Kinesitherapeutisch onderzoek wervelzuil theorie samenvatting.docx

# Anatomy and structure of the spine The spine, or vertebral column, is the central link in human function, balancing stability with mobility and protecting the central nervous system while providing a crucial anchor for muscles. ### 1.1 Divisions and curvature of the spine The trunk is functionally divided into four regions: cervical, thoracic, lumbar, and sacral. The spine exhibits a characteristic S-shaped sagittal curvature: lordosis (convex anteriorly) in the cervical and lumbar regions, and kyphosis (convex posteriorly) in the thoracic and sacral regions. Pathological exaggerations or flattening of these curves can impact overall posture and contribute to back pain. #### 1.1.1 Functional zones of the cervical spine The cervical spine has three functional zones: * **C0–C2 (high cervical):** Highly mobile with specialized and extensive movement capabilities. * **C3–C7 (mid-low cervical):** Exhibits typical cervical movements. * **C7–T3 (cervicothoracic transition):** A more rigid area. ### 1.2 Functions of the vertebral column The vertebral column serves three primary functions: * **Posture determination:** It largely dictates the body's overall posture. * **Protection:** It safeguards the spinal cord and cauda equina. * **Muscle attachment:** It provides a central attachment point for muscles of the shoulder and pelvic girdles, enabling movement between body parts. ### 1.3 Structure of the vertebral column The vertebral column is composed of individual vertebrae and functional segments. #### 1.3.1 Number of vertebrae * **Cervical:** 7 vertebrae * **Thoracic:** 12 vertebrae * **Lumbar:** 5 vertebrae * **Sacral:** 5 fused vertebrae * **Coccygeal:** 3–4 fused vertebrae #### 1.3.2 Functional spinal unit A functional segment consists of two adjacent vertebrae and the intervertebral disc and facet joints connecting them. #### 1.3.3 General vertebral anatomy Each vertebra typically consists of: * **Corpus vertebrae (vertebral body):** The main weight-bearing part, flattened distally and proximally in the lumbar and thoracic regions. * **Arcus vertebrae (vertebral arch):** Located dorsally, comprising: * Lamina (posterior part) * Pediculus (connecting to the vertebral body) * **Processes:** * Spinosus (dorsal) * Transversi (lateral) * Articulares superior/inferior (articulating facets) The vertebral foramina of all vertebrae align to form the **canalis vertebralis**, which houses the spinal cord and emerging nerve roots. #### 1.3.4 Cervical region anatomy Key features of cervical vertebrae include: * **Foramen transversarium:** An opening in the processus transversi (except on C7) through which the arteria vertebralis passes. * **Processus spinosus:** Bifid (split) on C3–C7, running approximately horizontally. * **Atlas (C1):** Lacks a vertebral body and spinous process. It has two lateral masses connected by short anterior and long posterior arches. The fovea dentis on the posterior surface of the anterior arch articulates with the dens of C2. The transverse processes project laterally. * **Axis (C2):** Features the dens axis, projecting cranially and articulating with the anterior arch of C1. * **Uncovertebral joints of Luschka:** Formed by the processus uncinati (raised lateral edges on the superior borders of vertebral bodies) on C3–C7. These are synovial joints. * **Vertebra prominens (C7):** Characterized by a long spinous process, making it easily palpable. #### 1.3.5 Thoracic region anatomy Thoracic vertebrae generally exhibit a typical structure, though T1 resembles a cervical vertebra, and T11–T12 resemble lumbar vertebrae. * **Processus spinosi:** In the mid-thoracic region, they project obliquely caudally, overlapping like roof tiles. They are more horizontal towards the cervical and lumbar regions. * **Costal facets:** Articular surfaces for the ribs are present on the lateral aspects of the vertebral bodies (superior and inferior) and on the processus transversi (for Th1–Th10). * **Associated structures:** The thoracic region also includes the ribs, sternum, clavicles, and scapulae. * **Joints:** Includes intervertebral joints, costovertebral/costotransverse joints (between vertebrae and ribs), sternocostal/sternochondral/costochondral joints, acromioclavicular joints, sternoclavicular joints, and scapulothoracic articulation. #### 1.3.6 Lumbar region anatomy Lumbar vertebrae are characterized by: * **Large vertebral bodies (corpus vertebrae).** * **Processus spinosi:** Thick and horizontal at their ends. * **Processus costalis:** These are modified transverse processes, functionally representing rudimentary ribs. * **Processus accessorius:** Rudimentary transverse processes located dorsal to the processus costalis. * **Processus mamillaris:** Teat-shaped projections superior to the processus accessorius. * **L4:** Marks the nadir of the lumbar lordosis. #### 1.3.7 Sacral region anatomy The sacrum consists of 5 fused sacral vertebrae. * **Crista sacralis mediana:** Fusion of the spinous processes. * **Crista sacralis intermedia/medialis:** Fusion of the articular processes. * **Crista sacralis lateralis:** Fusion of the transverse processes. The sacrum forms part of the pelvic ring and articulates with the ilium to form the sacro-iliac joints. ### 1.4 Articular facets (zygapophyseal joints) These joints are formed between the inferior articular processes of the superior vertebra and the superior articular processes of the inferior vertebra. Each vertebral segment has left and right facet joints. #### 1.4.1 Orientation of facet joints The orientation of the facet joints varies significantly by region, influencing