Download - Lumbar Spine and P elvic Dysfunctions
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Alex WongAlex WongSenior PhysiotherapistSenior Physiotherapist
Queen Elizabeth HospitalQueen Elizabeth Hospital19 September 200819 September 2008
Lumbar Spine andLumbar Spine and PPelvic elvic DysfunctionsDysfunctions
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ContentsContents Classification of Lumbo-sacral DysClassification of Lumbo-sacral Dys
functionsfunctions Clinical Reasoning PracticeClinical Reasoning Practice Clinical Concerns Related to ReasClinical Concerns Related to Reas
oning oning Take Home MessageTake Home Message
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Vague Diagnosis of LBPVague Diagnosis of LBP 80% no structural diagnosis80% no structural diagnosis Limited evidence to support classificatLimited evidence to support classificat
ionion Vague complaints to relate pathologyVague complaints to relate pathology Poor understanding biomechanicsPoor understanding biomechanics Complicated treatment outcomesComplicated treatment outcomes
impairment, disability, capabilityimpairment, disability, capabilitypsychosocial……….psychosocial……….
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Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions
PurposePurpose Direct Specific and Effective Direct Specific and Effective Treatments to Homogenous Treatments to Homogenous Sub-groupSub-group
Ford et al, 2007
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Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions
Treatment BasedTreatment Based Specific exerciseSpecific exercise – extension / flexion – extension / flexion / lateral shift syndrome/ lateral shift syndromeMobilization Mobilization – lumbar / sacroiliac mobi– lumbar / sacroiliac mobilizationlizationImmobilizationImmobilization – immobilization syndr – immobilization syndromeomeTractionTraction – traction / lateral shift syndro – traction / lateral shift syndrome me
George & Delitto, 2005
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Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions
McKenzie ApproachMcKenzie ApproachPostural Postural – symptoms after static – symptoms after static positionpositionDysfunctional Dysfunctional – symptoms at end – symptoms at end range range DerangementDerangement – symptoms – symptoms through rangethrough range
MeKenzie
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Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions
Physical Therapy Reviews 2007Physical Therapy Reviews 2007 632 papers retrieved from data base632 papers retrieved from data base 77 papers reviewed full document77 papers reviewed full document 55% uni-dimensional55% uni-dimensional 6% multi-dimensional6% multi-dimensional
Ford et al, 2007
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Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions
Physical Therapy Reviews 2007Physical Therapy Reviews 2007Classification DimensionsClassification Dimensions Patho-anatomy (47%)Patho-anatomy (47%) Signs and Symptoms (58%)Signs and Symptoms (58%) Psychological (51%)Psychological (51%) Social (14%)Social (14%)
No clear guideline to classifyNo clear guideline to classifyFord et al, 2007
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Clinical ReasoningClinical Reasoning
PracticePractice
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Hypothesis-Oriented Algorithm for Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)Clinicians II (HOAC II)
Physical Therapy, Vol 83, No.5, 2003Physical Therapy, Vol 83, No.5, 2003A Guide for Patient ManagementA Guide for Patient Management A framework for science-based cliniA framework for science-based clini
cal practicecal practice Focus on remediation of functional Focus on remediation of functional
deficits deficits How changes in impairments relateHow changes in impairments relate
d to these deficits d to these deficits
Rothstein, 2003
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Clinical Reasoning ProcessClinical Reasoning ProcessGenerate Patient Identified and Generate Patient Identified and
Non-identified Problem Lists (S/E)Non-identified Problem Lists (S/E)
Formulate Exam. Strategy Formulate Exam. Strategy
Conduct Examination and Analyze (O/E)Conduct Examination and Analyze (O/E)
Generate Working HypothesesGenerate Working Hypotheses
InterventionInterventionRe-assessment
Rothstein, 2003
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Clinical ReasoningClinical Reasoning Generate Patient Identified and Non-iGenerate Patient Identified and Non-i
