Restraints to Movement... 4 Restraints to flexion... 4 Primary restraint into Extension... 4

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1 CERVICAL SPINE... 4 Neck Pain Categories... 4 Kinematics... Error! Bookmark not defined. Ranges of Motion C Coupled Movements... 4 Ranges of Motion C Coupled Movements... 4 Restraints to Movement... 4 Restraints to flexion... 4 Primary restraint into Extension... 4 THORACIC SPINE... 5 Rib Cage... 5 Articulations... 5 Anterior Attachments... 5 Kinematics... 5 Coupling in the Thoracic Spine... 5 Range of Movement... 5 Rib Kinematics... 5 Axio- Scapular Muscle Contribution... 5 Cervical Radiculopathy... 6 Causes... 6 Assessment... 6 Treatment... 6 Cervicogenic Headache... Error! Bookmark not defined. Diagnosis... Error! Bookmark not defined. Assessment... Error! Bookmark not defined. Treatment... Error! Bookmark not defined. Acute Wry Neck: Z- Joint, Discal or OA... Error! Bookmark not defined. Z- Joint... Error! Bookmark not defined. OA Z joint Locking... Error! Bookmark not defined. Discogenic Wry Neck... Error! Bookmark not defined. Atlanto- axial Rotary Fixation (Grisel s Syndrome)... Error! Bookmark not defined. Whiplash Injury... Error! Bookmark not defined. Potential Pathologies... Error! Bookmark not defined. Presentation... Error! Bookmark not defined. Classification using the Quebec Task Force Scale... Error! Bookmark not defined. Red Flags... Error! Bookmark not defined. Assessment... Error! Bookmark not defined. Treatment... Error! Bookmark not defined. Vertebral Artery Insufficiency... Error! Bookmark not defined. Anatomy of the Vertebral Artery... Error! Bookmark not defined. Presentation... Error! Bookmark not defined. Assessment... Error! Bookmark not defined. Neck Muscle System... Error! Bookmark not defined. Cervical Muscles... Error! Bookmark not defined. Static Erect Posture... Error! Bookmark not defined. Movement of the Head... Error! Bookmark not defined. Arm Movement Influence... Error! Bookmark not defined. Changes in Muscles with Neck Pain... Error! Bookmark not defined. Developing an Exercise Program... Error! Bookmark not defined. 1

2 Phase 1: rehabilitation of motor control... Error! Bookmark not defined. Phase 2: Strength & Endurance... Error! Bookmark not defined. EXERCISE TREATMENT PLAN... Error! Bookmark not defined. Somatosensory Function of the Neck... Error! Bookmark not defined. Disturbances in Neck Afferents in Pain Patients... Error! Bookmark not defined. Causes... Error! Bookmark not defined. Demographic... Error! Bookmark not defined. Symptoms... Error! Bookmark not defined. Physical Examination Findings... Error! Bookmark not defined. Treatment... Error! Bookmark not defined. JPE... Error! Bookmark not defined. Movement Sense... Error! Bookmark not defined. Eye Movement Training... Error! Bookmark not defined. Overall Progressions... Error! Bookmark not defined. Progression of Technique... Error! Bookmark not defined. Mechanical Traction... Error! Bookmark not defined. Anatomical Features... Error! Bookmark not defined. Disc... Error! Bookmark not defined. Medial and Lateral Collateral Ligaments... Error! Bookmark not defined. Compartments of the Joint... Error! Bookmark not defined. Joint Capsule... Error! Bookmark not defined. Muscles... Error! Bookmark not defined. Biomechanics of the TMJ... Error! Bookmark not defined. Patient Interview... Error! Bookmark not defined. Area of Pain... Error! Bookmark not defined. ROM... Error! Bookmark not defined. Associated Symptoms... Error! Bookmark not defined. Behaviour of Symptoms... Error! Bookmark not defined. 24hr Picture... Error! Bookmark not defined. History... Error! Bookmark not defined. Patient Examination... Error! Bookmark not defined. Observation... Error! Bookmark not defined. Initial Palpation... Error! Bookmark not defined. Active Movements... Error! Bookmark not defined. Loading Tests... Error! Bookmark not defined. Passive Movements... Error! Bookmark not defined. Muscle Tests... Error! Bookmark not defined. Cervical Spine... Error! Bookmark not defined. Final Palpation... Error! Bookmark not defined. Diagnosis of Condition... Error! Bookmark not defined. Minor disc dysfunction- single click... Error! Bookmark not defined. Anterior Disc displacement with reduction... Error! Bookmark not defined. Anterior Disc displacement without reduction/closed lock... Error! Bookmark not defined. Treatment... Error! Bookmark not defined. Manual Therapy... Error! Bookmark not defined. Exercise Therapy... Error! Bookmark not defined. Anatomy... Error! Bookmark not defined. Ascending Pathways... Error! Bookmark not defined. Descending Pathways... Error! Bookmark not defined. What happens in SCI?... Error! Bookmark not defined. Upper & Lower MN Lesions... Error! Bookmark not defined. 2