movement: * **Cervical:** Facets are generally ventrocranially oriented, ranging from 45°–70° relative to the horizontal (C3 at 45°, T1 at 70°) and 85° to the sagittal plane. * **Thoracic:** Facets are oriented frontally. Superior facets face dorsally and laterally, while inferior facets face ventrally. * **Lumbar:** Facets are oriented sagittally. Lower lumbar facets rotate towards the frontal plane (45°). Superior facets face dorsally and medially, while inferior facets face ventrally and laterally. The superior articular process is slightly concave, and the inferior is slightly convex. #### 1.4.2 Clinical significance of facet joints The facet joints are richly innervated, making them susceptible to degeneration and a significant source of pain. ### 1.5 Intervertebral discs (discus intervertebralis) These cartilaginous discs act as shock absorbers and allow movement between vertebrae. #### 1.5.1 Location and prevalence The most cranial intervertebral disc is between C2 and C3. The most caudal is between L5 and the sacrum (S1). Discs are absent in the sacrum and coccyx due to vertebral fusion. #### 1.5.2 Structure of intervertebral discs Each disc comprises: * **Annulus fibrosus:** A ring of fibrous connective tissue. * **Nucleus pulposus:** A gelatinous center located within the annulus fibrosus. #### 1.5.3 Disc characteristics and variations * **Nucleus pulposus dehydration:** The nucleus dehydrates before the age of 30. * **Thickness variation:** Disc thickness varies by region, age, and spinal load. * **Cervical discs:** Bear less load and have less water and proteoglycans than lumbar discs, making them more vulnerable to trauma and degeneration. * **Lumbar discs:** Are more susceptible to injury from heavy physical loading. * **Height:** Cervical discs are typically 3–5 mm thick, while lumbar discs are 10–12 mm thick. Discs contribute up to 25% of the total length of the vertebral column. ### 1.6 Ligamentous structures Ligaments connect the bony structures of the spine, providing stability. * **Ligamenta longitudinalia anterior & posterior:** Connect vertebral bodies and discs, primarily posteriorly. * **Ligamenta flava:** Connect the ventral sides of the vertebral arches (laminae). * **Ligamenta interspinalia:** Connect the spinous processes. * **Ligamentum supraspinale:** Limits the dorsal extent of the spinous processes; in the cervical region, it forms the **ligamentum nuchae**. * **Ligamenta intertransversaria:** Span between the transverse processes. * **Ligamentum transversum atlantis:** Holds the dens of the axis in place. * **Ligamenta alaria:** Connect the dens to the inner surfaces of the occipital condyles, acting as collateral ligaments for the dens axis. ### 1.7 Myofascial system Spinal muscles can be classified based on function (global/local), intrinsic properties (phasic/tonic), or anatomical location (ventral/dorsal/lateral). #### 1.7.1 Local vs. global muscle system * **Local muscle system (stability):** * **Function:** Maintains segmental stability. * **Anatomy:** Attaches close to the vertebrae, stabilizing by attachment near the vertebrae and biomechanically by being close to the joint. * **Characteristics:** Attachments close to vertebrae, biomechanically suitable for stability, attaching to occiput, vertebrae, and sacrum. They can exert compressive forces on joints without causing shear forces or movement, thereby controlling neutral joint positions. They exhibit continuous activity during movement, regardless of direction. Histologically, they have a higher proportion of Type I fibers, indicating endurance for sustained low-intensity contractions. Neuromotorically, they are activated via a feedforward mechanism. * **Global muscle system (force and movement):** * **Function:** Generates force for daily activities and initiates/accelerates movement. * **Anatomy:** Do not attach directly to the vertebrae; they bridge multiple segments and are larger, more superficial muscles. * **Characteristics:** Do not exhibit continuous muscle activity; their activity is highly direction-specific. Histologically, they have a higher proportion of Type IIb fibers, suited for fast, powerful contractions. Neuromotorically, they are not activated preemptively and lack feedforward activation. #### 1.7.2 Phasic vs. tonic muscles (Janda) This classification is based on the perceived tendency of muscles to shorten or lengthen. * **Tonic muscles:** * Predominantly red muscle fibers (Type I). * Tend to shorten quickly, leading to hypertonicity and shortening syndromes. * **Kinesitherapeutic focus:** Assess muscle length. * **Phasic muscles:** * Predominantly white skeletal muscle fibers (Type II). * Tend to lengthen and lose strength more quickly. * **Kinesitherapeutic focus:** Assess muscle strength. ### 1.8 Neurogenic structures and pain Pain can arise from any innervated structure within the spine, or from injury to the spinal nerves or ganglia themselves. #### 1.8.1 Spinal cord * **Structure:** A cylindrical structure composed of white and gray matter. * **Origin:** Starts at the foramen magnum (medulla oblongata). * **Termination:** Ends at the cauda equina transition, typically at the L1–L2 vertebral level. * **Gray matter (horns):** * **Dorsal horn (posterior):** Contains interneurons for relaying sensory information to white matter tracts and receives sensory input from dorsal root afferents. * **Lateral horn (ventrolateral):** Contains preganglionic sympathetic neurons. * **Ventral horn:** Contains motor neurons. * **White matter:** Composed of myelinated nerve fibers arranged in tracts, each with a specific pathway and function. #### 1.8.2 Meninges These protective membranes