MS 2 Midterm Spine- protects spinal cord, mobility and stability, transmits weight from upper body, attachment site

for bones and muscles of UE and LE Facets innervated by medial branch of dorsal primary ramus Ligament o Anterior longitudinal ligament- covers anterior disc, anterior vertebral bodies o Posterior longitudinal ligament- prevents posterior disc protrusion, highly innervated by recurrent sinovertebral nerve o Interspinous ligament- connects spinous processes o Supraspinous ligament- covers spinous processes, o Ligament flavum- prevents separation of lamella or pedicles during flexion, attached lamella to lamella or pedicle to pedicle Deep muscles- core, multifidi, quad lumoborum, interspinalis, TrA o Multifidus- segmental muscle, transverse and spinous processes, segmental stability o TrA- linea alba to thoracofascia, anticipates movement of limbs and keeps spine stable, if weak then doesnt fire Articulation- inferior articular process on one vertebrae on superior articular process of vertebrae below Cervicalo small body, o superior lip of body is concave and forces a U-shape (uncovertebral joint), o short, bifurcated spinous processes o facets oriented 45 degrees from horizontal, o SB and rotate same directions, o herniations most common between 20-30 yo, disc become fibrocartilagenous consistency (no more nucleus fibrosus) at age 20, decreases blood supply and disc height, no disc between OA and AA joint Thoracico heart shaped body, o facets for ribs to attach, o facets in coronal orientation, rotation, o prevents forward translation, rotate and side bend opposite, Lumbar- long spinous processes, large bodies, facets in sagittal plane, o translation, resists rotation, rotate and side bend opposite side o L5- coronal plane for facets

Spine Movements- top vertebrae indicates the direction, planar movements are flexion and extension, coupled motions are SB and rotation, compression, distraction Flexion- glide superior and anterior, anterior disc is compression, limited by intraspinous ligament, ligamentum flavum, and posterior/extensor mm

Pain with inflamed facet joints, posterior disc herniations, muscle spasms, sprained posterior ligament, joint stuck in ext limits flexion Extension- glide inferior and posterior, limited by spinous processes, anterior longitudinal ligament, pars interarticularis often injured SB- facets open up on one side (contralateral to bend), ipsilateral Z joint glides inferiorly, contralateral Z-joint glides superiorly Pain with pars interarticularis, OA (CPP of facets) Rotation- ipsilateral facet opens up, contralateral facet compressed, opens lateral foramen, optimal stimulus for disc Distraction decreases pain, therapeutic effect on discs, facet joints, and ligaments

Fryettes Law- in a flexed LS SB and rotation to the same side, in an extended LS SB and rotate to the same side Intervertebral Disc: Function- mobility and stability, transmits load from one vertebral body to the next, proprioception Nucleus pulposus- in center of disc, gel-like material, 70-90% water, 15-20% collagen II, 65% which is proteoglycans to hold in the water, Annulus fibrosus- around the nucleus pulposus (no clear cut boundary), 60-70% water, 50-60% of dry weight is collagen type I and 20% is proteoglycans, has lamellae oriented at 65 degrees from vertical to protect the nucleus pulposus and resist tensile forces, innervated by recurrent sinuvertebral nerve, proprioception of spine o Recurrent sinuvertebral nerve- innervates outer 1/3 of annulus fibrosis, dura mater, posterior longitudinal ligament, supplies the disc at its level and the level above o Outer annulus and end plates are highly innervated Vertebral end plate- .6-1 mm thick of cartilage above and below the nucleus pulposus o If have a break in the end plate then bone marrow and blood from the vertebrae fill in to cover the nucleus pulposus

Disc Mechanics 1. Nuclear movement- Nucleus and annulus move together as one 2. Tension- Annulus resists tension from rotation, compression and distraction 3. Compression- Annulus fibrosus changes shape but volume always stays the same, transfers load from one vertebral end plate to the next, with age the annulus fibrosus dries out and cant WB as load or as much 4. Distraction- Strains the fibers, annulus fibrosus resists 5. Shear- Fiber orientation prevents shearing in all directions, only those fibers oriented in the line of stress can prevent that direction of shear 6. Rotation Nutrition for Disc:

Passive- imbibitions, diffusion due to concentration gradient Active- spinal motion No arteries or blood supply inside the disc, only get blood from arteries of vertebral bodies, capillary beds of end plates, and outer 1/3 of annulus (not very much supplied there) Tallest in morning bc at night the discs are hydrated (passive nutrition) and during the day mvmt takes out more than brings is (dehydrated discs by evening)

OPTIMAL STIMULUS FOR REGENERATION Annulus- rotation, modified tension in line of stress Nucleus- intermittent compression and decompression Disc Injuries: - Intra-spongy nuclear herniation: soft disc, break in endplate nucleus pulposus spreads into bone dries out, presents as LBP, localized pain, WBing and compression cause pain, can cause Schmorls nodes later in life - Protrusion- contained herniation o Normal disc o Nucleus escapes periphery, may or may not cause pain o Nucleus into outer 1/3 layer of annulus fibrosus, may or may not cause pain, still contained in annulus, puts pressure on annulus, no pressure on nerve root o Nucleus in outer 1/3 edge of annulus and pushing on spinal nerve, still contained in annulus fibrosus, pain in gluteal/buttock area, no radiating symptoms, morning stiffness, sit in slouched position - Extrusion- nucleus out of annulus, pain, + SLR, + Slump, neurological signs and symptoms, irritation of dura mater - Sequestration- free fragment of disc, may migrate - Prolapse Protrusion, extrusion, sequestration and prolapsed all are displacement of nucleus from end plate Negative prognosis- severe nerve root pain, structural instability, deformity or structural anomaly present, trauma, deteriorating condition according to history of condition Oswestry- 50-points, how function is affected by LBP Fear avoidance- how fearful the patient is about moving around, lower the score the better Spinal Stenosis: Usually age related (65+ yo), osteophytes, congenital Localized pain, back and leg pain, bilateral radiating symptoms, neulogical claudication (cramping in calf, thigh or buttocks) Aggravated by extension, prolonged standing or walking, walking downhill, lying flat Eased by flexion, sitting, squatting, walking uphill, bike riding Flat back posture (lose lordosis bc dont like extension), painful extension, side bend towards involved side, central and unilateral PAs reproduce symptoms, TM test (pain with level walking less pain with incline, more pain with downhill walking), have peripheral pulse, X-ray and CT scan tells where stenosis is at

