Professional Documents
Culture Documents
PTA 216
ORTHOPEDICS IN PTA
The Spine
• The functions of the spinal column
include:
– Supporting the majority of body weight
– Supporting the head, trunk, and UEs
against the forces of gravity
– Protection of the spinal cord
– Shock absorption
– Providing a stable structure by which we
can maintain an upright posture Magee, 2008. pg. 92
Spinal Design
• 33 vertical segments, divided into 5 regions:
– Cervical (7)
– Thoracic (12)
– Lumbar (5)
– Sacral (5 - fused)
– Coccygeal (4 - fused) Dutton, 2012. pg. 259
Spinal Design
• 2 functional pillars that assist spine
functionality
• Anterior Pillar: vertebral bodies and
intervertebral disks provide hydraulics,
weight bearing ability and shock-absorption
• Posterior Pillar: consists of articular
processes, facet joints, transverse processes,
and spinous processes. This allows spinal
movement and serves as the attachment for
posterior musculature. Dutton, 2012. pg. 260
Anatomy of vertebrae
THE INTER-VERTEBRAL DISC
• The inter-vertebral disc
• fibro-cartilagenous tissue
– in between vertebral bodies consisting
• an outer layer (annulus)
• an inner layer (nucleus pulposus)
• The inter-vertebral disc provides:
– Shock absorbtion
– Movement between vertebrae
– Separation between the vertebrae
– To allow passage of nerve roots through the intervertebral
foramina Magee, 2008. pg. 516-517
Spinal Mobility
• Flexion:
– Occurs in the sagittal plane
– Anterior portion of the vertebral bodies
approximate and the spinous processes
separate
• Extension:
– Occurs in the sagittal plane
– Anterior portion of the vertebral bodies
separate and the spinous processes
approximate Dutton, 2012. pg. 262
Spinal Mobility
• Lateral Flexion
– Occurs in the frontal plane
– The vertebral bodies approximate on the side
toward which the spine in bending, and
separate on the opposite side
• Rotation
– Occurs in the transverse pain
– The body of the vertebra will rotate towards the
side in which the person is moving as the
spinous process moves toward the opposite
side Dutton, 2012. pg. 263
Spinal Mobility
• Shear
– Occurs in sagittal, frontal, and transverse
planes
– When the body of the superior vertebra
translates over the body of the inferior vertebra
• Distraction/Compression
– Occurs in the transverse plane
– Result of longitudinal forces
– Vertebral bodies move either towards or away
from other vertebral bodies Dutton, 2012. pg. 263
CERVICAL SPINE
Anatomy, Pathology and Treatment Options
Cervical Spine
• Consists of 37 joints, allowing more motion
than any other region of the spine
• Vulnerable to direct and indirect trauma
• Accounts for 15-34% of all outpatient physical
therapy referrals. Dutton, 2012. pg. 267
Cervical Spine
Injuries to the cervical spine may manifest
themselves as localized
– “pain in the neck”
– or
– radicular
• symptoms that travel away from the site of
injury down one or both upper extremities
Radicular symptoms from the cervical spine may
affect the
– Face
– Head
– Neck
– Shoulder
– UE
– Peri-scapular region Magee, 2008. pg. 133 Dutton, 2012. pg. 268
Cervical Sprain/Strain
• Result from an overload to the cervical
muscle-tendon unit by way of excessive
forces
– Causes elongation and/or tearing of muscles or
ligaments, edema, hemorrhage, and
inflammation
– Patient complaints:
• Pain
• Stiffness
• Tightness in upper back and/or shoulder
• Occipital headaches Dutton, 2012. pg. 281
STRETCHING
ACTIVITIES
FOR THE CERVICAL
SPINE
Therapeutic Intervention
Stretching activities for Cervical Spine
Corner Stretch: Pectoralis Minor
Note: Avoid forward head posture during stretch Dutton, 2012. pg. 288
Upper Trapezius Stretch (Self)
Ensure that the shoulder is in a depressed position Dutton, 2012. pg. 289
Upper Trapezius Stretch (Manual)
Stabilize scapula into depression and downward rotation Dutton, 2012. pg.
289
Levator Scapula Stretch (Self)
Education tip: Have patient look at their opposite hip to ensure
appropriate stretch Dutton, 2012. pg. 289 and 292
Levator Scapula Stretch (Manual)
Can also be performed in sidelying
Massage
-Can be performed on any muscles in the cervical spine
-Goal is to place the patient in position where the muscles are
non – weight bearing Dutton, 2012. pg. 291
THORACIC SPINE
Anatomy, Pathology, and Treatment Options
Anatomy of Thoracic Spine
• 12 thoracic vertebrae
• Each vertebrae is involved in at least 6
articulations
• Decreased mobility in order to protect the
thoracic viscera Dutton, 2012. pg. 298
Anatomy of Thoracic Spine
• The rib cage in conjunction with the thoracic
spine provide stability
– Influences motion in other areas of the spine
as well as the shoulder girdle
– Provides assistance with weight bearing
– Increases potential for postural impairments Dutton, 2012.
pg. 298
Thoracic Spine
• Prone to both postural and biomechanical
dysfunction
• Treatment goals:
– Decrease pain, inflammation, and muscle
spasm
• Cryotherapy
• Electrical Stimulation
• Gentle exercises
• Possible bracing
• Heating agents after 48-72 hours
– Promote healing of tissue
• Join mobilization as performed by PT
• Massage
• Ultrasound
– Increase pain free range of vertebral and costal
motion
• Diaphragmatic breathing with stretching Dutton, 2012. pg. 300
Postural Dysfunction
• Create an imbalance between agonists and
antagonists.
