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SPINAL ANATOMY,
PATHOLOGY,
MOBILISATION AND
MANIPULATION
Theory Revision

SPORTS REHABILITATION
OLIVIA RATCLIFFE - 1400142

Spinal Anatomy and Stability

Integration of these models into this module:
• An accomplished Sport Rehabilitator must consider all of these aspects when assessing and treating
the spine
...


Anatomy of the Spine
Vertebral column
• Occipital Protuberance Cranium to the apex of the Coccyx
• Forms the skeleton of the neck and back
• Main part of the axial skeleton
• Protects the spinal cord and spinal nerves
• Supports the weight of the body?
• A series of bones; Vertebrae
• Provides a partly stable and flexible axis for the body
• Movement between vertebra is slight, but the spine is a very mobile structure
• Pivot for the head
• 5 regions;
Vertebrae
• Vary between regions but adhere to basic plan; Thoracic most typical
• The Body; weight bearing portion
• The Neural arch; surrounds and protects the spinal nerves
• Processes; for the attachment of ligaments and muscles
• Spinous Process; projects posteriorly and downward
• Transverse process; projects laterally
• Lamina; portion of neural arch between spinous and transverse process
• Pedicle - lies between the body and the transverse process have
notches on upper and lower borders
• Two adjacent notches form intervertebral foramen which contains
spinal nerve of that side
• Articular facets located on upper and lower aspects of the neural arch that articulate with adjacent
vertebra; Facet joint/zygapophyseal joint
• Cartilaginous end plate – with age bone strength decreases rapidly may result in endplate fractures
Facet / Zygopophaseal Joint
• Plane synovial joint
• Hyaline articular cartilage
• Synovial membrane
• Capsular ligament
N
...
Direction / orientation of facet joint determines the movement possible
in that region
Intravertebral Joints
• Between vertebral bodies
• Secondary cartilaginous joint
• Upper and lower surface covered by hyaline cartilage
• Between one vertebral body and next intervertebral disc composed of fibrocartilage
Intervertebral Disc
• Peripheral Zone – ‘annulus fibrosis’ has high proportion of fibres in a ring
• Nucleus Pulposus
• Central material – Nucleus Pulposus
• Softer and more elastic material
• Situated more to back than front of disc
• Thickness varies according to region Cx; thick Thx; thin Lx; very thick
• Fibres run obliquely therefore can withstand torsional force in any direction
• Attached to plates of Hyaline cartilage and to Anterior and Posterior longitudinal ligaments

• Nutrition of the disc is dependent on normal movement and has a high water content
Ligaments of the Spine
Intertransverse ligaments;
• Join the transverse process
• Often blend with intertransverse muscles
• Prevents excessive side flexion
Capsular ligaments;
• join the articular processes of the facet/apophyseal joints
• Provides stability for the synovial plane joints
Interspinous ligament and Supraspinous ligament;
• Join the spinous processes
• Interspinous ligament main part
• Supraspinous ligament is the thickened part that joins the tips
• In cervical spine the concavity of tips filled by midline vertical sheet of fibrous and elastic
tissue - ‘Ligamentum Nuchae‘
Ligamentum Flavum ‘The yellow ligament’;
• High elastin content
• Preserves upright posture/return to neutral from flexion
• Elasticity prevent buckling into the spinal canal
Anterior and Posterior longitudinal Ligaments;
• Join adjacent bodies
• From base of skull to sacrum
• Posterior ligament found in vertebral canal
• Attached to I
...
Discs and bodies

Posture and Spinal Stability
Posture types and pathology
• Most people will have a posture which deviates from the ‘ideal alignment’ to some degree
• This can lead to areas of hypermobility and hypomobility in the different regions of the spine
• E
...
With a hyper-kyphotic Thoracic spine, the Cervico-Thoracic spine may become - stiff/
hypomobile
...
This
may result in hypermobility of the cervical spine and potentially inflammation and eventually
degeneration of the cervical spine joints
...
The central theme demands a positive personal
commitment (empathy) to understanding what the person (patient) is enduring
...

• Communication – verbal, non-verbal
• Listening –not merely hearing
• Development of trust between patient and clinician
Purpose of examination
1
...

2
...

Possible sources of pain
1
...
Pain-sensitive structures in the vertebral Canal, the intervertebral foramina and the neural disorders

Subjective assessment
Severity, Irritability and Nature (SIN) factors
• Onset (traumatic/spontaneous)
• Socioeconomic factors
• Extent of damage
• Familial patterns
• Length of history
• Stability of disorder
• Stage of disorder
• Irritability of disorder
• Rate of impairment
• Age of patient
• Response to previous treatment
• Patients healing capacity; response to previous injuries
• Character and psychological demands of patient
Selecting the correct treatment
• Must be based on the findings of the Examination and
the aims of the treatment
• Ensure Appropriate to treat; consider Red Flags
• Decide what you aim to achieve through a technique
• Pain relief / improving healing; GI & GII
• Increase mobility GIII-GV
Options for progression of technique
• Repeat the technique
• Alter a component of the technique
• Add in new techniques
• Change the technique (same source)
• Choose a technique for a different source or cause of
the source
• Manipulate rather than mobilize
• Have a planned break from treatment followed by a retrospective assessment
• Stop Treatment