Work on ADLs with neutral spine, flexion and mobility exercises, stretch HS and hip flexors, traction, joint mobs in rotation to open foramina, TrA and glut muscle strengthening Must manage or else surgical intervention

Vascular Claudication: Plaque builds up inside the arterial walls PVD decrease in circulation TM test- walking produces pain in calf, incline produces more pain, stop walking and pain goes away, worse with increased effort or incline Change in spine position doesnt affect pain Aggravated by walking on level surface or up hills (buttock or calf pain) Eased by stopping walking or supine lying Skin color changes, temp changes, hair loss, LE cramping or tightness (calf muscles), no peripheral pulse Rarely have back symptoms or problems Acute Facet: Sharp unilateral pain over facet, increased pain with stretching and compression of joint, local tenderness with palpation, feels like back is locked into position, no peripheral symptoms History of unguarded movements (flexion and rotation) Limitations with facets opening Do manual therapy unilateral PAIVMs, manipulations, traction, mobility exercises, modalities Chronic Facet: Unilateral pain, less sharp over facet, increased pain with stretch of joint, local tenderness with palpation, stiff History of past acute facet Unilateral PAIVMs, traction, stretching and muscle re-education, ultrasound to decrease the inflammation Acute Nerve Root (ANR): Irritation/inflammation/compression to nerve root Distal symptoms are greater than proximal, starts as proximal ache and then gets more distal Severely limits ROM and activity, neurological exam are level specific, modalities, manual traction in supine or SLing, lumbar rotation Epidural steroid injection 1st to calm symptoms Chronic Nerve Root (CNR): Chronic irritation or nerve root History of acute nerve root injury, LBP, arthritic changes, slipped disc Gradually symptoms return to lesser degree, proximal symptoms are worse than distal Minimal limitation of activity, minor responses in neuro exam, localized thickness of tissues with palpation, stiff at segment May have pain with ROM OP, SLR tests reproduces symptoms, + slump test Unilateral PAIVMs, rotation, traction, treat neurodynamic signs, mobility exercises, segmental muscle re-ed

Instability: Defect in pars interarticularis of the spine (separated), most common at L5-S1, then L4-L5 Usually in teens, congenital or repeated trauma activities- flexion or extension activities Asymptomatic or pain with extreme extension and rotation, symptoms fluctuate, severe LBP after vigorous activity, must constantly change positions, catch pain, + Gowers sign (can flex but hard to get back to neutral), hinge (skin crease) at one segment with extension, central PAs are painful and have different end feel Flexion decreases pain Aggravated by end of ROM, flexion at 30-40 degrees (hesitation point) Need to avoid aggravating activities, extreme ROM and sustained posture Work on stabilization exercises, use external support (lumbar brace) Spondylolisthesis: Pars interarticularis slips due to spondylolysis Anterior slippage- superior vertebrae moves anterior on vertebrae below it

Neurodynamics- test if pt complains of symptoms during action or movements Nerves: Nervous system gets 25% of circulating blood Need blood, space, and movement! Have axoplasmic flow continuous with nervous system- flow goes in both directions If myelin sheath is damaged then more receptors come to help heal hypersensitive PTs treat the disruption Bad to immobilize Fascia, dura mater, pia mater, meninges, unhealthy tissue, and decreased foramina space can impact neurons Responds to pressure, absence of movement and lack of blood supply o Like movement and blood supply, dont like pressure Median nerve slides 2 cm in upper arm and 1 cm with wrist and fingers Sick nerve: AIGS- abnormal impulse generating sites (too much input hypersensitivity) Types: double crush or reverse double crush o Double crush- proximally compressed nerve, makes it vulnerable to secondary distal lesion o Reverse double crush- distal neural compression, causes effects on proximal nerve lesion Causes ischemia, inflammation, and disruption of axoplasmic flow Pain can be caused by changing the ion channels along the axon or injury inflammation Cfibers increase the concentration of substance-P CNS- dura mater, arachnoid mater, pia mater PNS- epineurium, perineurium, and endoneurium, covered by 50% connective tissue If nerve is immobilizednerves become more resistant to tensile stress (ROM)

3 weeks later- degenerative changes in myelin 6 weeks later- collagen deposition in the endoneurium 6-16 weeks later- decreases fiber diameter or myelinated fibers ULTT- upper limb tension test ULNT1- base test, tells what nerve to test next ULNT2a- Median nerve bias ULNT2b- radial nerve bias ULNT3- ulnar nerve bias Upper extremity entrapment: Can occur anywhere there is a change in direction of the nerve or joint it goes around (or connective tissue it goes through) Common at C6, shoulder and elbow Causes: trauma (direct blow or traction), posture, overuse (microtraumas), arthritic changes, soft tissue scarring, compression, chronic condition Detensioned posture- thumb in pocket, hard to put elbow up with HBH (to do hair or put on shirt), protracted shoulder girdle, elevated scapula, head side bent towards affected UE, supports affected arm Presents with detensioned posture, irregular active mvmts, may or may not have neurological signs, hypersensitivity of nerve palpation, + neural tension signs, symptoms are pulling, tight band Tension test-positive reproduces symptoms, abnormal or asymmetrical resistance through mvmt, less available ROM in tensioned positions, change in symptoms with added components (ex. PNFcervical), and asymmetrical response to tests *dont hold pt in a tensioned position any longer than have to to establish a positive test NOT for- malignancy, vertebral column instability, neurological signs worsening, CE symptoms, tethered spinal cord, unstable disc lesion, diabetes Slump Test- started with pt complaining while getting into and out of car, for low back and LE symptoms, elicits symptoms more proximally, more aggressive than SLR Sit straight up with knees together at back of table hands behind the back slouch thoracic OP neck flexion neck OP leg extension ankle dorsifleixon release neck OP + test- reproduces symptoms, restriction of mvmt, asymmetrical mvmt Normal to have thoracic stretch with neck flexion, posterior thigh or knee restriction with extension, DF intensifies symptoms, and releasing neck flexion should decrease the symptoms and increase the ROM SLR- tests sciatic nerve, elicits symptoms more distally, leg is lifted passively into hip flexion and knee extension, determine symptom response, quality and range of movement, can wind up distally (before lifting leg) or proximally (after lifting leg), should have s/sx between 35 and 70 degrees, greater than 70 degrees is likely to be HS tightness, DF- tibial nerve, DF + INV- sural nerve, PF + INV- common peroneal nerve, medial rotation/hip add- lumbosacral plexus, EVER- posterior tibial nerve, can also do reverse SLR in prone with leg hanging off table Crossed SLR- indicates presence of large disc protrusion if SLR produces pain in contralateral leg but no pain when it is then raised, pain in both legs, or when raising one leg and the leg on the table has pain

