1) altered compressive or tensile stress on the structures of the back.

2) altered positional/spatial relationships of structures

Alterations in compressive and/or tensile stresses and positional relationships can result from?

[4]

1) protusion or extrusion of disc materal

2) subluxation or the vertebrae

3) folding of ligmentous tissues

4) ostophyte formation

What are the stress that could harm the annular ring integrity?

[3]

1)Accumulation of microtrauma

2) isolated macrotrauma

3) fatigue loading [creep]

1) direct contact with discal material

2) regional inflammation 

3) fluid stasis

1) immunologic responses

2) discal material enzymes

L4-5

L5-S1

Forward displacement of one vertebrae over another. 

[commonly occurs where a bilateral pars fracture has occured]

Spondylolysis is an injury that you can be born with.

True or false

Complications that occur with a spondylolysis

[3]

1) instability

2) accelerated degeneration

3) disc lesion

Inferior 

superior

inferior

soft tissue inflamation

bone sclerosis

Fracture

1) initiation

2) strength

3) endurance

1) Congenital

2) developmental with genetic disposition

3) degenerative

4) metabolic

5) iatrogenic

6) miscellaneous

Treatment causes the problem

[laminectomy can sometimes cause stenosis]

60 years old with a long history of back pain in their 30's and 40's with decreased symptoms in their 50's.

Big indicator: complaints of LE numbness, paresthesias and weakness predominate.

Conservative treatments of stinotic pts.

[5]

1) bed rest

2) corsets and braces

3) Physcial Activity

4) durg therapy

5) back schools and education

Surgical innerventions for stenotic pts.

[2]

1) laminectomy [central stenosis]

2) foraminotomy [lateral stenosis IVF]

What causes lumbar segmental instability?

When does instability tend to increase?

[2]

1) Intersegmental injury

2) degeneration

When does segmental instability tend to decrease?

[2]

1) simulated muscle forces across the injured segment.

2) spinal fusion

Characteristics of spinal instability

[5]

1) recurrent painful episodes

2) pts. demonstrate a catch in their back during movement.

3) painful arc in semiflexion

4) Gower's sign

5) sharp pain in there back during a certian movement.

increases

less

neural 

active

Lumbar strains often occur in isolation.

True or false

Achy diffuse pain

loosens up or decreases as the day goes on

Signs of sprain or strain

[2]

1) difficulty returning upright from a flexed position

2) Gower's sign that resolves as the structure heals.

1) osteoporosis

2) high load on the axial skeleton [fall on tail bone]

Anterior 

thinning 

wedging

Signs and symptoms of compression fracture.

[5]

1) found at the anterior portion of the vertebral body

2) single fracture will create a prominent spinous process w/ an increased interspinous space above and below.

3) thoracic progressive increase in kyphosis

4) lumbar peripheralization of neurologic sign to LE

5) pt. will complain of increased sharp loacalized pain with all motions & severe hypertonicity 

Percutaneous vertebroplasty

Define?

when is it used?

injection of polyumethylmethacrylate to reinforce the vertebrae.

Used when the fracture is not getting better.

Rigid TLSO bracing

Prevents what motions?

Used when?

Flexion

After surgery

Weakness

Tightness

due to neuromuscular, musculoskeletal or congenital abnomalities.

*polio, muscular dystrophy, spinal cord injury, or CP.

location [vertebral level]

Direction [apex of convexity]

Number of fixed frontal plane curves

mild curve - < 20 degrees

Moderate curve - 20-50 degrees

severe curve - >50 degrees

Convex 

convex 

concave

concave

laterally,anterior

posterior,narrowed

curve is < 19 degrees but progresses > 10 degrees/yr

Curve is 20-29 but progresses > 5 degrees/yr

Curve is > 30 degrees no progression needed

Slump test

Describe the technique

1) pt. slumps with head held in neutral

2)overpressure across the shoulders

3) pt flexes c spine

4) overpressure to maintain flexion in all 3 spinal regions.

5) PT hold ankle in dorsi flexion pt. activly extends knee.

6) test is stopped when signs are reproduced.

Lumbar protective Mechanism

Quick push assess what?

Force of the push assess what?

holding the pressure assess what?

Quick = initiation

Force = strength

hold = endurance

SLR Test

tells us what?

