Spinal joints Flashcards
1
Q
Where do you look in your casenotes to assess severity?
A
- NRS (numerical rating scale ie 0-10)
- body chart (ie location of pain and whether it travels
- how disabling is the pain eg annoying or excruciating)
- sleep cycle
- any pain relief medication
2
Q
Where do you look in your casenotes to assess irritability?
A
- How easy it is to aggravate or ease
- sleep cycle
- is it affecting their sport or their work
3
Q
What would make you assess a patient’s pain as being mechanical in nature?
A
- movement causes pain
- intermittent pain related to movement
- mechanical usually responds well to manual therapy
4
Q
What would make you assess a patient’s pain as being chemical in nature?
A
- may hurt after use
- pain is usually throbbing, pulsing etc.
- can affect sleep more
- may see swelling, heat, discolouration
- pain may be constant cf intermittent
- responds less well to manual therapy
5
Q
Describe when you’d use the 4 treatment grades
A
Grades 1 (small amplitude) and 2 (large amplitude) are for pain reduction, and if you meet pain before resistance.
Grades 3 (large amplitude) and 4 (small amplitude) are for improving ROM, and if you meet resistance before pain
6
Q
How would you decide on dosage?
A
- Usually want about 2 mins of treatment time but can break that down into sets and repetitions if it’s painful/ irritable
- Eg low irritability 4 sets of 30 seconds with 10 seconds rest cf high irritability 12 sets of 10 seconds with 30 seconds rest between
7
Q
How does diabetes affect collagen, and how might this influence your decision making re manual therapy?
A
- When there is too much glucose in the bloodstream, excess sugars glue themselves to proteins and form AGEs (advanced glycation end products)
- AGEs cause crosslinking in collagen, which stiffens tissues that are normally flexible and elastic, making them stiffer and more brittle
- So choose grade 1 or 4 because they are smaller movements and more likely to be safe (more control over smaller amplitude oscillation)
- Grade 4 is generally at end of range, but because of type 2 diabetes you might decide to not do it totally at the end of range
8
Q
What evidence is there about the use of manual therapy with diabetics?
A
Small studies:
- found to be effective for diabetics with carpal tunnel syndrome
- may be safely applied in diabetic patients with frozen shoulder
- Manual therapy increased the ankle joint amplitude and improved the static balance in individuals with diabetes
9
Q
What are the two ways someone being on long term steroids eg an asthma inhaler would influence your thinking re manual therapy?
A
- Steroids are used in asthma as an anti-inflammatory:
- using anti-inflammatories during injury healing can mean patients get stuck in inflammatory phase for longer than normal
- if they have had an injury avoid grade 3 or 4 in proliferation phase
- grade 4 (if permitted by SIN) in remodelling as we have more control over a smaller amplitude oscillation - Steroids can have a negative effect on collagen synthesis:
- collagen laid down may be weaker
- associated with reduced bone density, fragile skin and bruising
- may choose not to work at end of range ie not grade 3 or 4
- may choose a smaller amplitude oscillation ie grade 1 or 4 for more control
10
Q
How might paracetamol and NSAIDs affect your thinking re manual therapy?
A
Paracetamol
- purely for pain suppression
- may affect the severity or number grade they put on their pain
NSAIDs
- anti-inflammatory and a painkiller
- may affect the severity or number grade they put on their pain AND
- can delay the inflammatory process and so have a negative impact on collagen formation during healing
11
Q
How long are each of the four stages of healing?
A
1.Bleeding – minutes
2.Inflammation (initial response): ie 0-4 days after injury – redness/ swelling/ heat
3.Proliferation (fibroblastic repair): 4 hours - 24 days after injury – unorganised scar tissue
4.Remodelling (maturation): 21 days – 2 years – realignment of collagen fibres
12
Q
Describe the pain gate theory?
A
- when several sensory stimuli reach the spinal cord at the same location and time, one of them becomes dominant
- activation of nerves that do not transmit pain signals, called nonnociceptive fibres, can interfere with signals from nociceptive fibres, thereby inhibiting pain
- ascending inhibition/ ascending pathway – about signals going up to where the perception of pain in the brain is created being interrupted
13
Q
Describe the opioid theory of pain?
A
- endogenous opioids such as enkephalin will inhibit the release of a neurotransmitter involved in pain transmission, thereby blocking pain transmission
- goal of this pathway is to allow the organism to function enough to respond to the pain source by reducing the pain signal through neuronal inhibition
- descending inhibition/ descending pathway ie brain decides to modulate pain – sends signal down brain stem that interrupts signal in spinal cord between synapse and sensory neuron, so no more pain signals can ascend
14
Q
Give 8 ways you could be critical about manual therapy?
