THE SPINE

PTA 216
ORTHOPEDICS IN PTA
The Spine
• The functions of the spinal column
include:
– Supporting the majority of body weight
– Supporting the head, trunk, and UEs
against the forces of gravity
– Protection of the spinal cord
– Shock absorption
– Providing a stable structure by which we
can maintain an upright posture

Magee, 2008. pg. 92

Spinal Design
• 33 vertical segments, divided into 5 regions:
– Cervical (7)
– Thoracic (12)
– Lumbar (5)
– Sacral (5 - fused)
– Coccygeal (4 - fused)

Dutton, 2012. pg. 259

Spinal Design
• 2 functional pillars that assist spine
functionality

• Anterior Pillar: vertebral bodies and

intervertebral disks provide hydraulics,
weight bearing ability and shock-absorption

• Posterior Pillar: consists of articular

processes, facet joints, transverse processes,
and spinous processes. This allows spinal
movement and serves as the attachment for
posterior musculature.

Dutton, 2012. pg. 260

Anatomy of vertebrae
THE INTER-VERTEBRAL DISC
• The inter-vertebral disc
• fibro-cartilagenous tissue
– in between vertebral bodies consisting
• an outer layer (annulus)

• an inner layer (nucleus pulposus)

• The inter-vertebral disc provides:
– Shock absorbtion
– Movement between vertebrae
– Separation between the vertebrae
– To allow passage of nerve roots through the inter-
vertebral foramina

Magee, 2008. pg. 516-517

Spinal Mobility
• Flexion:
– Occurs in the sagittal plane
– Anterior portion of the vertebral bodies
approximate and the spinous processes
separate
• Extension:
– Occurs in the sagittal plane
– Anterior portion of the vertebral bodies
separate and the spinous processes
approximate

Dutton, 2012. pg. 262

Spinal Mobility
• Lateral Flexion
– Occurs in the frontal plane
– The vertebral bodies approximate on the side
toward which the spine in bending, and
separate on the opposite side

• Rotation
– Occurs in the transverse pain
– The body of the vertebra will rotate towards the
side in which the person is moving as the
spinous process moves toward the opposite
side

Dutton, 2012. pg. 263

Spinal Mobility
• Shear
– Occurs in sagittal, frontal, and transverse
planes
– When the body of the superior vertebra
translates over the body of the inferior vertebra
• Distraction/Compression
– Occurs in the transverse plane
– Result of longitudinal forces
– Vertebral bodies move either towards or away
from other vertebral bodies

Dutton, 2012. pg. 263

Anatomy, Pathology and Treatment Options

CERVICAL SPINE
Cervical Spine
• Consists of 37 joints, allowing more motion
than any other region of the spine

• Vulnerable to direct and indirect trauma

• Accounts for 15-34% of all outpatient physical

therapy referrals.

Dutton, 2012. pg. 267

Cervical Spine
Injuries to the cervical spine may manifest
themselves as localized
– “pain in the neck”
– or
– radicular
• symptoms that travel away from the site of
injury down one or both upper extremities
Radicular symptoms from the cervical spine may
affect the
– Face
– Head
– Neck
– Shoulder
– UE
– Peri-scapular region

Magee, 2008. pg. 133

Dutton, 2012. pg. 268
Cervical Sprain/Strain
• Result from an overload to the cervical
muscle-tendon unit by way of excessive
forces

– Causes elongation and/or tearing of muscles or

ligaments, edema, hemorrhage, and
inflammation

– Patient complaints:
• Pain
• Stiffness
• Tightness in upper back and/or shoulder
• Occipital headaches

Dutton, 2012. pg. 281

Intervention for Cervical Sprain/Strain
• Pain management
– Cryotherapy and electrical stimulation
• Possible cervical (Philadelphia) collar
• Gentle range of motion
• Strengthening as tolerated
• Postural education
• Self care/ Home Management

Dutton, 2012. pg. 281-282

Cervical Spine
Torticollis
• an abnormal twisting of the neck
• the head is rotated toward the side that muscular
tightness is found.
– may be congenital or acquired

– In many situations of torticollis, the anterior

scalene musculature will be visible when
viewing a patient from the front.
Torticollis
• Treatment for infants with torticollis
– Parent education
– Patient positioning
– Manual stretching activities
Acute Torticollis (Wry Neck)
• Effects young and middle –aged adults
• Typically happens overnight as a result of an
injury to the muscles, joints, or ligaments
while sleeping
• Patient will complain of painful muscle
spasms which will be visible and/or palpable
• Patient will demonstrate significant
limitations with neck mobility
• Patient will most likely hold head in a position
of comfort (leaning towards the side of the
involved muscles)