Bilateral SLR- can detect central protrusions if bilateral SLR + DF + PNF (passive neck flexion) Slump and SLR NOT for: irritable and progressive disorders, unstable disc, recent progressive neuro changes, and CE symptoms Degenerative Disc Disease- males, 40-50s, commonly their occupation involves lifting, sitting, repetitive movements, or history of contact sport, pain is constant, low grade ache, rarely have leg symptoms, due to overuse, aggravated by bending, sitting, sit to stand, lifting, coughing, sneezing, sudden end of range motions, compression activities, eased by lying down and unloading the spine, may have history of repeated annular tear to produce disc narrowing, bone spur formation or hyper/hypo-mobility of a segment, ROM limited during acute episodes, difficulty returning to neutral (+ Gowers sign), - SLR test, minimal pain with palpation, diagnostics may reveal x-ray bone spur, narrowing space, breakdown of the end plates, sclerosis of facets and vertebral margins Cervical disc- thins with age bc loses H2O Lumbar- disc thickens with age Rare in thoracic spine- look for non-PT causes such as tumor Intervention- McKenzie protocol, central and unilateral PAs, traction, unloading, aqua PT, stabilization, body mechanics, stretches (SKTC, DKTC) Herniated Nucleus Propulsus- 20-55 year olds, common in construction works (poor body mechanics) or individuals who sit a lot (poor posture), possible lumbar stiffness, muscle spasms, signs of nerve root compression, aggravated by flexion, sitting, sit to stand, walking, sneezing, coughing, eased by lying down and unloading, may have history of sudden onset but usually due to repetitive bending, lifting, or frequent lifting activities, esp flexion + rotation, limited ROM, SLR test + or Intervention- McKenzie protocol (repeated extensions migrate HNP back to normal, centralize symptoms), central and rotation joint mobs, intermittent traction, stabilization, body mechanics, stretches, epidurals or steroids, surgery Supine rocking- rotation is optimal stimulus for annulus healing, intersegmental flexibility/motion Unloading- supine with legs up, hips at 90, pain relief position, no tension or rotation from the pelvis Hyperextension- good to unload spine, rehydrate discs, and improve disc nutrition, decrease tension on L5 nerve root McKenziePostural dysfunction- less than 30 yo, females, pain is next to spine, intermittent pain, due to prolonged stress of normal tissues, no pathology or deformity, no ROM loss, sustained position symptoms reproduce Intervention- pt edu, postural exercises, neuromuscular re-ed Dysfunction- more than 30 yo, males, pain next to spine, intermittent pain, pain with end range stress, no deformity, ROM loss, end of range pain, repeated movements reproduce symptoms but not worse Intervention- stretch shortened structures, posture education, pt edu Derangement- 20-50 years old, pathology present, pain is local, referred or radicular, constant or intermittent, has most success with centralization, deformity present, ROM loss, pain with movement and end range

Centralization: Distal symptoms moves proximally with certain movements Only in derangement syndrome/instability Symptoms may shift from side to side Indicates correct movement Means good prognosis for recovery Peripheralization: 1. Symptoms that are proximal move distally with certain movements 2. Not good for recovery Extensions Prone lying- 5-10 minutes Intermediate step- progressive extension with pillows- start with one pillow under chest and gradually add, hold 10 minutes, when finished take pillows away over several mins Prone lying on elbows- weight on forearms and elbows, hips on mat, sag lower back, hold 5-10 minutes, want segmental extension of LS, no contraction of back muscles Prone press-ups- repeated extensions, hips on mat, straight elbows, palms on mat, sag LS, repeat 10 times Standing extension- can do as HEP (nourishes spine), hands on small of back, hold 20 seconds, repeat 3-5x, do after flexion activities Spinal Stability Functional spine- tension, compression and shear stresses, all can be controlled by stabilization, must have proximal stabilization before distal mobility, stabilize in multiple positions, TA 24/7 (strength and endurance, make habit) *proximal stability safe dynamic mobility* Stabilized spine: 1. Passive support- osseoligamentous system, bones, ligaments 2. Active support- muscles 3. Control of muscles by CNS Segmental instability- abnormal movement of one vertebrae on another, increases size in the neutral zone, decrease in ability of stabilization to maintain intervertebral neutral zone in its physiological limits, leads to neurological dysfunctions, deformities, and pain Physiological range of intervertebral motion: Neutral zone- movement occurs with little resistance Elastic zone- between neutral zone and physiological range, mvmt occurs with internal resistance Clinical instability- reports signs and symptoms of instability, my back went out, shifting pain, increases size of neutral zone, mechanical back pain Due to instability in passive system (bones, ligaments), identified by radiographs, assessed with passive intervertebral or accessory movement testing Due to active system- unstable at low loads, decreased cross sectional area, decreased contraction with palpation, mm fatigue

Due to neural system- change in muscle onset timing, change in pattern of recruitment, change in muscle stiffness, change in kinematic patterns