dentified Problem Lists (S/E)dentified Problem Lists (S/E) Patient’s concernsPatient’s concerns Problems led to seek PTProblems led to seek PT Layman informationLayman informationeg. eg. inability to downstairs (PIP)inability to downstairs (PIP)
contracture after knee amp. (NPIP)contracture after knee amp. (NPIP)
Rothstein, 2003
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Clinical ReasoningClinical Reasoning
Formulate Exam. StrategyFormulate Exam. Strategy Establish clinical hypothesis Establish clinical hypothesis Base on Base on pathoanatomic activitiespathoanatomic activities
(pathology, physiology, anatomy, m(pathology, physiology, anatomy, movement science and biomechanicovement science and biomechanics)s)
Change to clinical informationChange to clinical information
Rothstein, 2003
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Clinical ReasoningClinical Reasoning Conduct Examination and AnalyzeConduct Examination and Analyze Test the tentative reasons Test the tentative reasons Pathology extent and type not Pathology extent and type not
observable and measurable by observable and measurable by PT PT
Confirm or reject the hypothesesConfirm or reject the hypotheses
Rothstein, 2003
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Clinical ReasoningClinical Reasoning
Generate Working HypothesesGenerate Working Hypotheses Working base for interventionWorking base for intervention Causes of problems usually due Causes of problems usually due
to impairmentto impairmenteg. joint stiffness, muscle weakneg. joint stiffness, muscle weakness ess
Causes sometimes relate to patCauses sometimes relate to pathologyhologyeg. wound infectioneg. wound infection
Rothstein, 2003
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Clinical ReasoningClinical Reasoning InterventionIntervention
Mainly base on examination findings Mainly base on examination findings (O/E) (O/E)
Usually focus on impairment and funcUsually focus on impairment and functional limitationstional limitationseg. LBP PID (MRI confirmed)eg. LBP PID (MRI confirmed)intervention not designed to change tintervention not designed to change the pathology, but rather the impairmehe pathology, but rather the impairment and disability that the pathology cant and disability that the pathology caused used
Sometimes attempt to eliminate a patSometimes attempt to eliminate a pathology, eg. eliminate the sepsis for whology, eg. eliminate the sepsis for wound healingound healing
Rothstein, 2003
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Formulate Examination StrategyFormulate Examination Strategy (base on clinical presentations)(base on clinical presentations)
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Formulate Examination StrategyFormulate Examination Strategy (base on clinical presentations)(base on clinical presentations)
Case 1• C/O anterolateral thigh pain during walking• much more pain when up & downstairs (likely hip problem)
Case 2• C/O pain over posterior thigh when bending forward to lift• much relieved when squatting to lift (likely hamstrings/neurodynamic problem)
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Conduct Examination, O/E Conduct Examination, O/E (base on examination strategy)(base on examination strategy)
InterventionIntervention(base on examination, O/E, findings)(base on examination, O/E, findings)
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Clinical Concerns Clinical Concerns Related to ReasoningRelated to Reasoning
ininLumbo-sacral DysfunctionsLumbo-sacral Dysfunctions
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Pathological “Pathological “RedRed Flags” Flags”
Most clues are in history Most clues are in history
NotNot in physical in physical examinationsexaminations
Wilk, 2004Wilk, 2004
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Cauda Equina & Widespread NeurologiCauda Equina & Widespread Neurological Disorderscal Disorders
Clinical ConcernsClinical Concerns Bladder dysfunction (rapid & immediatBladder dysfunction (rapid & immediat
e)e) Saddle anaesthesia Saddle anaesthesia Sphincter disturbanceSphincter disturbance Progressive motor weaknessProgressive motor weakness Gait disturbance (spastic, clonus in stairGait disturbance (spastic, clonus in stair
s walking)s walking) UMNL tests positive (Hoffman’s, BabinsUMNL tests positive (Hoffman’s, Babins
ki & Clonus)ki & Clonus) Surgical intervention within 48 hrsSurgical intervention within 48 hrs Wilk, 2004Wilk, 2004
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Potential Tissue InjuredPotential Tissue InjuredClinical ConcernsClinical Concerns Vascular Tissues:Vascular Tissues:
inflammatory signs appear within hainflammatory signs appear within half hour after injurylf hour after injurye.g. ligament, muscle, capsule….e.g. ligament, muscle, capsule….