Cervical
Spine

Anatomy
General anatomy
•  Begins at base of the skull; occipital protuberance
•  Seven vertebrae – C1-C7
•  Stability sacrificed for mobility
•  Allows for changes in direction of vision, movement of upper limb and locomotion
•  Divided into upper segment C1 and C2 and lower segment C3-C7
•  Each Motion segment consists of inter-body joint and two adjacent zygapophyseal joints
Cervical Vertebrae
•  Contain and protect spinal cord
•  Small in size
•  Bodies are small, oval and have curved surfaces
•  Spinous process are long, have split tip and point inferiorly
•  Transverse processes have transverse foramen
•  Unciform process on superior surface of body and facet on
inferior border
Upper Segment C1 & C2
•  Of the total movement of the cervical spine this segment contributes
• 1/3 of flexion and extension and over ½ of axial rotation
•  Atlas articulates with the head at the atlanto-occipital joint
•  Atlas and axis articulate at the atlantoaxial joint – most rotation occurs
Atlas and Axis
•  Atlas – Has no spinous process or body
•  Axis -During development body of axis and atlas fuse to form Dens or odontoid
process
•  Transverse ligament – binds dens to inner surface of atlas

Lower Cervical segments C3-C7
•  C7 – vertebra prominens – due to
long slender spinous process
•  Ligaments assist stability and
allow for mobility
•  Anterior longitudinal Ligament
•  Ligementum Nuchae – posteriorly
along spinous processes
•  Ligamentum flavum – joins
adjacent lamellae
•  Posterior longitudinal ligament –
broadest in cervical spine supports
disc
...
45° to the
vertical
•  Side flexion and rotation occur as a coupled movement
•  Adds to translator glide during flexion/extension

Intervertebral discs
•  Make up approximately 25% of the height in the cervical spine
•  Shape of the discs give the spine its lordotic shape
•  Nucleus pulposes absorbs axial compression
•  Annulus fibrosis withstands tension
•  Has some innervation on periphery
•  Nuclear protrusion less likely in cervical spine

Cervical Spinal Nerves
•  Although there are 7 Cervical vertebra there are 8 Cervical nerves
•  C1 nerve root exits between occiput and C1 vertebra
•  Each nerve root is named by the vertebra below it
•  In the rest of the spine it is the vertebra above
•  Nerve root
between C7 and T1
is C8
Cervical Arteries
•  The vertebral artery extends from the subclavian artery
•  Travels up through the foramen transversarium of C5/6-C2
•  Turns at a right angle to pass by the lateral mass of the atlas
•  Then turns vertically to join other vertebral artery to supply into the
basilary artery
•  Vertebrobasilar S&S must be recognised!!
Anterior Muscles of the Cervical Spine
• Rectus Capitis Anterior & Lateralis
• Longus Colli and Capitis
• Scalenes Anterior, Medius and Posterior
• Sternocleidomastoid
Posterior Muscles involved in scapular movement
• Trapezius
• Levator Scapula

Posterior Muscles of the Cervical Spine
• Extensors – 3 layers
•  Rotatores cervicus – between one and next
vertebra
•  Multifidus – to 2-3
vertebrae above
•  Semispinais – 3-4 vertebrae above
• Longissimus Cervicis
• Longissimus Capitus
• Splenius Cervicis
• Splenius Capitus

Conditions effecting the Cervical Spine
Capsular pattern of the Cervical Spine
•  Most loss of extension
•  Equal Loss of side flexion
• Equal loss of rotation
• Degenerative Arthritis
• Rheumatoid Arthritis
• Traumatic Arthritis

Stage;
•  Acute–within 4 weeks
•  Subacute – 4-12 weeks
•  Chronic - >12 weeks

Whiplash type injury
•  Follows sudden excessive extension/flexion/rotation of
the neck
•  Widespread pathology, varying degrees of trauma
...

•  May include cord compression, nerve root damage,
cervical subluxation or vertebral fracture
•  Most commonly rear-impact or side impact RTC
•  Psychosocial & cultural causative roles?
•  May occur in Sport with a blow or impact with the
ground
...

• Myelopathy – Acute or myleitis
...

• Thoracic Outlet syndrome: Middle aged females with night pain
...
Usually unilateral
...

Balance of Mobility and Stability
• Balance and stability is modulated by the demand of a task – load, treat value without compressing
respiratory function or intra-abdominal pressure
...
g
...

• Pain-free lack of Thx movement may result in Cx
or Lx pain due to compensation
• Dysfunctions of scapular stability may have a
causative effect on the Thoracic spine
Form Closure Anatomy
Cervical to Thoracic Vertebra
 12 thoracic vertebrae
 Distinctive heart-shaped body; greater mass than Cx
 Vertebral foramen relatively small
 Long slender spinous processes project in posterior & inferior direction →N
...
for locating
transverse process
...
T11 &
T12 may vary
Spinal Curvatures
 T7 is thought to be where the lower limb axial rotation alternates with the upper limb axial
rotation
...
  Intervertebral Joints
3
...
  Costochondral joint

2
...
Costotransverse joint

Intervertebral Joints
•  Intervertebral discs relatively thin
•  Along with presence of ribs results in
reduced movement at IV joints
•  Supported by ligaments;
• Anterior and posterior longitudinal ligament,
supraspinous, interspinous intertransverse
and ligamentum flavum with more support
costovertebral joints and ligaments

The zygapophyseal Joints – facets
•  Upper Thoracic facet (T1-T6) lie in the frontal
plane
•  Facilitates Rotation coupled with side flexion
•  Flexion and extension relatively limited in this area
•  Lower Thoracic facet (T9-T12) more in the sagittal
plane allowing increased flexion and extension
•  Lack of shearing in Thx spine
•  Dramatic change in orientation between T12&L1 –
T12 more susceptible to #