Anterior instability test- pt in SLing, pushing femur posteriorly, assessing anterior translation of superior segment, assesses passive system (bones, ligaments) Prone instability test- assesses active system (musculature), pt prone with legs hanging off table touching the floor, do PAs, if hurts then pt actively raises feet off ground, do PAs, if doesnt hurt then muscles are protecting the back, if still hurts then stabilization exercises wont be as effective and potential surgery candidate Beighton-Horan Ligamentous Laxity Scale- assesses laxity of joints, scored out of 9, if have 7 then prone to instability Muscle stabilization predictive factors- less than 40 yo, positive prone instability test, + Gowers sign, muscle spasms from flexion neutral, lateral shifting, SLR 90 degrees Negative factors- negative prone instability test, absence of lumbar hypermobility, FABQ score of 9 or higher (pt doesnt think they will get better) Global muscles- coactivation increases compressive load on LS, limited control of shear forces, can cause spinal rigidity, control load and compression, cant control intersegmental stability Rectus abdominis, internal obliques, external obliques, lateral fibers of quadratus lumborum, thoracic part of lumbar iliocostalis Local muscles- responds to WBing exercises, static WBing, antigravity working postures, intersegmental stability, erect posture, joint compression, provide stiffness, control translation (no excessive shear), anticipate load and movement, support and protect joints Diaphragm, pelvic floor muscles, TrA, multifidus, medial fibers of quadrates lumborum, lumbar part of ilocostalis and longissimus, posterior fibers of internal obliques attached to TFL Lumbar stabilization- TA and multifidus, submaximal contraction, regular breathing, 24/7 Multifidus- controls the neutral zone, lordosis, tension on the thoracolumbar fascia, adjusts spine, controls pelvic rotation, intersegmental muscle TA- 1st muscle to work when there are forces on the spine (UE or LE movement) Move UE- TA, multifidus and pelvic floor are all contracting beforehand Prone test- pt in prone, inflate cuff to 70mmHg, biofeedback under abdomen, draw in abdominal wall for 10 seconds while breathing normally, repeat 10 times for endurance, watch for compensations (pelvic tilts, flexed spine, rib cage depression) Correct- decreases 6-10 mmHg; incorrect- increase in pressure, decreases less than 2 mmHg, no change Contraindications- obesity, unable to lie prone, respiratory pts Leg load test- supine, hooklying, biofeedback under LS on opposite side of leg moving, inflate to 40 mmHg, leg moving is the loaded leg Ex. Load L leg cuff under R LS

Steps: heel slide with opposite leg support unsupported leg extension with opposite leg support heel slide with unsupported opposite leg unsupported leg extension with unsupported opposite leg Traction Effects of traction - Distraction of vertebral bodies - Distraction and gliding of facets - Tenses ligament structures (helps with HNP) - Widens intervertebral foramen - Straightens spinal curves - Stretched spinal muscles Technique - Determine force- start with lighter force and then increase (25-50% of body weight) - Determine duration start with 3-5 minutes and then progress - Static vs intermittent o Static- sustained pull for irritable mod-severe conditions o Intermittent- hold-rest time, use with less severe and irritable conditions - Pt position o Flexion Supine with posterior pull Prone with anterior pull o Extension Supine with anterior pull Prone with posterior pull - Harnesso secure pelvic belt first, then thoracic o belts should be on skin o top of the pelvic belt should be at umbilical, and top buckle should be above iliac crest o Take up all the slack in the harness Guidelines - Pt must be relaxed - Dont leave unattendedleave bell and stop button - Continually monitor symptoms - Consider SINS before treatment - Ask special questions - Traction is a short term treatment (less than 6 weeks) and should be used in conjunction with other interventions - Always test with manual traction before trying mechanical Indications for traction - HNP- distracts vertebra so creates negative pressure to suck the disc back in o Sustained or long hold-rest (60 on, 20 off) for intermittent, 5-10min treatment time, extension position - DDD/DJD- reduces intradiscal pressure to help nutrition of nucleus pulposus o Intermittent (20 hold, 10 sec rest), prone or supine, extension is preferred

Joint hypomobility- passive mobilization of joints o Intermittent with short hold-rest, prone or supine position Facet impingement- releases restriction of facet joints o 20 hold, 10 off Muscles spasm- separates painful joint structures so muscle spasm is relaxed o 60 hold, 20 offlonger hold times

Contraindications - structural disease secondary to tumor or infection - vascular compromise - RA - TMJ - A condition where movement is contraindicated Precautions - Acute sprains or strains - Inflammatory condition - Joint instability - Pregnancy - Osteoporosis - Hiatal hernia - claustrophobia Predictors of who will benefit - Low level fear avoidance beliefs - No neurological deficit involvement - Older than 30 - Non-involvement in manual work Cervical traction - Force 5-20 pounds - Consider 5 Ds for vertebral artery/ c-spine o Dizziness o Diplopia o Disarthria o Disphagia o Drop Attacks SI Joint- transfers load from trunk to legs during gait, WBing activities and changing positions, absorbs LE motions, joint made to limit mobility, cartilage increases friction to decrease mobility, irregular joint surface, covered by lots of ligaments, 2 innominates + 1 sacrum, 2 SI joints, innervated by L2-S5, usually have pain over buttock, lower lumbar, and sometimes radiates down post leg to knee (rarely past knee) Joint type- anteriorly diarthrodial (synovial), posteriorly (non-synovial), gaps more anteriorly than posteriorly Sacral surface- hyaline cartilage Sacral base is superior, sacral apex is inferior, sacral alae like TPs of spine, S2 at PSIS (only one palpable) Iliac surface- fibrocartilage

Lumbosacral junction- L5-S1, facets in frontal plane, dense superior articular process of sacrum, iliolumbar ligament crosses SIJ Ligaments: all connected to thoracolumbar fascia and back muscles- can MMT Iliolumbar ligament- L4/L5 transverse processes to iliac crest, restricts all planes of movement (extension and opposite side flexion), covers superior aspect Ventral/anterior sacroiliac- limits anterior gapping, covers anterior joint and superior capsule, weakest of all lig, if injured then hypermobility and source of pain, tested in anterior gapping test Interosseous- limits posterior gapping, can palpate below PSIS, tested with posterior gapping test Long dorsal ligament- limits counternutation Sacrotuberous- limits nutation, ischial tuberosity to spine of sacrum (S3, S4, and S5), prevents forward movement of sacrum, palpate above ischial tuberosity, blends with gluteus and biceps femoris Sacrospinous- limits nutation, deep lig, lateral sacrum to ischial spine, prevents forward rotation of sacrum Outer tube muscles: compress on inferior muscles side Anterior oblique system- internal and external oblique, abdominal fascia, contralateral adductors Posterior oblique system- latissimus dorsi, contralateral glut max and TFL Lateral system- glut medius and minimus and contralateral adductors Longitudinal system- erector spinae, TFL, biceps femoris, and sacrotuberous ligament Inner tube muscles: TA, multifidus, diaphragm, pelvic floor muscles, core stability Sacroiliac Motion- according to base of sacrum, sacrum moves on ilium Nutation- anterior + inferior movement Counternutation- posterior + superior movement Normal position in body: 30-45 degrees of anterior tilt Long arm- anteriorposterior plane, S2 to S4 Short arm- covers S1, superior to inferior aspect of joint, vertical plane Trunk bends forward- sacrum nutates of way, innominates anteriorly rotate Trunk bends backward- sacrum nutates to increase lordosis, innominates posteriorly rotate Trunk rotation- sacrum rotates with spine Gait- rotation + flexion/ext, lots of pain with walking if injured Iliosacral Motion- ilium moves on sacrum, ex. When hips are moving, anterior and posterior rotation, upslip and downslip, inflare and outflare (reference is midline or umbilicus) Hip flexion- unilateral innominate posterior rotation Hip extension- unilateral innominate anterior rotation Assess SIJ Stability- SLR test Form closure- passive stability, may need SI belt, anatomy and structure of joint Force closure- active stability, need neuromuscular re-ed, muscles, fascia, ligaments, and neural control