A
- Limited evidence on how much force needed to induce desired effects
- Amount of force delivered by individual therapists is subjective
- Theory that manual therapy during tissue healing and remodelling will improve extensibility and strength of a tissue: unclear whether relatively small dose of force at infrequent intervals could actually effect this
- Force applied will always be dispersed through neighbouring tissues as well as target structure
- Are you actually moving the joint or just pushing neighbouring soft tissue around studies looking at mobilisations on thumb and separately on vertebrae found no joint movement, only soft tissue deformation
- Movements are supposed to be passive ie patient completely relaxed. This will never be the case unless they are unconscious
- We use numerical rating scale for pain: individual perception. Patient saying 5 one day might forget and for same pain next time say 3
- Even though we use an objective marker to assess ROM/ pain before and after, how do we know if it was our treatment that caused any difference? Is patient just saying what we want to hear?
15
Q
Give an example intro speech to a manual therapy patient
A
- Hello my name is Olivia, I’ll be your sport therapist today. I propose using manual therapy on your [X]
- It’ll involve me putting my hands on you and moving your joints around. The idea is that it can help decrease pain and increase range of motion
- But it may be a little uncomfortable while I’m doing it and for a day or two after
- Do you understand?
- Do I have your consent to treat you?”
16
Q
Outline your step by step treatment protocol
A
- Intro speech
- Objective marker – an active movement where you ask about pain on a scale of 0-10
- Test movement – the same as your treatment movement to assess pain point
- You treat first set
- Test movement
- You treat second set (etc for correct number of sets)
- Repeat objective marker
17
Q
What could be a psychological benefit of manual therapy?
A
May help introduce movement when patient is self-limiting through fear
18
Q
What physical structures are affected by manual therapy?
A
- Joint arthro/osteo kinematics
- Collagen
- Muscles/tendons as a unit
- Synovium
- Ligaments
- Skin
- Joint capsules
- Mechanoreceptors
19
Q
Through what three systems might manual therapy affect connective tissue?
A
- Neurophysiological system
- Nutritional system
- Mechanical system
20
Q
What feature of/ issue with the neurophysiological system might manual therapy help with?
A
The pain spasm cycle
21
Q
What is the pain spasm cycle and how might manual therapy assist?
A
- pain causes muscles to spasm/ guard to limit movement
- spasm causes pain
- goes round in a cycle
- if we can reduce pain or spasms may reduce or interrupt the cycle
22
Q
Physiologically, how might manual therapy assist with the pain spasm cycle?
A
- Manual therapy, particularly PPMs, can lengthen shortened muscles via autogenic inhibition
- This in turn may reduce ischemic pain (ie pain caused by reduced blood flow).
Autogenic inhibition occurs when Golgi tendon organs sense muscle tension and send inhibitory signals to the muscle
23
Q
What can manual therapy increase or decrease that can help with the pain spasm cycle?
A
- decrease neuromuscular excitability
- decrease muscle spasm via alteration in muscle spindle / golgi tendon organ activation
- increase proprioceptive input
24
Q
What is the nutritional system?
A
System by which nutrients are passed from one structure to another eg blood flow, other fluids etc
25
What functions does synovial fluid have?
* lubrication of joint
* shock absorption
* nutrient and waste transportation to and from cartilage (cartilage has bad blood supply so mainly relies on synovial fluid for this)
26
How can manual therapy affect the trans synovial pump?
* the movement of a joint causes a fluctuation in pressure
* increased synovial flow therefore alterations in fluid exchange
* facilitate drainage into lymphatic system
* we can help these with our manual therapy - this will be more pronounced during grade 2 or 3 oscillations
27
What synovial fluid dynamics can manual therapy assist with?
* when we’re not moving the thickness of the synovial fluid increases from being like honey to more of a gel
* movement assists with
* improved lymphatic flow
* increase transportation for nutrients
* synovial fluid alterations: following immobilisation; in viscosity; in temperature response
*immediate advantageous pressure change
* stale with immobilisation = coating and little fluid exchange
* sucking/ squeezing with loading = heavy fluid exchange
28
What evidence is there that movement can help damaged cartilage?
‘Small movements have been shown to increase production of articulation cartilage when damaged compared to an immobilised knee” Lederman and Cramer 2005 - so we can potentially speed up the healing process
29
In what three areas may manual therapy affect the mechanical system?