Costovertebral Joint
• Synovial Plane joints
• 12x2=24 joints - The location and structure
of the articulation varies
• First rib originates at the body of T1 and has
a whole facet and an inferior demifacet
• Ribs 2 - 8; originate between adjacent
Vertebrae⇒T2-T8 have superior and inferior
demifacets on each side
• T9 has only a superior demifacet
• T10, T11 and T12 have a single whole facet
on each side

Costotransverse joint
•  T1-T10 have Costal facets on their transverse
processes – articulation with tubercles of ribs
•  Articular capsule (fibrous) surrounds each joint
and is strongest anteriorly
•  11th and 12th rib do not have these
•  Fibrous capsule is supported by
3 ligaments
•  Superior Costotransverse
•  Costotransverse ligament
•  Lateral costotransverse ligament

Costochondral Joints
•  Between ribs and costal cartilage
•  Joint between costal cartilage and sternum or ‘costosternal’ joints
•  Ribs 8-10 join directly with the costocartilage of the rib above; -‘false ribs’
•  Ribs 11&12 don’t attach to either cartilage or sternum – ‘floating ribs’

Movement of the Ribs during breathing/During Inspiration
• Ribs are pulled up & forward
• Increases anterioposterior & transverse diameter of the ribs Different mechanisms
1
...
 Bucket Handle – Middle T7-T10

3
...
g
...
Intermittent thoracic pain that may be aggravated by sitting and
may have Thoracic Root pain
•  Signs of Spinal cord compression
•  bladder involvement,
•  lower limb paraesthesia and gait disturbence,
•  hyperreflexia
•  +ve Babinski sign
•  If Dura Mater involved flexion of Cx spine may be painful sneezing/coughing
Facet

joint Lesion

Costovertebral Joint lesion

Costotransverse joint lesion

• All 3 will usually occur together to some degree
• T5-T7 facet joint lesion common
• T8-T10 Costovertebral it more common
• Difficult to distinguish between these 3 – most techniques will effect all three
...
Referred
to C8/T1 derm
...


Injuries of the Thorax;
Dislocation of ribs:
Separation of Ribs
•  Slipping rib syndrome
•  Dislocation of costochondral junction
•  Displacement of costal cartilage from sternum
•  Separation
3rd – 10th ribs
•  Common contact sports
•  Tearing perichondrium & periosteum usually
•  Complications pressure damage to nearby nerves,
occurs
vessels & muscles
•  Rib may move superiorly
•  Usually occurs unilaterally ribs 8,9&10
•  Overriding the rib above causing pain
•  Lump like deformity at displacement site
Serious Non-mechanical conditions
• Visceral disease;
• Malignant Disease
•  Angina; pain increased with
• Spinal Infection
exertion
• Bone Conditions;
•  Pulmonary embolism, pleurisy,
•  Scheuermann’s disease T9; backache and local dorsal kyphosis
pneumothorax
•  Schomorl’s modes; anterior prolapse
•  Acute pancreatitis
•  Osteoporosis – estrogen
•  Testes; may refer pain to
•  Fracture
T10/T11
• Shingles

Lumbar
Spine

Lumbar Lordosis
•  C = Normal lumbar lordosis (L1-S1) ranges
from 30° to 80° avg
...
40°
lumbosacral angle
•  Lumbosacral disc is wedge shaped

Nutrition to the Intervertebral Discs
•  The Intervertebral discs are the largest
avascular tissue in the human body
•  The main pathways are through the
vasculature within the vertebral body (V),
through the end plate (E) to the nucleus (N) or
through the blood vessels in the peripheral
annulus
•  The extent to which nutrients defuse is
dependent on posture and motion
•  The water content of the discs reduces due to
pressure and results in a diurnal reduction in
height which is offset with lying down at night
...

•  With end-plate fractures the nuclear fluid
escapes from the disc through the cracks
•  This will result in loss of height of the
interdiscal space
...

Disc Pressures and posture
•  Nachemson (1976) investigated the relative
changes in pressure in the third lumbar

Lumbar Intervertebral Discs
•  The Annulus Fibrosis of the discs in the
lumbar spine is thickened posteriorly to
withstand force during flexion
•  Consists of type I and II Collagen fibres and
elastin fibres arranged in concentric Lamellae
around the central nucleus
•  Outer half has nerve supply
•  At rest the disc possess an intrinsic pressure
•  This is increased in sitting and reduced in
lying
•  Due to its viscoelastic material the
intervertebral discs are subject to creep,
hysteresis and se
The posterior element of the vertebra
The Posterior vertebra is flexible, the neural
arch will bend up and down during flexion and
extension
...
Further repetition
may cause the crack to propagate through the
full width of the Pars leading to a fracture –
Spondylolysis
...


Vertebral Body
•  The Superior and inferior surfaces of the
vertebral body are made of deformable cartilage
plates – ‘end plates’
•  Porous for the transport of nutrients; O2 and
glucose
•  Central region cancellous bone with
trabeculae in line with the stress trajectories
•  With age or osteoporosis the transverse or
horizontal trabeculae thin and eventually loose
their ability to support the vertical trabeculae
Zygapophyseal Joints
•  Synovial joint – articular surface covered with
hyaline cartilage
•  Capsule is lax and holds approx
...
  Connective tissue rim; thickened wedge-shaped; similar to meniscus in knee
2
...
  Fibro-adipose meniscoid; 5mm leaf-like fold on sup and inf surface
2&3 have protective function for exposed cartilage during flexion
...