surround and protect the spinal cord, consisting of three layers: * **Dura mater:** The outermost layer. * **Arachnoidea:** The middle layer. * **Pia mater:** The innermost layer. #### 1.8.3 Spinal nerves Spinal nerves connect the spinal cord to the periphery. * **Formation:** A pair of spinal nerves emerges from the spinal cord between two vertebral arches. They are formed by the fusion of dorsal and ventral roots within the intervertebral canal and then immediately divide. * **Roots:** * **Dorsal root:** Contains peripheral sensory neuron fibers. * **Ventral root:** Contains peripheral motor neuron fibers. * **Branches:** * **Ramus ventralis:** A mixed nerve carrying motor and sensory information; it runs ventrally and forms various plexuses (e.g., cervical, brachial, lumbosacral). * **Ramus dorsalis:** A smaller branch supplying posterior structures. * **Ramus meningeus:** Innervates the meninges. * **Ramus communicans:** Connects to the sympathetic chain. #### 1.8.4 Pain-sensitive structures ("nociceptive sources") These include the intervertebral disc, facet joints, musculature, dura mater, and skin. ### 1.9 Clinical biomechanics of the spine #### 1.9.1 Spinal movements The spine allows for flexion, extension, lateral flexion, and rotation, which can also be combined. * **Mobility:** * **Cervical:** Most mobile. * **Thoracic:** Least mobile due to the rigid rib cage. * **Sacro-iliac:** Very limited movement. * **Attachment sites:** * **Cervicothoracic junction:** Attachment for major shoulder muscles. * **Lumbar spine:** Supports a significant portion of body weight and attachment for important hip flexors. * **Pelvic movement:** The pelvis (ilium and sacrum) allows for anteversion and retroversion, with minimal movement of the sacrum relative to the ilium due to joint surfaces and strong ligaments. * **Factors influencing mobility:** Facet joints, ribs (thoracic), intervertebral discs (annulus and nucleus), ligaments, and muscles. #### 1.9.2 Regional movement characteristics * **Flexion:** Possible in all regions, most pronounced in the cervical spine. * **Extension:** Most pronounced in the cervical and lumbar regions. * **Lateral flexion:** Similar ranges in cervical, thoracic, and lumbar regions. * **Rotation:** Primarily in the cervical and upper thoracic regions; least in the lumbar region. #### 1.9.3 Cervical region mobility The cervical spine exhibits the greatest mobility, allowing for larger ranges of motion compared to the thoracic or lumbar regions. Key joints for head movements include the atlanto-occipital joint (flexion/extension) and the atlanto-axial joints (lateral and median, allowing rotation, flexion, and extension). The uncovertebral joints guide all movements. Mobility decreases caudally due to the presence of ribs, disc height reduction, and facet orientation. #### 1.9.4 Thoracic region mobility The thoracic region is the least mobile due to: * Low intervertebral disc height. * Frontal orientation of facet joints. * Long, overlapping spinous processes. * The presence of the rib cage, sternum, and associated joints, which create a stable structure. Movement is primarily rotational, with limited flexion and extension. #### 1.9.5 Lumbar region mobility The lumbar spine's movement characteristics vary: * **Upper lumbar (L1–L3):** Sagittal facet orientation allows primarily for flexion and extension. * **Lower lumbar (L4–L5–S1):** Facets rotate towards the frontal plane (45°), allowing for lateral flexion and rotation. #### 1.9.6 Sacral region mobility Movement in the sacral region is minimal due to the sacro-iliac joints, characterized by irregular surfaces and strong ligaments, providing significant stability. Small movements like nutation (anterior sacral tilt) and counter-nutation (posterior sacral tilt) are possible. Mobility can temporarily increase during pregnancy. ### 1.10 Postural deviations Postural deviations can be evaluated in both the sagittal and frontal planes. #### 1.10.1 Sagittal plane deviations * **Anteroposition of head:** Occurs with altered cervical spine alignment. * **Thoracic hyperkyphosis:** An increase in the normal thoracic curve. Can be flexible or fixed. * **Thoracic flat back:** A reduction in thoracic curvature. * **Lumbar hyperlordosis:** An increase in the normal lumbar curve, often compensated by thoracic hyperkyphosis. Associated with tight hip flexors and weakened abdominal muscles. * **Lumbar hypolordosis:** A reduction in the lumbar curve, often with the pelvis in retroversion. * **Kyfo-lordotic posture:** A combination of thoracic hyperkyphosis and lumbar hyperlordosis. * **Sway back:** The trunk shifts backward relative to the pelvis, with the lumbar lordosis being small or absent. * **Flat back:** A straightened thoracic and lumbar spine. * **Total kyphosis:** A generalized rounded posture of the spine, often seen in conditions like ankylosing spondylitis. #### 1.10.2 Frontal plane deviations * **Scoliosis:** A flexible or rigid lateral curvature of the spine in the frontal plane. Named by the convex side (e.g., left lumbar scoliosis). ##### 1.10.2.1 Scoliosis diagnosis and assessment * **Clinical assessment:** Includes inspection, Adams Forward Bend Test, scoliometer measurements, and assessment of lateral pelvic balance using a plumb line. * **Imaging:** Radiography (X-ray) is the most common method for diagnosis and monitoring. CT scans offer more precise measurements, while MRI can evaluate soft tissues. * **Cobb angle:** A quantitative measure of the curvature determined from X-rays. * **Vertebral rotation:** Assessed to understand the degree of deformity. * **Gibbus (voussure):** A dorsal prominence resulting from vertebral