SLR test

Patient position

First test "normal" leg

hip medially rotated and adducted, knee extened

SLR test

Describe the technique

PT passively flexs the pt. hip until there is pain/tightness in the back or the back of leg.

PT lowers the leg until the pain leaves

PT then dorsi flexes the ankle

PT notes reproduction of symptoms

SLR test

With leg raise what does it mean if the pain is contained in the back?

SLR test

Progression through the hip ROM

0-35 degrees = slack taken up, no dural movement

35 degrees = tension applied to sciatic roots

35-70 degrees = sciatic roots tese over intervertebral disc

70+ degrees = no further root deformation

SLR test

What is most likely the cause of the pain once hip ROM gets greater than 70 degrees?

pt. extends there spine while the PT controls at the spine. 

PT applies over pressure into extension while the pt rotates and side bends.

A PTs treatment should include?

[3]

1) pt. ed

2) manual therapy interventions

3) therapeutic exercise

disc involvement

spondylolysis

spondylolysthesis

1) evaluate and treat trunk strength, coordination, and mobility.

2) facilitate lower extremity function

3) facilitate rolling

4) facilitate efficient lumbopelvic function

5) increase ROM of lower quadrant

6) treatment of sacroiliac dysfunction

In between the lateral and intermediate sacral crest.

Dorsal ramus of sacral spinal nerve.

Anterior to posterior

2nd and 3rd sacral segments

Lateral to the fused vertebral bodies.

Ventral rami

SI joint is classified as a synovial joint

True or False

Ventral sacroiliac ligament

describe it?

Where can it be palpated at?

a thickening of the capsule

Baer's point

Long dorsal sacroiliac ligament

Path?

1) contraction of muscles that join the ligament

2) counternutation of the sacrum

3) loading of the sacrotuberous ligament

1) nutation of the sacrum

2) contraction of lats or glute max

Sacrotuberous ligament

Pathway for the 3 bands

lateral band - ischial tuberosity to the posterior iliac spine

medial band - transverse tubes S3-5 to ischial tube

Superior band - connects the coccyx to the PSIS

Muscular attachments to the sacrotuberous ligament.

[4]

1) piriformis

2) glute max

3) biceps femoris

4) multifdus

Sacrospinous ligament

Path?

Iliolumbar ligament

Name the 5 segments

Path

anterior, superior, inferior, vertical and posterior

Consistently arise from the transverse process of L4 and 5 and blend with the sacroiliac ligaments and laterally with the iliac crest.

Thoracodorsal fascia

tension can be increase how?

[3]

1) Motion of the arms

2) contraction of the muscles that attach

3) stretching of the muscles that attach

1) nutation

2) Counternutation

Form Closure: Stability of a closely fitting joint that needs no extra forces to maintain the stability.

Force closure: Extra forces used to compress and increase the friction on the articular surface. Allowing it to resit friction.

1) shape of the joint surface

2) friction coefficient of the articular carilage

3) integrity of ligaments

Inner unit muscle that increases stability of the SI joint include what muscles?

[4]

1) pelvic floor muscles

2) Transversus abdominus

3) multifidus

4) diaphragm

1) posterior oblique

2) deep longitudinal

3) anterior oblique

4) lateral

What muscles are included in the posterior oblique group?

[3]

1) latissimus

2) glute Max

3) TLF

What muscles are contained in the deep longitudinal group?

[4]

1) Erector spinae

2) deep lamina of TLF

3) sacrotuberous muscles

4) biceps femoris

What is included in the Anterior oblique group of SI stability?

[3]

1) oblique abdominals

2) contralateral adductor muscles

3) anterior abdominal fascia

What is included in the lateral group of joint stability?

[3]

1) gluteus medius

2) glutes minimus

3) contralateral adduction of the thigh

Hypomobile Subjective findings?

[5]

1) Symptoms develop insidiously or suddenly

2) History of trama

3) pain is localized to the joint

*pain can radiate into the butt to the knee

4) Long standing hypomobility can cause contralateral pain

5) Very fidgety

What are activities that aggravate a hypomobile SI joint?

[5]

1) walking

2) ambulating up and down stairs

3)rolling in bed

4)sit to stand transfers

5) standing on one leg

Hypermobility subjective findings?