Shape and Orientation of Zygapophyseal Joints
• Governs the role these joints play in limiting forward displacement and rotatory dislocation
• Superior facet faces posteriorly; this will control forward displacement
• Extent to which superior facet faces medially resists rotation
Mechanics of flat zygapophyseal joints
• Flat joint at 60° resists both forward displacement (A) and rotation (B)
• 90° resists forward displacement not rotation
• Parallel to sagittal plane resists rot
...
- Sagittal plane flex/ext restricts rotation and lateral bending
•  L5-S1 facets j; - Frontal plane rotation resists anterior-posterior translation
•  This is an important feature to help to stabilise L5 and prevent forward translation due to the angle
of the Sacrum
Ligaments of the Lumbar spine
• Anterior Longitudinal Ligament
• Posterior Longitudinal Ligament
• Ligementum flavum -Forms anterior capsule of facet
jt, 80% elastin fibers
...
Controversy over it’s existence – fascia Iliolumbar?
False Ligament and fascia
•  Intertransverse ligaments - Sheets of connective tissue
...
Present in 47% of
subjects
•  Mamillo-accessory ligament- Covers medial branch of dorsal ramus ossification of ligament may
entrap nerve
Thoracolumbar Fascia is arranged in three layers:
Anterior
Middle
Posterior
Essential Role in stability

Passive Stability Lumbar Spine
• Angle of sacrum; tilted forward
• L5 disc – wedge like structure
• Therefore tendency to slip forward
• Resisted by L4 & L5 zygopophysial jt; 45% to sagittal plane
• Above L4 upper surface of vertebral body are horizontal or orientated backwards
• Angle of orientation progressively less than 45°
...
  ANNULUS FIBROSIS
2
...
  ANTERIOR LONGITUDINAL LIGAMENT – Resists separation of anterior ends of vertebrae
Active Stability of Lumbar Spine
Local Stabilisers
• Intertransverse muscles
• Transversospinalis;
• Multifidus;
• Trans abdominals

Global Stabilisers
• Quadratus Lumborum
• Latissimus Dorsi
• Erector Spinae
• Rectus Abdominus

Low Back Pain
• >80% people will suffer back complaints during their lifetime
...
V
...

• Aggravated by activity and inactivity
• Prolonged sit/standing causes ache, stiffness a
...

common
• When extending from flexed patient brings pelvis
and hips forward under trunk

Facet joint lesion
•  Tends to be described as deep aching pain
•  May refer pain into relevant segment or sclerotome
•  May have hyper/hypomobility of joint
...
Results in
immediate, persistent pain and ‘spasm’ with marked
deformity of spine
...


Intervertebral Disc Lesion
•  Most common in Lumbar spine - 10% of all back
cases
•  Most commonly L4-L5 or L5-S1
•  As a result of degeneration (begins at 20-25 years
of age)
...

•  Central prolapse - compress lower sacral nerves =
Bladder/Bowel dysfunction
...
(Kuslich et al, 1991)

Intervertebral Disc Lesion Disc Protrusion
•  Degenerative disc material bulges into the
weakened laminate structure of the annulus
...
Neoplasm – Uncommon, may be cause of
back pain
...
Weight Loss, weakness and Fatigue
...

2
...
Tenderness on percussion of vertebra
and widespread muscle spasm
3
...

When rupture patient presents with epigastric
pain that radiates to back
...

– This is a
medical EMERGENCY
...
7% females 3% - inc with age – significance with treating older males for SIJ problems
Motion of the Pelvis
Can occur in all 3 planes
- Anterior and posterior pelvic tilt in sagittal plane
- Lateral tilt in the coronal/frontal plane
- Axial rotation in the transverse plane
Combination of all 3 occur during normal gain
Innominate moves into anterior and posterior rotation, the sacrum into nutation and counter-nutation
...

- This causes the inferior portion of the sacrum and the coccyx to move posteriorly
...

Counternutation (Sacral extension) – lying supine
- The base of the sacrum moves posteriorly and superiorly
- causing the tip of the coccyx to move anteriorly
...
– less stable

Nutation Vs Counternutation





Optimal posture – slight nutation
During first stages of flex/ext nutation occurs and stays there through ROM
On return to standing sacrum counternutates slightly
Standing in kypholordotic or sway back – fully nutated

Stability
Vertical force = 5x body weight – amplified when on single leg
Joint is vulnerable to shear forces
Stabilised by a complex modified friction mechanism
Integrated approach to the SIJ

Stability and Form Closure
Passive comonents of stability
Structures passively limit ROM
Serve to increase the friction
coefficient and effectiveness of
the compressive forces in limiting
shear
The ligamanetous complex
contributes to the stability in a
unique way; most ligaments
tighten and slacken at the same
time
Nutation causes tightening of the
ligaments and counternutation
causes it to relax
As sacrotuberuos lig tightens – illium
and sacrum are drawn together –
increasing friction between 2
bones – self locking – functional
tension dynamics

Ligaments of the SIJ
Short posterior/dorsal SI lig –
strongest, between lateral sacral
crest and iliac tuberosity, prevents
palpation of SI joint
Sacrotuberous lig – resists nutation
Dorsal/long dorsal posterior SI lig –
tensed when rest slack, resists
counter-nutation
Sacrospinal lig – attaches from
lower lateral aspect of sacrum
and coccyx to ischial spine of
innominate
...