- collagen
- extracellular matrix
- stress/ strain curve
30
What is collagen?
Everything in the body is made of collagen, which is coiled into a triple helix. This means it has high tensile strength and responds to tensile stress
31
What happens with collagen during healing?
* collagen is laid down haphazardly unless stress is applied (at the proliferation stage onwards). If the fibres are laid down in all directions the scar won’t be as strong as if the fibres are laid down in line with rest of tissue
* during remodelling, maturation of type 3 to type 1 (which is stronger) - SAID principle ie specific adaptation to imposed demands
* collagen forms a scar tissue which shortens over time restricting mobility, therefore it needs to be lengthened or stressed to maintain length. If patient isn’t able to do that for themselves yet then we can help with it through manual therapy
32
What effects might manual therapy have on the extra cellular matrix?
* like a network between the cells, allowing them to communicate with other cells around them
* ECM synthesis rate (ie the rate it is produced - it is mainly secreted by fibroblasts) increases because of mechanotransduction (ie the process by which cells convert mechanical signals into biochemical responses that promote structural change)
* Hormones such as transforming growth factor beta increase in activity, which is a hormone that regulates fibroblast activity (which is needed to build collagen and they also secrete ECM)
* This knowledge is only from findings in vitro - can‘t really see what’s going on inside body!
33
How might the stress/ strain curve relate to manual therapy?
Idea that when we are trying to improve ROM and decrease stiffness we are trying to push that yield point by regularly applying stress up to the yield point ie grades 3 and 4.
This is just a theory from physics, not specific to the body as a whole or to manual therapy in particular. To be critical:
* us with our hands probably can’t apply stress strong enough to affect that yield point eg Achilles’ tendon can take loads of up to 7 times body weight
* McGregor et al (2011) applied grade 1 to 4 and found no change in position of the vertebrae, only soft tissue deformation
* We have no idea whether this physics theory would apply to the living human body
34
How could you summarise the effects of manual therapy on connective tissue?
Manual therapy may be beneficial as:
* A safe (physiologically and psychologically) environment at early stage
* Stretching to restore ROM (changes thought to be via neural adaptations)
* Influences collagen alignment (SAID principle)
* Increases turnover of synovial fluid exchange
* Improves tissue compliance as healing occurs
35
What does SOAP stand for in relation to evaluation and assessment?
Subjective assessment, objective assessment, analysis, plan
36
What type of questions would you ask as part of your subjective assessment?
- Where is the pain?
- Is there referred pain?
- How would they describe the nature of the pain? eg dull/ sore/ aching perhaps myogenic cf flashing, shooting, burning, tingling may be neurogenic
- How long have they been in pain?
- Is the pain getting worse/ better/ is it static/ episodic?
- When did it start ie traumatic or insidious
37
What steps would you go through for your objective assessment?
- Observation
- Active movements
- Passive movements
- Muscle tests
- Palpation
- Joints above and below
- Special tests
38
What are you thinking re the observation part of your objective assessment?
- Do they look generally unwell?
- There is no normal/correct posture
- head position
- shoulder height
- scapula position
- pelvic position, scoliosis
- degrees of lordosis/kyphosis, weight shifts
- muscle bulk
- reduced weight bearing
- knee flexion
39
What active movements would you test for the spine?
o Lateral flexion
o Extension
o Flexion
o Rotation
40
Which part of the spine would you test passive movements for? What movements would you test?
- Mainly for cervical, not so much lumbar or thoracic
- Lateral flexion
- Extension
- Flexion
- Rotation
41
What muscle tests might you do for spine?
- Mainly for cervical, not so much lumbar or thoracic
- Lateral flexion
- Extension
- Flexion
- Rotation
- For lumbar spine could also muscle test hip
42
Points to consider re palpation of spine?
o Palpate spinus processes and then bulk of erector spinae either side
o Palpate bony landmarks from peripheral joints ie hip and shoulder
o If you find a step deformity ie you’re going down the processes and get to one where it’s way deeper inside, then the one following is back up; this is generally caused by spondylolisthesis
43
What are your landmark vertebrae to help you navigate spinal palpation?
C2- Large spinous process – first one you can feel at top
C6- When athlete retracts neck C6 disappears
C7- Usually most prominent cervical spinous process
T1- Feel for differences in size, angle of spinous processes, between thoracic and cervical
T3- Level with spine of scapula if arms are by side
T7- Level with inferior angle of scapula
T12- Level with bottom floating ribs
L4- Level with iliac crests
44
What are normal causes of back pain?