Dutton, 2012. pg. 285

Acute Torticollis (Wry Neck)
• “Hanging Head” method
– Patient in supine with head in 20 degrees of
extension with or without manual traction for
approx. 5-10 minutes
• Moist heat
• Massage
• Postural education
– -including sleeping with painful side on low,
firm pillow
• Gentle range of motion
– Upper extremities and cervical spine
• Cervical collar PRN for first 24 hours
• Medication as per MD
– Muscle relaxants and analgesics

Dutton, 2012. pg. 285

Cervical Spine
Thoracic Outlet Syndrome
• compression of blood vessels and/or nerves
coming from the spinal cord as they pass through
the space between the clavicle and upper ribs
– Brachial plexus and/or subclavian artery or vein

Dutton, 2012. pg. 283

Thoracic Outlet Syndrome
• Chief Complaint: diffuse arm pain
• Other complaints:
– Pain in neck, face, head, upper extremity,
chest, shoulder, scapula
– Upper extremity parasthesia, weakness,
heaviness, edema, ulceration, or Raynaud
phenomenon

Dutton, 2012. pg. 284

Thoracic Outlet Syndrome
• Conservative Treatment
– Correction of postural abnormalities
– Strengthening of weak muscles
– Stretching shortened muscles
– Mobilization by the PT of hypomobile joints of
the shoulder complex, clavicle, and first rib

Dutton, 2012. pg. 284

Special Tests for the Cervical Spine
Vertebral Basilar Instability (VBI) Test
• The patient is interviewed for signs of VBI.
• Prior to other testing/examination, the practitioner
performs end range cervical rotation in either
sitting or supine and holds test position for 10
seconds while observing for signs and symptoms
of VBI.
• Head is put in neutral for 10 seconds, followed by
rotation to the opposite side for 10 seconds.

Cook, 2013. pg. 129

Special Tests for the Cervical Spine
Vertebral Basilar Insufficiency (VBI)Test
Positive results are identified by:
-Dizziness
-Diplopia
-Dysphasia
-Dysarthria
-Drop Attacks
-Nausea
-Nystagmus

Patient should be referred for an appropriate

medical consult following a positive response.

Cook, 2013. pg. 129

Special Tests for the Cervical Spine
FORAMINAL COMPRESSION
TEST
• The patient is seated on a
plinth with the examiner resting
the palmar surface of his or her
hands on top of the patient’s
head.

• The patient will then laterally

flex the head while the tester
applies a downward pressure.
– This is to be done with lateral
flexion bilaterally

Konin, 2006. pg. 11

Special Tests for the Cervical Spine
Foraminal compression test
• Positive Finding
– increase in pain on the same side that the
head is laterally flexed to
– demonstrating possible nerve root
compression.
• This would then be compared with dermatomal
distribution to find the level of lesion.

**This test should be performed carefully and with caution,

especially in patients previously diagnosed with OA,
RA, osteoporosis, and spinal stenosis.**
Special Tests for the Cervical Spine
Foraminal Distraction Test
• The patient is seated and the examiner places
one hand under the patient’s chin and the other
hand around the base of the occiput.

• The examiner distracts the patient’s head from

the trunk while the patient remains relaxed.

Konin, 2006. pg. 14

Special Tests for the Cervical Spine
FORAMINAL DISTRACTION TEST
• Positive if the patient reports
– decreased pain
– and/or elimination of pain with distraction
• indicative of nerve root compression with
normal positioning/posture

*****This should not be performed on a patient

who has vertebral instability.*****
Therapeutic Intervention

STRETCHING ACTIVITIES
FOR THE CERVICAL SPINE
Stretching activities for Cervical Spine
Corner Stretch: Pectoralis Minor

Note: Avoid forward head posture during stretch

Dutton, 2012. pg. 288

Upper Trapezius Stretch (Self)
Ensure that the shoulder is in a depressed position

Dutton, 2012. pg. 289

Upper Trapezius Stretch (Manual)
Stabilize scapula into depression and downward rotation

Dutton, 2012. pg. 289

Levator Scapula Stretch (Self)
Education tip: Have patient look at their opposite hip to ensure
appropriate stretch

Dutton, 2012. pg. 289 and 292

Levator Scapula Stretch (Manual)
Can also be performed in sidelying
Massage
-Can be performed on any muscles in the cervical spine
-Goal is to place the patient in position where the muscles are
non – weight bearing
Dutton, 2012. pg. 291
Anatomy, Pathology, and Treatment Options