Restores sacrum to resting position
as pelvis returns to neutral mid
stance

Force closure
Local stabilisers (pelvic floor, TVA, diaphragm and deep fibres of multifidus)
Function – stabilise the spone and pelvic girdle in preparation for additional
exercernal loads which is achieved through
- Inc intra-abdominal pressure
- Inc tension of the thoracodorsal fascia
- Inc articular stiffness
When CNS can predict the load, local system will anticipate the load

Muscles
Gluteus Maximus
Gluteus Minimus
Gluteus Medius
Piriformis
Tensor Fascia Lata

Global Muscle system
Contracting muscles produce forces that are transmitted tendons, ligs, muscles, capsules, bones and
other muscles
...
Areas of weakness or
tightness must be addressed
...
Glute med/min, TFL and lateral stabilisers of the thoracopelvic
region
Motor control
Patterning of muscle control – timing of muscle action and inaction
Coordinated action between local and global systems ensures stability without rigidity of posture and
without episodes of collapse
Emotions
Emotions can have a significant effect on the human function
...

Could lead to motor patterns indicative of defensive posture
...

Emotional state can lead to muscle tone which will increase compression of the SIJ
So its important to address emotional state and CBT may be required
Integrated biomechanics of the Lumbopelvic-hip region
Functiuonal movement – forward bending
•  Results in posterior displacement of the pelvic girdle
•  Shifts the centre of gravity behind the pedal base
•  The pelvis anteriorly tilts on the hip joints causing hip flexion
•  The lumbar spine flexes in a supero-inferior direction until L5 flexes on the sacrum
•  During the initial stages the sacrum completely nutates and should remain through full ROM
•  On return to standing in erect posture the sacrum counternutates
Functional Movement – bending backwards
•  Results in anterior displacement of the pelvic girdle and a shift of centre of gravity anterior to the
pedal base
•  Pelvic girdle posteriorly tilts on the hips – they extend
•  The Thoracolumbar spine extends in a superoinferior direction until L5 extends on the sacrum
•  The sacrum should remain in its nutated position
Functional movement – lateral bending
 Left lateral bending is initiated by displacing the upper legs to the right; maintaining the line of
gravity central within the pedal base
 The apex of the lateral bend should be at the greater trochanter
 The pelvic girdle laterally tilts causing left femur abducts and right femur adducts
 The right innominate posteriorly rotates relative to the left innominate and the sacrum rotates
to the right
...

•  Returning to erect posture involves backward rotation of the pelvis – produced by concentric
contraction of Glut Max
•  Sacrum should remain nutated
...


Nervous
system
and Pain

ANS
Responsible for monitoring conditions in the internal environment and bringing about
appropriate changes in them
...
Sympathetic – fight or flight
2
...
Cervical enlargement C4-T1- Most of the ventral rami arising form the brachial plexus are
nerves which innervate the upper limbs
2
...
Those associated with impulse conduction
...
Those associated with support and protection
...

• They travel to the dorsal horn of the spinal cord via the dorsal root ganglion
...

• Pain can be controlled by pain-inhibiting and painfacilitating neurons
...

3 mechanisms involved in pain perception
1
...
Processing - Information from the tissues and PNS received via the dorsal horn, mediated
by the descending inhibition from the brain
...
Pain is heavily effected by thoughts, feelings and emotions
3
...
Designed to deal with
acute response to pain
...

Pain is modulated at 3 level
1
...
The spinal cord; dorsal horn of the cord
3
...
N
...
in chronic
pain
Neuropathic Pain
• Injury to nerve fibers can lead to abnormal functioning of the nervous system
• Complete destruction/ transection – complete loss of muscle power and sensation
• Partial damage; due to crush injury/surgery or medical conditions (diabetes/shingles) can
lead to altered sensation – altered temperature sensation/unusual or unpleasant feelings or
pain
Neuropathic pain – radicular pain
• Pain evoked by ectopic discharges emanating from the dorsal root or its ganglion
• Disc herniation is the most common cause
• Pain is ‘lancinating’ /shocking / electric type and travels the length of the limb
• Is relatively uncommon when properly defined ; prevalence is only 12% or less (Deyo, 1987)
• Neurological state in which conduction is blocked along spinal nerve or its root
• If sensory fibers then – Numbness
• If motor fibers then – weakness
• Diminished reflexes occur as a result of sensory/motor
• Radiculopathy and radicular pain commonly occur together, radiculopathy may occur
without pain & radicular pain can occur without radiculopathy
Somatic referred pain
• Does not involve stimulation of the nerve roots
• Produced by stimulation of nerve endings within the spinal structure, eg discs,
zygapophyseal / SI joints
• Convergence of nociceptive afferents on second-order neurons in the spinal cord that
happen to also supply regions in the lower limb- share the same segmental innervation at the
source
• Dull, aching and gnawing /described as an expanding pressure

Red
Flags

Red Flags and Serious pathology
“Signs and symptoms of serious pathologies of the spine that need urgent attention
...
Cauda Equina
2
...
Myelopathy – disease/compression
4
...