* Myogenic ie muscular pain
* Joint pain
* Disc pain
* Nerve pain
45
What is the definition of a red flag and how might you identify one?
- Potentially dangerous symptoms that require an immediate medical referral as suspicious of sinister pathology
- Identify primarily through your subjective assessment questioning
46
What percentage of back pain is mechanical / non specific and how might you identify that?
- 85% of back pain is mechanical or non-specific low back pain
o even if it’s non specific you’d still get mechanical signs eg pain on flexion
o might refer down leg a bit but not past knee
o usually age 20-55 years
o they look otherwise well
47
What percentage of back pain is nerve root pain and how might you identify that?
- 15% nerve root pain
o they will tend to look more unwell as might not be sleeping properly
o numbness/ paraesthesia
o unilateral limb pain that is worse than back pain
48
What percentage of back pain will be a red flag/ serious pathology and how might you spot that?
- Less than 1% serious pathology/ red flags
o constant/ unremitting pain ie there all the time, no movements or positions that make it feel better
o unexplained/ rapid weight loss
o altered genital sensation/ loss of bladder or bowel control
o frequent or severe headaches
o fever or night sweats
o bilateral nerve root signs and symptoms
o dizziness/ difficulty with balance/ gait disturbance
49
Name some spinal red flags?
- cauda equina
- vertebrobasilar artery insufficiency
- lymphoma
- ankylosing spondylitis
50
Describe cauda equina and give some symptoms of it?
* Translates to horse tail. When spinal cord comes down to L2/L3 it starts to branch out into thinner cords like a tail
* This area gives sensation to genitals/ bladder area/ sexual function/ sitting bones area etc
* Neurological compression
* Is a medical emergency because it can become permanent. They need surgery to release pressure on the nerves
* Symptoms:
weakness/paraplegia of lower limb muscles
bowel or bladder incontinence or retention
sexual dysfunction
saddle paraesthesia and bilateral pins and needles
impaired gait
51
Describe vertebrobasilar insufficiency?
* Vertebrobasilar artery supplies 20% of blood to brain, mainly to hindbrain ie brain stem, cerebellum and occipital lobes
* Travels through foramen transversarium of cervical vertebrae
* Blood flow can be restricted by cervical movement
* Can cause strokes/ mini strokes due to ischemia
52
How might you diagnose vertebrobasilar insufficiency?
Diagnosed with any two of the 5 Ds or 3 Ns being present:
Drop attacks ie loss of consciousness or power
Dizziness
Dysphasia - difficulty swallowing
Dysarthria - difficulty speaking
Diplopia - blurred vision
Nystagmus – uncontrolled eye movement
Nausea or vomiting
Numbness/ other neurological symptoms
53
What is lymphoma?
* 5th most common type of cancer
* Occurs in all ages
* Affects lymphatic system (lymphatic system drains excess fluid that accumulates in bodily tissue, filters out foreign bodies, and transports it back into the bloodstream. Part of immune system and complimentary to circulatory system)
* White blood cells multiply rapidly and don’t die, then they group around a lymph node so you might see a lump (but not if it’s around a node that is deep within the body)
* You need to be asking ‘how’s your general health? How’s your history of general health?’ to ask if they have any history of cancer
54
Symptoms of lymphoma?
Drenching night sweats
Unexpected, rapid weight loss
Itching
Constant fatigue
Swollen lymph nodes - those near spine can cause spinal pain
55
Describe ankylosing spondylitis and when you might suspect it?
* Type of inflammatory back pain
* More common in 15 – 35 years
* Vertebrae develop bony spurs
* Facet joints begin to fuse causing increasing stiffness
* Morning stiffness which takes >1 hour to ease despite movement
* Extreme fatigue
56
What red herrings might you come across re red flags?
* Night pain can be a red herring if it’s just when they’re rolling over and not constant
* Frequent severe headaches can happen anyway
* Sexual dysfunction can happen for lots of other reasons
57
Give some NICE guideline dos and don'ts re working with back pain patients
DO:
- Consider using STarT back at initial consultation (a 9 question screening tool to help match patients with low back pain to the right treatment)
- Encourage return to work / normal activities as early as possible
- Offer education in addition to exercise +/- manual therapy
- Consider recommendation of NSAID’s (lowest effective dose)
DON'T:
- Routinely image low back pain. Only relevant if the findings
would potentially change your treatment
- Give belts, corsets, orthotics etc.
- Give acupuncture
- Use manual therapy without exercise or education
58
What does VBI stand for and what does it mean?
