sem. a week 2 day1

Connective TissuesConnective Tissues

CollagenCollagen

- Primary structural component of - Primary structural component of all connective tissuesall connective tissues

- Forms a matrix to support function- Forms a matrix to support function Sometimes rigid (bone, articular cartilage)Sometimes rigid (bone, articular cartilage) Sometimes fluid (blood, adipose tissue)Sometimes fluid (blood, adipose tissue) Sometimes something in between (tendons, Sometimes something in between (tendons,

ligaments) ligaments)

- Not a cell! Primarily fibrous, less energy need, - Not a cell! Primarily fibrous, less energy need, hence less vascularization.hence less vascularization.

Connective Tissue cont..Connective Tissue cont.. Results in slower growth rates and slower Results in slower growth rates and slower

healing process than muscle.healing process than muscle.

Injury to this tissue is frequently caused Injury to this tissue is frequently caused by muscle strength outstripping joint by muscle strength outstripping joint strength – usually found in beginners and strength – usually found in beginners and with drug induced muscularity.with drug induced muscularity.

This type of injury is particularly This type of injury is particularly gruesome: the tendon may snap (usually gruesome: the tendon may snap (usually at insertion) and the muscle rolls up like a at insertion) and the muscle rolls up like a window shade. Requires surgery to fix. window shade. Requires surgery to fix.

Types of Connective Types of Connective Tissue:Tissue:

BoneBoneBloodBlood

Adipose tissueAdipose tissueTendonsTendons

LigamentsLigamentsFasciaFascia

CartilageCartilage

- We’ll be dealing primarily with bone, - We’ll be dealing primarily with bone, tendons, ligaments, and cartilage in this tendons, ligaments, and cartilage in this course.course.

Bone cont…Bone cont…

Two different bone types: Two different bone types:

1.) S1.) Spongypongy ( (trabeculartrabecular) – Where ) – Where some blood cells are made and fats are some blood cells are made and fats are stored. Blood vessels extend from here as stored. Blood vessels extend from here as a network of horizontal and vertical a network of horizontal and vertical canals into the cortical bone.canals into the cortical bone.

2.) 2.) CompactCompact ( (corticalcortical) bone: the ) bone: the dense, compact outer shell that is bridged dense, compact outer shell that is bridged by trabecular bone by trabecular bone

Connective Tissue cont…Connective Tissue cont…

Bone Bone - Mineralized connective tissue- Mineralized connective tissue- - Prefix "Osteo” means - - Prefix "Osteo” means bonebone

OsteoOsteoblastblast: bone forming cells (mnemonic : bone forming cells (mnemonic

– you make things in a “blast furnace” – – you make things in a “blast furnace” – osteoblasts make bone)osteoblasts make bone)

OsteoOsteogenesisgenesis: Osteo - bone… “genic” - : Osteo - bone… “genic” - genesis - beginning of genesis - beginning of

OsteoOsteoporosisporosis: porous, as in sponge like…: porous, as in sponge like…

Bone cont..Bone cont..

• Locations of “Locations of “spongy”spongy” bone: bone:

- Vertebral bone is 70% trabecular - Vertebral bone is 70% trabecular (axial bone)(axial bone)

- In marrow cavities and ends of long - In marrow cavities and ends of long bones (appendicular bone).bones (appendicular bone).

• Locations of “Locations of “compactcompact” bone ” bone – the – the outer shell ofouter shell of all bonesall bones

Process for Process for Strengthening BoneStrengthening Bone

1.) Mechanical forces cause deformation at 1.) Mechanical forces cause deformation at specific sites (only need about 1/10th of the specific sites (only need about 1/10th of the force it would take to break the bone).force it would take to break the bone).

2.) 2.) OsteoOsteoblasts migrate to stress siteblasts migrate to stress site

3.) Start bone modeling:3.) Start bone modeling:- - osteoblasts secrete collagen to build bone osteoblasts secrete collagen to build bone matrix.matrix.- collagen molecules become mineralized in - collagen molecules become mineralized in the the presence of calcium and presence of calcium and phosphate “hence”- phosphate “hence”- bone becomes bone becomes denser, more rigid. denser, more rigid.

