SPINE

Structure
 Spinal column consists of 33 vertebrae
 (7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 3 or 4 coccygeal) and
their respective intervertebral discs.

STRUCTURE AND FUNCTION OF THE

SPINE
spinal column is div. anterior and posterior pillars
The anterior pillar is made up of the
 vertebral bodies and
 intervertebral discs
The posterior pillar, or vertebral arch, is made up of the
 articular processes
 and facet joints
 two transverse processes,
 and the spinous process

FUNCTIONAL COMPONENTS OF THE

SPINE
 Motion of the spinal column is described both globally and at the functional
unit or motion segment.
The functional unit
is comprised of two vertebrae and the joints in between(typically, two
zygapophyseal facet joints and one intervertebral disc).

MOTIONS OF THE SPINAL COLUMN

Flexion/Extension
 With flexion, the anterior portion of the bodies approximate and the spinous
processes separate;
 with extension, the anterior portion of the bodies separate and the spinous
processes approximate.

THE SIX DEGREES OF MOTION

 With side bending, the lateral edges of the vertebral bodies approximate on the
side toward which the spine is bending and separate the opposite side.

SIDE BENDING.
 Motion in the transverse plane results in rotation.
 Rotation to the right results in relative movement of the body of the superior vertebrae to
the right and its spinous process to the left; the opposite occurs with rotation to the left.
Anterior/posterior shear.
Forward or backward shear (translation) occurs when the body of the superior vertebra
translates forward or backward on the vertebra below.
 Lateral shear. Lateral shear (translation) occurs when the body of the superior vertebra
translates sideways on the vertebra below.
 Compression/distraction. Separation or approximation occurs with a longitudinal force,
either away from or toward the vertebral bodies

ROTATION
 Coupled motions typically occur at a segmental level when a person side
bends or rotates their spine.
Coupled motion is
 defined as “consistent association of one motion about an axis with another
motion around a different axis”and varies depending on the region, the spinal
posture, the orientation of the facets, and factors such as extensibility of the
soft tissues.
 When motions of side bending and rotation are coupled, foraminal opening is
dictated by the side bending component.

ARTHROKINEMATICS OF THE
ZYGAPOPHYSEAL (FACET) JOINTS
 The intervertebral disc, consisting of the annulus fibrosus and nucleus
pulposus, is one component of a three-joint complex between two adjacent
vertebrae

STRUCTURE AND FUNCTION OF

INTERVERTEBRAL DISCS
 The intervertebral foramina are between each vertebral segment in the posterior pillar.
Their anterior boundary is the
 intervertebral disc;
the posterior boundary is the
facet joint;
superior and inferior boundaries are the
 pedicles of the superior and inferior vertebrae of the spinal segment.
The mixed spinal nerve exits the spinal canal via the foramen along with blood vessels and recurrent
meningeal or sinuvertebral nerves.
 The size of the intervertebral foramina is affected by spinal motion, being larger with forward
bending and contralateral side bending and smaller with extension and ipsilateral side bending.

INTERVERTEBRAL FORAMINA
 two primary, or posterior, curves, so named because they are present in the
infant and the convexity is posterior
 and two compensatory,or anterior, curves, so named because they develop as
the infant learns to lift the head and eventually stand, and the convexity is
anterior

CURVES OF THE SPINE

Posterior curves are in the thoracic and sacral regions.
 Kyphosis is a term used to denote a posterior curve.
 Kyphotic posture refers to an excessive posterior curvature of the thoracic spine.
Anterior curves are in the cervical and lumbar regions.
Lordosis is a term also used to denote an anterior curve, although some sources reserve the
term lordosis to denote abnormal conditions such as those that occur with a sway Back.
■ The curves and flexibility in the spinal column are important for withstanding the effects
of gravity and other external forces.
■ The structure of the bones, joints, muscles, and inert tissues of the lower extremities are
designed for weight bearing; they support and balance the trunk in the upright posture.