3 Upper Motor Neuron Lesion... Error! Bookmark not defined. Lower Motor Neuron Lesions... Error! Bookmark not defined. UMN + LMN Lesion... Error! Bookmark not defined. Associated Impairments... Error! Bookmark not defined. Clinical Syndromes... Error! Bookmark not defined. Sacral Sparing... Error! Bookmark not defined. Brown- Sequard Syndrome... Error! Bookmark not defined. Central Cord Lesion... Error! Bookmark not defined. Anterior Cervical Cord Syndrome... Error! Bookmark not defined. Initial Management... Error! Bookmark not defined. # Instability... Error! Bookmark not defined. Surgical Fixation... Error! Bookmark not defined. Acute Assessment... Error! Bookmark not defined. Chart... Error! Bookmark not defined. Patient Interview... Error! Bookmark not defined. Physical Examination... Error! Bookmark not defined. ASIA Neurological Assessment... Error! Bookmark not defined. Neurological Level... Error! Bookmark not defined. Impairment Scale... Error! Bookmark not defined. Zone of Partial Preservation... Error! Bookmark not defined. Sensory Assessment... Error! Bookmark not defined. Motor Assessment... Error! Bookmark not defined. Assessment... Error! Bookmark not defined. Muscle Strength... Error! Bookmark not defined. Skin Condition... Error! Bookmark not defined. Muscle tone & Spasm... Error! Bookmark not defined. ROM... Error! Bookmark not defined. Proprioception... Error! Bookmark not defined. Posture... Error! Bookmark not defined. Balance... Error! Bookmark not defined. Functional Skills... Error! Bookmark not defined. Mobility... Error! Bookmark not defined. Equipment... Error! Bookmark not defined. Treatment... Error! Bookmark not defined. General Principles... Error! Bookmark not defined. Strengthening... Error! Bookmark not defined. Stretching... Error! Bookmark not defined. Mobilisation... Error! Bookmark not defined. Pressure Relief... Error! Bookmark not defined. Posture... Error! Bookmark not defined. Balance... Error! Bookmark not defined. Bed Mobility... Error! Bookmark not defined. Transfers... Error! Bookmark not defined. Exercise... Error! Bookmark not defined. Advice and Education... Error! Bookmark not defined. Queensland Spinal Cord Injury Services (QSCIS)... Error! Bookmark not defined. TRP... Error! Bookmark not defined. SPOT- spinal outreach team... Error! Bookmark not defined. 3

4 Lecture 1: Clinical Biomechanics of the Cervical and Thoracic Spines CERVICAL SPINE Neck Pain Categories Mechanical Neck Pain 80-90% Postural strain- overload: overload on cervical structures Occupational induced neck pain Degenerative joint disease (z- joint/disc) Cervical Radiculopathy Nerve root compression or irritation (lateral or central canal stenosis- disc, osteophytes) Trauma Induced Neck Pain MVC Sport, fall, blow to head Non- Mechanical Neck Pain AS, RA, tumor, congenital disorder Kinematics Functional Cervical Spine C0-1 to T3-4 Craniocervical Complex C0-2: Head on neck movement Cervical Region C2-7: Neck movement Cervicothoracic Junction C7- T4: neck on thorax movement Ranges of Motion C2-7 Movement is guided by the disc, shape of facets and uncinate processes Uncinate processes mean that movements need to be coupled Middle Cervical Spine Mostly rotation Lower Cervical Spine Mostly flexion Flex/Ext Lat Flex Rotation C C C C C C7- T Coupled Movements Flexion Anterior rotation and translation Extension Posterior rotation and translation Lateral Flexion Lateral rotation, ipsilateral axial rotation and medial translation Axial Rotation Rotation, ipsilateral lateral flexion and medial translation Ranges of Motion C0-2 Flex Ext LF Rot C C Flexion C0-1: forward rotation, posterior glide, occiput on atlas C1-2: Atlas rotates forward and translates backwards on axis Extension C0-1: backward rotation, anterior glide, occiput on atlas C1-2: atlas rotates backward and translates forwards on axis Coupled Movements C0-2 rotation and lateral flexion are coupled C1-2 rot coupled with contralateral LF at C0-1 Restraints to Movement Restraints to flexion alar ligaments: prevent posterior glide in F posterior short and long ligaments short suboccipital extensors dura mater: attaches to the foramen magnum to the back of the body of C2, it has a fibrous connection with RCPM and nuchal ligament Primary restraint into Extension Transverse ligament: prevents anterior glide 4