Bone cont..Bone cont..

Osteoporosis:Osteoporosis:

- Bones become porous (weak and - Bones become porous (weak and prone to fracture) without regular prone to fracture) without regular loading. loading.

- Can be caused by- - Can be caused by- InactivityInactivity

(i.e) - lack of vertical loading. (i.e) - lack of vertical loading.

ExampleExample: Astronauts lose 1% of bone mass : Astronauts lose 1% of bone mass within the first month of zero gravity.) within the first month of zero gravity.)

Bone cont…Bone cont…

Calcium leachingCalcium leaching (Remember that Ca++ (Remember that Ca++ is essential to a muscle contraction…) is essential to a muscle contraction…)

– –The body will leach Ca++ from the The body will leach Ca++ from the bones to support muscle function if bones to support muscle function if necessary). Very common problem in necessary). Very common problem in high protein diets. The high intake of high protein diets. The high intake of protein leaches calcium from the bones, protein leaches calcium from the bones, which leads to osteoporosis. which leads to osteoporosis.

Additional Causes…Additional Causes…

GeneticsGenetics

Hormonal changesHormonal changes

Thyroid disordersThyroid disorders

Excess Vitamin AExcess Vitamin A

Consider this…Consider this…

““Relying strictly on calcium Relying strictly on calcium supplements to fend off osteoporosis supplements to fend off osteoporosis is like someone gulping protein is like someone gulping protein shakes and thinking he's going to shakes and thinking he's going to grow huge muscles without lifting…”grow huge muscles without lifting…”

Bones cont..Bones cont..

Remember the operating principles of Remember the operating principles of overload & adaptation. Our muscles overload & adaptation. Our muscles grow because we cause them to work grow because we cause them to work harder than they're accustomed to. harder than they're accustomed to.

Bones respond in the same fashion. Bones respond in the same fashion. Bones grow strong in response Bones grow strong in response ((adaptationadaptation) to the stresses we put ) to the stresses we put on them (on them (overloadoverload) -- No overload = ) -- No overload = No adaptation. No adaptation.

Bones cont…Bones cont…

Need “Need “structuralstructural” or “” or “weight weight bearingbearing” exercises to stimulate ” exercises to stimulate adaptation: loaded, multi-joint adaptation: loaded, multi-joint exercises seem to be best. exercises seem to be best.

IsolationIsolation exercises (especially ones exercises (especially ones that don’t load the bones vertically, that don’t load the bones vertically, like leg extensions and leg curls) are like leg extensions and leg curls) are less effective less effective

““Window of Opportunity Window of Opportunity Theory”… Theory”…

– “– “Bone density is primarily formed Bone density is primarily formed young, in teen and adult years. If young, in teen and adult years. If you fail to optimize bone strength in you fail to optimize bone strength in this time, you may forfeit bone this time, you may forfeit bone density potential for the rest of your density potential for the rest of your life…”life…”

Tendons, Ligaments, and Tendons, Ligaments, and FasciaFascia

BothBoth tendonstendons and and ligamentsligaments:: Not very metabolically activeNot very metabolically active Have a low requirement for O2 and nutrientsHave a low requirement for O2 and nutrients DoDo have a limited direct blood supply have a limited direct blood supply Contain extensible protein “Contain extensible protein “elastinelastin”” allows allows

some stretch for normal joint motion.some stretch for normal joint motion. Attach directly to cartilage or boneAttach directly to cartilage or bone

- Ligaments attach bone to bone- Ligaments attach bone to bone

- Tendons attach muscle to bone- Tendons attach muscle to bone

Fascia Fascia

Fibrous connective tissue that Fibrous connective tissue that surrounds and separates different surrounds and separates different organizational levels w/n skeletal organizational levels w/n skeletal muscle.muscle.