rotation and wedging, most evident with structural scoliosis, especially during the Adams test. ##### 1.10.2.2 Types of scoliosis * **Static scoliosis (scoliotic posture):** Flexible, reversible with posture changes (e.g., lying down, active correction), no vertebral wedging or rotation, no gibbus. * **Structural scoliosis:** Involves vertebral wedging and rotation, irreversible, often associated with a gibbus. Can be further classified by etiology (congenital, idiopathic, neuromuscular, etc.), number of curves, and location. ##### 1.10.2.3 Factors influencing scoliosis progression * **Curve magnitude:** Larger curves are more likely to progress. * **Skeletal maturity:** Progression is more likely during periods of rapid growth (puberty). * **Location and type of curve:** Certain curve types and locations have a higher risk of progression. * **Gender:** AIS is more common and tends to progress more in girls. ##### 1.10.2.4 Treatment principles for scoliosis Treatment is guided by the risk of progression and curve magnitude. It can include bracing to prevent progression and physical therapy to strengthen muscles, improve motor control, and maintain mobility. Surgical intervention is considered for severe, progressive curves. --- # Spinal biomechanics and movement This topic explores the functional biomechanics of the spine, detailing its range of motion, the roles of its joints and ligaments, and how these components contribute to spinal stability and movement. ### 2.1 Introduction to spinal function The spine is a crucial central link in human functioning, requiring a balance between stability and mobility. It serves three primary functions: * Protecting the central nervous system (spinal cord and cauda equina). * Providing support, stability, and load-bearing capacity. * Offering attachment points for muscles, enabling movement between body parts. Functional stability refers to the spine's ability to maintain both stability and mobility under static and dynamic loads. This requires sufficient mobility for proper movement, adequate muscle tone to maintain an upright posture against gravity, and the control of correct neuromuscular patterns for optimal posture and quality of movement. Understanding spinal pain necessitates knowledge of its functional anatomy, clinical biomechanics, and diagnostic assessment. ### 2.2 Functional anatomy of the spine The trunk is divided into several regions: * Cervical * Thoracic * Lumbar * Sacral The spine exhibits a sagittal S-shaped curvature. The cervical and lumbar regions are lordotic (convex ventrally), while the thoracic and sacral regions are kyphotic (convex dorsally). Pathological changes in these curves can affect overall posture and contribute to back pain. The cervical spine is functionally divided into three zones: * **C0–C2 (high cervical):** Highly mobile with specific and extensive movement capabilities. * **C3–C7 (mid-low cervical):** Exhibits typical cervical movements. * **C7–T3 (cervicothoracic junction):** A rigid fulcrum. The spine's functions include: * **Postural determination:** Largely dictates body posture. * **Protection:** Safeguards the spinal cord and cauda equina. * **Attachment:** Forms attachment sites for shoulder and pelvic girdle muscles. ### 2.3 Articular structure of the spine The vertebral column consists of: * 7 cervical vertebrae * 12 thoracic vertebrae * 5 lumbar vertebrae * 5 fused sacral vertebrae * 3–4 fused coccygeal vertebrae A functional spinal unit comprises two vertebrae and the intervening intervertebral disc and facet joints (intervertebral joints). **General vertebral structure:** * **Vertebral body (corpus vertebrae):** Flattened distally and proximally at lumbar and thoracic levels. * **Vertebral arch (arcus vertebrae):** Located dorsally, composed of the lamina (posterior) and pedicle (connecting to the body). * **Processes:** * Spinous process (dorsal) * Transverse processes (lateral) * Articular processes (superior/inferior) The vertebral foramen of all vertebrae together form the vertebral canal, housing the spinal cord and emerging nerves. #### 2.3.1 Cervical region Key features of cervical vertebrae: * **Transverse foramina:** Present in the transverse processes (except C7) for the vertebral artery. * **Spinous processes:** Bifid from C3–C7, oriented nearly horizontally. * **Atlas (C1):** Lacks a vertebral body and spinous process. It has two lateral masses connected by short anterior and long posterior arches. The fovea dentis on the posterior surface of the anterior arch articulates with the dens axis of C2. Transverse processes are prominent laterally and palpable. * **Axis (C2):** Features the dens axis, which projects cranially and articulates with the anterior arch of C1. * **Joints:** * **Atlanto-occipital articulation (C0–C1):** Between the atlas and the occipital bone. * **Atlanto-axial joints (C1–C2):** Includes lateral and median atlanto-axial joints between the atlas and axis. * **Uncovertebral joints of Luschka:** Formed by the uncinate processes on the superior lateral margins of the vertebral bodies from C3–C7. These are synovial joints. * **C7 (vertebra prominens):** Has a long spinous process, making it easily palpable. #### 2.3.2 Thoracic region Typical thoracic vertebrae resemble the basic vertebral type. T1 is more cervical-like, while T11–T12 are more lumbar-like. Mid-thoracic spinous processes are directed obliquely caudally, overlapping like roof tiles, becoming more horizontal in the cervical and lumbar regions. Facet joints for the ribs are located on the lateral sides of the vertebral bodies (superior and inferior) and on the transverse processes (T1–T10). T7 is at the