Avascular Tissues:Avascular Tissues:inflammatory signs appear after few inflammatory signs appear after few hours following injury hours following injury
e.g. IV disc, meniscus…..e.g. IV disc, meniscus…..
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Facet Joint / Extension Syndrome Facet Joint / Extension Syndrome Applied Anatomy & PhysiologyApplied Anatomy & Physiology Lumbar facet joints orientation (sLumbar facet joints orientation (s
agittal plan)agittal plan) Increasing stress due to: Increasing stress due to:
- decreasing IVD height- decreasing IVD height- short hip flexor muscles- short hip flexor muscles- decreased performance of - decreased performance of
abdominal and gluteal muabdominal and gluteal muscles scles - excessive use of hip flexor and - excessive use of hip flexor and
paraspinal muscles paraspinal muscles Harris-Hayes, et al, 2005
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Facet Joint / Extension Syndrome Facet Joint / Extension Syndrome Clinical ConcernsClinical Concerns Common with increasing ageCommon with increasing age Facet Joints block excessive eFacet Joints block excessive e
xtension, associate with OA chxtension, associate with OA changes (morning stiff)anges (morning stiff)
Aggravate in prolonged comprAggravate in prolonged compression usuallyession usually
Regular pattern presentationRegular pattern presentation Relieve in stretch patternRelieve in stretch pattern
(opposite to lig./mm strain)(opposite to lig./mm strain) Palpable local joint signPalpable local joint sign Positive finding in local diagnosPositive finding in local diagnos
tic injectiontic injectionHarris-Hayes, et al, 2005
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Pathogenesis of Pathogenesis of Inter-vertebral DiscInter-vertebral Disc
Applied Anatomy & PhysiologyApplied Anatomy & PhysiologyIntrinsic Discogenic DisorderIntrinsic Discogenic Disorder Avascular tissueAvascular tissue Pain nerves over periphery Pain nerves over periphery After injury, ingrowth of vascular After injury, ingrowth of vascular
granulation tissues & nervesgranulation tissues & nervesalong torn fissures, extend from externaalong torn fissures, extend from external layer of anulus fibrosus to nucleus pull layer of anulus fibrosus to nucleus pulposusposus
Painful disc from injury and repairPainful disc from injury and repairPeng, et al, 2006
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Pathogenesis of Pathogenesis of Inter-vertebral DiscInter-vertebral Disc
Applied Anatomy & PhysiologyApplied Anatomy & PhysiologyProlapsed Inter-vertebral DiscProlapsed Inter-vertebral Disc Fissures communicated, disc materialFissures communicated, disc material
s protrudeds protruded Axilla / shoulder regions protrusion Axilla / shoulder regions protrusion
ipsilateral / contralateral Lx listingipsilateral / contralateral Lx listing L5 nerve may be compressed by L4/5 L5 nerve may be compressed by L4/5
or L5/S1 discor L5/S1 discL5/S1 disc may compress L5 and /or L5/S1 disc may compress L5 and /or S1 nervesS1 nerves
Nerve compression irritation Nerve compression irritation Neural tissues ischaemic inflammationNeural tissues ischaemic inflammation
Peng, et al, 2006
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Clinical ConcernsClinical Concerns Nature of injury (F/Rot)Nature of injury (F/Rot) Delayed symptoms after injuryDelayed symptoms after injury Sensitive to vibrationSensitive to vibration Morning symptoms Morning symptoms Increase symptoms on changingIncrease symptoms on changing
intra-abdominal pressureintra-abdominal pressure Restricted mov’t of neuro-tissuesRestricted mov’t of neuro-tissues Lumbar listing (ipsilat. / contralat.)Lumbar listing (ipsilat. / contralat.) Diagnosed by MRI (match with sym)Diagnosed by MRI (match with sym)
Pathogenesis of Pathogenesis of Inter-vertebral DiscInter-vertebral Disc
Peng, et al, 2006
