Myotome Testing

L2 - hip flexion

L3 - knee extension

L4 - ankle dorsiflexion

L5 - great toe extension

S1 - ankle plantarflexion

NOTE: L4/L5 nerve roots are most commonly involved

Dermatomes

L4 - distal medial tibia

L5 - medial aspect of 1st metatarsal

S1 - lateral border of 5th toe and metatarsal

sensibility differences are best found by testing the dermatome at its most distal area of innervation

• severe narrowing of the vertebral canal (central) or intervertebral foramina (peripheral) due to hypertropic bony changes
• rarely affects people under 60
• nerve root impingement can occur (peripheral) - disc space narrowing, enlarged facet joints and laminae, hypertrophy of ligamentum flavum
• impingement greatest with extension
• neurogenic claudication can occur - pain, bowel and bladder dysfunction, sensory changes in lower limbs, weakness in lower limbs

Lumbar Spinal Stenosis

common exam findings

• decreased reflexes at the knee & ankle (asymmetrical = bad)
• decreased sensation: buttock or lower limb
• possible bowel & bladder changes
• reduced lumbar lordosis
• symptoms relieved with lumbar flexion
• symptoms increased with extension
• muscle weakness in lower limbs

Spinal Stenosis

Surgical Interventions if:

• drop foot/or other LE weakness
• sensory dysfunction (anesthesia)
• bowel/bladder changes
• things to be considered prior to surgery: response to conservative care, pt's age & physical condition

Spinal Stenosis

Physical Therapy Intervention

• flexion activities (knees to chest, pelvic tilt)
• posterior pelvic tilting - may need to stretch to permit this motion, lumbar corset
• passive positioning in a posterior pelvic tilt position: sacral sitting, sitting with knees higher than hips, sleep in fetal position

Clinical Practice Guidelines

Acute LBP

• screen for RED FLAGS - visit 1
• in 1st 4 weeks if no red flags: imaging studies and lab testing aren't indicated
• relief can be safely provided by: spinal manipulation, OTC meds
• low stress aerobic activities can be initiated within 1st 2 weeks to avoid debilitation
• trunk conditioning exs should be delayed 2 weeks
• have pts return to work & other normal activities ASAP
• pts with sciatica can be safely treated without additional tests
• surgery if in 1st 3 months: serious spinal pathology (nerve root compromise corroborated on imaging studies), severe debilitation, severe sciatica
• 80% of pts with sciatica recover eventually
• recovery may be affected by nonphysical factors
• evidence for use of physical modalities is poor & cost isn't justified

• ROM depends on facet joint orientation
• lumbar region: sagittal plane, flexion/extension facilitated
• thoracic region: coronal plane, lateral flexion facilitated
• adipose tissue found b/w capsule and synovium in superior/inferior aspect of joints
• fibrous meniscoid structures
• adipose and meniscoid structures involved in jt pain (i.e. impingement = facet syndrome)
• degenerative changes result of increased loading stresses (bodies collapse with age --> puts more stress on facet jts --> increased loading)
• stretch if something is being pinched to make more room

• travels inferior to pedicle of corresponding vertebrae
• compression and irritation possible due to close proximity of anatomical structures (IV disc, vertebrae, facet joints)
• ventral and dorsal rami have funnel shaped extensions of dura mater and arachnoid around them (become epineurium and protect SN in trunk mov't; lumbar SN slide approx 1/2 cm with SLR)
• may adhese to surrounding tissue after surgery and decrease vertebral space

intervertebral foramen

structures that pass through

• structures that pass through: spinal nerve, sinuvertebral nerve (recurs back into spinal canal to supply outer fibers of AF, PLL, dura mater), blood vessels, lymphatics 

• anterior: disc and adjacet vertebral bodies (2)
• inferior and superior: pedicles
• posterior: superior and inferior articulating processes (facet joints)
• degenerative changes can decrease cross section space of foramen