5 THORACIC SPINE There is less movement in the thoracic region due to: Smaller disc height Longer spinous processes Increased stability from ribcage and sternum to protect the heart and lungs Rib Cage Articulations Head of ribs articulate with the corresponding numbered vertebral body + the one above through the costovertebral join Tubercle of the ribs articulates with the transverse process of the same numbered vertebrae at the costotransverse joint Axio- Scapular Muscle Contribution The trapezius and levator scapulae muscles are important in scapular postural control. These muscles help the scapula sit on the posterior rib cage during rest and contribute to arm movement during tasks. Downwardly rotated scapulae adversely affects the neural and vascular structures of the neck. Levator scap: Bilaterally: produces an extension movement on the cervical curve Unilaterally helps with ipsilateral rotation Anterior Attachments Rib 1: manubrium by cartilaginous joint Rib 2: manubrium and sternum Ribs 3-7: sternum by synovial joints Ribs 8-10: via common fused cartilage Ribs 11-12: free floating Kinematics Cervicothoracic Region C7- T4: moves with cervical region Mid Thoracic Region T4- T8 Thoracolumbar Region T8- L1 Transitional area Coupling in the Thoracic Spine Weak Ipsilateral Transition to lumbar region Range of Movement Flexion/extension: 4-6 (upper- mid), 9-12 (thoracolumbar) Lateral flexion: 6-8 Rotation: 9-7 (upper mid thoracic), 2 thoracolumbar Rib Kinematics Thoracic Flexion: anterior rib rotation Thoracic Extension: posterior rib rotation Thoracic Rot: ipsilateral rib posteriorly rotates Thoracic LF: ipsilateral rib anteriorly rotates = stiff rib joints may limit ThSp movement 5

6 Pathologies of the Cervical Spine Cervical Radiculopathy Cervical radiculopathy is a neurologic condition characterized by dysfunction of a cervical spinal nerve and/or the nerve roots. Characteristics Pain in the neck and one arm +/- sensory loss +/- loss of motor function +/- reflex changes in the affected nerve- root distribution Prevalence & Incidence % for the entire population Most common between 40-65years C6 & 7 are most commonly affected due to the spinal nerve occupying the largest space within foramen out of all cervical spinal nerves Causes Cervical Spondylosis (70-75%) Cervical spondylosis (degeneration) causes foraminal encroachment on the spinal nerve. Causes of encroachment can be from: Decreased disc height Degenerative changes in uncovertebral joints or z- joints The onset of symptoms in this type is much slower and causes less pain due to the spinal nerve being compressed rather than inflamed. Disc Herniation (20-25%) Herniation of the nucleus pulposis causes inflammation of the spinal nerve. The onset of symptoms is fast and they are painful. Tumor of the spine, spinal infection, synovial cyst Identify with red flags Assessment Neurological examination: MANDATORY A neurological examination is a clinical test of the spinal nerve conduction (spinal reflex arc). Nerve Root Muscle Skin supply Reflex C1 UCF No skin supply C2 UCE Back of head C3 Scalenes Back of head, neck C4 Lev Scapulae Superior shoulder C5 Deltoid Lateral border arm to wrist C6 Biceps Lateral border of arm into thumb Biceps C7 Triceps Posterior arm to middle three fingers Triceps C8 EPL, Finger flexors Medial border of arm to medial border of hand and ulnar two fingers T1 Interossei Medial border of arm to wrist If there is a non- dermatomal spread of symptoms it may be due to the structures giving rise to non- radicular referred pain. It is hypothesized that the reason for this may be central sensitization. 6

7 Mechanisms of Central Sensitisation Sprouting Phenotypic change Expansion or creation of novel receptive fields Disinibition Glutamate transporter and NMDA receptor activation Activation of glial cells Descending modulation from the brain stem Etc Neurodynamic Testing During ADLs the nervous system moves. A healthy nervous system can cope with these mechanical challenges, however, when the nervous system is affected, minimal strain and compression may provoke symptoms. A wide range of tests (clinical provocation tests) exist which aim to either alleviate or intensify symptoms by: Enlarging or narrowing the IVF Placing the peripheral nerves on slack or stretch Increasing intrathecal pressure A POSITIVE TEST is: Reproduction of symptoms Symptoms altered by structural differentiation Reduced ROM (may be prevented by muscle spasm) Upper Limb Neurodynamic Test 1: Conventional Test (C5-6) SG fixation, abduction, wrist extension, supination, shoulder ER, elbow extension Normal: 0-20 degree lack of full elbow extension Biasing Median Nerve SG depression, shoulder ER, wrist thumb & finger extension, shoulder abduction Biasing Radial Nerve SG depression, elbow extension, shoulder IR, pronation, wrist & finger flexion, shoulder abduction Biasing Ulnar Nerve Wrist & finger extension, pronation, elbow flexion, shoulder ER, SG depression, shoulder abductiontreatment Prognosis of cervical radiculopathy is favourable with 90% of patients improving with conservative treatment. Main objectives: Relieve pain Improve neurological signs Prevent recurrence Non- Invasive Treatment Modalities Mulitmodal approach: A&E: o Condition o Prognosis o Pharmacological management: refer to GP for neural pain medication o Activity modification Mobilization of structures o Directed to the surrounding structures o Directed to the nervous system (sliding or tensioning) Occasionally immobilization for <2wks eg. Soft collar 3-6wks Traction Exercise Therapy: ROM 7

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