THORACIC SPINE
Anatomy of Thoracic Spine
• 12 thoracic vertebrae
• Each vertebrae is involved in at least 6
articulations
• Decreased mobility in order to protect the
thoracic viscera

Dutton, 2012. pg. 298

Anatomy of Thoracic Spine
• The rib cage in conjunction with the thoracic
spine provide stability
– Influences motion in other areas of the spine
as well as the shoulder girdle
– Provides assistance with weight bearing
– Increases potential for postural impairments

Dutton, 2012. pg. 298

Thoracic Spine
• Prone to both postural and biomechanical
dysfunction
• Treatment goals:
– Decrease pain, inflammation, and muscle
spasm
• Cryotherapy
• Electrical Stimulation
• Gentle exercises
• Possible bracing
• Heating agents after 48-72 hours
– Promote healing of tissue
• Join mobilization as performed by PT
• Massage
• Ultrasound
– Increase pain free range of vertebral and costal
motion
• Diaphragmatic breathing with stretching

Dutton, 2012. pg. 300

Postural Dysfunction
• Create an imbalance between agonists and
antagonists.
– Results in adaptive shortening and muscle
weakness
– Not typically reproducible with physical
examination
– Pain is typically aggravated by stress, fatigue,
and possibly change in weather.

Dutton, 2012. pg. 304

The Spine
Kyphosis:
• an increase in the thoracic convexity

• resulting in a rounded back with protracted

scapulae

– Also know as the “hump-back deformity”

Therapeutic Interventions

STRETCHING ACTIVITIES
FOR THE THORACIC SPINE
Supine Shoulder Sweep
-Important for the patient to maintain contact with their arm on
the plynth.
-Manual assistance may be used on the scapula or rib cage
- Perform with diaphragmatic breathing Dutton, 2012. pg. 301
Thoracic Spine Flexion
-Cat/Camel Stretch

Dutton, 2012. pg. 301

Thoracic Spine Extension over foam roll
-Allows focus to be made over a specific vertebral segment

Dutton, 2012. pg. 302

Supine Thoracic Spine Rotation
Keeping shoulders, trunk, and feet on the plynth, drop legs
down to one side together as far as comfortable and then
repeat on the opposite side

Dutton, 2012. pg. 302

Supine Thoracic Rotation using one leg
Progression as patient’s tolerance increases

Dutton, 2012. pg. 302

Anatomy, Pathology, and Treatment Options

LUMBAR SPINE
Lumbar Spine
-almost entirely flexion and extension
-minimal rotation and lateral flexion
-Motions occur in sagital, coronal, and
transverse planes

Dutton, 2012. pg. 315

Low Back Pain
Did you know that it is….
• the 2nd leading cause of physician visits in the
United States

• affects approximately 80% of the adult

population at some point in their lives

• one of the leading causes of Physical

Therapy referrals in the orthopedic setting
Some of the primary causes of low back pain
include:

• Muscle Strains

• Ligamentous Sprains

• Disk Injuries

• Spondylolisthesis

• Spinal Stenosis

• Spinal Fractures
The Inter-vertebral Disc
• Health of the intervertebral disc maintains the
health of the integrity of the mechanics of the
spine
• Low back pain may be due to
– Aging
• Reduces the moisture content in the disc
– Reduces overall height
– account for 20-25% of the total length of the
vertebral column
– natural degeneration of the disc
– trauma, inter-vertebral discs can be
responsible for causing low back pain in many
individuals.

Magee, 2008. pg. 516

The Inter-vertebral Disc
1 Disc Herniation
A general term used to describe when
there is any change in the shape of the
annulus

2 Disc protrusion
The nucleus of the disc bulges
against an intact annulus

2 Extruded disc
The nucleus of the disc bulges
through the annulus however
remains within the posterior
longitudinal ligament

3 Sequestrated disc
The nucleus of the disc breaks
through all barriers and is free
within the spinal canal
Magee, 2008. pg. 369
Dutton, 2012. pg. 338-339
Inter-vertebral Disc Herniations

Treatment will depend upon

– Pain
– Flexibility
– Strength
– Dermatomal and myotomal involvement
– Pain with movement
– Patient understanding
• This may include:
– physical agents
– therapeutic exercise
– therapeutic activity
– strengthening
– flexibility training
– patient education
– body mechanics training
– manual intervention

Shankman, 2011. pg. 371

Surgical Intervention for lumbar disk disease
• Discectomy
– Surgical removal of the herniated disk material
• May also be performed with laminectomy
• Microdiscectomy
– Surgical removal of only the portion of the disk
that is impinging on the spinal nerve root
• Requires decreased recovery time
• Percutaneous discectomy
– Decompression of the disk performed through
needles

Dutton, 2012. pg. 343

The Spine
• Scoliosis
– a lateral curvature of the spine
– usually demonstrated by an abnormal
curve and a second curve that results due
to compensatory movements in the
opposite direction.
• This results in a deformity resembling
the letter S.