• divides outside the IV foramen into ventral and dorsal rami -- comes out as neurovascular bundle
• dorsal rami supply: capsules of facet joints, interspinouse lig, fascia of back (lumbothoracic), erector spinae and transversospinalis muscles, sensation to dorsum of back (midline)

intervertebral disc

composed of: 

• annulus fibrosus - thick, outer covering
• nucleus pulposus - like raw crab meat, dries as you age and becomes more like annulus 
• cartilaginous endplates

• composed of fibrocartilaginous tissue
• makes up largest portion of disc - approx 12 lamellae in lumbar area (like skin of onion); lamellae separated by loose CT
• thicker anteriorly than posteriorly in lumbar spine; nucleus pulposus is located more posterior than in thoracic discs

• located posteriorly within lumbar disc
• has high proteolycn content (high affinity for water) - slight change in height from morning to night
• in young appears like raw crab meat
• with age - becomes less fluid and ability to transmit forces decreases --> increases stress on annulus

• fulcrum for movement (like ball bearing)
• distributes mechanical stresses
• shock absorption
• receives nutrition by diffusion through vertebral endplate or annulus: water returning to disc has nutrients, loading and unloading of disc are important to facilitate exchange of water and nutritional process, intermitent loading facilitates water return and nutrition --> MOVE!!

• vertebral stability: holds individual vertebrae together
• allows normal movement because of spiral arrangement - successive layers are at right angles
• acts as a check ligament
• a container for nucleus pulposus
• shock absorption

• nucleus pulposus has high proteoglycan and water content

• proteoglycan and water content decrease
• unable to differentiate the nucleus from annulus (has dry granular appearance)
• consequently lower incidence of disc herniations but there are other issues
• disc degeneration may have significant hereditary contribution
• also related to exercise and movement

annular tears

RADIATING TEARS

• defect is from inside and moves peripherally
• radial fissures in inner 2/3 of annulus may eventually reaach innervated outer 1/3 and will then cause symptoms
• outer 1/3 innervated = pain

annular tears

CONCENTRIC TEARS

• defect is between layers of the lamellae
• usually not symptomatic 
• compress area

annular tears

• discs have very limited ability to heal
• no direct correlation between imaging and symptoms --> treatment can help relieve symptoms but bulge will still be present 

• definition: nucleus pulposus escapes from its normal position
• anterior prolapse: generally asymptomatic; uncommon because tough ALL
• superior or inferior prolapse: central herniation with protrusion of disc tissue into adjacent vertebral bodies produces Schmorl's node; generally asymptomatic
• 98% of all lumbar disc prolapses/herniations occur at L4-L5 and L5-S1 levels
• posterior much more common because flex forward, PLL = thinner

• in lumbar area is the thinnest and weakest area of annulus fibrosus
• this prolapse is restrained by PLL - posterolateral more common
• if PLL is intact, then prolapse may deviate posterolaterally
• if PLL is ruptured, prolapse may move centrally into spinal canal
• PLL narrows as it goes down spine

• relatively stable despite multisegmental composition
• only small amt. of muscular activity needed to maintain upright position
• discs add to stability
• movement of nucleus pulposus offers stability

• lumbar extension - anteriorly; produces tension in anterior disc and prevents further extension
• lumbar flexion - posteriorly
• lateral flexion - to contralateral side

• annulus fibrosus: diagonal orientation of fibers (limits ROT), fibers running counter to mov't act as ligaments
• nucleus pulposus: rotation compresses nucleus (like screwing lid on jar) --> puts fibers under more tension, limiting ROT; also compresses nucleus and limits further motion

spinal movements

summary

• internal pressure on nucleus pulposus increases with movement
• this pressure pushes outward on the annulus fibrosus (stretches it)
• stretching tends to oppose the movement and restore the spine to a neutral position