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Sacral Iliac Joint SyndromeSacral Iliac Joint SyndromeApplied Anatomy & PhysiologyApplied Anatomy & Physiology Weight-bearing synovial jointWeight-bearing synovial joint MovementMovement
A-P translation : ~3 to 7 mmA-P translation : ~3 to 7 mmA-P rotation : ~3 to 5 degreeA-P rotation : ~3 to 5 degree
Male: likely fused in late 40 Male: likely fused in late 40 Female in late 60Female in late 60
DonTigny, 1990 DeMann, 1997
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Sacral Iliac Joint SyndromeSacral Iliac Joint SyndromeApplied Anatomy & PhysiologyApplied Anatomy & Physiology Stable with form and force closureStable with form and force closure
Form closure: closely fit joint surface (sulcuForm closure: closely fit joint surface (sulcus)s)Force closure: muscles, ligaments & thoracoForce closure: muscles, ligaments & thoracolumbar fascialumbar fascia
No direct prime mover muscle No direct prime mover muscle Strong dorsal / ventral SI Strong dorsal / ventral SI
& sacrotuberous ligaments& sacrotuberous ligaments Anterior dysfunction more likelyAnterior dysfunction more likely One of common metastasis areaOne of common metastasis area
DonTigny, 1990 DeMann, 1997
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Inter-rater Reliability of SIJ TestsInter-rater Reliability of SIJ Tests(Oldreive,1995)(Oldreive,1995)
Test % of AgreementIliac crest standing level 35
Iliac crest level in sitting 41
PSIS level in standing 35
PSIS level in sitting 35
ASIS level in sitting 43
ASIS level in standing 38
Standing flexion test 43
Sitting flexion 50
Side-lying iliac approximation 76
Supine/long sitting test 40
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Reliability SIJ TestsReliability SIJ Tests(Freburger JK & Riddle DL,1999)(Freburger JK & Riddle DL,1999)
♦ 4 Tests:Gillet,stand flexion,sit flexion,supine to sit test
♦ Results:– Sensitivity:8-44%– Specificity:64-93%– Negative predictive value:28-38%– Positive predictive value:61-79%
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Reliability of SIJ TestsReliability of SIJ Tests(Cibulka MT & Koldehoff R, 1999)(Cibulka MT & Koldehoff R, 1999)
♦ 4 clinical tests used together:stand flexion test,PSIS palpation,supine long sitting leg length test,prone knee flexion test
♦ at least ¾ test should positive for positive♦ Result
– Sensitivity :82%– Specificity: 86%– Negative predictive value: 84%– Positive predictive value: 86%
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Sacral Iliac Joint SyndromeSacral Iliac Joint SyndromeClinical ConcernsClinical Concerns Age / Sex Age / Sex History of Trauma / child-birthHistory of Trauma / child-birth Buttock pain / tender over PSISButtock pain / tender over PSIS Symptoms likely not below kneeSymptoms likely not below knee Symptoms when rolling at nightSymptoms when rolling at night Occ cross SLR / Step forward painOcc cross SLR / Step forward pain Muscle imbalanceMuscle imbalance
Priformis, Priformis, Hamstring, iliopsoasHamstring, iliopsoas, , Gluteus maximusGluteus maximus
Cluster of tests to confirmCluster of tests to confirmDonTigny, 1990 DeMann, 1997
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Vascular Vs Spinal ClaudicationVascular Vs Spinal Claudication Applied Anatomy & PhysiologyApplied Anatomy & Physiology Vascular Vascular (Intermittent Claudication)(Intermittent Claudication) : :
- arterial insufficient of distal aorta,- arterial insufficient of distal aorta, iliac or femoral arteries iliac or femoral arteries- ischemic symptoms- ischemic symptoms
Spinal Spinal (Spinal Stenosis):(Spinal Stenosis): - IVF occlusion- IVF occlusion- mechanical constriction and irrita- mechanical constriction and irritation of spinal nervestion of spinal nerves- impinging spinal nerves usually i- impinging spinal nerves usually in dynamic extension pattern n dynamic extension pattern Gray, 1999
