Chapter 1: Spinal Conditions

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dmshaw9
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Chapter 1: Spinal Conditions
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2015-03-05 15:15:09
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Spinal Conditions
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NPTE: Chapter 1
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  1. Muscle Strain: Definition and Characteristics 
    • May be related to sudden trauma, chronic or sustained overload, or abnormal muscle biomechanics secondary to faulty function (abnormal joint or muscle biomechanics)
    • Commonly will resolve without intervention
    • If trauma is too great or related to chronic etiology, patient will benefit from intervention
  2. Muscle Strain: Diagnosis
    Made by clinical examinatio through comparing results of flexibility (AROM/PROM), resistitve tests, and palpation
  3. Muscle Strain: Medications
    • Acetaminophen (pain)
    • NSAIDs (pain and/or inflammation
    • Corticosteroids injection or by mouth
    • Muscle relaxants (Flexeril (cyclobenzaprine) or Valium (diazepam)
    • Trigger point injections
  4. Muscle Strain: PT Goals, Outcomes, and Interventions
    • Biomechanical faults correced with joint mobs
    • Pt education regarding elimination of harmful positions and postural reeducation
    • Spinal manipulation for pain inhibition generally indicated
  5. Spondylolysis/Spondylolisthesis: Definition and Characteristics
    • Etiology thought to be congenitally defective pars interarticularis
    • Spondylolysis: fracture of the pars interarticularis with positive "Scotty dog" sign on oblique radiographic view of spine
    • Spondylolisthesis: actual anterior or posterior slippage of one vertebra on another, following bilatearl fracture of pars interarticularis
    • Spondlolisthesis graded from 1 (25% slippage) to 4 (100% slippage)
  6. Spondylolysis/Spondylolisthesis: Diagnostic Tests
    • Plain film (oblique to see fx and lateral to see slippage)
    • Clinical exam = stork test
  7. Spondylolysis/Spondylolisthesis: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammatio
    • Corticosteroid injection or by mouth
    • Muscle relaxants
    • Trigger point injections
  8. Spondylolysis/Spondylolisthesis: PT Goals, Outcomes, and Interventions
    • Joint mobs to correect biomechanical faults
    • Exercise should focus on dynamic stabilization of trunk (emphasis on abdominals)
    • Avoid ext and other positiosn that add ress to defect (ext, ipsilateral side bend, contralateral rotation)
    • Pt education regarding elimination of ext positions and postural reeducation
    • Boston brace and TLSO have traditioally been use but frequency is decreasing
    • Spinal manipulatio may be contraindicated, particularly at level of defect
  9. Spinal or Intervertebral Stenosis: Defintion and Characteristics
    • Etiology: congenital narrow spinal canal or intervertebral foramen, coupled with hypertrophy of spinal lamina and ligamentum flavum or facets
    • Result of age-related degenerative process or disease
    • Results in vascular and/or neural compromise
    • Signs and symptoms = B pain and paresthesia in back, buttocks, thighs, calves, and feet; pain decreases in flex, increases in ext; pain increases with walking and relieved with prolonged rest
  10. Spinal or Intervertebral Stenosis: Diagnostic Tests
    • Plain Films
    • MRI
    • CT Scan
    • Occasionally myelography is helpful
    • Clinical exam includes bicycle (van Gelderens test) - helps differentiate condition from intermittent claudication
  11. Spinal or Intervertebral Stenosis: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammatio
    • Corticosteroid injection or by mouth
    • Muscle relaxants
    • TP injections
  12. Spinal or Intervertebral Stenosis: PT Goals, Outcomes, and Interventions
    • Joint mobs to correct biomechanical faults
    • Flexion-based exercises
    • Exercises that promote dynamic stability throughout trunk and pelvis
    • Avoid ext and other positios that narrrow spinal canal or intervertebral foramen (ipsilat side bend and ipsilat rotation)
    • Manual traction/mechanical traction (cspine positioned at 15 deg of flex to provide optimum intervertebral foraminal opening; contraindications include hypermobility, pregnancy, RA, downs syndrome, or any other systemic disease that affects ligamentous integrity)
  13. Disc Conditions: Internal Disc Disruption
    • Internal structure of disc annulus is disrupted
    • External structures remain normal
