
time factor, pain not immediate
pain removed immediately by postural correction
What is dysfunction syndrome?
occurs when adaptively shortened structures surrounding the vertebrae are subjected to mechanical stress on attempting normal end range movement
characteristics of dysfunction syndrome:
pain always intermittent in nature
no time factor
pain immediate
pain abolished immediately when stress is removed
pain occurs only at end range of motion, never while moving throughout range of movement
not rapidly reversible
managed by gradual stretching of tight structures
pain should be relieved immediately after stretch
is complete
What is derangement syndrome?
anatomical disruption and displacement of part of the intervertebral disc complex at the affected spinal level
characteristics of derangement syndrome?
pain usually constant in acute stage
pain produced or exacerbated immediately or eventually by certain movements and positions
pain appears during movement range
prevention of low back pain
learn and participate in daily exercise program "Back school" reduce stress quit smoking watch weight always warm up and cool down
majority of acute low back pain will spontaneously resolve within:
2-6 weeks
an aggressive rehabilitation program is focused around an individualized, structured exercise program geared to create improved:
stamina, balanced strength, flexibility, and endurance
goal of acute treatment
relieve pain and muscle spasm
name several acute treatments:
bed rest 1-2 days cryotherapy thermotherapy massage manipulation electrical stimulation
goals for post-acute treatment
restore ROM, strength, endurance, and flexibility to enable patient to return to work, sport, etc.
McKenzie has popularized the use of _____.
extension exercises to strengthen erector spinae and maintain the neutral curvature of the spine
goals of spinal stabilization:
increase capacity of muscular stabilizing system to maintain neutral zone of spine within physiological limits
increase the low back’s tolerance to insult through the conditioning of the key musculature
restore muscle, strength, and endurance
reestablish a coordinated muscle activity as required for prevention of recurrence and restoration of function
reduce pain associated with spinal instability
stage 1 of spinal stabilization
focuses on activating the local stabilizing muscles
stage 2 of spinal stabilization
involves exercises that require a co-contraction of the TrA and MULT during assumption of additional positions
stage 3 of spinal stabiliztion
designed to maintain the abdominal draw and nature lordosis contraction during performance of exercises designed to recruit global stabilizers.
Etiology of Herniated Intervertebral Discs
Natural degeneration
Sudden or sustained increases in intradiscal pressure
lifting, fall on buttocks, direct trauma to back
anything that increases intradiscal pressure causes posterior fibers of annulus to give way
disc becomes softer and more susceptible to injury during:
pregnancy and labor and prolonged periods of bed rest
____ of herniated disc patients had a positive family history
32%
patients who have a positive family history are _____ greater risk
4-5 times
herniated disc pain is accentuated by:
forward bending, coughing, sneezing, lifting, etc.
relieved by recumbency
sciatic pain first appears:
as an ache in the buttocks followed by pain in posterior thigh, popliteal area, calf, ankle, and foot
lumbar spine deviates away from:
affected side
herniation is usually posterolateral, listing toward affected side increases:
pressure on the nerve and therefore increases symptoms
______ is usually restricted as it exacerbates the pain.
flexion
if tenderness is felt it is found where?
over the vertebral interspace just lateral to the midline in a large protruded disc
motor signs are present in ______ of cases
96%
sensory signs are found in ______ of pateints
80%
straight leg test
patient is supine, hip slightly internally rotated, knee extended, examiner slowly flexes hip until patient complains of pain or tightness.
pain after 70d is probably joint pain
then examiner dorsi flexes the patients foot, if radiating sciatic pain returns, the test is positive
well-leg raising test
patient supine, examiner raises unaffected leg, test is positive if sciatic pain produced on affected leg. these ruptures medial to nerve root.
Bowstring Test
straight leg test with knee slightly flexed. thumb or finger pressure applied in popliteal space. if radiating sciatic pain, test is positive.
most common site of problems in vertebral column
L5,S1 because it bears the most weight
transition between fixed sacrum and flexible lumbar vertebrae
greatest angle
studies by Armstrong and Shah found that the nucleus migrates:
forward in lumbar extension and backward in lumbar flexion
Protruded Disc
blugling of an intact annulus fibrosus
prolapsed disc
only the outer fibers of the annulus contain the bulging nucleus
extruded disc
disc material that extend beyond the annulus but still in continuity with disc material within disc space
sequestrated disc
disc material lies outside the annulus and is no longer in continuity with the disc material
schmorl’s nodes
herniation of nucleus pulposus into the vertebral body
before surgery is undertaken, ____ and ____ of herniation must be established
existence and exact location
x rays
narrowing of disc space is indicative of old rupture
CT scan
reveal other pathology that may simulate a disc protrusion such as facet syndrome, spinal stenosis, tumor.