• ligamentum flavum: between laminae of adjacent vertebrae; can be up to 1cm thick; thicken as age
• interspinous ligament: found between spinous processes
• supraspinous ligament: connects the tips of the spinous processes; changes to nuchal ligament in C-spine

• muscles reinforce the region and absorb some of the forces that would otherwise go to the ligaments; ligaments would elongate and joints become unstable if muscles weren't active
• short single-segment muscles of spine (rotatores, interspinales, intertransversarii) are predominantly thought to be involved in proprioception, given the high density of muscle spindles and poor mechanical advantage for torque production

• consists of 3 layers: anterior, middle, posterior
• latissimus dorsi may indirectly assist in providing support for lumbar spine due to attrachments through thoracolumbar fascia

facet joints 

stability

• the orientation of the lumbar facets limits rotation: in sagittal plane
• except: L5 facets are more in frontal plane to prepare for articulation with sacrum

• the vertebrae tilt anterior on each other
• lower articular processes of the superior vertebrae glide superior and anterior
• the superior vertebrae moves anterior over the inferior vertebrae

• posterior muscles
• disc: acts as ligament; fibers of annulus fibrosus, nucleus pulposus
• PLL
• ligamentum flavum
• interspinous ligament
• supraspinous ligament

• inferior articular processes of the upper vertebrae glide inferiorly
• superior vertebrae moves posterior over the inferior vertebrae
• controlled by: iliopsoas, anterior abdominal muscles
• limited by: ALL, intervertebral disc (anterior portion), apposition of the spinous processes, apposition of the facet joints

• only a small amount of lateral flexion is available 
• facet joints of the ipsilateral side become close-packed and intervertebral foramen decreases on ipsilateral side
• facet joint on contralateral side opens and intervertebral foramen size increases
• *very important info for mechanical intervention
• limited by: intertransverse ligaments of contralateral side, muscles on contralateral side

• only a small amount is possible
• facet joint orientation limits rotation
• in neutral, there is a narrow gap with in facet joints
• rotation continues until gaps are obliterated
• position dictates ROM: spinal extension = very little rotation; spinal flexion = more rotation due to less facet contact

accessory movement

(Maitland - Australian Concept)

• joint movement that can't be performed actively but needs to occur with normal physiologic movement
• i.e. PA glide on vertebra

comparable sign

(Maitland - Australian concept) 

• a test or measure that reproduces the patient's symptom
• the symptom that brought the patient inot your office
• important bench mark to assess if patient is moving on (assessment tool)

end-feel

(Maitland - Australian concept)

• the sensation imparted to the examiner's hands at the extreme of ROM when testing passive movement
• helps decide what tissue is involved

mechanical

(Maitland - Australian concept)

• affected by positions and/or repeated movements
• position or movement changes symptoms

oscillation

(Maitland - Australian concept)

• back and forth motion
• performed during passive movements of physiological movements

physiological movement

(Maitland - Australian concept)

• movement that can be performed actively by the patient (i.e. trunk flexion)
• requires accessory movements to occur

severity

(Maitland - Australian concept)

• the therapist's assessment of the intensity of the patient's symptoms based on how they affect function
• can also become goals for patient (i.e. play with daughter on the floor, etc.)

irritability

(Maitland - Australian concept)

• how a pt's symptoms react to repeated movements
• i.e. symptoms worsen with very little movement, or symptoms persist for a long period of time after testing
• what/how long brings symptoms on and how long it takes to go away
• consider type of movement and amount of movement

clinical reasoning

(Maitland - Australian concept)

• the application of relevant knowledge and clinical skills to the evaluation and intervention of a patient problem

theory versus clinical exam

(Maitland - Australian concept)

• diagnositc imaging - no direct correlation; don't let this dictate your clinical examination or evaluation
• the permeable wall - use all information to reach a dx
• clinical examination - signs and symptoms, tests and measures