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Vascular Vs Spinal ClaudicationVascular Vs Spinal Claudication Clinical ConcernsClinical ConcernsVascular:Vascular: Heavy smoker, > age 40 maleHeavy smoker, > age 40 male Diabetes, obesity, coronary heart disease Diabetes, obesity, coronary heart disease Common in calf, cramp, decrease dorsaliCommon in calf, cramp, decrease dorsali
s pedis pulses pedis pulse Symptoms appear after similar distance wSymptoms appear after similar distance w
alk, fast symptoms relieve with rest, alk, fast symptoms relieve with rest, even even slow walking or standingslow walking or standing
Worse in slope walking Worse in slope walking Gray, 1999
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Vascular Vs Spinal ClaudicationVascular Vs Spinal Claudication Clinical ConcernsClinical ConcernsSpinal:Spinal: Symptoms aggravated by walking aSymptoms aggravated by walking a
nd change of body positionsnd change of body positions Slow relieve by sitting or squattingSlow relieve by sitting or squatting Worse even in prolonged standingWorse even in prolonged standing Various walking toleranceVarious walking tolerance Neuropathy symptomsNeuropathy symptoms Gelderen Bicycle testGelderen Bicycle test
Gray, 1999
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Applied Anatomy & PhysiologyStructural Defect (Spondylolisthesis) Grade (I – III), likely at L4/L5 and L5/
S1 Review the flexion / extension
x-ray view Lumbar curvature kink Usually associated with abdominus
weakness / hamstring tightness
Lumbar Dynamic StabilityLumbar Dynamic Stability
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Applied Anatomy & PhysiologyNeuromuscular Defect Global Muscles
larger torque producing musclesbalance external loadsspine: erector spinae
Intrinsic Musclessmall local musclescontrol joint position & mov’t planesspine: multifidus; transversus abdominus
Lumbar Dynamic StabilityLumbar Dynamic Stability
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Neuromuscular Control
Lumbar Dynamic StabilityLumbar Dynamic Stability
Active StructuresPassive Structures
Panjabi, 1992Panjabi, 1992
Neutral ZoneNeutral Zone
• A region of no or little resistance to motion in the middle of an IV joint’s ROM
• Min. Passive Tissue StiffnessGay et al, 2006
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Lumbar Dynamic StabilityLumbar Dynamic StabilityNeutral ZoneNeutral Zone
• A feature of natural ROM• Exists mainly in flexion / extension• Facet joint contribute much on NZ
stability• Small change in torque gives
moderate change in position
• Require complex control of IV joints by spinal muscles
• Increase with increasing disc degeneration or injuries
• Decrease with addition of muscle forces / spinal instrumentation
Gay et al, 2006
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Clinical ConcernsChronic LBP Studies demonstrated delay on
set or poor motor control of the intrinsic muscles
Multifidus max contracts at upright standing in normal subjects, while max. in 25 forward stooping in LBP patients
Lumbar Dynamic StabilityLumbar Dynamic Stability
Hides, 1994; Lee et al, 2006
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Clinical Concerns Decrease the cross section are
a of multifidus over the injured / defect segment
Clinically ‘catching pain’ in different range of motionesp. forward flexion
Intrinsic muscles minimize unnecessary rotational stress over the disc
Lumbar Dynamic StabilityLumbar Dynamic Stability
Hides, 1994; Lee et Al, 2006
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Thoracolumbar Junction SyndromeThoracolumbar Junction Syndrome
Applied Anatomy & PhysiologyApplied Anatomy & Physiology Transition zone between two regioTransition zone between two regio
ns of facet orientationns of facet orientation Thoracic – coronal planeThoracic – coronal plane
Lumbar – sagittal planLumbar – sagittal plan T12 - Superior facet inclined as TxT12 - Superior facet inclined as Tx
Inferior facet inclined as Inferior facet inclined as Lx Lx
T12 as an intermediate vertebrae T12 as an intermediate vertebrae during trunk rotationduring trunk rotation