Shankman, 2011. pg. 337

The Spine
• Functional scoliosis
– not caused by an actual spinal deformity

• secondary to another condition

– such as leg length discrepancy

• The curvature usually resolves itself

when the primary condition is
addressed.

Dutton, 2012. pg. 307

The Spine
Non-functional (structural) scoliosis

• the opposite of functional scoliosis

• the curvature is incorporated into the natural

growth and development of the spine

• curvature and the vertebral bodies are rotated

toward the convexity.
The Spine
More severe cases of scoliosis
• may require bracing
• to prevent further curvature of the spine from
occurring
– bracing is not intended to correct the curvature
already in place
– prevents further curvature
• minimal correction may occur

Shankman, 2011. pg. 338

The Spine
Lordosis:
• an abnormal anterior
convexity of the
lumbar spine

• Persons with lumbar

lordosis will present
as if they are sticking
out their stomach and
their buttocks.

**Both Kyphosis and

Lordosis can be
congenital,
neuromuscular, or
postural**
The Spine
What effects can these have on a person
clinically?
– Pain

– Poor posture

– Change in functional mobility

– Decrease in muscle strength

– Respiratory difficulties

– Neurological symptoms

– Psychological concerns
Muscle Strains and Ligamentous
Sprains can be caused by:
• Sudden movements
• Rapid Stretching
• Overuse injuries
• Treatment goals include:
– Decreasing pain and edema
– Increasing flexibility and strength
– Improving aerobic fitness to achieve prior level of
function
Treatment Plan for Sprains/Strains
Physical Agents as needed for
• Pain
• Inflammation
• Muscle guarding
Therapeutic Exercise
• Core stability
• Flexibility training
• Strength training
Manual Therapy
• Joint and muscle flexibility
• Soft tissue massage
Patient education
• Posture
• Body mechanics
• Aerobic capacity/fitness
• Home exercises
Piriformis Syndrome

• The sciatic nerve runs through the muscle

belly of the piriformis as opposed to
underneath it
– occurs in approximately 15% of the population
– characterized by pain reported deep in the
buttocks
– may be irritated by sitting

Magee, 2012. pg. 696

Spondylolisthesis

• condition in which
one vertebrae
anteriorly glides over
another
• usually occuring at
the L4-L5 and L5-S1
levels
• graded through X-ray
• measured by the
percentage of
displacement noted

Shankman, 2011. pg. 374-375

Spondylolisthesis
• Congenital
– Results from dysplasia of the 5th lumbar and
sacral arches and zygapophyseal joints
• Isthmic
– Caused by a defect in the pars interarticularis
resulting from an acute or stress fracture or an
elongation of the pars
• Degenerative
– Usually affects older population
– Most common at L4-L5 level
• Traumatic
– Occurs with fracture or dislocation of the
zygapophyseal joint
• Pathologic
– Resulting from a systemic disease causing
weakness of the pars, pedicle, or
zygapophyseal joint
Dutton, 2012. pg. 346
Grading for Spondylolisthesis:

Grade 1: 0-25%
Grade 2: 25-50%
Grade 3: 50-75%
Grade 4: 75-100%

Example: Grade 2
Shankman, 2011. pg. 375
Spondylolisthesis
• Patient complaints
– Chronic midline pain at lumbosacral junction
– Pain worsened with activity
– Pain alleviated with rest
– Pain exacerbated by repetitive extension
– Possible reports of radicular symptoms

Dutton, 2012. pg. 346

Spondylolisthesis Treatment Options
Conservative Treatment
-pelvic positioning
-lumbar stabilization
-flexibility of rectus femoris
-flexibility of iliopsoas

Surgical Intervention
-remove pressure on spinal nerves
-provide stability

Dutton, 2012. pg. 347

Spinal Stenosis
• Narrowing of the spinal canal secondary to
degenerative changes or trauma to the
lumbar spine.
– Facet joint arthrosis and/or hypertrophy
– disc bulging
– spondylolisthesis

• Most common in middle-aged and older

males

Shankman, 2011. pg. 374

Dutton, 2012. pg. 343
Spinal Stenosis
• Postural education
• Flexibility
• Core stabilization
• Aerobic conditioning

Dutton, 2012. pg. 344

Spinal Fractures
• Lumbar spinal fractures are usually a result of
a traumatic event and may be classified
according to the mechanism of injury
(compression, flexion, extension, etc…)

• Compression fractures are most commonly

noted in the osteoarthritic population as a
result of a rapid deceleration when
transferring to a seated position.