• a skill that needs to be developed
• don't accept what pt's say at face value (i.e. constant pain)
• parallelling - following up on comments pt made
• ask a pt what her symptoms are and not where the pain is (pain may not be concern to pt)

evaluation 

(Maitland - Australian concept)

• highlight significant findings with an asterisk
• also mark comparable signs with an asterisk with circle around it to evaluate progress (reassessment)
• items with an asterisk should be repeated for comparison during or following intervention
• at the beginning of each session ask how were you immediately after last visit, later that day, and the next day

before abandoning a technique try modifying the: 

(Maitland - Australian concept)

• rate of oscillation
• angle of force (line of drive)
• grade of mobilization
• have a hypothesis and seek to prove it

questions to include when taking a history 

(Maitland - Australian concept)

• what is the effect of forward bending? (directional preference?)
• what is the effect of sitting? 
• discogenic (generally worse with both; usually posterolateral)
• stenosis (generally better with both; flexion)
• any difficulty rising from sitting? (disc)
• does coughing or sneezing affect your symptoms? (disc)
• what positions or movements decrease symptoms? (can help decide if mechanical, pt will give clues regarding principle of intervention)

during the examination

(Maitland - Australian concept)

• goal is to reproduce pt's symptoms (within limits of irritablility/severity)
• consider: joints/soft tissues located deep to area of symptoms (i.e. muscles, tendons, nerves, bursae, ligaments); joints/structures that could refer to that area (i.e. LBP consider pelvis, hips, uritogenital system)
• only consider movement normal if: ROM is full range and symptom free, end range overpressure  is symptom free

passive accessory movement testing to determine: 

(Maitland - Australian concept)

• which spinal levels are involved
• the extend of resistance (hyper/hypomobility)
• the behavior of they symptom (better or worse with PAIVMs = passive accessory intervertebral motions)
• the intervention to be used

passive movement testing

(Maitland - Australian concept)

• begin with PAs to lumbar vertebrae
• perform oscillations at 2-3/sec
• can be performed over the spinous process or bilaterally on the transverse processes
• if no symptoms with light pressure increase the pressure
• you can bias manual force to particular vertebral segment but you can's specifically isolate that segment

3 types of passive movement tests

(Maitland - Australian concept)

• PA (postero-anterior force) on the spinous process - causes extension of vertebrae
• PA on transverse process - causes some rotation of vertebrae
• transverse pressure to a spinous process - causes rotation of the vertebrae

• in not needed in many cases of LBP
• consists of: myotomes, circumferential meausrements (if atrophy), dermatomes, reflexes, neurodynamic testing (slide nerve roots)

vertebral disorders

inflammatory disease

• spondyloarthritis (aka ankylosing spondylitis): bilateral sacroiliac inflammation, inflammatory chagnes in lumbar area, formation of granulation material, incidence in population = 1.4%, clinically you'll see a rigid spine, etiology is unknown
• rheumatoid arthritis: commonly involves cervical spine (instability of odontoid process), rarely involves lumbar spine

vertebral disorders

metabolic diseases

osteoporosis 

• reduced bone density
• causes: idiopathic, disuse, endocrine related, genetic
• symptoms: may be asymptomatic, pain in lumbar or thoracic areas (i.e. fx), loss of height of vertebral body, development of kyphoscoliosis
• interventions: flexion should be avoided b/c could increase incidence of vertebral body fx, strengthening exs increase bone density (gentle extension, lateral flexion, rotation), walk and stay active, exs to promote good posture (correct forward head, lengthen short pectoral and hip flexor muscles)

vertebral disorders

metabolic diseases

osteomalacia

• defective calcification of bone tissue
• inadequate supply of vitamin D (due to dietary deficiency or malabsorption of vitamin D)
• bone pain and tenderness is common
• softening and bending of bones will occur
• not mechanical - won't respond to movement