- Vertebrobasilar inefficiency
- Vertebrobasilar artery supplies 20% of blood to hindbrain ie brain stem, cerebellum and occipital lobes
- Hind brain responsible for balance, communication and coordination
- Artery travels through foramen transversarium of Cx and its flow can be restricted by Cx movement
- This can cause mini strokes or strokes due to ischemia
59
What does the VBI test aim to achieve?
- screening tool for prior to manual therapy on Cx (esp for grades 3 or 4 PPMs into extension or rotation)
- diagnostic tool to see if patients dizziness symptoms are caused by insufficient hindbrain flow
- use if you want to do Cx manipulation or if patient has history of dizziness/ stroke
60
What is a positive result for VBI test?
Any two of the 5 Ds or 3 Ns being present:
- drop attacks or loss of consciousness/ power
- dizziness
- dysphasia ie difficulty swallowing
- dysarthria ie difficulty speaking
- nystagmus ie uncontrolled eye movement
- nausea or vomiting
- numbness or other neurological symptoms
61
What might you say to patient before you do the VBI test on them?
‘We’re going to go through a series of simple movements for your head and neck and are looking out for you feeling dizzy, nauseous, having pins and needles, having difficulty swallowing or speaking or anything similar. I will ask you after each movement how you feel. Are we ok to begin?’
62
What can you say about the different versions of VBI test?
Has to be done sitting and then lying down. Do one side sitting, then other side sitting, then one side lying down, then other side lying down
63
What are the steps for the sitting version of the VBI test?
*ask for symptoms after each step*
- patient sits on edge of bed with feet on floor
- patient rotates head to one side then returns to centre
- patient rotates head to same side, you hold it still for 10 secs, then returns to centre (‘rtc’)
- patient extends neck rtc
- patient extends neck then you hold in extension for 10s rtc
- patient rotates to same side, then also extends, then rtc
- patient rotates to same side, then also extends, you hold in position for 10s rtc
- patient rotates head to other side rtc
- patient rotates head to other side, you hold in place for 10s
- patient rotates to other side, then extends rtc
- patient rotates to second side, then extends, you hold there for 10s rtc
64
What is the setup and steps for the lying version of the VBI test?
Patient lies with shoulders in line with edge of bed, you’re supporting their head
Same steps as sitting version
65
What are the treatment/ referral implications of a positive VBI test?
- Referral to GP for further investigations with vascular specialists, or
- Referral to A&E if suspected dissection ie if accompanied by ipsilateral posterior neck pain/occipital headache (arterial dissection means tearing of the innermost layer of the artery wall)
66
Critical evaluation of VBI test?
* Dizziness is the most commonly reported sign of the test but can be attributed to vertigo (non-ischemic symptom)
* Inconsistencies in the literature: false negatives have been reported by Rivett (1998) and Westaway (2003) and false positives by Licht (2000)
* Some authors argued for the abandonment of VBI tests due to:
- lack of validity in detecting reduced blood flow
- lack of ability to predict arterial dissection and risk from manipulation
- conflicting symptomatic responses when blood flow is reduced
* Thomas and Treleaven (2000) argued that the test is still useful and should not be abandoned without further research. They state that the test does not detect vertebral artery flow because ultrasound studies have shown that vertebral artery flow is inherently variable. But, the tests should be considered as testing for adequacy of collateral flow in particular head positions rather than decreased blood flow in a particular artery, and therefore are still useful (collateral circulation is alternate or “backup” blood vessels in your body that can take over when another artery or vein becomes blocked or damaged. Your collateral circulation provides alternative routes for blood flow).
67
What are meninges and what do neural provocation tests test?
- Meninges are the three layers of tissue that surround brain and spinal cord. During a sudden impact meninges will tighten as a protective mechanism, but they can get stuck in this tightened state
- Tests look for the free movement of vertebral nerve roots
- Tests might show up irritation from a nerve root meninges restriction
68
When would you use the slump test?
Use if patient is experiencing:
- cervical pain
- thoracic pain
- lumbar pain
- headaches
- lower limb radicular symptoms
- if performed with hands clasped behind back can also stress brachial plexus – so can use for upper limb symptoms too
Use neural provocation tests for patients experiencing neural symptoms:
- If they are feeling pain near spine say you are testing for nerve root irritation
- suitable for radiating lower limb pain, and upper limb if done with hands behind back
69
What could you say to a patient you were about to perform the slump test on?
‘We are going to go through a series of simple movements. We’re looking to see if any of these movements bring on or aggravate your symptoms - you might feel some stuff stretching but we're looking more specifically for sensations that relate to your symptoms. After each movement I’m going to ask you about your symptoms. Shall we start?’