Sacral axial rotation- torsion: rotation + SB Pubic symphysis- no direct muscle attachment, fibrocartilaginous disc Painful side of SIJ is the problem side. Innominate dysfunction- rotations, upslips, and flares. Sacral dysfunction- torsions and rotations. Can have pain in pubic symphysis- change in activity contract adductor mm to help stabilize, adductors attach close to pubic symphysis Hypermobility- WBing activities, changing positions in bed, history of trauma or pregnancy, pain with change in position, deep shift of clunk, difficult load shift test, positive pain provocation test Test- SLS, hop on one leg, sit to stand Intervention- work in diagonal/transverse planes, support/brace, strengthen inner and outer tub muscles, pt edu to avoid agg activities, modalities to decrease inflammation Hypomobility- LS and hip movements, anterior or posterior direction, positive mobility tests, asymmetric palpation Intervention- mobilization, manipulation, muscle energy SIJ Syndromes: Systemic disease- infection, inflammation, AS Trauma- pregnancy, high velocity, falls, infants, hypermobility, hypomobility Chronic dysfunction- hip and spine pathologies put too much force on SIJ Always work on/assess LS or hip related dysfunctions with SIJ problems! SIJ Success Prediction Rate- FABQ below 18, symptoms for 15 days or less, no symptoms distal to knee, LS hypomobility at any level, hip with IR greater than 35 degrees

UPPER CERVICAL SPINE

Anatomy C1:

C2:

Ligaments: from T spine-> to what they are in C spine Ant long ligament becomes-> anterior atlantooccipital membrane Post long lig becomes -> tectoral membrane Lig flavum-> becomes post atlanto-occipital membrane Transverse lig across posterior articular facet of dens, holds C1 to C2 Facets- convex, only joint where both surfaces convex, allows rotation, 50% comes from C1/C2 LOWER CERV spine problem more problems with SB, UPPER difficulty with ROT Alar lig: prevents mvmt in ROT and SB -holds C2 to occiput UPPER CS Innervation: Dorsal and ventral rami of C1-C3 supplies all structures: muscles, the OA, AA joint and C2-3 Z joint, all ligaments and the vertebral arteries BIOMECHANICS: OA joint: primary flex/ext motion AA joint: primary rotation motion

**ROTATION & SIDEBENDING OCCUR IN OPPOSITE DIRECTIONS** VERTEBRAL ARTERY: Avoid treatments that combine EXT and ROT These progressively occlude VA: Rotation rotation + extension Rotation + extension + traction

CLINICAL SYNDROMES: UPPER CERVICAL SPINE

FORWARD HEAD POSTURE: Forward head posture can stress upper cervical structures and lead to headache -> Correction of posture starts /C T-SPINE Vertebral Artery o Agg: N/T around lips, dbl vision, dizziness, dysarthria, dysphagia, drop attack o Rotation and extension is more painful (occlude the artery). o Hx: MVA (extension injury), trauma (compression from osteophytic or disc, o Stretching, kinking). Cervical instability and fractures, manipulation or o Sudden neck movements. Cervicogenic HA o Agg: reproducible with neck movmt, posture, position. 50% are occipital (may radiate into ear) and suboccipital. o Ease: medications, change in position/posture, lying down. o Hx: hx of neck pain. Due to hypo/hyper mobility, DJD, trauma. o Objective: AROM, alar lig, transverse lig, central PAs, o Manual Therapy: Central PAs, traction, o Ther-ex: cervical isometrics, thoracic stretching/strengthening Postural correction, scap squeezes, neck stretches. Tension HA o Agg: bilateral, trigeminal distribution o Hx: stress or lack of sleep. Women more than men. o Objective: AROM, central PAs, unilateral PAs. o Manual Therapy: Central PAs, Unilateral PAs, traction. o Ther-ex: Postural correction, neck stretches

Whiplash o Agg: Pain is dominant complaint. Cautious/apprehensive with active Movements of neck. Dizziness with active movements. Pain location: Suboccipital, neck, shoulders, scapulae, back, frontal HA, retro-orbital, Facial/throat pain, larygneal disturbances, numbness/parasthesia in UE

o o o o o

Hx: MVA. Special questions: hearing or vision disturbances? Dizziness? Feelings of unsteadiness? Depression or fatigue? Irritability? Insomnia? Light-headed? 5 Ds? Vertebral artery? Objective:, ALAR lig, transverse lig, central PAs, AROM Manual Therapy: Central PAs, traction, Ther-ex: Chin nod, cervical stretches, AROM, scap squeezes.

OTHER TRAUMATIC UPPER CS INJURIES A-O dislocation: 100% fatal, shear force of occiput on atlas Fracture of posterior arch of atlas: result of vertical compression; results in massive subocc HA A-A dislocation: rupture of transverse ligament, JEFFERSON Fx: fracture of ant. and post. arches of C1, usually from blow to back of head DENS Fx: common in MVA, seen on open mouth x-ray, Dens will Fx b4 alar ligaments will tear Hangmans Fracture: results in dens into brainstem, not always fatal Rotary A-A Subluxation: face mask injury

CERVICAL SPINE
Consists of 37 joints, which allow for more motion than any other region of the spine Stability is sacrificed for mobility More vulnerable to both direct and indirect trauma The lordotic curve develops secondary to the response of an upright posture provides a shock-absorbing mechanism

ANATOMY Each pair of vertebrae in this region is connected by a number of articulations: a pair of zygapophyseal joints, the uncovertebral joints, and the intervertebral disc very little bony stability Intervertebral foramina o principal routes of entry and exit for the neurovascular systems to/from vertebrae o intervertebral foramen decrease with full extension and ipsilateral side bending of the cervical spine, uncovertebral osteophytes may compress the nerve root and cervical cord posteriorly Ligaments o Anterior longitudinal(ALL). narrower in the upper cervical spine but is wider in the lower CS than in TS o Posterior longitudinal(PLL). considerably thicker in the CS than in the thoracic & lumbar regions Neurology o cervical spine is the only region that has more nerve roots than vertebral levels o structures supplied by the upper three cervical nerves can cause neck and head pain o mid to lower cervical nerves can refer to shoulder, anterior chest, upper limb, and scapular area BIOMECHANICS Segmental side bending is extension of the ipsilateral joint and flexion of the contralateral joint Rotation, coupled with ipsilateral side bending, involves extension of the ipsilateral joint and flexion of the contralateral