vertebral disorders

metabolic diseases

chondrocalcinosis

• deposits of calcium crystals in the articular cartilage
• occurs more commonly in large peripheral joints (i.e. knees)
• will have pain and swelling in involved joints (constant)
• medical cause

vertebral disorders

metabolic diseases

gout

• hereditary
• deposits of urate crystals in the tissues (CT, articular cartilage)
• spine is rarely involved
• distal joints of the limbs are affected the most
• leads to progressive chronic arthritis
• constant pain

vertebral disorders

metabolic diseases

acromegaly

• excess growth hormone is produced by the pituitary gland
• leads to bone enlargement (width of vertebrae increases and height of disc increases)
• hypermobility is produced by bony enlargement
• may benefit from stabilization exs/core exs

vertebral disorders

traumatic and degenerative conditions

spondylolysis

• defect within bone of posterior neural arch (genetic or develops as a degenerative process or a repetitive loading-induced stress fx)
• common site: the isthmus b/w the superior and inferior facets of the vertebrae (the pars interarticularis)
• may be asymptomatic (prevalence in asymptomatic adults = 6-9%)
• CT scan is most sensitive imaging technique to visualize it 
• will complain of central LBP - doesn't radiate

vertebral disorders

traumatic and degenerative conditions

spondylolisthesis

• anterior displacement of one vertebral body on the vertebrae below
• 5th lumbar vertebrae on the sacrum is the most commonly affected
• the 30 degree lumbosacral angle is the likely reason for the slippage at L5-S1

• staph infection is most common
• usually begins in disc
• occurs at any age
• insidious onset
• a primary infection is uaually present somewhere else in body: streptococcal, coliform organism (salmonella)
• not mechanical - constant pain

• may be located in the vertebrae or spinal cord
• primary bone tumors are much less common
• suspect a tumor if: pt has spinal pain and a hx of malignancy, pt over 50 y/o with back pain and no previous hx of LBP, spinal pain is exacerbated at night (when quiet and calm), if symptoms are unremitting and getting worse (despite PT)
• tumors may be in the: SC (extra- or intra-dural), vertebrae, spinal nerve
• the majority of spinal tumors are metastatic (most common primary sites are: breast, lung, thyroid, kidney, prostate - BLT with Kosher Pickle)

• spinal structures: any structure of the lumbar spine receiving neural innervation can cause LBP and possibly refer symptoms into lower limb; structures that aren't innervated and unable to produce symptoms = nucleus pulposus, ligamentum flavum; muscles can cause LBP
• visceral structures
• vascular structures
• psychogenic origin (lower pain tolerance/threshold)

• discs (i.e. prolapse)
• bone
• facet joints - loss of disc height puts additional loading stresses on the facet joints and leads to degeneration
• nerves
• ligaments
• surrounding soft tissues

• retroperitoneal structures (aorta, kidneys)
• pelvic structures (prostate gland, uterus, ovaries)
• intra-abdominal structures (gastric ulcer, pancreatitis, gall bladder disease)
• symptoms will not change with spinal test movements if produced by viscera
• always ask if change in bowel/bladder function; if yes then not mechanical!

• aneurysm of the abdominal aorta - typically at bifurcation of common iliac arteries
• atherosclerosis of the abdominal aorta (check peripheral pulses; is intermittent claudication present; skin color changes, hair loss)
• the patient will have a normal spinal exam (no restriction in motion, no changes in strength, no changes in symptoms with sustained positions or repeated movements of the spine)