Shankman, 2011. pg. 330

Spinal Fractures

• Spinal fractures will most likely be

immobilized
– Casting
– Bracing
– until such time that physical therapy
intervention is appropriate

Shankman, 2011. pg. 330

Special Tests for the Lumbar Spine
Special Tests for the Lumbar Spine
WELL LEG RAISE TEST:
– the patient lying
supine on a plynth
– the examiner holds
the calcaneous of the
uninvolved leg and
places their superior
hand on the anterior
surface of the
patient’s thigh to
prevent knee flexion
– the examiner
passively flexes the
patient’s hip while
maintaining the knee
in extension

Cook, 2013. pg. 301

Special Tests for the Lumbar Spine

• A positive result for the Well Leg Raise

Test is demonstrated with complaints of
pain on the involved side, indicating
vertebral disk damage.
Special Tests for the Lumbar Spine
SLUMP SIT TEST:
– The patient sits at the end of a table with the arms
behind the back and legs together.
– The patient slumps as far as possible, producing
full trunk flexion
– If no changes are noted, the examiner asks the
patient to extend their knee or passively extends
one of the pt’s knees, symptoms are assessed
– If no changes are noted still, the examiner
passively dorsiflexes the pt’s ankle with the knee in
extension, symptoms are assessed.
– Neck flexion is then added to assess symptoms,
then released to see if symptoms subside
– This is to be performed on bilateral LE’s

Cook, 2013. pg. 302

Special Tests for the Lumbar Spine
SLUMP TEST
• Positive Findings
– Concordant reproduction of symptoms,
sensitization, and asymmetry findings.
Special Tests for the Lumbar Spine
VALSALVA’S MANEUVER:
– The patient should sit with the examiner next
to the patient
– The tester asks the patient to hold their
breath and bear down as if having a bowel
movement
• This test is considered positive if
– increase in pain secondary to the increase in
intrathecal pressure.
– May indicate:
• herniated disk, tumor, or osteophyte in the lumbar
cana.
• pain may be localized or referred to a
corresponding dermatome

Konin, 2006. pg. 132

Special Tests for the Lumbar Spine
• FABER TEST: (also known as the Patrick Test)
– This test is used to determine iliopsoas,
sacroiliac, and/or hip joint abnormalities.
• The patient lies supine on a table
• The examiner passively flexes, ABDucts,
and externally rotates the involved LE until
the foot rests on top of the opposite knee.
• The examiner then provides a gentle,
downward pressure on both the knee of
the painful side and the ASIS of the non-
painful side

Cook, 2013. pg. 333

Special Tests for the Lumbar Spine
FABER’S TEST
Concordant pain is assessed
-location
-type of pain
Treatment Interventions

STRETCHING ACTIVITIES
FOR THE LUMBAR SPINE
Single Knee to Chest

Dutton, 2012. pg. 344

Lower Trunk Rotation
Hamstring Stretch
Childs Pose Stretch
Gastrocnemius Stretch
Piriformis Stretch
Quadriceps Stretch
Lumbar Spine

CORE STABILITY EXERCISES

Posterior Pelvic Tilt Dutton, 2012. pg. 328
Bent leg fall out
Dutton, 2012. pg. 329
Bridging

Dutton, 2012. pg. 332

Quadruped Activities

Dutton, 2012. pg. 331

Bibliography
• Dutton, Orthopaedics for the Physical
Therapist Assistant. Jones&Bartlett. 2012
• Shankman, Fundamental Orthopedic
Management for the Physical Therapist
Assistant, 3rd edition. Mosby.2011
• Konin, Wiksten, Isear, Brader, Special Tests
for Orthopedic Examination, 3rd edition. Slack.
2006
• Cook, Hegedus, Orthopedic Physical
Examination Tests, 2nd edition. Pearson. 2013
• Magee, Orthopedic Physical Assessment, 5th
edition. Saunders. 2008