apex of the thoracic kyphosis. The thoracic region also includes ribs, sternum, clavicles, and scapulae. Joints in this region include intervertebral, costovertebral/costotransverse, sternocostal, acromioclavicular, sternoclavicular, and scapulothoracic joints. #### 2.3.3 Lumbar region Lumbar vertebrae have large vertebral bodies. Spinous processes are thick and horizontal at their ends. **Costal processes** replace transverse processes, representing rudimentary ribs. Accessory processes are rudimentary transverse processes located dorsally to the costal processes. Mammillary processes are nipple-shaped projections cranial to the accessory processes. L4 marks the apex of the lumbar lordosis. #### 2.3.4 Sacral region The sacrum consists of five fused sacral vertebrae. The median sacral crest is the fusion of spinous processes, the intermediate/medial sacral crests are the fusion of articular processes, and the lateral sacral crests are the fusion of transverse processes. The sacrum forms part of the pelvic ring and articulates with the ilium to form the sacroiliac joints. #### 2.3.5 Facet joints (Zygapophyseal joints) These joints are located between the inferior articular processes of the superior vertebra and the superior articular processes of the inferior vertebra. Each spinal segment has left and right facet joints. The atlanto-occipital segment involves the atlas and occipital bone. The sacroiliac joints articulate the sacrum with the ilium. Facet joints are richly innervated and are a significant source of pain due to degeneration. **Facet joint orientation:** * **Cervical:** Ventrocranially oriented, 45°–70° to the horizontal (C3 at 45°, T1 at 70°), and 85° to the sagittal plane. * **Thoracic:** Frontally oriented. Superior facets face dorsally and laterally; inferior facets face ventrally. * **Lumbar:** Sagittally oriented, with lower lumbar facets rotating towards the frontal plane (45°). Superior facets face dorsally and medially; inferior facets face ventrally and laterally. Superior articular processes are slightly concave, and inferior ones are slightly convex. ### 2.4 Intervertebral discs The intervertebral discs are fibrocartilaginous structures located between vertebrae. The most cranial disc is between C2 and C3, and the most caudal is between L5 and S1. Discs are absent in the sacrum and coccyx due to vertebral fusion. **Disc structure:** * **Annulus fibrosus:** A ring of fibrous connective tissue. * **Nucleus pulposus:** A gelatinous center within the annulus fibrosus. The nucleus dehydrates with age, typically before the 30th year. Disc thickness varies with region, age, and spinal load. Cervical discs bear less load and have less water and proteoglycans than lumbar discs, making them more vulnerable to trauma and degeneration. Lumbar discs are more susceptible to injury from heavy physical exertion. Disc height contributes to approximately 25% of the total spinal length. * **Cervical discs:** 3–5 mm thick. * **Lumbar discs:** 10–12 mm thick. ### 2.5 Ligamentous structures Ligaments connect bony structures and provide stability. * **Anterior and posterior longitudinal ligaments:** Connect vertebral bodies and discs, with the posterior ligament being particularly important for spinal stability. * **Ligamenta flava:** Connect the ventral aspects of the laminae. * **Interspinous ligaments:** Span between spinous processes. * **Supraspinous ligament:** Borders the dorsal aspect of spinous processes, becoming the ligamentum nuchae in the cervical region. * **Intertransverse ligaments:** Extend between transverse processes. * **Transverse ligament of the atlas:** Stabilizes the dens. * **Alar ligaments:** Connect the dens to the inner surface of the occipital condyles, acting as collateral ligaments for the dens axis. ### 2.6 Myofascial system Muscles can be categorized in several ways: by function (global/local), intrinsic properties (phasic/tonic), or anatomical location (ventral/dorsal/lateral). #### 2.6.1 Local vs. Global muscle system (Bergmark, 1989) * **Local muscle system (stability):** * **Function:** Maintains segmental stability. * **Anatomy:** Attaches close to the vertebrae, stabilizing by being near the joints. * **Biomechanics:** Contraction generates joint compression without shear forces, maintaining neutral joint positions. * **Characteristics:** Primarily type I (slow-twitch) fibers, allowing for sustained, low-intensity activity. They are activated via a feedforward mechanism. * **Examples:** Deep spinal stabilizers. * **Global muscle system (force and movement):** * **Function:** Generates force for daily activities and initiates/accelerates movement. * **Anatomy:** Overbridges multiple segments; larger, more superficial muscles. * **Biomechanics:** Do not exhibit continuous activity; activity is highly direction-specific. * **Characteristics:** Primarily type IIb (fast-twitch) fibers, suited for rapid, powerful contractions. They are not activated via feedforward mechanisms. * **Examples:** Superficial back muscles. #### 2.6.2 Phasic vs. Tonic muscles (Janda, 1987) * **Tonic muscles:** * Predominantly red muscle fibers (Type I). * Tend to shorten quickly, leading to hypertonia and shortening syndromes. * Require attention to muscle length during therapy. * **Phasic muscles:** * Predominantly white skeletal muscle fibers (Type II). * Tend to lengthen and lose strength more rapidly. * Require attention to muscle strength during therapy. ### 2.7 Neurogenic pain Pain can originate from any innervated structure in the spine, as well as from spinal nerves or ganglia themselves. * **Spinal cord:** A cylindrical structure of white and gray matter, extending from