70
How would you perform the slump test?
- patient sits on the edge of the bed with feet flat on the floor
- holds hands behind back
- slump into thoracic and lumbar flexion while holding the head erect
- ask for symptoms
- slump into cervical flexion
- ask for symptoms
- you apply overpressure to thoracic and cervical flexion
- ask for symptoms
- they straighten leg on asymptomatic side first
- ask for symptoms
- they dorsiflex foot
- ask for symptoms
- you apply overpressure on dorsiflexion, while maintaining it on spine
- ask for symptoms
- they bring that leg down and then straighten leg on symptomatic side
- ask for symptoms
- they dorsiflex foot
- ask for symptoms
- you apply overpressure on dorsiflexion, while maintaining it on spine
- ask for symptoms
- desensitise by extending cervical and then plantarflexing foot
71
What is a positive result for the slump test?
- During the test we are maximally stretching the neural structures of the vertebral canal and foramen
- positive test is reproducing neurological symptoms like shooting pain, numbness or tingling
- test is really sensitive so will cause most people some symptoms. You’re looking for aggravation of the symptoms they have come to see you about
72
What are the treatment/ referral implications of a positive slump test?
- positive result can indicate neural tension, disc herniation, or impingement of a nerve root
- patient should be referred for further testing
- symptoms when testing the asymptomatic side this should be referred on as a positive crossed response that suggests there may be a more sinister pathology
73
Critical evaluation of the slump test?
Studies have found:
- slump test was more sensitive than straight leg raise test for detecting lumbar disc herniations, but the SLR test was more specific
- slump test is sensitive but not specific enough to rule out nerve root involvement
- slump test to have a high false positive rate ie symptoms that are not caused by the restriction of meninges.
False positives could arise from:
- sitting causing pain. This can be intervertebral disc pressure, rather than constriction of meninges, as there is more pressure sitting erect/slumped compared to other postures i.e. lying and standing
- mechanical back pain may be brought on by sitting
- tight hamstrings, tight calves - stretching sensation being a false positive
74
What nerves branch out of the brachial plexus and what are their nerve roots?
- Radial nerve C5-T1
- Median nerve C6-T1
- Ulnar nerve C7 and T1
75
What does the median nerve innervate?
Motor function: index/ middle finger and some wrist flexors
Sensory function: lateral palm and lateral 3 and half fingers
76
What does the ulnar nerve innervate?
Motor function: ring, little finger, and some wrist flexors
Sensory function: anterior and posterior surfaces of the medial one and a half fingers and associated palm area
77
What does the radial nerve innervate?
Motor: elbow, wrist and finger extensors and supinators
Sensory: posterior aspect of the arm and forearm, posterolateral aspect of the hand
78
What nerves branch out of the lumbosacral plexus and what are their nerve roots?
- Femoral nerve L2-L4
- Obturator nerve L2-L4
- Sciatic nerve (which them branches into tibial and fibular nerve L4-S3
- Superior gluteal nerve L5-S2
- Inferior gluteal nerve L5-S2
79
What does the sciatic nerve innervate?
Motor: muscles of posterior thigh and hamstring portion of adductor magnus
Sensory function: none direct
80
What does the tibial nerve innervate?
Motor: ankle plantar flexors and toe flexors
Sensory: posterolateral side of leg, medial side of foot, sole of foot
81
What does the superior fibular aka peroneal nerve innervate?
Motor: foot everters
Sensory: anterior fibula and dorsal aspect of the foot
82
What does the deep fibular nerve innervate?
Motor: foot dorsiflexors and toe extensors
Sensory: upper third lateral lower leg
83
What does the femoral nerve innervate?
Motor: hip flexors and knee extensors
Sensory: anterior thigh and medial leg
84
What does the obturator nerve innervate?
Motor: hip adductors
Sensory: medial thigh
85
What does the superior gluteal nerve innervate?
Motor: Glute med, min and TFL
Sensory: none
86
What does the inferior gluteal nerve innervate?
Motor: glute max
Sensory: none
87
What might make you classify a patient's pain as neural?
- pain normally radiates along a neural pathway and is eg shooting/ numb/ pins needles etc
- caused by irritation of a peripheral nerve through compression or traction
88
If a patient has unilateral neural pain would you apply PPM/ PAMs towards or away from that side?
- away
- don’t mobilise towards radiating pain because nerve is probs being unilaterally compressed
89
If multiple vertebra are marked on your patient notes how would you know which one to pick?