CURVES OF THE SPINE

 Ankle. For the ankle, the gravity line is anterior to the joint, so it tends to rotate
the tibia forward about the ankle. Stability is provided by the plantarflexor
muscles, primarily the soleus muscle.
 Knee. The normal gravity line is anterior to the knee joint, which tends to keep the
knee in extension. Stability is provided by the anterior cruciate ligament, posterior
capsule (locking mechanism of the knee), and tension in the muscles posterior to
the knee (the gastrocnemius and hamstring muscles). The soleus provides active
stability by pulling posteriorly on the tibia. With the knees fully extended, no
muscle support is required at that joint to maintain an uprightposture; however, if
the knees flex slightly, the gravity line shifts posterior to the joint, and the
quadriceps femoris muscle must contract to prevent the knee from buckling.

GRAVITY
 Hip. The gravity line at the hip varies with the swaying of the body. When the line
passes through the hip joint, there is equilibrium, and no external support is necessary.
When the gravitational line shifts posterior to the joint, some posterior rotation of the
pelvis occurs, but is controlled by tension in the hip flexor muscles (primarily the
iliopsoas). During relaxed standing, the iliofemoral ligament provides passive stability
to the joint, and no muscle tension is necessary. When the gravitational line shifts
anteriorly, stability is provided by active support of the hip extensor muscles.
 Trunk. Normally, the gravity line in the trunk goes through the bodies of the lumbar
and cervical vertebrae, and the curves are balanced. Some activity in the muscles of the
trunk and pelvis helps maintain the balance. (This is described in greater detail in the
following sections.) As the trunk shifts, contralateral muscles contract and function as
guy wires. Extreme or sustained deviations are supported by inert structures.
 Head. The center of gravity of the head falls anterior to the atlanto-occipital
joints. The posterior cervical muscles contract to keep the head balanced
Global Muscles
Characteristics
 Superficial: farther from axis of motion
 ■ Cross multiple vertebral segments
 ■ Produce motion and provide large guy wire function
 ■ Compressive loading with strong contractions
 Lumbar region
 Rectus abdominis External and internal obliques
 ■ Quadratus lumborum (lateral portion)
 ■ Erector spinae
 ■ Iliopsoas

STABILIZING FEATURES OF MUSCLES

CONTROLLING THE SPINE
 Sternocleidomastoid
 Scalene
 Levator scapulae
 Upper trapezius
 Erector spinae

CERVICAL REGION
Deep
closer to axis of motion
 Attach to each vertebral segment
 ■ Control segmental motion; segmental guy wire function
 ■ Greater percentage of type I muscle fibers for muscular endurance
Lumber region
 transversus abdominis
 Multifidus
 Quadratus lumborum (deep portion)
Cervical
 Deep rotators
 Rectus capitis anterior and lateralis
 ■ Longus colli

DEEP SEGMENTAL MUSCLES

 Extensors, arranged in three layers
Most superficial is the strong Erector Spinae or sacrospinalis muscle
Middle layer is the multifidus. The fibers of the multifidus are centered on each
of the lumbar spinous processes.
 Third layer is made up of small muscles arranged from level to level, which
not only have an extension function but are also rotators and lateral flexors.

BACK MUSCLES CAN BE DIVIDED INTO FOUR

FUNCTIONAL GROUPS: FLEXORS, EXTENSORS,
LATERAL FLEXORS AND ROTATORS
 intrinsic group (psoas major, psoas minor and iliacus)
 extrinsic group (abdominal wall muscles)

FLEXORS
 internal and external oblique,
 the intertransverse and quadratus lumborum muscles.
Remember that pure lateral flexion is brought about only by the quadratus
lumborum.

LATERAL FLEXORS AND ROTATORS

 Pelvic and Lumbar Region/Lordotic Posture
 Relaxed or Slouched Posture
 Flat Low-Back Posture

COMMON FAULTY
POSTURES:CHARACTERISTICS AND
IMPAIRMENTS
Lordotic Posture
 Lordosis is the normal curve (anterior convexity) of cervical and lumbar spine
which is found all normal individual pathologically. it is an exaggeration of the
normal curve found in cervical and lumbar spine. Potential Sources of Pain
• Stress to the anterior longitudinal ligament
• Narrowing of the posterior disk space and narrowing of intervertebral foramen.
• Approximation of the articular facets. The facets may become weight bearing
which may cause syonovial irritation and joint inflammation.