• any pt with LB symptoms may have psychogenic overlay (upset, worked up)
• the pain is usually described dramatically (instead of calmly)
• areas of pain are described vaguely (can't point to)
• pain characteristics are inconsistent (say they can't bend over but sitting in chair is fine; both = 90%)
• pain unrelieved by medication
• consider secondary gains: finiancial/emotional (i.e. lawsuit, enjoy attention)
• malingering: the pt is aware that their complaint of symptoms isn't true (look for inconsistencies)
• don't be too hasty in labeling pt (be objective in reports)

ancillary tests

MRI

• x-ray/MRI/CT scan
• MRI is most accurate and sensitive for dx of soft tissue and spinal pathology
• best imaging technique to evaluate disc pathology (annular tears, herniation)
• T2 weighted MR images, fluid appears bright white (tend to be superior to T1 for assessment of pathology)
• MRI provides poor bone detail (pts with metallic implants can't undergo MRI)

ancillary tests

CT scan

• useful for assessment of fx, spondylolysis, vertebral alignment, and bony morphology
• there is not a direct cause-and-effect relationship between visible degeneration of discs and spinal joints on imaging studies and clinical presentation
• not all arthritis is symptomatic, radiographic changes of osteoarthritis are equally common in pts with and without LBP
• imaging studies are used to complement the physical exam and shouldn't be sole means of arriving at dx or developing POC

• blood tests (WBC count increased with infections)
• EMG
• bone scan (good for searching for bony metastasis)
• myelogram - radio-opaque substance injected into the sub-arachnoid space: most sensitive test for detection of spinal stenosis, more invasive than MRI or CT, headache is most common complication
• if someone isn't getting better don't keep treating them

• radio-opaque substance injected into the nucleus pulposus under flouroscopic guidance
• invasive and uncomfortable
• looking for deficits in disc

• hypomobility (stiffness dominant) - joint mobs, stretches
• hypermobility (instability) - trunk strengthening exs significantly reduce pain and disability in pts with chronic LBP
• pain dominant - low grade joint mobs to calm down
• disc derangement
• facet syndrome
• sacro-iliac dysfuction 
• muscle imbalance

• modify/abolish symptoms
• promote movement and increased physical activity (return to work/leisure activities)
• enhance neuromuscular performance (quality of movement)
• biomechanical counseling: posture (standing, sitting, lifting, etc), sleep positions, daily activities (work, leisure)

1. similar occurence rate of pathological lumbar spine anatomy (disc herniation/degeneration, osteophytes, stenosis) for asymptomatic and symptomatic individuals
2. presence of pathological lumbar spine anatomy is not usually associated with LBP development for asymptomatic individuals
3. psychological factors play critical role in development of chronic LBP (may not get pt better if don't work on psych problems 1st)
4. treatment of psychological factors targeting at-risk pts may result in favorable outcomes

• primary role of PT in treatment-based classification approach is to identify RED FLAGS = systemic or serious pathology that mimics LBP presentation; identified through pt hx and lab tests
• identify YELLOW FLAGS that can predict LBP development = psychological influence on a pt's LBP presentation; goal is to find factors that can positively impact recovery process and prevent long-term disability

1. depression
2. nonorganic signs (report pain with movement that shouldn't produce pain if they have LBP)
3. fear-avoidance beliefs (fearful and anxious about moving, going back to work/activity)
4. pain catastrophizing (exaggerated symptoms)
5. psychological factors are a stronger predictor of LBP outcomes than the traditional PT physical exam

• commonly experienced with chronic LBP - associated with increased pain intesnity, medication use, disability, unemployment
• currently is not being adequately screened for in pts  presenting with LBP: 63% of spine surgens occasionally or never use psychological tests; clinical impressions aren't sensitive enough to detect depression; self-Report Questionnaires are more effective (back depression inventory, depression anxiety stress scales)

• using the following 2 questions from the Primary Care Evaluation of Mental Disorders questionnaire can effectively screen for depression in primary care settings: (1) "during the past month, have you often been bothered by feeling down, depressed, or hopeless?" (2) "during the past month, have you often been bothered by little interest or pleasure in doing things?"
• these questions accurately identified depression in individuals seeking PT treatment for LBP
• if yes to both questions, refer out 

• PTs should refer pts with suspected depression to an appropriate health care practitioner (family physician, psychiatrist, clinical psychologist)
• it may be determined that PT is not currently a priority for these pts (depression may be larger roadblock)