    • Most common in lumbar region
    • Symptoms = deep, achy pain; increased pain with movement
    • No objective neurological findings
    • Pt may have referred pain in LE
  14. Internal Disc Disruption: Diagnosis
    • CT Discogram
    • MRI
    • (Cannot be diagnosed by regular CT or myelogram)
  15. Internal Disc Disruption: Medications
    • Acetaminophen for pain
    • NSAIDS for pain and/or inflammation
    • Muscle relaxants
    • TP injectios
    • Corticosteroid injection or by mouth
  16. Internal Disc Disruption: PT Goals, Outcomes, and Intervention
    • Joint mobs to correct biomechanical faults
    • Spinal manipulation may be contraindicated
    • Pt education regarding proper body mechanics, positios to avoid, limited repetitive bending/twisting, limiting UE overhead and sitting activities, and carrying heavy loads
  17. Disc Conditions: Posterolateral Bulge/Herniation
    • Most commonly observed disc disorder of lspine due to three structural deficiencies:
    • Post disc is narrower in height than ant disc
    • Post longitudinal ligament is not as strong and only centrally located in lumbar spine
    • Posterior lamellae of annulus are thinner

    • Etiology = overstretching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures (from high compression forces or repetitive microtrauma)
    • Results in loss of strength, radicular pain, paresthesia, and inability to perform ADLs
  18. Posterolatearl Bulge/Herniation: Diagnostic Tests
    MRI
  19. Posterolateral Bulge/Herniation: Medications
    • Acetaminophen for pain
    • NSAIDs (pain and/or inflammation)
    • Muscle relaxants
    • TP injections
    • Corticosteroid injection or by mouth
  20. Posterolateral Bulge/Herniation: PT Goals, Outcomes, and Interventions
    • Exercise to promote dynamic stability throughout trunk and pelvis and provide optimarl stimulus for regeneration of disc
    • Positional gapping for 10 minutes to increase space within region of space occupying lesion
    • If L posterolateral lumbar herniation is present = have pt sidelying on R side with pillow under R trunk (accentuates trunk SB R), flex both hips and knees, rotate trunk to L (or pelvis to R) - pt can be taught to perform this at home
    • Spinal manipulatio may be contraindicated - particularly at level of herniation
    • Pt educatio regarding proper body mechancis, positions to avoid, limiting repetitive bending and twisting movements, limiting UE overhead and sitting activities, and carrying heavy leads
    • Manual and/or mechanical traction (cspine at 15 deg of flex to provide optimal intervertebral foraminal opening; contraindications include hypermobility, pregnancy, RA, downs, or any systemic disease that affects ligamentous integrity)
    • Efficacy of traction for intervetnion of disc conditions currently under scrutiny
  21. Disc Conditions: Central Posterior Bulge/Herniation
    • More commonly observed in the cspine but also seen in lumbar
    • Etiology: overstretching and/or tearing of annular rings, vertebral endplate, and/or ligamenous structures (PLL) from high compressive forces and/or long-term postural malalignment
    • Results in loss of strength, radicular pain, paresthesia, inability to perform ADLs, and possible compression of spinal cord
    • Pt exhibits CNS symptoms (hyperreflexia and positive Babinski)
  22. Central Posterior Bulge/Herniation: Diagnostic Tests
    MRI
  23. Central Posterior Bulge: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
    • Muscle relaxants
    • TP injections
    • Corticosteroid injection or by mouth
  24. Central Posterior Bulge/Herniation: PT Goals, Outcomes, and Interventions
    Refer to posterolateral intervention
  25. Disc Conditions: Anterior Bulge/Herniation
    Very rare due to structural integrity of anterior intervertebral disc
  26. Facet Joint Conditions: Degenerative Joint Disease
    • Etiology = part of normal aging process due to weight bearing properties of facets and intervertebral joints
    • Results in bone hypertrophy, capsular fibrosis, hypermobility or hypomobility of joint, and proliferation of synovium
    • Symptoms = reduction in mobility of the spine, pain, and possible impingement of associated nerve root --> results in loss of strength and paresthesias
  27. Degenerative Joint Disease: Diagnostic Tests
    • Plain film imaging
    • Clinical exam = lumbar quadrant test
  28. Degenerative Joint Disease: Medications
    • Acetaminophen for pain
    • NSAIDs for pain/inflammation
    • Muscle relaxants
    • TP injections
    • Corticosteroid injection or by mouth