LORDOTIC POSTURE
 Weakness of abdominals muscle
 Tightness or contracture of hip flexor (iliopsoas)
 Congenital problems such as bilateral congenital dislocation of hip
 Pregnancy
 High heel shoes / foot wears
 Spondylolisthesis
 Anterior tilt of pelvis as a result of weak extensor of hip and Abdominals
 Tightness or shortening of cervical extensor

COMMON CAUSE OF EXCESSIVE

LUMBAR LORDOSIS
 Mobilization of the lumbar spine.
 Anterior stretching of the lumbar spine
 Strengthening of the abdominals, glutei and hamstring.
 Training in grade correction of pelvic tilt has to be emphasized active
backward or posterior pelvic tilting by contracting abdominals and glutei in
supine is initiated.
 Toe touching in long sitting or forward bending sitting exercise
 Spinal extension or hyper extension should be strictly avoided.
 Treat the cause of increase lumbar lordosis.

TREATMENT FOR EXCESSIVE

LUMBAR LORDOSIS
 It is a faulty posture in which lumbar spine and cervical spine get hyper
extended while thoracic spine get flexed and head become slightly forward.
 Potential Sources of Pain
 * Stressed to the posterior longitudinal ligament.
 * Fatigue of the thoracic erector spinae and rhomboid muscle.
 * Thoracic outlet syndromes.
 * Cervical posture syndromes

KYPHOTIC POSTURE / ROUND BACK

 Shortening or tightness of extensors of cervical spine and lumbar spine and
flexor of hip joint.
 Weakness of neck flexors,upper back extensors (erector spinae) and Hamstring
muscle.
 Bony anomaly generally in anterior tilt of pelvis, abdominals get elongated but
in this posture excessive flexion of thoracic spine offsets the effect of anterior
pelvic tilt.
 Ankylosing spondylitis.
 Other congenital anomalies.

COMMON CAUSE OF KYPHOSIS

 Relaxation
 Postural belt
 Repeated stretching session
 Posture of head, neck and shoulder
 Mobilization of the whole spine
 Resistive exercise for longitudinal and transverse back muscle
 Controlled pelvic tilt

TREATMENT OF KYPHOSIS
 A lateral curvature of spine which exceeds 10 degree bending of the vertebral
from the normal is tended as scoliosis column to one side combined with
rotation of the vertebral bodies towards the convexity and the spinous process
towards the concavity

SCOLIOTIC POSTURE
I. Non structural Scoliosis (Postural)
II. Transient Structural Scoliosis
III. Structural Scoliosis

CLASSIFICATION
1:Non structural Scoliosis
• Postural Scoliosis
• Compensatory Scoliosis
2: Transient Structural Scoliosis
• Sciatic Scoliosis
• Hysterical Scoliosis
• Inflamatory Scoliosis
 III. Structural Scoliosis
Structural scoliosis – Neuromuscular disease,osteopathic disorder, and idiopathic disorder
 • Idiopathic Scoliosis
Old classification
Infantile Onset < 3 yrs Age
Juvenile Onset 3-10 yrs Age
Adolescent Onset > 10 yrs Age
 New Classification
Early onset Onset < 8 yrs Age – Late onset Onset > 8 yrs Age
 Muscle fatigue and ligamentous strain on the side of convexity.Nerve root
irritation on the side of concavity.
Non structural – Leg length discrepancy,either structural or functional, muscle
guarding or spasm a painful stimuli in the back or neck, and habitual or
asymmetric posture.

POTENTIAL SOURCE OF PAIN

• Mid-back pain
• lower back pain,
• neck pain, headaches,
• premature disc and joint degeneration
• Decreased pulmonary function

PHYSIOLOGICAL EFFECTS OF
SCOLIOSIS
• Plumb line - On posterior aspect, line drawn from occiput should normally align
with gluteal cleft
SCOLIOMETRY
ADAM’S FORWARD BEND TEST

CLINICAL EVALUATION
 Active Correction with postural adaptation
 Passive Correction by Hanging
 Educate the patient by active effort
 Relaxation technique
 Repeated sessions of maintenance
 General free mobility exercises
 Deep breathing
 Balance Exercises
 Traction