• a way to investigate the possibility of psychological influence during the physical exam
• poor predictive value for return-to-work status (some studies indicate inorganic signs were predictive of a delayed return to work)

• hesitancy to resume therapeutic exs in response to musculoskeletal pain
• belief that activity would result in re-injury even if exs were applied appropriately
• Fear-Avoidance Beliefs Questionnaire (FABQ): developed by Waddell et al to measure effect of physical activity and work on LBP, cutoff scores indicating risk of developing chronic LBP due to pain-related fear not well established, other factors such as centralization phenomenon play important role in determining long-term prognosis of LBP

• a negative coping style with beliefs that pain is beyond individual's control
• belief that the worst possible outcome will occur
• involves magnification, helplessness, and pessimism

• strategy: graded exs; gradual increase in intensity and duration improves patient's exs tolerance (behavioral goal), pts receive positive reinforcement by reaching quotas, beneficial coping strategies are reinforced by NOT limiting activity due to pain, performing activity with pain decreases fear of LBP (pain isn't causing any pathology)
• goal: shift pt's focus away from pain reduction and towards improving activity tolerance; PTs are encouraged to limit anatomical explanations of LBP

• 44% pts get better in 1 week w/o tx
• 86% pts will be better in 1 month w/o tx
• 92% pts will be better in 3 months w/o tx

• very acute
• in severe constant pain (most LBP is intermittent)
• worse with weight bearing
• found to have no movement or position that improves symptoms 

• didn't respond to conservative measures/care - hopefully they see PT 1st
• have allowed an adequate passage of time (>3 months) - 92% pts recover
• have nerve root compression - anesthesia (i.e. saddle anesthesia, in perineum), significant muscle weakness: knee buckling, foot drop
• straight leg raising should be performed by pts post-lumbar surgery to prevent incidence of nerve root adherence

• symptoms arising from spine and felt distally are reduced and transferred proximally with certain movements and postures 
• symptoms may increase centrally as long as distal symptoms decrease or move proximally (the more it peripheralizes the worse it is; sx may not be continuous down the leg but may jump; most distal sx move higher to origin, may worsen at center, then dwindle away)
• centralization of sx only occurs in derangement syndrome 

• concentric layers of collagen fibers
• consecutive layers are at 90 degrees to each other
• attached to the vertebral endplates
• retains the nucleus pulposus
• helps hold the adjacent vertebral bodies together
• weakest part is postero-lateral due to the thinness of the wall and lack of external ligamentous support

• has a high water content
• located in central part of the disc
• water content decreases as day progresses (compression and gravity) - normal returns at night
• overall water content decreases with age (disc herniation less common after 50)
• nucleus found in posterior aspect of disc
• nucleus shifts: posterior with trunk flexion, anterior with trunk extension, to contralateral side with lateral flexion
• migration of nucleus centrally through annular fissure causes kyphotic deformity; posterolaterally causes scoliotic deformity
• extension may cause compression and pain if nucleus extruded (b/c hydrostatic mechanicsm of disc lost b/c incomplete annular wall; unlikely to benefit from mechanical therapy)
• further sx are from midline of back, larger the derangement 

• nucleus pulposus enters the fissure separating annular surfaces and causing symptoms

• posterior pressure continues and more nucleus enters the fissure causing the outer annulus to bulge

• the inner wall of the annulus is disrupted, but the outer wall is intact

• the weakened annular wall fails and nuclear material leaves the disc
• annular wall that has ruptured or has been cut does not heal
• time is on your side if you have LBP (at 5 yrs, pts with and without lumbar surgery were doing the same

• approximation of anterior vertebral rims with relaxation (bulging) of anterior annular wall
• distraction of posterior vertebral rims with tensing of posterior annular wall
• fluid volume of anterior disc reduced, posterior disc volume increased
• nucleus polposus shifts its center of mass posteriorly, facet joints disengage ultimately limited by tension in capsular ligaments and contact of superior articular surface
• posterior ligamentous system tautens, anteriorly relaxes
• spinal canal and IV foramen open, neural components placed under tension