  29. Degenerative Joint Disease: PT Goals, Outcomes, and Interventions
    • Exercise to promote dynamic stability throughout trunk and pelvis and provide optimal stimulus for regeneration of facet cartilage and/or capsule
    • Joit mobs to correct biomechanical faults
    • Spinal manipulation may be useful
  30. Facet Joint Conditions: Facet Entrapment (Acute Locked Back)
    • Caused by abnormal movement of fibroadiopose meniscoid in facet during extension (from flex)
    • Meniscoid does not properly reenter joint cavity and bunches up - becomes a space-occupying lesion (distends capsule and causes pain)
    • Flex most comfortable for pts, ext increases pain
  31. Facet Entrapment: Clinical Exams
    Lumbar quadrant test
  32. Facet Entrapment: Medications
    • Acetaminophen for pain
    • NSAIDs for pain/inflammation
    • Muscle relaxants
    • TPinjections
    • Corticosteroid injection or by mouth
  33. Facet Entrapment: PT Goals, Outcomes, and Interventions
    Positional facet joint gapping and/or manipulation are appropriate
  34. Acceleration/Deceleration Injuries of C-Spine: Definition and Characteristics
    • Formerly known as whiplash
    • Occurs when excess shear and tensile forces are exerted on cervical structures
    • Structures injured may include facets/articular processes, facet joint capsules, ligaments, disc, ant/post muscles, fx to odontoid process and SP, TMJ, sympathetic chain ganglia, spinal and cranial nerves
  35. Acceleration/Deceleration Injuries of C-Spine: Signs and Symptoms
    • Early = headaches, neck pain, limited flexibility, reversal of lower cervical lordosis and decrease in upper cervical kyphosis, vertigo, change in vision and hearing, irritability to noise and light, dysesthesias of face and B UEs, nausea, difficulty swallowing, and emotional lability
    • Late = chronic head and neck pain, limitation in flexibility, TMJ dysfunction, limited tolerance to ADLs, disequilibrium, anxiety, and depression
    • Common clinical findings = postural changes, excessive muscle guarding with soft tissue fibrosis, segmental hypermobility, and gradual development of restricted segmental motion, cranial and caudal to injury (segmental hypomobility)
  36. Acceleration/Deceleration Injuries of C-Spine: Diagnostic Tests
    • Plain film imaging
    • CT scan
    • MRI
  37. Acceleration/Deceleration Injuries of C-Spine: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
    • Muscle relaxants
    • TP injections
    • Corticosteroid injection or by mouth
  38. Acceleration/Deceleration Injuries of C-Spine: PT Goals, Outcomes, and Interventions
    • Spinal manipulation generally indicated
    • Correctional of muscle imbalances and biomechanical faults using strengthening, endurance, coordination, and flexibility exercises
    • Joint mobs to correct joint restrictions
    • Progression to functional training
    • Pt education regarding elimination of harmful positions and postural reeducation
    • Manual and/or mechanical traction (cspine at 15 degrees of flex, contraindicatiosn include joint hypermobility, pregnancy, RA, downs, and other systemic diseases that affect ligamentous integrity)
  39. Hypermobile Spinal Segments: Definition and Characteristics
    An abnormal increase in ROM at a joint due to insufficeint soft tissue control (i.e. ligamentous, discal, and/or muscle)
  40. Hypermobile Spinal Segments: Diagnostic Tests
    Plain film imaging (particularly dynamic flex/ext views)
  41. Hypermobile Spinal Segments: Medications
    • Acetaminophen for pain
    • NSAIDS for pain and/or inflammation
    • Muscle relaxants
    • TP injections
    • Sclerosing injections
    • Corticosteroid injection or by mouth
  42. Hypermobile Spinal Segments: PT Goals, Outcomes, and Intervention
    • Pain reduction modalities to reduce irritability of structures
    • Passive ROM within normal range of movement
    • Passive stabilization with corsets, splints, casts, tape and collars
    • Increase strength/endurance/coordination, especially in multifidus, abdominals, extensors, and gluteals (control posture)
    • Regain muscle balance
    • Pt education regarding postural reeducation, limiting excessive overloading, limiting sustained activities, and limiting end range postures
  43. SIJ Conditions: Definition and Characteristics
    • Cause and specific pathology unknown
    • Since this is a joint, it may become inflamed, develop degenerative changes, or develop abnormal movement patterns
    • Anatomically and functionally, SIJ is closely related to lspine (thorough exam of both regions is indicated if pt presents with pain in either)