Formed primarily inFormed primarily in sheets sheets arranged in different planes to arranged in different planes to provide resistance to forces from provide resistance to forces from several different directionsseveral different directions

FasciaFascia

All three layers of fascia converge All three layers of fascia converge near the end of the muscle to form a near the end of the muscle to form a tendontendon that actually attaches to the that actually attaches to the periosteum, or in some cases, to the periosteum, or in some cases, to the bone’s surface. Muscle contraction bone’s surface. Muscle contraction force is thus transmitted to the bone force is thus transmitted to the bone via fascia to tendon to periosteum to via fascia to tendon to periosteum to bone .bone .

CartilageCartilage

Very dense matrix to handle Very dense matrix to handle tremendous forcestremendous forces

Little to no blood supplyLittle to no blood supply

- Gets O2 and nutrients through - Gets O2 and nutrients through diffusion from “diffusion from “synovial fluid”synovial fluid” – so – so it’s very slow to heal, if at all.it’s very slow to heal, if at all.

Cartilage cont..Cartilage cont..

Articular CartilageArticular Cartilage - Formed over - Formed over the ends of bones to allow smooth the ends of bones to allow smooth movement and reduce friction. ( Also movement and reduce friction. ( Also called: “hylinecalled: “hyline” ” cartilage..)cartilage..)

Fibrous CartilageFibrous Cartilage - Forms the - Forms the “intervertebral disks” and the “intervertebral disks” and the “symphysis pubis”, to absorb shock. “symphysis pubis”, to absorb shock.

Tendonous cartilage Tendonous cartilage

Strengthens attachment point of Strengthens attachment point of tendon to bonetendon to bone

COMMON INJURIES OF THE COMMON INJURIES OF THE SPINE:SPINE:


Cervical, thoracic, lumbar and sacral regionsCervical, thoracic, lumbar and sacral regions The spine is central to all movement of the The spine is central to all movement of the

human bodyhuman body Instrumental in posture and alignment Instrumental in posture and alignment Structurally designed to carry the weight of the Structurally designed to carry the weight of the

head and provide a stable base for locomotionhead and provide a stable base for locomotion Most common complaint seen in physical therapy Most common complaint seen in physical therapy

and the third most common complaint seen in and the third most common complaint seen in physician’s officesphysician’s offices

‘‘Back pain’ accounts for 175.8 million days of Back pain’ accounts for 175.8 million days of restricted activity per year and costs an restricted activity per year and costs an estimated $85 billion per year estimated $85 billion per year


Intervertebral joint complex Intervertebral joint complex comprises: comprises: Vertebra aboveVertebra above Vertebra belowVertebra below Intervertebral discIntervertebral disc Facet jointsFacet joints


Nerves exit the spinal column posterior to the disc Nerves exit the spinal column posterior to the disc and vertebral bodiesand vertebral bodies

Nerves transmit “do” messages from the brain and Nerves transmit “do” messages from the brain and spinal cord to the muscles and joints of the body (for spinal cord to the muscles and joints of the body (for example: lift your arm so that you can push that example: lift your arm so that you can push that door). These messages are carried in motor nerve door). These messages are carried in motor nerve fibers.fibers.

Nerves also transmit “feeling” messages back from Nerves also transmit “feeling” messages back from the body to the brain and spinal cord (for example: the body to the brain and spinal cord (for example: the surface I am walking on is an incline, so I need to the surface I am walking on is an incline, so I need to recruit more muscles to stabilize my ankles). These recruit more muscles to stabilize my ankles). These messages are carried in sensory nerve fibers.messages are carried in sensory nerve fibers.

One nerve contains multiple motor and sensory One nerve contains multiple motor and sensory fibers.fibers.