FORWARD HEAD POSTURE causes neck muscles to lose blood, suffer damages, fatigue, strain, cause pain, burning and fibromyalgia. Creep: When spinal tissues are subject to a significant load for a sustained period of time, they deform and undergo remodeling changes that could become permanent. o this is why it takes time to correct FHP. EXAMINATION o Screen!! the patient first Instability, trauma, 5Ds, The examination must be graduated and progressive so that the testing can be discontinued at the first signs of serious pathology Hx: pain source, MOI, Aggs= washing hair, turning around in car, getting dressed, reading Combined motion testing o A restriction of cervical extension, side bending and rotation to the same side as the pain is termed a closing restriction. Can interfere with nerve root Treat differently, may combine movement to facilitate closing o A restriction of cervical flexion, side bending and rotation to the opposite side of the pain is termed an opening restriction Special Tests o Foraminal compression Fingers laced across top of head, Axial compression, looking for increased symptoms o Axial distraction Tell them you are going to cover their ears o Upper limb neural tension Median, Ulnar, Radial INTERVENTION STRATEGIES postural re education neck specific strengthening stretching exercises mobilization ergonomic changes at work

CLINICAL SYNDROMES: C-SPINE

Cervical Disc o Agg: extension, rotation to painful side, prolonged flexion. ADLs limited, o Speed of movement altered, driving and sitting is uncomfortable. Cloward o Sign, ache/stiffness, may or may not have distal sxs (nerve root involved).

o o o o o

Hx: Not associated with incident. May be related to sustained posture. Slow Onset or wake with pain. May have history of MVA. Objective: central PAs, PPs, dermatomes, reflexes, Spurlings test, AROM Manual Therapy: Central PAs, unilateral PAs, traction. Ther-ex: postural correction, chin nod.

Spondylosis (Cspine) o Agg: sustained flexion, quick movements, EOR movements. Bilateral or o Unilateral. Ache may refer to suprascapular fossa. May c/o sharp pain. o HX: long history of neck pain. May have history of MVA. o Objective:, central PAs, unilateral PAs, AROM o Manual Therapy: Central PAs, Unilateral PAs, traction. o Ther-ex: cervical isometrics, postural, scap squeezes, neck stretches. Acute Nerve Root (Cspine) o Agg: any movement of the neck (closing down of foramen), arm movements, o Sustained flexion. +/- cough, awakes at night. Pain worse distally in o Dermatomal pattern. Possible cloward sign. o Ease: NSAIDS o Hx: Older patients that have degenerative changes. May occur in younger o Individuals, trauma included. May start with neck stiffness or from scapular o Area. Insidious, then spreads out. Prior episodes of neck stiffness. o Objective: Unilateral Pas, AROM, dermatomes, reflexes, o Manual Therapy: Traction, unilateral PAs (if severity allows) o Ther-ex: postural exercises, scap squeezes, chin nod, cervical stretches.

Chronic Nerve Root (Cspine) o Agg: sustained flexion, movements that narrow foramen. Can be nagging, o Able to sleep at night. o Hx: more common in middle age and older population with already o Established degenerative changes. Dermatomal pattern, not necessarily o Distal. Usually intermittent. Patchy distribution. Result of past acute nerve o Root that didnt completely resolve. Prior episodes of neck stiffness. o Objective: AROM, dermatomes, reflexes, neurodynamics, o Manual Therapy: Unilateral PAs, traction, neurodynamics. o Ther-ex: Postural exercises, scap squeezes, chin nod, cervical stretches,

MS II Comp Review Part 4 Thoracic Spine Anatomy Joints

Costotransverse Joint: The synovial joint between the articular facet on the posterior aspect of the rib and the articular facet on the anterior aspect of the transverse process. Found on T1-T10. Costovertebral Joint: Where the rib articulates with the disc and vertebral body at the same level and the level above the rib. Zygapophyseal Joint: Limits flexion and anterior translation of the vertebral segment. Allows rotation. Rule of Three: used to determine location of transverse processes T1-T3: spinous process and transverse process at same level T3-T6: transverse processes are half a level above the spinous process T7-T9: transverse processes are a full level above the spinous process T10- T12: gradual return to same level Ligaments Anterior Longitudinal Ligament: narrow but thick compared to the rest of the spine Posterior Longitudinal Ligament: wider at intervertebral disc level but narrower at the vertebral narrower at the vertebral body than the lumbar region Ribs True Ribs: ribs 1-7 which attach directly to the sternum Typical Ribs: ribs 3-9 which have a posterior end (head, neck, tubercle) Ribs 11-12: no anterior articulation and no articulation with superior vertebra Ribs 1, 6, 7: have costal cartilage that is linked to the sternum by a synchrondosis Ribs 2-5: connected to the sternum by a synovial joint Blood Supply: Provided by the dorsal branches of the posterior intercostal arteries. Venous drainage occurs through the anterior and posterior venous plexuses. Overall the spinal cord is poorly vascularized between T4-T9. Thoracic Spine Biomechanics Flexion: Initiated by abdominal muscles, continued with gravity, and eccentrically controlled by the erector muscles. Vertebral body translates anteriorly, transverse processes upwardly rotate, and ribs downwardly rotate. Extension: Produced by lumbar extensors and results in an inferior glide of the superior facet of the zygapophyseal joint. Overall thoracic extension ROM is 15-20 degrees with 1-2 degrees available per a segment.

