Spinal syndromes of body movement, Lecture notes of Physiotherapy

Download Spinal syndromes of body movement and more Lecture notes Physiotherapy in PDF only on Docsity! SPINAL SYNDROM ES Dr. Asif Islam PT,SMC,UOS. spinal syndromes  Also important to the orthopedic manual therapist are the subtle autonomic and visceral changes associated with spinal dysfunction and treatment in general, and the visceral disorders that mimic and are mimicked by spinal dysfunction.  Although there are few clinical studies of these phenomena, such symptoms are commonly reported by patients and are important to monitor during OMT evaluation and treatment. Lower cervical spine dysfunctions (C4 to T3) present primarily with  local pain  symptoms radiating into the upper thoracic area,  shoulder girdle  arm  However, clinicians often report that mobilization in this region influences symptoms that seem to originate in the upper cervical spine.  It is possible that decreased mobility in one part of the spine (e.g., lower cervical or thoracic) disturbs function and provokes symptoms in another region (e.g., upper cervical).  Manual therapists sometimes augment mobilization treatment for upper cervical symptoms with mobilization to the lower cervical and upper thoracic regions, at least on a trial basis . Thoracic syndromes  The anatomy of the thoracic spine is not substantially different from that of other spinal regions except that the spatial relationships in the spinal canal and the intervertebral foramen are larger than in other regions. This is probably why thoracic nerve root irritation is rare. On the other hand,  the numerous small joints in this region, including the costovertebral and costotransverse joints, make the thoracic region more susceptible to painful joint restrictions, including the facet syndrome.  The OMT evaluation revealing a painful segmental restriction can be critical to the differential diagnosis in these cases.  A successful trial treatment of specific mobilization techniques can confirm the therapist's tentative diagnosis.  The characteristic radiating pain associated with thoracic segmental dysfunctions, if dominant, can also mimic internal organ diseases, making differential diagnosis in the thoracic region difficult.  Many internal organs share a common innervation with the thoracic spine, so symptoms can be similar with  heart,  gallbladder,  nephrolithiasis,  appendicitis,  thoracic spinal disorders  The terms pseudoangina pectoris, pseudodyskinesia, and pseudoappendicitis are used to describe these diagnostic problems. Hospital admission diagnoses with cases of thoracic segmental pain syndrome Number Effective Treatment Positive Diagnosis of cases Anesthesia Mobilization thoracic x-ray Angina Pectoris 8 2 5 1 Coronary Artery Thrombosis 5 1 3 Heart Disease 10 2 4 4 Hyperventilation 5 5 Pneumothorax 1 Dyspnea 9 2 7 2 Gall Bladder 8 3 4 5 Kidney Disease 1 1 1 Chest Pain 28 1 24 5 TOTALS 75 12 52 16 Causes of back Pain Mechanical:  Apophyseal ’osteoarthritis  Diffuse idiopathic skel etal hyperostosis  Degenerative discs  Spinal disc herniation ("slipped disc")  lumbar spinal stenosis  Spondylolisthesis and other congenital abnormalities  Fractures  Sacroiliac joint dysfu nction  Leg length difference  Restricted hip motion  Misaligned pelvis - pelvic obliquity, anteversion or retroversion  Abnormal foot pronation Inflammatory:  Seronegative spondyloarthropathie s (e.g. ankylosing spondylitis)  Rheumatoid arthritis  Infection - epidural abscess or osteomyelitis  Sacroiliitis Neoplastic:  Bone tumors (primary or metastatic)  Intradural spinal tumors Metabolic:  Osteoporotic fractures  Osteomalacia  Chondrocalcinosis  Paget's disease  Pelvic/abdominal disease  Kidney  Bladder  appendix  Prostate Cancer  Cauda equina syndrome  Posture  Myofacial pain syndrome  FM  Injury or overuse of muscles, ligaments, and joints.  Pressure on nerve roots in the spinal canal.  With nerve root involvement, patients describe varying forms of lower extremity pain and paraesthesia.  These symptoms must be differentiated from pseudoradicular pain of visceral origin.  