Nerves are often affected in spinal injuries and can cause Nerves are often affected in spinal injuries and can cause upper extremity pain and/or weakness (cervical spine upper extremity pain and/or weakness (cervical spine involvement) or lower extremity pain and/or weakness involvement) or lower extremity pain and/or weakness (lumbar spine involvement)(lumbar spine involvement)

Intervertebral discs are responsible for Intervertebral discs are responsible for shock absorption throughout the spinal shock absorption throughout the spinal columncolumn

Discs consist of an outer fibrous layer: the Discs consist of an outer fibrous layer: the annulus fibrosis and an inner gelatinous annulus fibrosis and an inner gelatinous substance: the nucleus pulposus (like a substance: the nucleus pulposus (like a jelly donut)jelly donut)


Because the discs are positioned between Because the discs are positioned between the vertebrae, they are susceptible to the vertebrae, they are susceptible to changes in pressure as we move through changes in pressure as we move through our daily livesour daily lives

Age and weight are predisposing factors for Age and weight are predisposing factors for disc injury:disc injury: Every 10# of body mass gained increases disc Every 10# of body mass gained increases disc

pressure by 40%pressure by 40% The average person loses ½ to 2” in height by The average person loses ½ to 2” in height by

the age of 70.the age of 70. After 12 weeks in orbit, astronauts grow 2”After 12 weeks in orbit, astronauts grow 2”

Herniated disc:Herniated disc: Commonly called “slipped disc” which is a misnomerCommonly called “slipped disc” which is a misnomer Intervertebral discs begin to degenerate by the third Intervertebral discs begin to degenerate by the third

decade of lifedecade of life In younger adults the nucleus pulposis is 70-90% water. In younger adults the nucleus pulposis is 70-90% water.

Fluid content decreases with age.Fluid content decreases with age. Annulus fibrosis 10-20 concentric collagen layers Annulus fibrosis 10-20 concentric collagen layers

weaken and loose elasticity with age (just like skin gets weaken and loose elasticity with age (just like skin gets wrinkles)wrinkles)

Prolonged seated postures, poor body mechanics, poor Prolonged seated postures, poor body mechanics, poor choice of exercise type and poor form during work-outschoice of exercise type and poor form during work-outs

Decreased activity level and subsequent muscle weaknessDecreased activity level and subsequent muscle weakness Above factors predispose discs to degeneration and Above factors predispose discs to degeneration and

herniationherniation Most common locations are L4, L5 and S1 in the lumbar Most common locations are L4, L5 and S1 in the lumbar

region and C5, C6 and C7 in the cervical spineregion and C5, C6 and C7 in the cervical spine

Herniated disc:Herniated disc: Symptoms might include lower back pain and/or Symptoms might include lower back pain and/or

stiffness with associated muscle spasmstiffness with associated muscle spasm Worse after running or prolonged sittingWorse after running or prolonged sitting

Herniated disc:Herniated disc: Treatment: Treatment:

Stop all potential aggravating activities Stop all potential aggravating activities (crunches, high impact exercise)(crunches, high impact exercise)

Early physical therapy before disc disease Early physical therapy before disc disease progresses (once disc is extruded will probably progresses (once disc is extruded will probably need surgery)need surgery)

Educate patient in body mechanics (bending Educate patient in body mechanics (bending and lifting techniques) and posture (sitting, and lifting techniques) and posture (sitting, standing, walking, lying)standing, walking, lying)

Ergonomic evaluation and prescription for Ergonomic evaluation and prescription for correct work station set-upcorrect work station set-up

Modify work-outs to low impact, core stability-Modify work-outs to low impact, core stability-based activities with neutral or extended spinebased activities with neutral or extended spine

Herniated disc:Herniated disc: Avoid flexion-based activities like sit-ups for Avoid flexion-based activities like sit-ups for

‘acute discs’‘acute discs’ Stretching of hamstrings and hip flexors Stretching of hamstrings and hip flexors If unresponsive to physical therapy and If unresponsive to physical therapy and

exercise, might benefit from epidural exercise, might benefit from epidural injections into the nerve (up to 3 /year)injections into the nerve (up to 3 /year)

Minidiscectomy is commonly performed for Minidiscectomy is commonly performed for large herniations, but runs a risk of large herniations, but runs a risk of recurrence where annulus is weakenedrecurrence where annulus is weakened

If disc is sequestrated or extruded (part of If disc is sequestrated or extruded (part of nucleus pulposus has broken off from disc) nucleus pulposus has broken off from disc) might require surgery to remove free segment might require surgery to remove free segment