– Results in adaptive shortening and muscle
weakness
– Not typically reproducible with physical
examination
– Pain is typically aggravated by stress, fatigue,
and possibly change in weather. Dutton, 2012. pg. 304
The Spine
Kyphosis:
• an increase in the thoracic convexity
• resulting in a rounded back with protracted
scapulae
– Also know as the “hump-back deformity”
STRETCHING
ACTIVITIES
FOR THE THORACIC
SPINE
Therapeutic Interventions
Supine Shoulder Sweep
-Important for the patient to maintain contact with their arm on
the plynth.
-Manual assistance may be used on the scapula or rib cage
- Perform with diaphragmatic breathing Dutton, 2012. pg. 301
Thoracic Spine Flexion
-Cat/Camel Stretch Dutton, 2012. pg. 301
Thoracic Spine Extension over foam roll
-Allows focus to be made over a specific vertebral segment Dutton, 2012.
pg. 302
Supine Thoracic Spine Rotation
Keeping shoulders, trunk, and feet on the plynth, drop legs
down to one side together as far as comfortable and then
repeat on the opposite side Dutton, 2012. pg. 302
Supine Thoracic Rotation using one leg
Progression as patient’s tolerance increases Dutton, 2012. pg. 302
LUMBAR SPINE
Anatomy, Pathology, and Treatment Options
Lumbar Spine
-almost entirely flexion and extension
-minimal rotation and lateral flexion
-Motions occur in sagital, coronal, and
transverse planes Dutton, 2012. pg. 315
Low Back Pain
Did you know that it is….
• the 2nd leading cause of physician visits in the
United States
• affects approximately 80% of the adult
population at some point in their lives
• one of the leading causes of Physical
Therapy referrals in the orthopedic setting
Some of the primary causes of low back pain
include:
• Muscle Strains
• Ligamentous Sprains
• Disk Injuries
• Spondylolisthesis
• Spinal Stenosis
• Spinal Fractures
The Inter-vertebral Disc
• Health of the intervertebral disc maintains the
health of the integrity of the mechanics of the
spine
• Low back pain may be due to
– Aging
• Reduces the moisture content in the disc
– Reduces overall height
– account for 20-25% of the total length of the
vertebral column
– natural degeneration of the disc
– trauma, inter-vertebral discs can be
responsible for causing low back pain in many
individuals. Magee, 2008. pg. 516
The Inter-vertebral Disc
1 Disc Herniation
A general term used to describe when
there is any change in the shape of the
annulus
2 Disc protrusion
The nucleus of the disc bulges
against an intact annulus
2 Extruded disc
The nucleus of the disc bulges
through the annulus however
remains within the posterior
longitudinal ligament
3 Sequestrated disc
The nucleus of the disc breaks
through all barriers and is free
within the spinal canal Magee, 2008. pg. 369 Dutton, 2012. pg. 338-339
Inter-vertebral Disc
Herniations
Treatment will depend upon
– Pain
– Flexibility
– Strength
– Dermatomal and myotomal involvement
– Pain with movement
– Patient understanding
• This may include:
– physical agents
– therapeutic exercise
– therapeutic activity
– strengthening
– flexibility training
– patient education
– body mechanics training
– manual intervention Shankman, 2011. pg. 371
The Spine
Lordosis:
• an abnormal anterior
convexity of the
lumbar spine
• Persons with lumbar
lordosis will present
as if they are sticking
out their stomach and
their buttocks.
**Both Kyphosis and
Lordosis can be
congenital,
neuromuscular, or
postural**
The Spine
What effects can these have on a person
clinically?
– Pain
– Poor posture
– Change in functional mobility
– Decrease in muscle strength
– Respiratory difficulties
– Neurological symptoms
– Psychological concerns
Muscle Strains and Ligamentous
Sprains can be caused by:
• Sudden movements
• Rapid Stretching
• Overuse injuries
• Treatment goals include:
– Decreasing pain and edema
– Increasing flexibility and strength
– Improving aerobic fitness to achieve prior level of
function
CORE STABILITY
EXERCISES
Lumbar Spine
Posterior Pelvic Tilt Dutton, 2012. pg. 328
Bent leg fall out Dutton, 2012. pg. 329
Bridging Dutton, 2012. pg. 332
Quadruped Activities Dutton, 2012. pg. 331
Bibliography
• Dutton, Orthopaedics for the Physical
Therapist Assistant. Jones&Bartlett. 2012
• Shankman, Fundamental Orthopedic
Management for the Physical Therapist
Assistant, 3rd edition. Mosby.2011
• Konin, Wiksten, Isear, Brader, Special Tests
for Orthopedic Examination, 3rd edition. Slack.
2006
• Cook, Hegedus, Orthopedic Physical
Examination Tests, 2nd edition. Pearson. 2013
• Magee, Orthopedic Physical Assessment, 5th
edition. Saunders. 2008