Transcript Dr Hafiz Sheraz Arshad

Vertebral Motion Dynamics
Dr Hafiz Sheraz Arshad
Outlines
•
•
•
•
•
•
•
•
Motion Segment
Physiologic Motion
Motion Axes
Rule of Superior Motion
Rule of vertebral body Motion
Coupling
Apophyseal Joint Kinematics
Mc Kenzie Three syndrome
Motion Segment
• Definition:
• Example
• C3-C4 Motion Segment
• Movement Junctions
• Cervicothoracic
• Thoracolumbar
• Lumbosacral
Physiologic Motion
• Each of the 24 vertebrae (7 cervical, 12 thoracic, and 5 lumbar) have the
ability to move in 3 planes of reference
Sagittal Plane
Forward and backward bending
Flexion & Extension
Frontal Plane
Lateral Flexion
Horizontal Plane
Rotation
Motion Axes
• Each of these 6 spinal motions can be considered rotations around or about
an orthogonal axis (Figure 1-1). Forward and backward bending are rotations
about the X or horizontal axis, side bending is a rotation about the Z or
anteroposterior axis, and axial rotation occurs about the Y or vertical axis
Rule of Superior Motion
• During manual therapy we usually mention superior vertebrae
first
• E.g; T5,T6 means fifth thoracic vertebrae T5 is moving on the T6
• When only one vertbra mentioned
• E.g; T5 side bending means movement of the T5 over the T6
• Movement can be noted from above below or from below
above
• Example:
Rule of Vertebral Body Motion
• A vertebra's motion is always described by the direction of
vertebral body motion and not spinous process (SP)
movement.
• Consequently, a passive movement of the T11 SP to the left,
which induces vertebral rotation to the right, is described as
T11,12 rotation right because of the direction of vertebral
body motion
2
Coupling
Region of the Spine
Coupling
Upper cervical spine ( above C2)
(In flexion & Extension & resting Position)
Opposite Side
Cervical spine ( below C2)
(In flexion & Extension & resting Position)
Same Side
Thoracic Spine in the resting position and in flexion
Same Side
Thoracic spine in marked extension (flattened or
lordosis)
Opposite Side
Lumbar Spine in the resting position and in
extension
Opposite Side
Lumbar spine spine in marked flexion (kyphosis)
Same Side
Apophyseal Joint Kinematics
A.
B.
C.
D.
Facet Opening
Facet Closing
Facet Gapping
Roll-Gliding
A. Facet Opening
• Facet opening refers to the
anterior and superior glide of
the inferior articular process of
the superior vertebra on the
superior articular process of
the vertebra below
• Example:
• Opening bilaterally In Spinal
Flexion
• Open on the left during flexion,
side bending and rotation to
the right
• Open on the right during
flexion, side bending, and
rotation to the left
B. Facet Closing
• Facet closing refers to the
posterior and inferior glide of
the inferior articular process of
the superior vertebra on the
superior articular process of the
vertebra below
• Example
• Bilateral closing in spinal
extension
• Close on left during extension,
side bending and rotation to the
left
• Close on the right, during
extension, side bending and
rotation to the right
C. Facet Gapping
• Facet gapping refers to the separation or distraction (traction) of the
joint surfaces in a perpendicular direction
• If a thoracic or lumbar facet gaps on the left, this implies that the
inferior articular process of the superior vertebra separates away
from the superior articular process of the inferior vertebra.
• Gapping of the facets generally occurs in the thoracic and lumbar
spine in response to neutral rotation on the ipsilateral side
• On the contralateral side of the rotation, the facets approximate
each other as they are compressed together.
• No gapping occurs in either the upper (occiput-atlas-axis) or lower
(C2-C7) cervical spine because of the absence of a neutral articular
position
D. Roll-Gliding
 Occipital condyles, convex surfaces moving on the concave
surfaces of the atlas, the remainder of the motion segments
of the spine behave as concave surface (superior vertebra)
moving on a convex s one (inferior vertebra)
 Superior Component follows Concave Rule
 Inferior Component follows Convex Rule
• In summary, it can be said that motion of the superior
component of the motion segment demonstrates rotation and
translation in the same direction, whereas the inferior
component of the segment rotates and translates in opposite
directions
• It is also common to perform a combination of roll-gliding in
the spine with a simultaneous roll of the superior component
while gliding the inferior component in the opposite direction.