Sebastian, 2006
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Thoracolumbar Junction Syndrome Thoracolumbar Junction Syndrome
Clinical ConcernsClinical Concerns Symptoms at upper Lx and gluteal reSymptoms at upper Lx and gluteal re
gions gions Considerable Considerable rotational stressrotational stress in TL a in TL a
nd LS junctions nd LS junctions Associated with impact injuryAssociated with impact injury
(slipped / fell with buttock landed)(slipped / fell with buttock landed) One of the common osteoporotic siteOne of the common osteoporotic site
Sebastian, 2006
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Neurodynamic Dysfunction Neurodynamic Dysfunction Applied Anatomy & PhysiologyApplied Anatomy & Physiology Neuro- connective tissues involvemeNeuro- connective tissues involveme
ntnt Dynamic mechanical irritationDynamic mechanical irritation Circulation deficiency (extra / intraneuCirculation deficiency (extra / intraneu
ral circulatory systemral circulatory system Occasionally associated with neurogeOccasionally associated with neuroge
nic signsnic signs Common adhesion sites at C6, T6 anCommon adhesion sites at C6, T6 an
d L4 (approximate points)d L4 (approximate points) SLR, Slump, ULTTsSLR, Slump, ULTTs
Bulter, 1992; Ko et al, 2006
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Neurodynamic Dysfunction Neurodynamic Dysfunction Clinical ConcernsClinical Concerns Relative dynamic mov’t of neuro-connectiRelative dynamic mov’t of neuro-connecti
ve tissues deficiency:ve tissues deficiency:- total length insufficiency, adhesion to se- total length insufficiency, adhesion to sensitive structures, poor excursion / glidinnsitive structures, poor excursion / gliding movementsg movements
Distal symptoms dominatedDistal symptoms dominated Morning severityMorning severity Associated with spine post-op complicatiAssociated with spine post-op complicati
onon Aware latency effect after neurodynamic Aware latency effect after neurodynamic
treatmenttreatment- prefer for stable symptoms- prefer for stable symptoms Bulter, 1992; Ko et al, 2006
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Piriformis Syndrome Piriformis Syndrome Applied Anatomy & PhysiologyApplied Anatomy & Physiology Sacral plexus L5, S1,2Sacral plexus L5, S1,2 Mainly hip external rotatorMainly hip external rotator Entrapment of sciatic nerve Entrapment of sciatic nerve Comparable to sciaticaComparable to sciatica Buttock pain with muscle Buttock pain with muscle
trigger pointstrigger points
Kuncewicz, et al, 2006
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Piriformis Syndrome Piriformis Syndrome Clinical ConcernsClinical Concerns Symptoms similar to sciaticaSymptoms similar to sciatica After fall / leg twisting injury, pyAfter fall / leg twisting injury, py
omyositis, fibrosis after deep iomyositis, fibrosis after deep injectionnjection
Tight hip external rotatorTight hip external rotator Supine lying with different hip rSupine lying with different hip r
otation when compared on bototation when compared on both sidesh sides
Buttock pain on stretching the Buttock pain on stretching the musclemuscle
Fair tolerance on SLSFair tolerance on SLSKuncewicz, et al, 2006
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Thoracic Outlet Syndrome Thoracic Outlet Syndrome Applied Anatomy & PhysiologyApplied Anatomy & Physiology Non-specific labelNon-specific label Vascular: obstruction of subclaviaVascular: obstruction of subclavia
n artery / veinn artery / veindue to: stenosis, cervical rib, throdue to: stenosis, cervical rib, thrombosis mbosis
Neurogenic: brachial plexus comNeurogenic: brachial plexus compression pression due to: scared / tight scalene mudue to: scared / tight scalene musclesscles
Sanders et al, 2007
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Thoracic Outlet Syndrome Thoracic Outlet Syndrome