C4/5)
• Serratus ant (long thoracic n
...
chiefly from C4 but also C3&C5 (motor,
sensory, sympathetic fibres)
• Main motor nerve of the diaphragm – significance?
Brachial Plexus
• Most nerves in upper limb arise here
• Arises in the neck and extends in to the axilla after
crossing 1st rib
• Formed by the union of ventral rami C5-8 & T1
• The roots unite to form 3 trunks
• Superior trunk union C5-6
• Middle union, continuation of C7 root
• Inferior union, C8-T1
• Each trunk divides in to anterior and posterior
divisions
• Contributions C4&T2
• Each peripheral nerve is a collection of nerve fibres
bound together by connective tissue
• Results from fibres dividing in the 3 branches
• 2 form median nerve C5-8
• 1 forms ulnar nerve C8-T1
• Radial nerve C7

Lumbar Plexus - Obturator
• Lower branches L2-4
• Divides ant/posterior branches (Obturator
ant/posterior)
• Anterior – adductor longus, brevis, gracilis and
pectineus
• Posterior – obturator externus, adductor
magnus
• Sensory to the hip joint

Plexus
• The anterior division of the spinal nerve are
called ventral rami, the posterior called dorsal
rami
• Collectively called the nerve roots
• Root – trunk- division-cords-terminal
branches
• More or less plaited together to form nerve
plexuses

Lumbar Plexus
• Formed by the ventral rami first 3 Lumbar
nerves with part of 4th
• L1-4 some fibres T12
• Form dorsal and ventral divisions
• Two major branches
• Obturator nerve
• Femoral nerve
• Minor cutaneous & motor branches to
• Iliohypogastric n
...

• In/external oblique muscles, sensory skin
femoral triangle, part genitalia
• Genitofemoral n
...
ventral rami L4-S3 (largest / broadest in the body)
nerve
• ½ down posterior thigh divides
• Resist the rise in strain when coughing
• Common Peroneal n
...
L4-S3
• Sacroccygeal joint
• Branches innervate Gluteal muscles, inner surface of pelvis
• Cutaneuos supply coccyx to anus
basin & muscles run between femur and pelvis
• Obturator, Piriformis, Quadratus Femoris
• Cutaneuos branches supply buttock, perineum and posterior thigh
Adverse Neurodynamic Tension (ANT)
1
...
Adaptation to Movement
Two ways the NS adapts to lengthening
1
...
Movement Gross movement; a peripheral nerve moves through a tunnel (median nerve in carpal
tunnel)
...
The Spinal Canal, Neuraxis & Meninges
• Considerable space in the canal to allow movement of the neuraxis and meninges • Spinal canal
undergoes substantial length changes during movement
• From extension to flexion elongates by 5-9cm
• Neuraxis and meninges must adapt to this change in length
Adaptive Mechanisms
• During flexion, extensions and side flexions neuraxis moves within spinal canal ant-post
• Tension in neuraxis increases with flexion
• Certain points where no movement of nervous system compared to interface; C6, T6 & L4 = tension
points

4
...
Movement
• McLellan & Swash (1976)
• 15 volunteers, needles placed in median nerve midway in upper arm
• Wrist and finger extension pulled nerve down avg 7
...
Pressure
• Pechan & Julis (1975)
• Measured intraneural pressure ulnar nerve at the elbow
• Sig changes with wrist and shoulder movement
• Position similar to ULTT3 – intraneural pressure quadrupled
5
...

• Provides motor function to most extensor muscles
• Includes; facet joint, IVD, muscle, fascia & blood vessels
• Pathological interfaces; Osteophyte, ligamentous swelling, fascial scarring
• A tight plaster / bandage
• Odeama / blood around the nervous system
Nerve Compression Syndromes
• Carpal Tunnel Syndrome – median nerve
• Double crush syndrome
• Ulnar nerve
• Common peroneal entrapment
• Interdigital neuritis – Morton’s neuroma
6
...
Soft tissue, osseous or fibro osseous tunnels Median nerve in carpal tunnel
2
...
unite to form common plantar digital n
...
Morton’s neuroma
3
...
at head of fibula
4
...
Tension points

7
...

Intraneural & Extraneural Pathology
May be one, other or both
• Intraneural; injury to structures of the NS (demyelination, scarred epineurium)
• Effects development of tension
• Etraneural; involves the nerve bed or mechanical interface; blood in nerve space, epinerium tethered
to interface
• Effects movement in relation to interface
Pathological Process
• Vascular factors
• Nerves require blood to function
• Neuro-ischemia can lead to paraesthesia and or pain
• Mechanical factors
• May effect connective and / or neural tissue
• Symptoms of greater intensity from stretch rather than compression
Consequences of Nerve Injury
• Fibrosis at site of original injury may protect or cause further tissue insult
• Damaged peripheral nerve in mice increases strength and stiffness and reduced elasticity
• Double crush syndrome
• Cervical arthritis and bilateral carpal tunnel syndrome

Adverse
Neural
Tension

1
...
Neurodynamic Tension Tests
• Neurodynamics; the biomechanics of the nervous system (Shacklock, 1995)
...
SLR Mechanically? Sciatic nerve move in
relation to surrounding tissues Physiologically?
Blood flow, ion channel activity, inflammation, changes in CNS, the leg and its movement
Structural Differentiation of the NS
• Other continuous systems
• Fascial planes and blood vessels
• Subjective and objective examinations may indicate
• Neural involvement indicated when sensitising movement is remote from area of symptoms
• Careful and meticulous handling is imperative for differentiation!
• Symptoms do not have to worsen
Ax of Dysfunction of NS
• Neruodynamic tests
• Examination of conduction
• Derm/myotomes, reflexes
• Palpation of peripheral nerve
• Sites of abnormal impulse generation will be mechanosensitive
• Electro-diagnostic testing / scanning – req referral via GP, neurologist
Neurodynamic Testing
• Tests the mechanosensitivity & pathomechanics of the NS #
• SLR; tibial, peroneal, sciatic tracts, lumbar roots, meninges, cord
• Passive neck flexion; cord, meninges
• Slump;
• Upper Limb Neurodynamic Test
• Femoral Nerve Test
• NB: addition of sensitising mvmts helps identify nerves
...
Precautions & Contraindications
1
...
Irritability; SIN factors How much activity before symptoms appear Severity and distribution
How long to dissipate
3
...
GH problems; Diabetes, leprosy, AIDS, MS – weakened NS 5
...
Circulatory disturbance
Precautions & Contraindications
1
...
Cauda equine lesions…
...
Injury to the spinal cord Tethered cord syndrome Symptoms; enuresis & cord symptoms?
4
...
Red Flags!!
4
...
Symptom response; range at which symptoms start (P1), what symptoms and symptoms at
EOR (P2)
2
...
Also
behaviour of resistance
3
...