Visceral pain that mimics a nerve root problem and refers pain into the lower extremities is unlikely to benefit from mobilization treatment. Neurologic evaluation of nerve root syndromes  The differential diagnosis of nerve root syndromes requires a working knowledge of the innervation patterns of the spinal nerve roots (including dermatomes, myotomes, and sclerotomes) and the peripheral nerves.  Normal anatomical variations and overlapping patterns of segmental innervation require testing not only the key muscles and dermatomes in the suspected spinal region, but also the key muscles and dermatomes in the spinal segments above and below the suspected lesion. Sensory innervation of the skin  When testing for sensory paraesthesias, the manual therapist  differentiates patterns of peripheral nerve innervation from segmental cutaneous innervation (dermatome).  When a patient reports diffuse sensory disturbance there can be a significant amount of dermatomal overlap.  Dermatomes Table 2: Cervicothoracic nerve root syndromes Root Key Muscle(s) Reflex Dermatome C1 Intrinsic upper cervical flexors and extensors between O-C1 C2 Intrinsic upper cervical Posterior head rotators between C1-C2 C3 Scaleni "Shaw!" C4 Diaphragm “Epaulets” C5 Biceps brachii Biceps tendon reflex Shoulder and lateral Infraspinatus and supraspinatus side of upper arm C6 Brachioradialis Brachioradialis reflex Forearm (radial side) Wrist extensors Radialperiosteal reflex Thumb and index finger C7 Triceps brachii Triceps tendon reflex Forearm (dorsal side) Wrist flexors Middle and index finger Finger extensors Abductor pollicis brevis Opponens pollicis ca Flexor digitorum Thumb reflex Forearm (ulnar side) Adductor pollicis Small and ring fingers Abductor digiti minimi T1 Interossei Arm (medial side) Table 3: Lumbosacral nerve root syndromes Triceps surae (primarily gastrocnemius, medial) Root Key Muscle(s) | Reflex Dermatome L1-2| Cremaster Cremasteric reflex Waist “backbelt" L2-3| Hip adductors Adductor reflex Ventral thigh down to the knee L4 | Tibialis anterior Patellar tendon reflex Medial side of lower leg Quadriceps (vastus medialis) down to the malleolus L5 | Extensor hallucis longus Tibialis posterior reflex | Dorsal foot Extensor digitorum Semitendinous reflex Big toe longus and brevis Tibialis posterior Si | Peroneals Achilles tendon reflex Lateral foot and sole Small toe L4 L5 31 transverse cutaneous nerve of meck supraclavicular nerves anterior cutaneous branch of second intercostal nerve upper lateral cutaneous nerve of arm medial cutaneous nerve of arm lower lateral cutaneous nerve of arm Medial cutaneous nerve of forearm lateral cutaneous nerve of forearm lateral cutaneous branch of subcostal nerve femoral branch of genitofemoral nerve median nerve ulnar nerve ilioinguinal nerve lateral cutaneous nerve of thigh obturator nerve medial cutaneous nerve of thigh intermediate cutaneous nerve of thigh infrapatellar branch of saphenous nerve lateral sural cutaneous nerve saphenous nerve superficial peroneal narve deep peroneal nerve CD Figure 1-2 Dermatomes and dis- tribution of cutaneous nerves on the anterior aspect of the body. MCKENZIE'S THREE SYNDROMES POSTURAL SYNDROME DYSFUNCTION SYNDROME DERANGEMENT SYNDROME Postural Syndrome According to McKenzie, patients with postural syndrome are usually  less than 30 years old  by definition, are devoid of restrictive barriers  These patients develop symptoms that appear locally and usually adjacent to the spine.  The pain is provoked by mechanical deformation of normal, healthy tissue when spinal segments are subjected to static loading over prolonged periods of time.  The resulting pain disappears when the structure under load is released from tension. The pain from postural syndrome is not induced by movement and is never referred to a distant site. Because there is no associated inflammation, it is never constant.  Examination of these patients fails to reveal impairment because there is no underlying tissue pathology.  The only consistent finding is pain provocation with static loading at end-range.  