• approximation of posterior vertebral rims with relaxation (bulging) of posterior annular wall
• distraction of anterior vertebral rims with tensing of anterior annular wall
• fluid volume increase anteriorly, decreases posteriorly
• nucleus pulposus shifts center of mass anteriorly
• facet joints are approximated an engage with inferior articular processes ultimately contacting lamina below
• posterior ligamentous system relaxes, anteriorly tautens

• lateral vertebral rims approximate on side of concavity, distract on side of convexity
• nucleus shifts center of mass towards side of convexity
• facet joints engage on side of concavity and disengange on side of convexity
• IV foramen on side of convexity opens, neutal contents placed on tension
• IV foramen on side of concavity reduces in size, neural contents relax

1. sitting posture
2. sleep positions
3. work-related postures
4. loss of lumbar flexion
5. frequency of flexion
6. lifting without maintaining a lordosis 

• relaxed unsupported sitting promotes a decreased lumbar lordosis
• sitting posture needs to be included in pt edu
• intradiscal pressure increases as lumbar spine moves into flexion while seated and decreases as extended 
• poorly designed seating promotes poor posture 
• LBP produced "following" strenuous activity is many times inaccurately attributed to activity 
• consider posture pt assumed after this activity as possible cause (sitting)

1. postural syndrome
2. dysfunction syndrome
3. derangement syndrome

• prolongued mechanical stress of normal tissues produces intermittent symptoms that cease with posutral correction 
• no pathology
• symptoms never peripheralize b/c just pulling on local tissues
• i.e. bent finger to illustrate what's going on in back

• adaptive shortening of tissues cause intermittent symptoms when normal ROM is attempted to endrange
• symptoms are absent when stress is released and a partial loss of motion is evident
• loss of ROM (i.e. after immobilization)
• a pathology - sometimes peripheralizes but usually central or midline pain
• named by what you can't do

• a mechanical deformation of soft tissues that causes constant or intermittent symptoms 
• partial loss of motion is usually evident
• * pt responds to repeated movements and static positions, directional preference
• * episodic - have it, goes away, comes back worse than before
• symptoms can peripheralize or centralize

1. no position or repeated movement can be found to reduce pt's symptoms - bedrest may be indicated
2. saddle anesthesia or urinary incontinence is present (signs of a major disc herniation involving sacral nerves --> signs of cord or sacral nerve compression) - probably need surgery
3. pts in extreme pain (severe reactions to movement or palpation) - may be fearful or condition is irritated - everything needs to be very gentle

taking history

specific questions

• strain when go to bathroom
• bladder/bowel problems - looking for incontinence
• changes in walking - look for red flags, motor issues
• general health - go through systems
• night pain - when lying there not moving = red flag
• unexplained weight loss = red flag
• other - anything I haven't asked that you feel is relevant

repeated movement testing

(looking for directional preference)

• symptoms of mechanical origin are always affected by repeated movement or static positioning
• centralization provides most reliable guide in selecting appropriate movement to reduce derangement - look for centralization
• in dysfunction pt experiences end range pain that doesn't increase with repetition (difference b/w dysfunction and derangement)
• with postural syndrome, pts will not have symptoms with any repeated movements (only static positioning reproduces symptoms)

• standing: produces tension on sciatic nerve b/c nerve being stretched over hip and knee, pain is increased in both derangement and dysfunction (adherent nerve root)
• lying provides slack for sciatic nerve: pain still produced with derangement, but will not be produced with dysfunction 

• lying: spine is unloaded; increased extension is achieved by weight of abdomen and pelvis
• standing: more vertical compression forces are present and some derangements are too large to be reduced in this position - spine is loaded