TREATMENT OF SCOLIOSIS
 Nonoperative treatment • Observation • Orthotics – braces • Traction and Casting
 • Exercises maintain muscle tone but no effect on the curve • If curve between 20
degree & 30 is progressing, bracing done TREATMENT
 Orthotics • Hibbs and Risser – Turnbuckle cast • Milwaukee brace ( CTLSO )•
Thoracolumbosacral othosis (TLSO’s) Milwaukee brace .
Contra indictions for orthosis
• Curve > 40 ° • Extreme thoracic kyphosis • Mature adolescent ; girls 2 yrs post
menarchal • High thoracic or cervicothoracic curve.
Halo traction device • Spinal skeletal traction & fixation device • Halo traction device
attached to skull & is connected to a plaster body cast by a steel frame

TREATMENT
 Daily application of longitudinal & lateral traction forces mobilize the spine
gradually
• Patient in lying position, head end attached with 10 pounds weight pulls
proximally
• Pelvic girdle & traction straps with 20 to 30 pounds weight pull distally
Stretching.

STREACHING
 Curve correcting pad Milwaukee brace

CCP
 It is faulty posture in which head becomes slightly forward there is extension of
cervical spine, flexion of thoracic and loss of lordosis of lumbar spine extension
of hip and knee joint during standing are also the feature of sway back posture
pelvis rotates posteriorly.
* In this there is increased pelvic inclination up to 40.
When standing for prolonged period the person usually assumes an asymmetric
stance.
* In which most of the weight is borne on one lower extremity with periodic
shifting of weight to the opposite extremity.

SWAY BACK POSTURE/SLOUCHED

 Stress to iliofemoral ligament, the anterior longitudinal ligament of lower
lumbar spine and posterior longitudinal ligament of upper lumbar and thoracic
spine.
 Narrowing of intervertebral foramen in lower lumbar spine that may
compress the blood vessel dura & nerve root. Approximation of articular
facets in to lower lumbar spine

POTENTIAL SOURCE OF PAIN

1)Tightness of hamstring and abdominal muscle.
2)Weakness of one joint iliopsoas
3)Bony anomaly

COMMON CAUSE OF SWAY BACK

• Stretching of hamstring and abdominal muscle
• Relaxation of the body
• Strengthening of Iliopsoas
• Maintain position of head is backward, extension of thoracic Spine
• Maintain normal lordosis of lumbar spine
• Always standing in erect position

TREATMENT OF SWAY BACK

 Flat Back Posture –
Flat back is faulty posture in which whole lumbar and thoracic spine gets
flattened. Although the cause and symptom of both flat back and sway back are
common but can be differentiated by excessive flexion and back ward deviation
of the upper thoracic spine in sway back posture while in flat back posture spine
become almost straight. It is reverse a lumbar lordosis. There is flattening of
normal lumbar lordosis

FLAT BACK POSTURE SWAY BACK

POSTURE
 Lack of the normal physiologic lumbar curve which reduces the shock
absorbing effect of lumbar region and predisposes the person to injury.
• Stress to the posterior longitudinal ligament.
• Increase of the posterior disk space which allow the nucleus pulposus to imbibe
extra fluid and under certain circumstance may protrude posteriorly when the
person attempts extension.

POTENTIAL SOURCE OF PAIN

 1) Tight trunk flexor (rectus abdominis and intercostal) and hip extensor
muscle.
 2) Stretched and weak lumbar extensor and possibly hip flexor muscle.

COMMON CAUSE OF FLAT BACK

• Increase lumbar lordosis which results in forward tilting of pelvis.
• Maintance of arch by active holding and also passive support in sitting are
effective in maintaining lordosis.
• Mobility and strengthening exercise of lumbar extensor are important.
• Stretching of trunk flexor and hip extensor muscle