If numerous consecutive vertebrae are symptomatic choose the middle one as this will also affect the ones above and below
90
What PAMs are there for all areas of spine and what symbols would be used to mark them on your patient notes?
- posterior to anterior (PA): downwards arrow
- transverse: arrow pointing sideways in direction of action
- unilateral: arrow pointing across then down on side of action
91
What actions does a posterior to anterior PAM help with?
- will help with flexion or extension
- to improve flexion at a vertebral joint, apply to the superior spinous process because the superior vertebra will glide anteriorly
- to improve extension, apply to the inferior process because the inferior vertebra will glide anteriorly
92
How do you apply a posterior to anterior PAM?
- palpate to find spinous process of the vertebra you want to manipulate
- with both thumbs press either:
-> down and towards eyes for cervical
-> down and a tiny bit towards eyes for thoracic
-> straight down for lumbar
93
What are your landmark vertebrae to help you navigate spinal palpation?
C2- Large spinous process – first one you can feel at top
C6- When athlete retracts neck C6 disappears
C7- Usually most prominent cervical
T3- Level with spine of scapula if arms are by side
T7- Level with inferior angle of scapula
T12- Level with bottom floating ribs
L4- Level with iliac crests
94
What actions does a unilateral PAM help with?
Left rotation if applied to right transverse process
Right rotation if applied to left transverse process
95
How would you apply a unilateral PAM?
- palpate to find spinous process of the vertebra you want to manipulate, then shift laterally to find transverse process
- for cervical and lumbar spine, the transverse processes are roughly in line with the spinous processes of that vertebra
- for thoracic, Geelhoed et al (2006) found that the transverse processes are generally in line with the spinous processes of the vertebra above
- with both thumbs press anteriorly on transverse process
96
What actions does a transverse PAM help with?
- left or right side rotation
- to improve left rotation, apply from left to right
- to improve right rotation, apply from right to left
97
How would you apply a transverse PAM?
- palpate to find spinous process of the vertebra you want to manipulate
- with both thumbs press laterally
98
How would you apply a longitudinal caudad PAM for lumbar?
- patient semi supine, you hold their legs either side of your waist/ hips and pull inferiorly
- legs higher for L1-3
- legs lower for L4-5
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How would you apply a longitudinal cephalad PAM for cervical?
- patient supine on bed with shoulders level with end of bed. Have their head at foot end of bed so there is no face hole
- one hand around occiput, one under chin
- head level for C2-4
- pulling head at slight upwards tilt for C5-7
100
Describe cervical flexion PPM
- Patient supine on bed with one hand in a fist on their chest
- You have one hand under their occiput, and other on top of their fist
- With chest hand stop their thoracic moving, with head hand bring chin towards chest
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Describe cervical extension PPM
- Patient supine on bed with shoulders level with end of bed. Have their head at foot end of bed so there is no face hole
- With one hand you hold under occiput and other is under chin
- Lower their head into cervical extension
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Describe cervical rotation PPM
- Patient supine on bed with shoulders level with end of bed. Have their head at foot end of bed so there is no face hole
- One hand around occiput, one under chin with forearm on side of face
- Rotate them towards your forearm so their head is supported
103
Describe cervical lateral flexion PPM
- Patient supine on bed with shoulders level with end of bed. Have their head at foot end of bed so there is no face hole
- One hand around occiput, one under chin
- Side flex away from your forearm, otherwise arm is in the way
104
Describe cervical protraction/ retraction PPM
- Patient supine on bed with shoulders level with end of bed. Have their head at foot end of bed so there is no face hole
- One hand around occiput, one under chin
- Protraction is face towards ceiling, retraction is face away from ceiling
- Make sure you’re not flexing/ extending their neck
105
Describe thoracic flexion PPM
- Patient sitting on edge of high bed with feet on chair and hands in lap
- They slump forward from thoracic
- You put hands on their shoulders and push them further into flexion
106
Describe thoracic extension PPM
- Patient sitting on edge of high bed with feet on chair
- They have arms crossed with elbows at shoulder height
- You have one arm round their chest (with a cushion beneath it with female)
- Heel of other hand on thoracic where you are wanting to produce extension
- Extend their spine using your back hand as a fulcrum to extend them over
107
Describe thoracic rotation PPM
- Patient sitting on edge of high bed with feet on chair
- They have arms crossed with elbows at shoulder height
- Cushion over their chest, wrap one arm around their front so you have one hand on either side of their ribs
- Rotate them towards you
108
Describe thoracic lateral flexion PPM