the foramen magnum to the L1–L2 level (where it transitions to the cauda equina). * **Gray matter (horns):** * **Dorsal horn:** Contains interneurons for sensory information processing. * **Lateral horn:** Contains visceromotor neurons of the sympathetic system. * **Ventral horn:** Contains motor neurons. * **White matter:** Contains myelinated nerve fibers organized into tracts with specific functions. * **Meninges:** Protective membranes surrounding the spinal cord (dura mater, arachnoid, pia mater). * **Spinal nerve connection:** Spinal nerves arise from the fusion of dorsal (sensory) and ventral (motor) roots within the intervertebral foramen. They quickly divide into: * **Ventral ramus:** Mixed nerve carrying motor and sensory information, forming plexuses (cervical, brachial, lumbosacral). * **Dorsal ramus:** Innervates the posterior structures of the trunk. * **Meningeal ramus:** Recurrent branch innervating meninges. * **Communicating ramus:** Sympathetic fibers. * **Pain-sensitive structures ("nociceptive sources"):** * Intervertebral disc * Facet joints * Musculature * Dura mater * Skin ### 2.8 Clinical biomechanics of the spine #### 2.8.1 Spinal movements The spine allows for flexion, extension, lateral flexion, and rotation. These movements can also be combined. * **Mobility:** * Cervical: Most mobile. * Thoracic: Least mobile due to the rib cage. * Sacroiliac: Very limited movement. * **Attachment points:** The cervicothoracic junction is an attachment for large shoulder muscles. The lumbar spine is crucial for hip flexors and bears significant body weight. * **Pelvic movement:** The pelvis (ilium bilaterally and sacrum) can undergo anteversion and retroversion. Sacral movement relative to the ilium is minimal due to joint surfaces and strong ligaments. * **Factors influencing mobility:** Facet joints, ribs (thoracic), intervertebral discs (annulus and nucleus), ligaments, and muscles. **Summary of movements by region:** * **Flexion:** Possible throughout the spine, most pronounced in the cervical region. * **Extension:** Most pronounced in the cervical and lumbar regions. * **Lateral flexion:** Similar ranges in cervical, thoracic, and lumbar regions. * **Rotation:** Primarily in the cervical and upper thoracic regions; least in the lumbar region. #### 2.8.2 Cervical region The cervical spine has the greatest mobility. * **Key joints for head movements:** * **Atlanto-occipital articulation (C0–C1):** Flexion and extension. * **Atlanto-axial lateral articulations (C1–C2):** Rotation, some flexion, extension, and lateral flexion. * **Median atlanto-axial articulation (C1–C2):** Primarily rotation, with some flexion, extension, and lateral flexion. * **C2–C7 joints:** Allow flexion, extension, lateral flexion, and rotation. Lateral flexion and rotation are coupled due to facet orientation. Uncovertebral joints guide these movements. * **Range of motion decreases caudally** due to the presence of ribs, decreasing disc height, and facet orientation. #### 2.8.3 Thoracic region The thoracic spine is the least mobile due to: * Low disc height (narrow intervertebral discs). * Frontal orientation of facet joints. * Long, overlapping spinous processes. * Presence of ribs and stable costovertebral/costotransverse joints. * Presence of the sternum and sternocostal joints. * Movement is predominantly rotation, with limited flexion and extension. #### 2.8.4 Lumbar region * **Upper lumbar (L1–L3):** Sagittal facet orientation allows primarily flexion and extension. * **Lower lumbar (L4–L5–S1):** Facets rotate towards the frontal plane (45°), allowing for lateral flexion and rotation. #### 2.8.5 Sacral region Movement is nearly absent due to the sacroiliac joints, which have irregular surfaces and strong ligaments, providing significant stability with minimal mobility. * **Nutation:** Sacrum tilts anteriorly relative to the ilium. * **Counternutation:** Sacrum tilts posteriorly relative to the ilium. * SI joint mobility temporarily increases during pregnancy. #### 2.8.6 Pelvic region The pelvis acts as a pivotal point between the spine and lower limbs, allowing movement in three planes: * **Sagittal plane:** Anteversion and retroversion (influencing lumbar lordosis). * **Frontal plane:** Lateral tilting, stabilized by muscles like the gluteus medius and quadratus lumborum. * **Transverse plane:** Subtle but functionally important rotation. ### 2.9 Passive structures and pathology * **Hypomobility:** Loss of normal intervertebral mobility in one or more directions. * **Hypermobility:** Excessive intervertebral mobility. * **Instability:** Abnormal mobility in the mid-range of motion. ### 2.10 Clinical diagnostics Back complaints are common, particularly in the working population. Back and neck pain are significant health issues. * **Epidemiology of back pain:** 80% experience it at some point; 30–35% seek medical help; 55% recover within a week; 1 in 3 experience recurrence within a year; over 10% develop chronic complaints. Prevention of recurrence is crucial. #### 2.10.1 Classification of spinal pain Classification is based on: * **Cause/pathogenesis:** Congenital, traumatic, degenerative, postural, inflammatory, neoplastic, metabolic, neurogenic, psychogenic. * **Duration and outcome:** Acute (< 6 weeks), subacute (6–12 weeks), chronic (> 12 weeks). * **Location:** Lumbalgia (low back pain), lumbo-ischialgia (low back pain with leg radiation), ischialgia (leg radiation only). #### 2.10.2 The lumbar spine * **Non-specific low back pain:** 80–95% of cases, with an unknown but often multifactorial cause. Imaging is not routinely recommended unless serious underlying pathology is