Radiculitis/ Radiculopathy:Radiculitis/ Radiculopathy: Inflammation or irritation of the nerveInflammation or irritation of the nerve Often called ‘pinched nerve’Often called ‘pinched nerve’ Can be at the nerve root (as it emerges from the Can be at the nerve root (as it emerges from the

spinal column) or along the path of the nervespinal column) or along the path of the nerve Various causes of inflammation including: Various causes of inflammation including:

herniated discs, muscle spasm, scar tissue, herniated discs, muscle spasm, scar tissue, osteophyte formationosteophyte formation

Patient will complain of symptoms radiating Patient will complain of symptoms radiating down the arm or legdown the arm or leg

May not experience ANY back or neck painMay not experience ANY back or neck pain Can experience pain, weakness, numbness/ Can experience pain, weakness, numbness/

tingling along the path of the affected nerve roottingling along the path of the affected nerve root

Radiculitis/ Radiculopathy:Radiculitis/ Radiculopathy:

Might affect patients function (for Might affect patients function (for example walking in a lumbar example walking in a lumbar radiculopathy or gripping a pen in radiculopathy or gripping a pen in the case of a cervical radiculopathy)the case of a cervical radiculopathy)

In advanced condition, patient may In advanced condition, patient may present with atrophy of muscles present with atrophy of muscles along the affected dermatomealong the affected dermatome

Radiculitis/ Radiculopathy:Radiculitis/ Radiculopathy: Treatment: Physical therapy:Treatment: Physical therapy:

Full evaluation including movement testing (what Full evaluation including movement testing (what direction of motion reproduces symptoms)direction of motion reproduces symptoms)

Identify cause of nerve irritation and treat the cause Identify cause of nerve irritation and treat the cause (muscle spasm, pressure on nerve root from bulging (muscle spasm, pressure on nerve root from bulging disc, instability of spinal segment)disc, instability of spinal segment)

If disc related, often respond to extension-based If disc related, often respond to extension-based program (Demonstrate REIL and RRIS)program (Demonstrate REIL and RRIS)

Eliminate forward bending and axial loading from work-Eliminate forward bending and axial loading from work-out routineout routine

Discontinue high impact activities (replace cardio with Discontinue high impact activities (replace cardio with elliptical trainer in good posture)elliptical trainer in good posture)

Educate patients in correct posture and body Educate patients in correct posture and body mechanics and re-enforce during all activities of daily mechanics and re-enforce during all activities of daily livingliving

Ergonomic evaluation and prescription Ergonomic evaluation and prescription

Muscular sprain/ strain:Muscular sprain/ strain: Lower back muscles designed for postural Lower back muscles designed for postural

support, as opposed to heavy liftingsupport, as opposed to heavy lifting Larger, stronger leg muscles can handle heavier Larger, stronger leg muscles can handle heavier

loadsloads ““Bend with you knees, not with your back”Bend with you knees, not with your back” When overstrained, back muscles tend to go into When overstrained, back muscles tend to go into

painful spasmspainful spasms Patient will present with pain on all directions of Patient will present with pain on all directions of

motion involving affected musclesmotion involving affected muscles Might have visual ‘hypertrophy’ of paraspinal Might have visual ‘hypertrophy’ of paraspinal

musclesmuscles If severe, can cause pelvis to shift/ tiltIf severe, can cause pelvis to shift/ tilt Patient will feel most comfortable lying down Patient will feel most comfortable lying down

(muscles relaxed and supported)(muscles relaxed and supported)

Muscular sprain/ strain:Muscular sprain/ strain: Treatment:Treatment:

Manual techniques for muscle relaxation/ lengtheningManual techniques for muscle relaxation/ lengthening Modalities for painModalities for pain StretchesStretches Strengthening exercisesStrengthening exercises Body mechanics re-educationBody mechanics re-education If prolonged, could lead to further complications due to If prolonged, could lead to further complications due to

compensatory techniquescompensatory techniques

Physiatrist/ primary care physician might Physiatrist/ primary care physician might prescribe muscle relaxantsprescribe muscle relaxants

sem. a week 2 day1

Education