myelography
rule out possibility of nerve root tumor
should allow _______ of therapy before surgery
6 weeks
conservative management
1-2 weeks bedrest ice or heat to relax low back muscles muscle relaxants exercise proper posture practiced
criteria for surgery
impaired function of bowel or bladder
progressive motor weakness
severe sciatic pain
chemonucleolysis
injection of enzyme chymopapain into herniated nucleus pulposus
cause dissolution of mucopolysaccharides of the disk and reduce intradiscal pressure
3-6 months recover
percutaneous automated discectomy
posterolateral approach, nucleotome is positioned in nucleus pulposus, activated by a foot pedal and moved gently back and forth within disc while suction aspiration takes place
permits immediate mobilization
microdiscectomy
1-2 inch incision, use of operating microscope and microdiscecting technique to remove the disc under general anesthesia.
knee-chest position which decreases intraabdominal pressure and minimizes epidural bleeding.
laminectomy
most common
portion of lamina and some of ligamentum flavum is excised.
7-10 days for office workers
8-12 weeks for laborers
exaggeration of the normal posterior thoracic curve
kyphosis
includes kyphosis, forward head, and forward (rounded) shoulders
kyphosis syndrome
etiology of kyphosis
congenital failure of curves to develop acquired imitated posture occupation ectomorph more prone
postural kyphosis
functional, non-fixed curves
result of minor muscle imbalances
curvature can be corrected easily by patient
scheuermann’s disease
adolescent roundback more common form of kyphosis seen in young teenagers between ages 13-16 juvenile epiphysitis fixed, structural males more than females
Adam’s Test
patient assumes adam’s position
in postural or functional kyphosis spine assumes normal smooth arc
in scheuermann’s or structural kyphosis the spine forms sharp angle or hump at the apex of the kyphosis
muscles and ligaments involved
stretched/weak: thoracic erector spinae
scapular adductors
shortened: pectoral muscles
serratus anterior
pathological changeds
can result in impaired vital capacity
increased lordosis common
exercise alone will not prevent the _____
progression of a progressive spinal deformity
major component in conservative management of scheuermann’s disease is ___
the use of a brace
most common brace
milwaukee brace
braces not found effective in patients with:
vertebral wedging of >10d
initial kyphosis of >65d
initiation of treatment after iliac epiphyses has closed
exercises for kyphosis
strengthen scapular adductors strengthen thoracic erector spinae stretch pectoralis major stretch serratus anterior stretch anterior thoracic ligaments
lateral curvature of vertebral column >10d
scoliosis
scoliosis is characterized not only by lateral curvature but by ________
vertebral rotation
in structural scoliosis, the curve fails to
straighten out on side bending, this is indicative of vertebral and paravertebral bone and soft tissue deformities.
infantile scoliosis
onset between birth and 3 yrs usually noticed in first year males dominate left thoracic curve most common majority resolve spontaneously life span limited to 30 yrs
juvenile scoliosis
occurs between 3 and 10 yrs
13-21% of all idiopathic scoliosis
right thoracic most common
the older the child the more likely to be girl
adolescent
from 10 till skeletal maturity
right thoracic most common
80% of idiopathic scoliosis
chest flatness on side of
convexity
rotation of vertebral bodies toward _______ and spinous processes toward _______
convexity, concavity
intervertebral discs are compressed on the ______ side
concave
distortion of vital structures
heart displaced downward
right thoracic
most common
highly structural, cosmetic deformity
thoracolumbar
t8-l3
not as cosmetically deforming
double major
right thoracic and left lumbar
double thoracic major
upper curve to the left and lower to the right, both in thoracic region
less deforming than simple curves because of symmetry
lumbar
t11-l4
most to the left
lead to arthritic pain
screening
takes 1 min per child, every 6-9 months
when rotation occurs, the pedicle on the convexity ______ and the pedicle on the concavity _______
rotates toward the midline
away from the midline
progression of scoliosis
girls more likely to progress
female to male ratio 8-10:1
younger the child at onset, the more likely curve is to progress
most likely to least likely to progress
double major
thoracolumbar
thoracic
lumbar
risser sign
measurement of excursion of iliac apophyses from anterolateral to posteromedial. when apophysis reaches SI junction and fuses to ilium, maturation nearly complete.
scoliosis curves progress most rapidly during time of ____
peak height growth velocity
girl: 11-13
boy: 13-15
3 major approaches to treatment
bracing and observation
exercise
surgery
expectations of orthosis
prevent further curve progression
reduce initial curvature as much as possible
maintain curve reduction
encourage patient compliance through providing a comfortable fit