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Thoracic Outlet Syndrome Thoracic Outlet Syndrome Clinical ConcernsClinical Concerns ~ 90% neurogenic ~ 90% neurogenic Adson Test minimum clinical valuAdson Test minimum clinical valu
ee Neck rotation, head tilting elicit syNeck rotation, head tilting elicit sy
mptoms over contralateral armmptoms over contralateral arm Abducting arm to 90Abducting arm to 90in external roin external ro
tation leads to symptoms within 6tation leads to symptoms within 60 sec0 sec
Symptoms with carrying low weigSymptoms with carrying low weightht
Symptoms during sleeping Symptoms during sleeping Sanders et al, 2007
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Take Home MessageTake Home Message Make use of anatomy, physiology, pathMake use of anatomy, physiology, path
ology, movement sciences and biomecology, movement sciences and biomechanics knowledge to analyze hanics knowledge to analyze pathoanpathoanatomic activitiesatomic activities
Integrate into clinical contextIntegrate into clinical context Test your Test your clinical hypothesesclinical hypotheses Looking for Looking for physical problemsphysical problems to treat to treat Confirm with patient’s responseConfirm with patient’s response
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ReferenceReferenceButler DS (1992) Mobilization of Nervous System. Churchill LivingstonesButler DS (1992) Mobilization of Nervous System. Churchill LivingstonesCibulka MT,Koldehoff R.(1999) Clinical usefulness of a cluster of sacroiliac jCibulka MT,Koldehoff R.(1999) Clinical usefulness of a cluster of sacroiliac joint test in patietns with and without low back pain.Journal of orthopaedic anoint test in patietns with and without low back pain.Journal of orthopaedic and sports d sports Physical TherapyPhysical Therapy 29(2): 83-92 29(2): 83-92DeMann LE (1997) Sacroiliac Dysfunction in Dancers with Low Back Pain, DeMann LE (1997) Sacroiliac Dysfunction in Dancers with Low Back Pain, Manual TherapyManual Therapy 2(1), 2-10. 2(1), 2-10. DonTigny RY (1990) Anterior Dysfunction of the Sacroiliac Joint as a Major DonTigny RY (1990) Anterior Dysfunction of the Sacroiliac Joint as a Major Factor in the Etiology of the Idiopathic Low Back Pain Syndrome. Factor in the Etiology of the Idiopathic Low Back Pain Syndrome. Physical TPhysical Therapyherapy 70: 250-256 70: 250-256 Ford J, Story I, O’Sullivan P and McMeeken J (2007) Classification Systems Ford J, Story I, O’Sullivan P and McMeeken J (2007) Classification Systems for Low Back Pain: A Review of the Methodology for Development and Validfor Low Back Pain: A Review of the Methodology for Development and Validation Physical Therapy Reviews 12: 33-42.ation Physical Therapy Reviews 12: 33-42.Gay R E, Ilharrebode B, Zhao K, Zhao C and An K N (2006) Sagittal Plane Gay R E, Ilharrebode B, Zhao K, Zhao C and An K N (2006) Sagittal Plane Motion in the Human Lumbar Spine: Comparsion of the in Vitro Quasistatic Motion in the Human Lumbar Spine: Comparsion of the in Vitro Quasistatic Neutral Zone and Dynamic Motion Parameters, Neutral Zone and Dynamic Motion Parameters, Clinical BiomechanicsClinical Biomechanics 21, p. 21, p.914-919.914-919.George SZ, Delitto A (2005) Clinical Examination Variables Discriminate AmGeorge SZ, Delitto A (2005) Clinical Examination Variables Discriminate Among Treatment-based Classification Groups: A Study of Construct Validity in ong Treatment-based Classification Groups: A Study of Construct Validity in Patients with Acute Low Back Pain, Patients with Acute Low Back Pain, Physical TherapyPhysical Therapy vol 85 (4) 306-314. vol 85 (4) 306-314. Harris-Hayes M, Linda R, Van Dillen, Sahrmann S A (2005) Classification, THarris-Hayes M, Linda R, Van Dillen, Sahrmann S A (2005) Classification, Treatment and Outcomes of a patient with Lumbar Extension Syndrome reatment and Outcomes of a patient with Lumbar Extension Syndrome PhysPhysiotherapy Theory and Practiceiotherapy Theory and Practice, 21: 3, 181-196., 21: 3, 181-196.