When is it positive?
• It reproduces PTs symptoms
• Tests response can be altered by movement of distant body part
• Differences between L & R in
• ROM
• Resistance
• Symptom resonse
5
...

• May be done in position of tension
• Neuro-mobilisations may be used short of the PTs symptoms; Sliders and Tensioners
• Self mobilisations
• Posture correction
Neural Mobilisations as an Rx
• Sliders – 1 and 2 ended
• 1 end moves up and down
• Both ends move up and down (less irritable)
• Tensioners
• One end is fixed to increase tension
• Extent of pain allowed is dependant on their SIN factors

Rx Effects
• Sliders
• Venous return, odema dispersal, ↓ pressure inside perineurium, ↑ circulation, ↑ axonal
transport, ↑ O2, ↑ confidence, facilitates normal motor performance with pain free ROM
(Coppieters & alshami, 2007)
Precautions
• Care when pain production referring in to distal segment
• All spasm is respected and never forced movement
• Tethering of NS – repeated movements = ↑ symptoms
• Upper motor neuron signs
Progression of Rx and Grades
• Start out of tension, gradual ↑
• Technique well removed from symptom area
• Non symptom provoking initially
• Best to under treat initially, until irritability related to Rx is established
• Grades
• Large amplitude grade II’s slowly and rhythmically through range
• IV just up to resistance
• Largest amplitude of movement to be done
• Symptoms – respected and monitored at all times!
6
...
’
• Techniques – Mobs Grade A-C, Transverse Frictions, Injection therapy – corticosteroid & local
anaesthetic
• Key signs tested following each technique
Clinical Examination
• Observation, noting; face, gait & posture
• Detailed history
• Inspection of bony deformities, colour changes, muscle wasting, swelling
• Palpation – Heat / swelling / synovial thickening
• State at rest
• Examination by Selective Tissue Tensioning – active, passive and resisted movements
• Once causative structure identified – palpation for the site of the lesion
Selective Tissue Tensioning
 Active Movements – Range, Pain, Power, Willingness to move, painful arc
 Passive movements – Pain, Range, End Feel
 End Feel - Normal (Hard/soft/elastic) or Abnormal (bony/springy/empty)
 Capsular Pattern – indicates arthritis/intracapsular pathology
 Non-capsular – intra-articular displacement, ligamentous lesion /extra-articular lesion
 Resisted Movements – see following slide

D
...
Suggestive history
2
...
Posterior displacement may interfere with dura mater reducing its mobility
...
Posterolateral protrusion may impinge on nerve root Mild pressure nerve roots dural sleeve
suffers resulting in:
a) pain in the dermatome
b) restriction of the nerve roots mobility
Severe pressure
a) conduction loss
b) weakness in relevant muscle group c) sensory and reflex changes
5
...
Cyriax sources of Pain
1
...
Nerve Root
3
...
Zygapophyseal Joint
5
...
Rules of Referred Pain

1
...
g
...
Nerve roots

Nerve roots projecting from dura
mater through dural sleeve for approx 2cm

Compression of Dural Sleeve
causes segmental pain distribution e
...
C8 to
4th and 5th fingers

Nerve root mobility tested through
SLR or ULTT

Mild pressure results in
 1
...
No impedence of conduction (no
parasthesia nor weakness)
Greater Pressure interferes with sensory
conduction
 1
...
Numbness
 3
...
Therefore test for
weakness
...
No way of
testing mobility or strength
• Lx; L1 & L2 rare
• L3 is uncommon and produces pain in 3rd lumbar nerve root
• L4, L5 disc lesions common and produce monoradicular and
polyradicular pain
• Test resisted movements and SLR

Polyradicular Pain
At lumbar levels the nerve roots project obliquely and can therefore compress 2 roots simultaneously
Displacement at L4 level can effect 4th, 5th or both roots
...








The Intervertebral Disc
Annulus Fibrosis; fibrocartilage
Loose fragment either detaches or lies hinged in joint
Nucleus Pulposus
Either pushes past Annulus fibrosis or displaces fibrocartilage
...
Zygopophyseal Joints
Cyriax believes the argument for facet joints as a source of pain other than capsular conditions is
poor
...
Localised pain - radicular pain
2
...
Anatomically protected by IVD and vertebra?
4
...
Stretching of anatomical structures
of spine
• To tighten the ligaments around a joint; produces a centripetal force
...
May be brought on by
Cx flexion