Motion Barriers
• There are 4 barriers (3 normal and 1 abnormal) to joint motion
A. Physiologic Barrier
 End of active, voluntary effort in a normal joint is the physiologic
barrier for that motion
 Every movement in the body is associated with physiologic
barrier
B. Elastic Barrier
 Is the point where the soft tissue slack is taken up during a
passive movement in a normal joint ( i.e the beginning of the
end)
C. Anatomic Barrier
• Is the absolute end-pont in the passive range of motion in a
normal joint beyond which tissue injury occurs (i.e the end)
D. Restrictive Barrier
• The premature motion loss in an impaired joint is known as the
restrictive barrier
• It may represent a restriction at any point in the overall range of
motion of a joint
• It is associated with an abnormal end-feel (i.e hard or non
yielding versus resilient and supple)
Restrictive Barrier
• Causes
• Muscle Splinting
• Capsular Fibrosis
• Internal Derangement
• Myofascial tightness
• Major restriction more than 50% or minor restriction less than
50%
• The restrictive barrier is an impairment that results from tissue
pathology and can led to functional limitation and disability if not
given appropriate intervention
Diagrammatic Representation
Mc Kenzie’s Three Syndromes
A. Postural Syndrome
B. Dysfunction Syndrome
C. Derangement Syndrome
A. Postural Syndrome
• Usually less than 30 years Old
• By definition, devoid of restrictive barriers
• Local symptoms that appear locally and usually adjacent to the
spine
• Pain is induced by static loading at end range and not by movement
• Pain is never referred and never constant
• Examination: only consistent finding is pain provocation with static
loading at end-range
• Useful intervention is to correct the faulty alignment, whenever it is
found (i.e sitting, standing, lying, walking)
• Requires ergonomic assessment of furniture, computer height,
mattresses, pillows as well as analysis of patient’s conditions at the
worksite
• Complications:
• Treatments:
B. Dysfunction Syndrome
• Computer operator / driver 10 hours daily
• Adaptive shortened soft tissues have reduced elasticity (loss of
hyaluronic acid/water, adhesions)
• Exam: painful symptoms that tend to arise at the end of range
rather than during movement
• This patient has intermittent pain similar to the postural patient, but
differs in that his or her soft tissues are abnormally tight
• Symptoms are usually adjacent to the spine and are never referred
distally except in the case of an adherent nerve root
• Simply, pain of dysfunction syndrome is produced immediately when
shortened tissues are overstretched
• Pain occurs at end-range when shortened structures are placed
under tension
• Pain is never felt during movement and is never referred
• Long term complications: destructive pathology will result in
derangement syndrome
• Trauma
• In the presence of dysfunction syndrome
• In the absence of dysfunction syndrome: can lead to derangement i.e
PIVD
C. Derangement Syndrome
• Usually a history of poor posture and progressive stiffness
• Misalignment of the intervertebral disc material causing
blockage
• Often occurs in cervical and lumbar spine often describe their
neck or back OUT
• With the onset of degenerative disc disease, patient may
develop clinical instability, which requires stabilization
training of the hypermobile segment in conjunction with
manual therapy of the stiff, hypomobile segments above and
or below
• Symptoms are made worse or better by specific movements,
can be referred distally, and tend to be constant and often
severe
• The patient may present with acute spinal deformity of
sudden onset (e.g; kyphosis, torticollis, or lateral shift), which
is often improved dramatically with manual therapy/
therapeutic exercise
• Goals of the interventions are
•
•
•
•
The derangement must be properly reduced
The reduction must be stabilized in order for healing to occur
Once the derangement is stable, lost function must be recovered
The prevention of recurrence of the derangement must be
emphasized
References
• Mc kofsky’s
• Kalenborn Vol II Spine