- Patient sitting on edge of high bed with feet on chair
- They have arms crossed with elbows at shoulder height
- Cushion over their chest, one arm wraps around their chest and is on their opposite scapular, your closer hand on side of their lower ribs
- Side flex them away from you
109
Describe lumbar flexion PPM
Grades 1 and 2:
- patient in semi supine
- you lift their legs into hip flexion and then keep lifting until you get lumbar flexion
Grades 3 and 4:
- patient seated on bed with legs crossed
- they fold into lumbar flexion and then you apply overpressure
110
Describe lumbar extension PPM
- Patient sitting on edge of high bed with feet on chair
- They have arms crossed with elbows at shoulder height
- You have one arm round their chest (with a cushion beneath it with female)
- Heel of other hand on lumbar where you are wanting to produce extension
- Your head behind their neck so they can lean their head back on yours
- Extend their spine using your back hand as a fulcrum to extend them over
111
Describe lumbar lateral flexion PPM
- Patient sitting on edge of high bed with feet on chair
- They have arms crossed with elbows at shoulder height
- Cushion over their chest, one arm wraps around their chest and is on their opposite side of rib cage, your closer hand on side of their lower ribs
- Use your shoulder to help side flex them away from you
112
Describe lumbar rotation PPM
- 4 different positions – one for each grade
- they are side lying with knees bent
- if you’re working lower lumbar you need knees higher; more L1/2 knees don’t need to be so high
- palpate the area of the lumbar you want to work with as you’re bringing their knees up
- test movement for rotation is get them into the position you want to mobilise in and apply a sustained pressure. Then work the grade you’ve chosen
grade1
- Them side lying with knees bent and top arm resting on their side
- You have one hand on their shoulder and one on the greater trochanter
- Trochanter hand pushes towards knee while other hand stabilises shoulder
grade 2
- Same position except their same side hand is on their top hip so already in more rotation
- Your action is the same ie stabilise top shoulder and push trochanter towards knee
grade 3
- From that same side lying position, put your hand under their bottom scapular and pull them round into more rotation (so chest is facing more towards the ceiling)
- They now have both hands on top hip so they are in more rotation
- Your action is the same ie stabilise top shoulder and push trochanter towards knee
grade 4
- From the grade 3 position, drop their top leg off side of bed
- Your action is the same ie stabilise top shoulder and push trochanter towards knee
113
What can you say generally about upper limb myotome testing?
Nerve roots supply to specific muscles that can be assessed via isometric contraction to test for nerve root compression.
o Testing the ability to MAINTAIN contraction
o +ve test = muscle will ‘switch off’, not necessarily weaken or tire. It will totally lose its ability
to maintain contraction
o All tests done seated
114
How would you test the myotome for nerve root C1?
Cervical flexion - resist flexion of the cervical region by placing
your hand on the patients forehead
115
How would you test the myotome for nerve root C2?
Cervical extension - resist extension of the cervical region by placing your hand on the patients occiput
116
How would you test the myotome for nerve root C3?
Cervical lateral flexion - resist lateral flexion of the cervical region by
placing one hand on the shoulder and one hand
on the side of the patients head
Perform on both sides
117
How would you test the myotome for nerve root C4?
Shoulder elevation - resist shoulder elevation by placing your hands over the ACJs
118
How would you test the myotome for nerve root C5?
Shoulder abduction - resist shoulder abduction by placing the patients shoulders into 90° abduction with a 90°
bend in the elbows. Resist just above the elbow
119
How would you test the myotome for nerve root C6?
Elbow flexion - resist elbow flexion by placing the patients
elbows into 90° of flexion with the shoulder in neutral
120
How would you test the myotome for nerve root C7?
Elbow extension - resist elbow extension by placing the patients
elbows into 90° of flexion with the shoulder in neutral
121
How would you test the myotome for nerve root C8?
Thumb extension - resist extension of the thumb by placing the patients elbows into 90° of flexion, forearm into
mid-prone and resisting over nail bed
122
How would you test the myotome for nerve root T1?
Finger adduct - resist adduction of the fingers by placing the
patients elbows into 90° of flexion, forearm into pronation, placing your finger in between the fingers of the patient and asking the patient to squeeze your fingers
123
Why would you use myotome testing?
Changes in muscle strength within a specific myotome may help you identify the pathological disc level
In cervical spine the most common causes of nerve root pathology are herniated discs (20-25% of cases) and degenerative disc disease (70-75% of cases)
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Criticism of myotome testing?
- different charts in different books will list different things
- charts aren't based on much up to date evidence and is difficult to gather evidence in live humans