Side Bending: Initiated by the ipsilateral abdominals and erector muscles and continued with gravity. Total thoracic side bending ROM is 25-45 degrees with 3-4 degrees available in the upper segments and 7-9 degrees available in the lower segments. Axial Rotation: Produced by abdominal muscles, other trunk rotators, or by unilateral elevation of the arm. Coupled Motions Cervicothoracic Region: Side bending and rotation occur to the same side Thoracolumbar Region: Side bending and rotation occurs to the opposite side Mid Thoracic Region: Variable coupling Respiration Upper Ribs: Pump handle which results in an anterior elevation to increase the anteriorposterior diameter of the thoracic cavity Middle and Lower Ribs: Bucket handle which results in a lateral elevation to increase the transverse diameter of the thoracic cavity Clinical Prediction Rule for Thoracic Manipulation for Neck Pain 1. Symptoms less than 30 days 2. No symptoms distal to shoulder 3. Cervical extension does not aggravate 4. FABQPA score less than 12 5. Decreased upper thoracic kyphosis 6. Cervical extension less than 30 degrees *3/6 variables = 86% success rate

Thoracic Syndromes

Syndrome Upper Rib Conditions

Pt profile

Causes Elevation of ribs, thoracic outlet syndrome, forward head posture, open mouth breather, cervical trauma Increased tension in nervous system, natural posture, constant loading of joint

Symptoms Pain, tingling, numbness, and vascular changes in arm and hand

Assessment

Intervention

1st rib Muscle assessment and stretching, posture x-ray education, mobs/manip, C/R technique

Flattened Upper Thoracic Spine

Mid-back pain and stiffness

Stiff cervicothoracic junction or thoracic spine, x-ray Stiff and painful PAIVMs, limited arm elevation, muscle imbalance

Unload joints, improve mobility, scapular and thoracic stability Mobilization, flexibility and strengthening exercise, posture education, breathing techniques, rib screw mobilization Flexibility exercises, central PA, transverse glide, soft tissue work, rib mobility, mobility exercise, manipulation if appropriate Mobilize adjacent segment, generalized strengthening, avoid end range movement, caution with

Generalized upper/mid thoracic stiffness

Middle or older age

Prolonged acquired posture, natural posture, metabolic changes

Stiffness, limited arm elevation

T4 Syndrome

Sympathetic reaction due to hypomobile joint from T2-T6 caused by trauma or posture

Aggravated by pushing/pulling, headache, N/T in arm and fingers, ache in mid back

Localized tenderness and stiffness with PA, hypermobility of adjacent segment, thickening of soft tissue, +/slump/ULTT Pain and muscle spasm with PA, increase segmental mobility, positive stability test

Upper/mid Thoracic Hypermobility

History of trauma, gymnast, ballet dancer

Trauma including microtrauma

Mid scapular pain, pain with prolonged position, constantly changing position, pain with overhead

lifting Costal Joint Derangement Reduced costal mobility (rotation) Aggravated by twisting or reaching, pain with breathing Painful trunk rotation, painful unilateral PA over costotransverse joint, pain and stiffness with rib mobility Positive cough/sneeze, painful PA

manipulation Acute stage: limit trunk rotation; chronic stage: mobilize and exercise

Thoracic Disc Lesions

Acute: forceful rotation injury; Chronic: degenerative changes

Pain shooting around or through chest wall, aggravated by any movement, pain with cough/sneeze, pain with breathing Snapping scapula

Scapulocostal Syndrome

Unknown may be due to scapular muscle imbalance, soft tissue irritation, or postural changes Costochondritis (localized irritation of costosternal joint of rib 2) due to posterior lesion, inflammation, or repetitive movement Young men Systematic rheumatic disease causing inflammation of the spine

Palpation

Trunk mobility, scapular stability exercises

Tietzes Syndrome

Anterior chest pain, localized or superficial pain, pain with breathing, pain with trunk movement

Pain and swelling over joint

Treat posterior lesion, RICE

Ankylosing spondylitis

Starts in SI joint and migrates up the spine, gradual onset, progressive stiffness

Pain, limited Mobility chest exercise, active excursion, lifestyle limited spinal mobility, x-rays, bone scan

Osteoporosis

Female, petite, use of steroids, lack of nutrition and exercise

Wedging and increased kyphosis, compression fractures due to lack of bone density Wedging of multiple vertebral bodies

Can be symptomless, if there is a compression fracture there is pain with breathing and movement Pain and stiffness

Increase kyphosis, x-ray, bone scan

Weight bearing exercise, muscle strengthening, dietary advice

Scheuermanns Male child Disease

Rigid curved spine

Exercise to improve mobility and back car, bracing, surgical intervention

Non-Neuromuscluloskeletal Conditions of the Thorax Non-Neuromuscluloskeletal Causes of Thorax Pain Cancer: Occurs in thoracic spine most often from lymphoma, breast, or lung cancer. Patients usually report symptoms of cancer and have neurological signs due to spinal cord compression. Patients with prostate and lung cancer usually present with back pain as initial complaint. Patients with breast, kidney, or colon cancer usually present with visceral symptoms as the initial complaint. Cardiac Conditions: aortic aneurysm, angina or acute MI. These are usually accompanied by cardiac symptoms such as weak pulse, abnormal BP, unexplained perspiration, or a pulsating sensation in the abdomen. Pulmonary Conditions: Symptoms should increase with coughing or deep breathing. Renal Conditions: Pain is usually dull and constant with possible radiation to groin. For an acute infection the patient will experience chills, frequent urination, and blood in their urine. Percussion should be positive in the flank areas in patients with renal problems. Gastrointestinal Conditions: severe esophagitis, peptic ulcer, and an acute gallbladder infection. Take a thorough history to identify GI conditions vs. musculoskeletal conditions. Scapular Pain: Respiratory viral infection or pneumothorax cause scapular pain that is aggravated by respiratory movements

Location of Systemic Thoracic/Scapular Pain

Systemic Origin Cardiac Pulmonary

Conditions MI Basilar pneumonia Emphysema Pneumothorax

Location Mid thoracic spine R upper back Scapular Ipsilateral scapula Lower costovertebral region or angle posteriorly Midback between scapulae 6-10 vertebral region Midback between scapulae; R upper scapula or subscapular area Midback between scapulae; R upper back; R interscapular or subscapular area Midthoracic or lumbar spine

Renal GI

Acute Infection Esophagitis Peptic ulcer (stomach/duodenal) Gallbladder diseases

Biliary colic

Pancreatic carcinoma

Recognizing Pain Patterns Vascular Throbbing Pounding Pulsing Beating Neurogenic Stabbing Burning Shooting Pricking Stinging or pinching Systemic Knife-like Boring Coming in waves Deep aching Progressive pattern with a cyclic onset Musculoskeletal Aching Sore Heavy Hurting Dull or sharp Visceral Knife-like Stabbing Boring Deep, poorly localized

Neuromusculoskeletal vs. Visceral Pathologies

Neuromusculoskeletal Description of Symptoms Dull ache, sharp or shooting pain with movement or breathing, localized pain or pain may radiate along dermatome pattern History of trauma, episode, or incident, postural dysfunction, etc Typically better with rest and worse with activity