TREATMENT OF FLAT BACK

 Structural and Functional Impairments
 • Pain from mechanical stress to sensitive structures and from muscle tension
 • Impaired mobility from muscle, joint, or fascial restrictions
 • Impaired muscle performance associated with an imbalance in muscle length and strength
between antagonistic muscle groups
 • Impaired muscle performance associated with poor muscular endurance
 • Insufficient postural control of scapular and trunk stabilizing muscles
 • Decreased cardiopulmonary endurance
 • Altered kinesthetic sense of posture associated with poor neuromuscular control and prolonged
faulty postural habits
 • Lack of knowledge of healthy spinal control and mechanics

MANAGEMENT OF
IMPAIRED POSTURE
 1. Develop awareness and control of spinal posture
 2. Educate the patient about the relationship between
 faulty posture and symptoms
 3. Increase mobility in restricting muscles, joints, fascia
 4. Develop neuromuscular control, strength, and
 endurance in postural and extremity muscles
 5. Teach safe body mechanics
 6. Ergonomic assessment of home, work, recreational
 environments
 7. Stress management/relaxation
 8. Identify safe aerobic activities
 9. Promote healthy exercise habits for self-maintenance

PLAN OF CARE INTERVENTION

 1. Kinesthetic training; cervical and scapular motions, pelvic tilts, control of neutral spine. Utilize procedures to
develop and reinforce control of posture when sitting, standing, walking, and performing targeted functional
activities
 2. Practice positions and movements to experience control of symptoms with various postures
 3. Manual stretching and joint mobilization/manipulation; teach self-stretching
 4. Stabilization exercises; progress repetitions and challenge with extremity motions; progress to dynamic trunk
strengthening exercises
 5. Functional exercises to prepare for safe mechanics(squatting, lunges, reaching, pushing/pulling, lifting and
turning loads with stable spine)
 6. Adapt work, home, recreational environment
 7. Relaxation exercises and postural stress relief
 8. Implement and progress an aerobic exercise program
 9. Integration of a fitness program, regular exercise, and safe body mechanics into daily life

INTERVENTION
 ■ Postural stress, strain
 ■ Abnormal posture
 ■ Muscle strain, tear, contusion
 ■ Acute low back or cervical pain
 ■ Degenerative disc disease (DDD), disc herniation
 ■ Degenerative joint disease (DJD), spondylosis
 ■ Rheumatoid arthritis
 ■ Radiculopathy, nerve root lesions, sciatica
 ■ Spinal stenosis

SPINAL PATHOLOGIES AND IMPAIRED

SPINAL FUNCTION
 ■ Segmental instability
 ■ Spondylolistheses
 ■ Sprains, strains
 ■ Laminectomy
 ■ Anterior cervical disc fusion (ACDF)
 ■ Transforaminal lumbar interbody fusion (TLIF)
 Compression fracture
 ■ Spondylosis with myelopathy
 ■ Intervertebral disc disorders
 Herniation: a general term used when there is any change in the shape of the
annulus that causes it to bulge beyond its normal perimeter.
 Protrusion: nuclear material is contained by the outer layers of the annulus
and supporting ligamentous structures.
 Prolapse: frank rupture of the nuclear material into the vertebral
canal.

PATHOLOGY OF THE
INTERVERTEBRAL DISC
 Extrusion: extension of nuclear material beyond the confines of the
posterior longitudinal ligament or above and below the disc space, as detected
on magnetic resonance imaging (MRI),but still in contact with the disc.
 Free sequestration: the extruded nucleus has separated from the disc and
moved away from the prolapsed
 Pain, muscle-guarding
 ■ Flexed posture and deviation away from (usually) the symptomatic side
 ■ Neurological symptoms in dermatome and possibly myotome of affected nerve
roots
 ■ Increased symptoms (peripheralization) with sitting, prolonged flexed postures,
transition from sit to stand, coughing, straining
 ■ Limited nerve mobility, such as straight-leg raising (usually between 30° and
60°)
 ■ Peripheralization of symptoms with repeated forward bending (spinal flexion)
test

COMMON IMPAIRMENTS RELATED TO

DISC PROTRUSIONS IN THE LUMBAR
SPINE
 Facet joints are synovial articulations that are enclosed in a capsule and
supported by ligaments
 locked-back mechanism