Simply , postural pain develops gradually when normal tissues are overstretched. Dysfunction Syndrome An uncorrected postural problem will cause  pathologic changes over time For example, a 35-year-old computer operator who spends 8 hours per day in a forward head position wilI eventually develop adaptive shortening of the occipital extensor muscles. Likewise, the 40-year-old truck driver who spends 10 hours per day in a slumped sitting posture will eventually discover an inability to assume a normal lumbar lordosis in standing because of adaptive shortening of the trunk flexors. These adaptive changes in connective tissue  ie, loss of hyaluronic acid/water, adhesions  represent pathophysiologic events that cause such macroscopic tissue impairment as  Restricted joint mobility,  muscle weakness,  faulty alignment that is often associated with imbalance in the musculoskeletal system. If the patient does not correct his or her impairment with the proper interventions,  he or she can go on to develop functional limitations and disability,  which can adversely affect performance at work, home.  A distinguishing feature of the patient with dysfunction syndrome includes painful symptoms that tend to arise at the end of range rather than during movement. McKenzie’s Three Syndromes | Y — 1, Normal, healthy tissues. 1. Shortened soft tissues have 1. Misalignment of intervertebral 2. Pain is induced by static reduced elasticity. disc material (annulus or nu- loading at end-range and 2. Pain occurs at end-range cleus) causing blockage. not by movement, when shortened structures 2, Symptoms are made worse or 3. Pain is never referred and are placed under tension. better by specific movements, never constant. 3. Pain is never felt during can be referred distally, and movement and is never tend to be constant and often referred, severe. 3. The patient may present with acute spinal deformity of sud- den onset (eg, kyphosis, torti- collis, or lateral shift), which is often improved dramatically with manual therapy/therapeu- tic exercise. FF Derangement Syndrome Postural Syndrome | Dysfunction Syndrome Figure 327. kick enzie’« mechanical diagnnecic of eninal nain and related ewmatnme. Derangement Syndrome Characteristics of this syndrome can include  neurologic signs and symptoms,  pain during movement,  acute deformity eg, torticollis, lumbar kyphosis, lateral shift phenomenon,  pain that is severe and disabling. Patients with derangement syndrome often have a history of  poor posture and progressive stiffness  It is believed that the lack of motion-based nutrition in conjunction with off-center loading on the intervertebral disc causes the displacement of disc material. The young are more likely to have a nuclear displacement, while those over the age of 50 tend to develop annular lesions. With the onset of degenerative disc disease,  patients may develop clinical instability, which requires stabilization training of the hypermobile segment in conjunction with  manual therapy of the stiff, hypomobile segments above and/or below. Patterns of dysfunction When a chain reaction evolves in which some  muscles shorten and others weaken, predictable patterns involving imbalances develop,  Janda has described the upper and lower 'crossed' syndromes . Upper cross syndrome i WA eae Tight deep neck upper trapezies flesors anc levator scapidea Tight WiWhealk pectoras howe: trapezies and Serrats ante nor Figure 2.14 The upper crossed syndrome, as described by, Janda. Table 2.2 Upper crossed syndrome ' Pectoralis major and minor All tighten and shorten Upper trapezius Levator scapulae Sternomast oid while Lower and middle trapezius All weaken Serratus anterior and rhomboids BeWWWht WE VW Wt WU syndrome = Tight erector spinae Weak abdominals Weak Tight gluteus finopsoas maximus Figure 2.15 The lower crossed syndrome, as described by Janda. Table 2.3 Lower crossed syndrome Hip flexors All tighten and shorten INliopsoas, rectus femoris TFL short adductors Erector spinae group of the trunk while Abdominal and gluteal muscles All weaken The result of the chain reaction is that  the pelvis tips forward on the frontal plane,  Flexion of the hip joints  lumbar lordosis  stress at LS-Sl with pain and irritation. A further stress commonly appears in the sagittal plane in which  quadratus lumborum tightens  gluteus maximus and medius weaken.