Visceral Throbbing, pounding, cramping, heaviness, dull and difficult to localize

Mechanism of injury

Insidious onset, history of cancer or constitutional symptoms (fever, chills, nausea, fatigue, etc) Unrelenting or worse with rest; insignificant relief with rest Unremitting night pain; night pain not relieved by change in position Pain may be associated with food intake or physical exertion

Behavior of Symptoms

Associated Symptoms

Unexplained weight loss, loss of appetite, muscular weakness, cyclical and progressive nature or symptoms

TMJ Lecture Pain due to: inflammation of ligaments/capsule, internal derangement, arthritis, muscle imbalance Clicking Loud click on opening is disc reduction Smaller click on closing is disc dislocation If disc fully anteriorly displaced no clicking will be present and the patient will have limited range of motion when opening their mouth. This is called a locked joint. If disc is fully posteriorly displaced then it is an open lock. This occurs most frequently after a dental procedure

Local vs. Global Muscles

Local: A deep muscle that controls a single segments translation. Most likely to become inhibited or down regulated with pain. Global: A muscle that produces movement. Most likely to become up regulated with pain. Actions and Muscle Involvement Elevation (closing): masseter, temporalis, medial pterygoid, superior fibers of lateral ptyergoid Depression (opening): inferior fibers of lateral ptergoid, supra hyoids, infrahyoids, gravity Protrusion: superficial masseter, medial pterygoid, lateral pterygoid Retrusion: deep fibers of masseter, temporalis, suprahyoids *medial pterygoids are the most common muscle to cause problems* Normal Kinematics Elevation (closing): teeth approximation Depression (opening): maximum 40-50 mm or 4 finger widths, to be functional only need 35 mm or three finger widths Posterior rotation of condyles during first half of the movement with anterior rotation occurring during the second half of the movment Protrusion: 6-9 mm Mandible and disc translate anterior and inferior Retrusion: 3 mm Lateral Deviation: the opening range Physical Therapy: mobilize restrictions, stabilize hypermobility, improve stabilizer muscle control through full range, educate about posture, empower the patient with self-management techniques, stretches, address pain control and daily activities Rehabilitation After Cervical Spine Surgery Imaging: Not necessary unless there is a neurological deficit. MRI used for soft tissue definition. Surgical Indications: fractures from major trauma, fractures from minor trauma patients with osteopenia, progressive myelopathy (sensory disturbances in hand, intrinsic muscle wasting of hand, trouble walking, hyperreflexia), neoplasm Posterior Approach: used for lateral herniation, allows patients to avoid fusions, more technically difficult surgery, more pain due to increased musculature Anterior Approach: problems with swallowing and vocal changes Cervical Radiculopathy

Description: nerve root impingement usually from disc herniation MOI: forced hyperextension, rotation or both Initial Treatment: non-operative, rest/NSAIDS/oral steroids, cervical traction Surgical Indications: failed conservative management of at least 2-3 months, progression of neurological dysfunction (weakness), persistent numbness in dominant hand Surgery: discectomy, possible fusion

Cervical Stenosis Description: narrowing of spinal canal causing compression on spinal cord and nerve roots MOI: congenital or acquired, acute trauma with fracture or herniation Surgery: laminectomy Cervical Myelopathy Description: spinal cord compression causing upper/lower extremity weakness, bowel and bladder dysfunction, gait disturbance Indication for Surgery: always, no indication for conservative care Surgery: removal of vertebral body and disc and insertion of prosthesis, possible fusion Rehabilitation Strategies Acute Phase General Rules: brace/collar for fusion patients (doctor will specify), no ROM, keep head of bed elevated (sleep in recliner), no lifting over 5-10 lbs Physical Therapy: bed mobility, ambulation, stairs (may have trouble seeing with brace on the way down) Outpatient Physical Therapy: precision of movement including intrinsic muscles for fine control and making sure the extrinsic muscles do not become dominant, posture education, proper alignment of shoulder girdle Rehabilitation After Lumbar Spine Surgery Indications for Imaging: back pain in children less than 18 or adults older than 55 with severe pain, history of violent trauma, night pain, history of cancer, systemic steroids, drug abuse, HIV, marked morning stiffness, persistent severe restriction of motion, severe pain with motion, structural deformity, difficulty with urination, loss of bowel/bladder function, saddle anesthesia, motor weakness or gait disturbance, peripheral joint involvement

X-rays: used for young patients with spondylolisthesis and older patients with possible compression fractures MRI: examining neural compression, can detect infections with gadolinium enhancements, problems with MRI include picking up pathologies that the patient is unaware of because they have no symptoms Herniated Disc Treatment from a Surgeon Perspective: most patients get better with time, epidural steroid injections, not likely to refer to PT and if do refer just want modalities Indications for Surgery: positive straight leg raise, concordant imaging showing extruded disc herniations, cauda equine, severe motor deficit (MMT 1-2/5), no low back pain, few psychological stressors Indications for Conservative Care: disc protrusions, annular disruption, mild to moderate weakness (MMT 3-4/5) Surgery: discectomy/microdiscectomy Research: no long term difference in outcomes between herniations treated with surgery vs. conservative care Spinal Stenosis Differential Diagnosis: rule out vascular claudication by treadmill test (spinal stenosis patients see less pain with uphill walking because they are in flexion) Treatment from a Surgeon Perspective: pain meds, bracing, activity modifications, epidurals (especially good for elderly patients), laminectomy Comorbidites: if a patient also has spondylolisthesis or significant scoliosis they will need a fusion Spondylolisthesis Causes: degenerative, congenital, post-surgical complication Treatment from a Surgeon Perspective: bracing, pain meds, PT for grades I and II involving stabilization and core strengthening, epidurals, fusion and decompression Lumbar Fusion Complications: decreased bone mineral density and increased segmental instability Rehabilitation Strategies General Precautions: log roll (patient should have hips at bend of bed), spinal orthotics, no hip flexion greater than 90 degrees, no twisting/bending/rotation, no forward bending/stooping, no lifting over 5-10 lbs, no sitting for longer than 30 minutes due to increased compression Inpatient Acute: walking (may need roller walker), bed mobility (log roll), transfers Outpatient: movement exercises, educate about positions of comfort, modify functional tasks if needed, stabilization exercises (Transverse abdominus and multifidus)