PATHOLOGY OF THE
ZYGAPOPHYSEAL (FACET) JOINTS
 Pain: When acute, there is pain and muscle guarding with all motions; pain when
subacute and chronic is related to periods of immobility or excessive activity.
 ■ Impaired mobility: Usually hypomobility and decreased joint play in affected joints;
there may be hypermobility or instability during early stages.
 ■ Impaired posture.
 ■ Impaired spinal extension: Extension may cause or increase neurological symptoms
due to foraminal stenosis; therefore, may be unable to sustain or perform repetitive
extension activities without exacerbating symptoms.
 ■ Any functional activity that requires flexibility or prolonged repetition of trunk
motions, such as repetitive lifting and carrying of heavy objects, may exacerbate
symptoms in the arthritic spine
 Spondylosis and OA are synonymous terms. This pathology may also be
referred to as DJD. Osteoarthritis involves degeneration of the IV disc as well
as the facet joints. Usually, ther is a history of faulty posture, prolonged
immobilization after injury, or severe or repetitive trauma.

SPONDYLOSIS, OSTEOARTHRITIS, AND

DEGENERATIVE
JOINT DISEASE
 osteophyte formation with spurring and lipping along the joint margins and
vertebral bodies. Progressive hypomobility with boney stenosis results. The
encroachment of osteophytes on the spinal canal and intervertebral foramina
may cause neurological signs, especially with spinal extension and side
bending.
 The degenerating joint is vulnerable to facet impingement,sprains, and
inflammation, as is any arthritic joint.
 ■ In some patients, movement relieves the symptoms; in others, movement
irritates the joints, and painful symptoms increase.

DJD
 Forward translation of one vertebra on another in the sagittal plane of the
spine

 Spondylolisthesis is the slippage of one vertebral body with respect to the

adjacent vertebral body causing mechanical or radicular symptoms or pain

SPONDOLYSTHESIS
MEYERDING
CLASSIFICATION
 Pain is exacerbated by extending at the affected segment
 Pain decreases as the patient assumes flexed posture
 Pain may be exacerbated by direct palpation of the affected segment
 Pain can sometimes improve in certain positions such as lying supine.
 Atrophy of the muscles, muscle weakness
 Tense hamstrings, hamstrings spasms
 Disturbances in coordination and balance, difficulty walking
 Rarely loss of bowel or bladder control.

CLINICAL PRESENTATION
 Initially resting and avoiding movements like lifting, bending, and sports.
 Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-
inflammatory effect on nerve root and joint irritation.
 Epidural steroid injections can be used to relieve low back pain, lower
extremity pain related to radiculopathy and neurogenic claudication.
 A brace may be useful to decrease segmental spinal instability and pain.
 Physiotherapy focuses on relieving extension stresses from the lumbosacral
junction (hamstring and hip flexor stretching), as well as working on core
strengthening (deep abdominal muscles and lumbar multifidus strengthening).

CONSERVATIVE   TREATMENT
SI JOINT
 The Sacroiliac joint (simply called the SI joint) is the joint connection between
the spine and the pelvis.
 Large diarthrodial joint made up of the sacrum and the two innominates of
the pelvis
 Low back pain
 Thigh pain
 Difficulty sitting in one place for too long due to pain
 Local tenderness of the posterior aspect of the sacroiliac joint (near the PSIS)
 Pain occurs when the joint is mechanically stressed eg forward bending
 Absence of neurological deficit/nerve root tension signs
 Aberrant sacroiliac movement pattern
 The joint can be hyper or hypo-mobile which can cause pain
 Pain is usually localized over the buttock
 Patients can often complain of sharp, stabbing, and/or shooting pain which extends down the posterior thigh usually not
past the knee.
 Pain can frequently mimic and be misdiagnosed as radicular pain
 Patients will frequently complain of pain while sitting down, lying on the ipsilateral side of pain, or climbing stairs

CLINICAL PRESENTATION
 Physiotherapists use a variety of orthopaedic provocation tests.
 Gaenslen Test
 Distraction Test/compression test
 Faber test(Patrick Sign)
 Yeoman's test
 Sacral Thrust Test
 Thigh Thrust test

DIAGNOSTIC PROCEDURES
 First stage of treatment is to reduce the inflammation with ice packs and anti-
inflammatory medication.
 second goal is to improve mobility using mobilizations, manipulation or
exercise therapy.
 complaints of instability, it can be useful to make use of a sacroiliac belt to
temporarily support the pelvis, together with progressive stabilization training
to increase motor control and stability.
 If there are complaints of instability, it can be useful to make use of a
sacroiliac belt to temporarily support the pelvis, together with progressive
stabilization training to increase motor control and stability.