[3]

1) onset after repeated microtrauma, macrotrauma, hormonal changes

2) pt. c/o sudden onset of unilateral SI or pubic symphysis pain. 

* pain will radate into the butt, groin, thigh and abs

3) mechanism of injury unexpected vertical loading

Things that may aggravate a hypermobile joint.

[6]

1) unilateral weight bearing

2) forward bending

3) lifting

4) laying supine and rolling 

5) fast walking

6) any prolonged activity

Objective findings of a hypermobile joint

[7]

1) soft end feel with stability testing

2) muscle guarding/holding patterns

3) joint play tests are blocked

4) Gait

5) functional tests

6) posture

7) articular mobility/stability tests

With a hypermobile SI joint what would one notice during gait?

[objective finding]

What will you notice in the posture of a hypermobile SI joint.

[objective]

1) sacral nutation

2) sacral counternutation

3) posterior innomiate rotation

4) anterior innomiate rotation

Sacral Nutation Causes

[hypermobile]

(5)

1) increased lumbosacral angle secondary to structure, overweight, poor ab tone

2) posterior sacroiliac joint ligament weakness

3) lumbar spine hyperextension

4)labor delivery complication

5) weak gluteus med and max

Sacral Nutation Symtoms

[hypermobile]

[4]

1) diffuse lumbosacral pain

2) gluteal pain

3) walking and stair climing

4) prolonged standing

Sacral Nutation signs

[hypermobile]

[5]

1) deep sacral sulci and shallow Inferior lateral angle [ILA]

2) palpation tenderness over ILA Posterior sacroiliac joint ligament and baer's point

3) increased piriformis and psoas tone

4) sacarl nutation hypermobility if not compressed.

5) swelling of posterior sacral area

Sacral counternutation Causes

[hypermobile]

[5]

1) reduced lumbosacral angle secondary to structure

2) flexed sitting and standing postures

3) lumbar spine hyperflexion

4) squatting, bending and lifting

5) coccygeal muscle spasm

1) diffuse lumbosacral pain

2) occasional gluteal pain

3) pain with walking and stair climbing

4) pain with sit to stand transfer

1) shallow sacral sulci and deep ILA

2) less prominent PSIS

3) Spasm or tight pelvic diaphragm muscles

4) sacral flexion restriction

1) repeated or prolonged weight bearing on effected side.

2) direct fall on to ischial tuberosity

3) hamstring tightness on affected side

4) posterior sacroiliac ligamentous weakness on affected side

5) Glute med weakness on affected side

6) short leg on affected side

7) jarring landing on straight left leg

Posterior Innominate rotation symptoms

[hypermobile]

[4]

1) unilateral sacral pain on affected side

2) gluteal pain/sciatic pain on affected side

3) pain with flexed sitting

4) Pain with walking up stairs

Posterior Innominate rotation signs

[hypermobile]

[7]

1) affected side PSIS inferior and posterior

2) affected ASIS superior and anterior

3) Tenderness over affected post. sacroiliac ligament and sacral sulcus

4) tenderness over affected ischial tuberosity and ILA

5)increased tone of affected piriformis

6) apperant short affected leg in supine

7) affect hypermobility noncompressed restriction compressed

1) affected hip hyperextension

2) affected hip flexor tightness

3) gofing

4) affected side Glute med, max, ab weakness

5) jarring landing on outstretched affected leg

Anterior Innominate rotation symptoms

[hypermobile]

[4]

1) affect side lumbosacral and gluteal pain

2) affected side anterior hip pain

3) pain walking and stairs

4) occasional pain relief with walking

[decrease muscle tone]

Anterior Innominate rotation signs

[hypermobile]

[5]

1) affected PSIS superior and ASIS inferior

2) affected ischial tuberosity is posterior

3) tenderness over affected PSIS and ILA

4) long leg on affected side in supine

5) affected iliac posterior rotation restriction while compressed, hypermobility noncompressed

Osteitis Pubis

definition

Mechanisums of injury for osteitis pubis?

[5]

1) Long lasting or acute

2) Activities that stress muscles that are attached

3) Activites that require forceful abduction

4) Single limb support activites

5) secondary to avulsion fractures