suspected. * **Terminology:** * **Lumbalgia:** Local pain in the low back. * **Lumbo-ischialgia:** Low back pain with radiating leg pain. * **Lumbago:** Local low back pain. * **Causes of Lumbalgia:** Disc issues (bulging, protrusion, herniation, degeneration), facet joint problems (arthrosis, blockage), muscular issues (deconditioning, trauma, poor posture, stress). * **Lumbar spinal stenosis:** Narrowing of the vertebral canal (central or foraminal). Causes include disc degeneration, arthrosis, ligament hypertrophy, tumors. Symptoms: low back and buttock pain, leg pain/fatigue with activity, numbness, tingling, altered reflexes. * **Spondylolysis and Spondylolisthesis:** Often related to extension and rotation, axial loading, and postural abnormalities. * **Lumbo-ischialgia (Sciatica):** Refers pain to the pelvic, hip, and/or leg, potentially originating from the lumbar spine. * **Non-radicular:** Pain referred from discs, facet joints, or muscles. * **Radicular:** Irritation of a lumbar nerve root, often from a disc herniation (younger individuals, acute) or spinal stenosis (older individuals, chronic). #### 2.10.3 The thoracic spine * **Specific conditions:** * **Tietze's syndrome:** Painful swelling of costochondral joints. * **Scoliosis:** Lateral curvature of the spine, often thoracic. Can be idiopathic, congenital, neuromuscular, or degenerative. Can lead to postural asymmetry, breathing problems, and organ dysfunction in severe cases. * **Scheuermann's disease:** Common kyphosis in adolescents due to vertebral developmental disorders. Symptoms include a visible gibbus, interscapular pain, and stiffness. * **Ankylosing spondylitis (Bechterew's disease):** Chronic inflammatory disease primarily affecting the spine, leading to morning stiffness, back pain, progressive kyphosis, and joint fusion. * **Non-specific conditions:** Costosternal, costovertebral, and facet dysfunction. Breathing mechanics are highly relevant. #### 2.10.4 The cervical spine * **Syndromes:** * **Cervical syndrome:** Neck pain from facet joint issues, disc degeneration, disc herniation, muscular strain (e.g., whiplash), repetitive strain injury, poor posture, or stress. * **Cervico-brachial syndrome:** Neck pain with arm radiation, either non-radicular (referred from discs, facets, muscles) or radicular (nerve root irritation from disc herniation or cervical stenosis). * **Cervico-cephalic syndrome:** Neck pain radiating to the head, potentially from high cervical structures, causing headaches, dizziness, or tinnitus. * **Other cervical conditions:** Vascular issues (vertebrobasilar insufficiency), form abnormalities (rheumatoid arthritis, ankylosing spondylitis), infections, and tumors. ### 2.11 Principles and structure of spinal examination #### 2.11.1 Introduction to spinal examination The spinal examination process follows a logical sequence: anamnesis (history taking), inspection, and clinical examination. The anamnesis helps form a hypothesis, which is then tested during the clinical examination. The physiotherapeutic diagnosis is based on this information, leading to a treatment plan that considers functional and anatomical impairments, activity and participation limitations, and personal/environmental factors (ICF framework). Evaluation of treatment effectiveness involves repeating the anamnesis and clinical examination. #### 2.11.2 Clinical reasoning process This involves a continuous cycle of hypothesis generation, testing, diagnosis, treatment, and evaluation. Parallel lines of inquiry focus on factors like the timeline of symptoms, risk assessment (red flags), and psychosocial influences. * **Timeline of complaints:** Acute (< 6 weeks), subacute (6–12 weeks), chronic (> 12 weeks). Flare-ups and recurrences are important to note. * **Risk assessment (Red Flags):** Clinical signs indicating a serious underlying cause that require immediate medical referral. These include widespread neurological symptoms, cauda equina syndrome signs, severe motor deficits, or suspicion of infection, tumor, or inflammatory conditions. * **Yellow, Orange, Black, and Blue Flags:** Indicators of psychosocial and contextual factors that may influence pain perception, treatment adherence, and recovery. * **Yellow flags:** Psychological factors (beliefs, emotions, behaviors). * **Orange flags:** Psychiatric symptoms (depression, PTSD). * **Black flags:** Systemic and contextual factors (legal issues, unsupportive work environment). * **Blue flags:** Work-related factors (job satisfaction, work pressure). #### 2.11.3 Anamnesis (History Taking) The goal is to rule out serious underlying conditions and identify red flags. Screening tools like the STarT Back and Örebro Musculoskeletal Pain Screening Questionnaire can help assess the risk of chronic pain. * **Key areas to cover:** * **Onset, course, and present status:** Traumatic/idiopathic onset, timeline, location, nature, severity (VAS), provoking/relieving factors, 24-hour pattern, previous episodes. * **Load:** Age, family history, occupation, hobbies. * **Medical interventions:** Imaging, medication, previous physiotherapy. * **General health:** Comorbidities. * **Contextual factors:** Personal (psychosocial) and environmental (work-related) factors. #### 2.11.4 Inspection Observing the patient's posture from frontal, sagittal, and global perspectives, both standing and sitting. * **Frontal plane:** Assess symmetry of shoulders, scapulae, iliac crests, and lower extremities. Check for scoliosis. * **Sagittal plane:** Observe spinal curvatures (lordosis, kyphosis), pelvic tilt, and alignment of the head, shoulders, and pelvis. * **Sitting inspection:** Evaluate habitual sitting posture. **Classification