PHYSICAL THERAPY MANAGEMENT

 If the sacroiliac joint is severely inflamed, a sacroiliac belt can also be used.
 Postural and ergonomic advice will help the patient to decrease the risk of
reinjure
 If the sacroiliac joint is severely inflamed, a sacroiliac belt can also be used
 Postural and ergonomic advice will help the patient to decrease the risk of
reinjury.
 The main function of the SI joint is to provide stability and attenuate forces to
the lower extremities. 
 The strong ligamentous system of the joint makes it better designed for
stability and limits the amount of motion available.
Nutation 
 sacrum moves anteriorly and inferiorly, the coccyx moves posteriorly relative
to the ilium.
Counternutation
 sacrum moves up, backward,

MOTIONS AVAILABLE
NUTATION AND COUNTER NUTATION
 Ankylosing Spondylitis > previously known as Bechterew's disease ,
Bechterew syndrome , Marie Strümpell disease
 It is a form of arthritis that is long-lasting (chronic) and most often affects
the spine. It affects joints in the spine and the sacroilium in the pelvis ,
causing eventual fusion of the spine.
 Complete fusion results in a complete rigidity of the spine, a condition
known as bamboo spine
 AS is a systemic rheumatic disease and is one of the seronegative
spondyloarthropathies.

ANKYLOSING SPONDYLITIS (AS)

 The typical patient is young, aged 18-30 Men are affected more than
women by a ratio about of 3:1
What causes ankylosing spondylitis?
The cause of ankylosing spondylitis is unknown , but a tendency to develop
the condition may be genetic .
> HLA-B27 genotype. -90% of patients
Tumor necrosis factor-alpha (TNF α) > IL-1 10%
 ■ There is a gradual loss of motion and the person will complain of general
stiffness. The patient may initially complain of bilateral pain in his or her
sacroiliac joints, thoracic spine,or shoulders. The person will wake up early
with pain and stiffness and have difficulty standing up straight.
 ■ In advanced cases, radiographs will reveal a “bamboo”spine. This imaging
identifies where the anterior longitudinal ligament has fused to the vertebral
bodies. Decreased joint spaces may also be identified on the film.
 PRECAUTION: Atlanto-axial subluxation is the hallmark of
 cervical spine involvement. Extreme caution should be used when assessing
and manipulating the cervical spine region to avoid causing serious or fatal
injury.
 With a sudden or unusual movement, the meniscoid of a facet capsule may be
extrapped, impinged (entrapped), or stressed,which causes pain and muscle
guarding. The onset is sudden and usually involves forward bending and
rotation.

FACET JOINT IMPINGEMENT

(BLOCKING, FIXATION,EXTRAPMENT)
■ There is loss of specific motions and attempted movement induces pain. At
rest, the individual has no pain.
■ There are no true neurological signs, but there may be referred pain in the
related dermatome.
■ Over time, stress is placed on the contralateral joint and on the disc, leading to
problems in these structures.
 a blood test for the HLA-B27 gene
 X-ray -which show characteristic spinal changes and sacroiliitis.
 tomography and magnetic resonance imaging of the sacroiliac joints -but the
reliability of these tests is still unclear
 Schober's test -a useful clinical measure of flexion of the lumbar spine
performed during examination.
 X-ray demonstrating in ankylosing spondylitis

DIAGNOSIS
 educate about the nature of the disease >baseline ROM including chest expansion
should be advised
 pain should be managed by appropriate medications, heat, massage and gentle exercise.
 excessive physical exertion during periods of active inflammation should be
discouraged.
 proper positioning at rest is essential >the mattress should be firm,
 the patient should sleep on the back and avoid positions that encourage flexion
deformity.
 postural training emphasizes avoiding flexion, heavy lifting and prolonged walking,
standing or sitting.