  44. SIJ Conditions: Diagnostic Tests
    • Plain film imaging
    • MRI
    • Occasionally,, double-blind injectios may be used to assist in making the diagnosis (first injection is provocative in nature and second is analgesic) -- if increased "same" pain with 1st injectin and decreased pain followign second, joint is determined to be pathological
    • Clinicial exam = Gillets test, Ipsilateral ant rotation test, Gaenslens test, Long-sitting (supine to sit) test, Goldthwaits test
  45. SIJ Conditions: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
    • Muscle relaxants
    • TP injections
    • Corticosteroid injecton or by mouth
  46. SIJ Conditions: PT Goals, Outcomes and Interventions
    • Spinal manip such as SIJ gapping is generally indicated to inhibit pain, reduce muscle guarding, and resotre normal joint motion
    • Correction of muscle imbalnaces throughout pelvis using strengthening, endurance, coordinaton, and flexibility exercises to gain restoration of normal function
    • Joint mobs for joint restrctions
    • Pt education on elimination of harmful positions and posrual reeducation
    • SI bls may be useful in some patients
  47. Repetitive/Cumulative Trauma to Back: Definition/Characteristics
    • Disorders of nerves, soft tissues, and bones precipitated or aggravated by repeated exertions or movements of the back, occuring most often in the workplace
    • Repetitive trauma disorders account for 48% of all reported occupational diseases
    • Diagnosis difficult, wth up to 85% of back pain nondiagnosed
    • Typically causes one of the conditions previously listed above = muscle, disc, and/or joint impairment
    • Intervention should focus on prevention, onsisting of education
    • Vocational factors include physically heavy static work psotures, lifting, frequent bending and twisting, repetitive work and vibration

    Chronic disability may be reduced by enrollment in a work-conditioning program (includes pt education, aerobic exercises, general strengthening, and functional stability exercises that promote endurance for work-related activity)
  48. Bone Tumors: Definition and Characteristics
    • May be primary or metastatic
    • Primary: multiple myeloma (most common primary bone tumor), Ewing's sarcoma, malignant lymphoma, chondrosarcoma, osteosarcoma, and chondromas
    • Metastatic: has primary sites in lung, prostate, breast, kidney, and thyroid
    • Pt history should always include questios about prior episode of cancer
    • Signs/symptoms = pain that is unvarying and progressive, not relived with rest or analgesics, and more pronounced at night
  49. Bone Tumors: Diagnostic Tests
    • Plain film imaging
    • CT
    • MRI
    • Laboratory tests
  50. Visceral Tumors
    • Esophageal cancer symptomatology may include pain radiating to the back, pain with swallowing, dysphagia, and weight lsos
    • Pancreateic cancer symptomatology inclues deep, gnawing pain that may radiate from chest to back
    • Diagnostic tests = plain film imaging, CT, MRI, Laboratory tests
  51. Gastrointestinal Condititions
    • Acute pancreatitis: may manifest itself as mid-epigastric pain radiating through to the back
    • Cholecystitis: may present with abrupt, severe, abdominal pain and R upper quadrant tenderness, nausea, vomiting and fever
    • Diagnositc tests = plain film imaging, CT, MRI, laboratory tests
  52. Cardiovascular and Pulmonary Conditions
    • Heart and lung disorder can refer pain to chest, back, neck, jaw, and UE
    • Abdominal aortic aneurysm (AAA) usually appears as nonspecific lumbar pain
    • Diagnostic tests = plain film imaging, CT, MRI, laboratory tests
    • Will be identified as pain during examinatio of abdominal region
  53. Urological and Gynecological Conditions
    • Kidney, bladder, ovary, and uterus disorders can refer pain to trunk, pelvis and thighs
    • Diagnostic tests = plain film imaging, CT, MRI, laboratory tests
  54. Temporomandibular Joint Conditions: Definition and Characteristics
    • Common signs/symptoms = joint noise (clicking, popping, and/or crepitation), joint locking, limited flexibility of jaw, lateral devation of madible during depression or elevation, decreased strength/endurance of muscles of mastication, tinnitus, HA, forward head posture, and pain with movement of mandible
    • C-spine must be thoroughly examined due to close biomechanical and functional relationships bewteen TMJ and cervical region
    • Many pts with TMJ have a component of cervical dysfunction (3 categories)

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