5555
ReferenceReferenceHides JA, Stokes MJ, Saide M, Jull GA, Copper DH (1994) Evidence of LumHides JA, Stokes MJ, Saide M, Jull GA, Copper DH (1994) Evidence of Lumbar Multifidus Wasting Isilateral to Symptoms in Patients with Acute/Subacutbar Multifidus Wasting Isilateral to Symptoms in Patients with Acute/Subacute Low Back Pain. e Low Back Pain. SpineSpine. 19: 165-172.. 19: 165-172.Ko HY, Park PK, Park JH, Shin YB, Shon HJ and Lee HC (2006) Intrathecal Ko HY, Park PK, Park JH, Shin YB, Shon HJ and Lee HC (2006) Intrathecal Movement and Tension of the Lumbosacral Roots Induced by Straight Leg Movement and Tension of the Lumbosacral Roots Induced by Straight Leg Raising. American Physical Medical Rehabilitation. March , 85(3), 222-227.Raising. American Physical Medical Rehabilitation. March , 85(3), 222-227.Kuncewicz E, Gajewska E, Sobiska M and Samborski W (2006) Piriformis Kuncewicz E, Gajewska E, Sobiska M and Samborski W (2006) Piriformis Muscle Syndrome, Ann Acad Med Stetin, 52(3) 99-101.Muscle Syndrome, Ann Acad Med Stetin, 52(3) 99-101.Lee S W, Chan CKM, Lam TS, Lam C, Lau NC, Lau RWL and Chan ST (20Lee S W, Chan CKM, Lam TS, Lam C, Lau NC, Lau RWL and Chan ST (2006) Relationship Between Low Back Pain and Lumbar Multifidus Size at Diff06) Relationship Between Low Back Pain and Lumbar Multifidus Size at Different Postures. erent Postures. SpineSpine, vol 31, 19, p. 2258-2262., vol 31, 19, p. 2258-2262.Oldreive WL.(1995) A critical review of the literature on tests of the sacroiliaOldreive WL.(1995) A critical review of the literature on tests of the sacroiliac joint.J.Manual c joint.J.Manual Manipulative TherapyManipulative Therapy 3(4):156-161. 3(4):156-161.Peng P, Hao J, Hou S, Wu W, Jiang D, Fu X and Yang Y Possible PathogenPeng P, Hao J, Hou S, Wu W, Jiang D, Fu X and Yang Y Possible Pathogenesis of Painful Intervertebral Disc Degeneration Spine vol 31 (5) p.560-566 esis of Painful Intervertebral Disc Degeneration Spine vol 31 (5) p.560-566 Rothestein J M, Echternack J L and Riddle D (2003) The Hypothesis-OrientRothestein J M, Echternack J L and Riddle D (2003) The Hypothesis-Oriented Algorithm for Clinicians II (HOACII): A guide for Patient Management, Phed Algorithm for Clinicians II (HOACII): A guide for Patient Management, Physical Therapy Vol 83, Number 5, 455-470ysical Therapy Vol 83, Number 5, 455-470Sanders RJ, Hammond SL and Rao NM (2007) Journal of Vascular Surgery. Sanders RJ, Hammond SL and Rao NM (2007) Journal of Vascular Surgery. Sept. 46(3): 601-604.Sept. 46(3): 601-604.Sebastian D (2006) Thoracolumbar Junction Syndrome: A case Report. Sebastian D (2006) Thoracolumbar Junction Syndrome: A case Report. PhyPhysiotherapy Theory and Practicesiotherapy Theory and Practice 22:1 53-60. 22:1 53-60.Wilk V (2004) Acute low back pain: assessment and management, Wilk V (2004) Acute low back pain: assessment and management, Aust FaAust Fam Physicianm Physician, June; 33(6): 403-7., June; 33(6): 403-7.