Spinal Disorders
PTA 104 Orthopedic Dysfunctions

Spinal Disorders - Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment. Contact howardc@lanecc.edu for permissions.

Introduction

Note: There are approximately 30 minutes of embedded screencasts as part of this interactive lecture. Additional supplemental materal is included as hyperlinks.

4 minute video

 

In this lesson, students will apply knowledge of anatomy and kinesiology of the spine to specific disorders encountered in physical therapy. The content and instruction assumes students have a working knowledge of the bones, ligaments, nerves, and muscles of the spine. Spinal pain is the number one reason people encounter and use physical therapy. PTAs must have an understanding of normal and abnormal spinal function and degenerative conditions in order to correctly select, apply, and compare results with the physical therapy evaluation and assessment.

Objectives

  1. Describe the phases of spinal joint and disc degeneration
  2. Describe mechanisms, signs and symptoms of common spinal disorders
  3. Differentiate between conditions of hypomobility versus instability
  4. Identify the most commonly involved spinal segments in degenerative disc disease
  5. Discriminate between clinical scenarios which indicate a surgical or other medical emergency/complication
  6. Compare and describe common surgical interventions for the spine
  7. Describe findings of musculoskeletal, neuromuscular, and special tests performed during PT examination of spinal disorders.
  8. Compare and contrast classification systems for low back and spinal pain

 

Definition of regional pain

 Link to Screencast (About 4 minutes)

Incidence

% of adults in U.S. reporting LBP x 1 day / year

56%

% of adults in U.S. reporting LBP x 6+ days / year

34%

% of adults in U.S. reporting LBP >30 days/year

14%

% workforce receiving disability income due to LBP

2%

% pregnant women reporting LBP

48-90%

% of adults who experience recurrence of LBP following a single episode

up to 85%

 

According to the National Institute of Health, spine impairment is the most frequent musculoskeletal impairment and low back pain is the most frequent reason for referral to physical therapy.

 

 

Phases of Degeneration

Video about 4.5 minutes

 

Facet joint and intervertebral disc degeneration can be classified in three (3) phases of degeneration, resulting in pain and fluctuating levels of spinal stability

Phases of Spinal Rehab.jpg

 

Complete this self-assessment of your ability to recall medical terminology related to the spine.

 

 Show activity 

 

 

Spinal Disorders

Radiculopathy

Sciatica

 

 

 

NerveRootEntrapment.jpg

Intervertebral Disc Disease

Watch this video on lumbar disc herniation to reinforce concepts from your Cameron text

 

Spinal Stenosis

Watch this video on spinal stenosis to reinforce concepts from your Cameron text

Osteoarthosis

 

CervicalOA.jpg

Spondylolysis and Spondylolisthesis

Spondylolysis

Fracture of the pars interarticularis (segment of bone between the superior and inferior articulating facets)

Can occur with some forceful impact in extension (hopping/landing on one foot)

 

Spondylolysis.jpg

 

Result is instability at the affected segment and abnormal weight-bearing forces in adjacent spinal segments

Vertebra translates forward in the sagittal plane with respect to adjacent vertebra

 

Spondylolisthesis

Mostly a condition of the lumbar spine which is associated with chronic, repetitive trauma

Mostly involves and anterolisthesis of the affected segment

May require surgical intervention/posterior fusion to prevent further instability or loss of nerve function

 

SpondylolithesisLat.png

Ankylosing Spondylitis

An inflammatory condition of unknown etiology which initiates as inflammation in the sacral region. It results in progressive loss of spinal motion due to progressive inflammation and vertebral fusion.

arthritis_ankylosing_spondylitis_ankylosing_spondylitis.jpg

Whiplash-Associated Disorders (WAD)

Refers to bony and/or soft tissue injury in the cervical spine and upper quarter due to acceleration-deceleration forces

Injury is to ligaments and muscles; stretch forces to neuromuscular structures may account for increase sensitization

Symptoms of WAD include:

Classification of WAD

 

 

Discitis / Osteomyelitis

Discitis.jpg

 

Malalignment

Self-Assessment

Prepare for the test by checking your understanding of spinal disorders

 Show quiz question

 Show quiz question

 Show quiz question

 Show quiz question

 

Common Spine Surgery

 

  1. Foraminotomy: Bone and/or other fibrous tissue is removed in and around the foramen to decompress the affected nerve root
  2. Laminectomy: The vertebral lamina is removed to decompress the central canal or to relieve pressure secondary to spondylosis and spondylolisthesis
  3. Discectomy: A portion of the herniated disc is removed to decompress nervous tissue; involves a laminectomy to access disc contents
  4. Fusion: Use of hardware, bone grafts, screws and metal cages to eliminate segmental motion due to instability and/or pain
  5. Disc replacement: replacement of IVD with prosthesis
  6. Vertebroplasty: bone is injected with cement-like compound to increase strength of bone tissue following compression fracture

Post-operative Complications

 

PT Examination and Evaluation

 

History: Includes positions and movements which increase and/or relieve pain, duration of symptoms, level of irritability, pattern during the day/night, pain quality and location, onset and history of previous episodes.

May include self-report questionnaires to quantify level of pain and/or disability due to lumbar symptoms; can be used to differentiate between physical findings and psychosocial contributors to pain presentation.

Red Flags

During the examination, the PT will review the patient's history to rule out evidence of serious medical pathology. PTs use a systems review process to confirm the condition is within the scope of practice of physical therapy:

Musculoskeletal

lumbar ROM2.JPG

 

 Show quiz question

 

Neuromuscular

Special Tests

Standing flexion.jpg

Sacral fixation test/Gillet's Test: Positive (+) if there is no PSIS movement as one hip flexes toward the trunk (iliosacral problem) (Approximately 1 minute)

Sitting flexion test: Positive (+) if PSIS moves cranially as trunk flexes forward (iliosacral hypomobility) (Approximately 30 seconds)

ForwardFlexionTest.gif

ThomasTest1.jpg

 

 Show quiz question

 

 

Classification Systems for Spinal Disorders

McKenzie Method

Most common classification system for low back pain used in physical therapy

Patients are classified as having mechanical pain (reproduced with movement) or non-mechanical (associated with inflammation or other pathology)

Results of PT examination leads toward categorization of mechanical low back pain. Patients with neuromuscular findings are generally not included in a McKenzie classification system

Specific elements of the PT examination include:

Movement testing

Lumbar motion tests are performed in straight planes and with combined motions

The PT monitors symptom location and intensity with sustained and repeated motions

centralization: pain presents proximally and in the spine

peripheralization: pain presents proximally and radiates laterally and distally with movement

Following the examination, patients are can be placed in one of three (3) syndromes:

  1. Postural
  2. Dysfunction
  3. Derangement

 

Delitto Treatment-Based

Determines if the patient can be managed by PT alone or requires MD or other health care provider involvement

Factors level of disability due to LBP into treatment classification

Key examination findings result in classification as needing immobilization, mobilization, specific exercises, traction

Movement-Based Impairment (Sahrmann)

Based on postural and kinesiological assessment which includes postural and spinal changes in static positions and with limb motion.

Patients are classified based on the direction of motion which reproduces the pain complaint.

Treatment emphasis is on restoring normal muscle length/balance and eliminating compensatory strategies.

 Show quiz question

End of Lesson

In lab we will apply some of these concepts to exercise selection and traction applications.

I recommend you work through the practice activities more than once to confirm your understanding of the material as it relates to the objectives