• Thx or Lx - Tingling in both lower limbs
• +ve Plantar response
Contraindications to manipulation
Disorders
 spinal deformities i
...
spondylolisthesis/lysis
 suspicion of a disc herniation
 acquired hypermobility or instability
 neoplastic disease of musculoskeletal tissue
 bone disease – osteoporosis, osteomyelitis
 inflammatory arthritis – ankylosing spondylitis
 advanced degenerative changes
 central nervous disorders : cord signs cauda equina lesions – bladder/bowel
dysfunction/saddle anaesthesia/paraethesia
 4
 cervical/thoracic conditions causing neurological deficits in upper and lower limbs
 severe nerve root pain – advanced diabetes and other metabolic disorders
 haemophilia - dizziness and vertebrobasilar insufficiency - vascular disorders – undiagnosed
pain/visceral pain
 steroid or anticoagulation medication
 pregnancy – last two months
 recent whiplash - psychologically unsuitable
Contraindications to manipulation
Clinical considerations –
 where features do not fit symptoms and signs do not match
 high irritability
 acquired instability or hypermobility of segment involved
 protective muscle spasm - rubbery end feel inability of patient to relax
Indications for manipulation
To increase the range of movement in a vertebral joint or region of the spine:
 following a course of mobilisation when the range of progress is inadequate with regard to
range of movement
 when a non-irritable pain is due to loss of range of movement and mobilisations have not
relieved the symptoms
 when mobilisations are aggravating a non-irritable condition
 when an irritable joint disorder may be better treated by a single gentle manipulative thrust
than repeated mobilisation
 when a “locked” facet joint is suspected
Evidence for the effect of manipulation
• Manipulation induced hypoalgesia (pain relief) well documented
• Restoration of functional movement may reduce pain
• Pain-gate mechanism – stimulation of mechanoreceptors
• Stimulation of the descending inhibitory control pathways – endogenous analgesia (Wright, 1995)
• Increased cortical response
• Placebo effect (Ernst, 2000)
• Modified reflex motor response – changes in muscle tone

Mulligans
and
Mckenzie

Mulligans and Mckenzie
Mulligan’s - mobilisation approach (don’t just slide over each other)
Mckenzie’s – centralisation process of pain – referred pain?
Dr Brian Mulligan – NAGS, SNAGS and MWM are articular techniques with neuromuscular results
Brian Mulligans viewpoint:
Proposed that joints are designed so the shape and joint surfaces and thickness of cartilage, the
orientation of the fibres in ligs and capsules and the pull of muscles and tendons
...

Minor positional faults occur following injuries or strains
...
All techniques should be pain free
Some palpation or pressure pain is permitted but must not reproduce pain
If pain is reproduced technique is abandoned
2
...
Joint surfaces should be realigned in the least provocative way – judgment based on effect of
persons symptoms
Indications for use
- Pain, weakness or stiffness on movement
- Pain occurs due to movement of the joint
- Resting pain – underlying pathology or inflammatory process – aggravated by SNAGS

-

Mild ache indicate disturbance of proprioception which may respond to correcting joint
position
Dependant on SIN factors

Sequence of treatment
Explain to patient pain is due to mal-tracking and treatment aims to correct it
...
Establish speed should perform the movement and they should
start the movement
...
Asked is
symptoms eased or made worse
...
Oscillatory accessory glides done in postero-anterior direction
...
Applied centrally or unilaterally and patients cervical
spine is natural or in direction of movement that is limited
...
g
...

Precautions for Mulligans
 Dizziness/drop attacks; VA test if in doubt; in sitting
 RA
 Steroids
 Cancer; care to be taken, not in area of cancer
 Diabetes
 Severe unremitting pain
 SIN factors
 Clinical patterns

McKenzie’s findings
• As the patient lay in this position his pain changed location
• From the leg and right side of his back to the centre point at the waist line
• This movement as become known as the “centralization phenomenon” Donelson,1997
• This is an important clinical sign of improvement
McKenzie’s Approach
 When soft tissues are overstretched – ligaments usually give the first rise to pain
 Ligaments in the spine are also important as Shock absorbers between the vertebrae
...

 The pain response to repeated movements, positions and activities during the assessment
process
 Active treatment philosophy
 Emphasizes teaching the client how to manage and treat pain themselves
 How to prevent the pain from occurring again
 The importance of posture is explained
 Personalized exercise programme for maintaining an active lifestyle
McKenzie’s View
 Most low back pain is caused by prolonged overstretching of ligaments and other surrounding
soft tissues
 Most common cause – poor postural habits, standing, sitting or lying
 Mechanical pain may be caused by severe overstretching – damages soft tissue

Exam
topics
and what
to include

Red Flags Question


Explain what red flags are



Mention 163 in literature we look at 11



Mention Greenhalghs Red Flags



Found out by subjective



Mention 3 common by palliative care team

-

Band like pain

-

Decreased mobility

-

Vague non-specific lower limb symptoms

Serious spinal pathologies
Cauda equina, malignancy/infection, myelopathy, serious trauma /skeletal injury


Explain 4 major pathologies



Explain signs and symptoms

Movement of SIJ


Explain type of joint



Explain how thought it was immobile originally



Explain movement – counternutation + nutation and gliding

Integrated Model of Function


Explain 4 elements – force and form closure, emotions and motor control



Give example if need be



Talk about slings – makes SIJ move properly causing lumbopelvic stability



Explain treating bones, ligs and muscles – imbalances



Emotions – depressed = inc cortisol = inc pain perception



Draw model



Link with cervical, thoracic, lumbar and SIJ

Neuro anatomy


Reflex pathway



Pain pathway



Pain modulated at 3 levels



How we perceive pain – link integrated model of function



Somatic and radicular referred pain

Maitlands


Outline his concept/principles



Assess – treat – reassess



Why important? – other therapists use principles



Verbal/non-verbal communication



Selecting technique



Subjective assessment



SIN Factors

Adverse Neural Tension


Continuous track



How it is continuous track – chemically/neurally



Stress transmitted



Moving neural system

Thoracic Spine
Explain what type of joint it is
Explain movements of the joint
Explain connection with ribs and movement of breathing
If a joint out of place – lig/muscle pain – link with integrated model of function



---