of postural deviations:** * **By severity:** First, second, or third degree (based on flexibility and bony deformity). * **By type:** Non-structural (flexible) vs. structural (fixed). * **By plane:** Sagittal plane deviations (e.g., anterior head carriage, thoracic hyperkyphosis, lumbar hyperlordosis) and frontal plane deviations (scoliosis). #### 2.11.5 Basic functional examination This involves active and passive range of motion (ROM) assessment for each spinal region to assess segmental mobility, movement patterns, and identify pain provocation. * **Active examination:** Tests contractile and non-contractile structures; assesses ROM, pain, and coordination. * **Passive examination:** Primarily tests non-contractile structures; assesses ROM, pain, and end-feel. #### 2.11.6 Additional examination * **Articular examination:** Provocation tests to assess joint play and pain provocation. * **Neurogenic examination:** Provocation tests to assess nerve root involvement. * **Myofascial examination:** Evaluates muscle length and strength. * **Muscle length testing:** Assesses global mobilizers prone to shortening. * **Muscle strength testing:** Manual Muscle Testing (MMT) with a 0–5 scale. * **Motor control examination:** Assesses sensorimotor control, including proprioception, postural control, and movement quality. Tests like dissociation tests and lumbopelvic control assessments are used. ### 2.12 Postural deviations in the sagittal plane These relate to the normal physiological curves of the spine. * **Cervical posture types:** Assessed by the relationship between cervical lines and the facial plane. Deviations include anterior head carriage and chin poke. * **Thoracic posture types:** * **Thoracic hyperkyphosis:** Increased dorsal curvature. Can be flexible or fixed. Often compensated by cervical and lumbar lordosis. * **Thoracic flat back:** Reduced thoracic curvature. * **Lumbar posture types:** * **Lumbar hyperlordosis:** Increased ventral curvature. Often involves pelvic anteversion, weak abdominal muscles, and tight hip flexors. * **Lumbar hypolordosis (flat back):** Reduced lumbar curvature, often with pelvic retroversion. * **Total posture types (Kendall & Kendall):** * **Kyphotic-lordotic:** Combination of thoracic hyperkyphosis and lumbar hyperlordosis. * **Sway back:** Trunk shifts posteriorly relative to the pelvis. * **Flat back:** Reduced lumbar lordosis and thoracic kyphosis. * **Total kyphosis:** Generalized dorsal curvature, seen in conditions like ankylosing spondylitis. ### 2.13 Postural deviations in the frontal plane #### 2.13.1 Determination of scoliosis Scoliosis is a flexible or rigid spinal deviation in the frontal plane. It is named by the side of the convexity. * **Normal spine:** Vertical and straight in the frontal plane, maintained by vertebral shape and balanced paraspinal and oblique muscle tone. * **Clinical presentation:** Can be asymptomatic or symptomatic. In children, it may be diagnosed during school screenings. In adults, pain, stiffness, and radiating pain are common. * **Adolescent Idiopathic Scoliosis (AIS):** The most common type, affecting approximately 4% of adolescents, more commonly in girls. * **Diagnostic tools:** Adams Forward Bend Test (to assess for gibbus), scoliometer, and imaging (X-ray, CT, MRI). #### 2.13.2 Imaging for scoliosis * **Radiography (X-ray):** Most common. Used to measure Cobb angle, assess vertebral rotation, and evaluate curve reducibility. Serial X-rays are used to monitor progression. * **3D CT scan:** Allows for more precise measurement of curves and deformities. * **MRI:** Useful for evaluating soft tissues and neurological involvement but less ideal for assessing spinal alignment under load. * **Non-invasive methods:** Photography, rasterstereography, and smartphone apps can be used for screening and monitoring. #### 2.13.3 Measuring scoliosis * **Cobb angle:** Measures the degree of curvature between the upper and lower neutral vertebrae bounding the curve. * **Vertebral rotation:** Assessed by the degree of wedging and rotation of the vertebral bodies and spinous processes, often quantified on X-ray. * **Gibbus (Voussure):** A dorsal prominence indicating vertebral rotation, most evident during the Adams forward bend test. Its height is measured. * **Shoulder girdle and iliac crest asymmetry:** Height differences are noted. * **Waist triangle asymmetry:** Assessed by measuring the space between the arms and the trunk. * **Plumb line assessment:** Evaluates the lateral balance of the spine and pelvis. * **Leg length discrepancy assessment:** Can contribute to functional scoliosis. #### 2.13.4 Mechanism of gibbus formation In structural scoliosis, vertebral bodies become wedge-shaped, and rotation occurs. The wedging is more pronounced on the concave side, and the spinous processes rotate towards the concave side. This asymmetry leads to a dorsal prominence (gibbus) on the convex side. #### 2.13.5 Clinical forms of scoliosis * **Static scoliosis (scoliotic posture):** A reversible spinal alignment deviation that disappears with active muscle contraction, lying down, or forward bending. It is not associated with wedged vertebrae or rotation. * **Structural scoliosis (S-scoliosis):** Involves wedged vertebrae and rotation, and the primary curve does not fully correct. #### 2.13.6 Classification of structural scoliosis * **By number of curves:** Single, double, or triple curves. * **By location:** Lumbar, thoracic, thoracolumbar, or combined. * **By etiology:** * **Idiopathic:** Most common (80%), with unknown exact cause but multifactorial influences (genetics, growth patterns, biomechanics). * **Congenital:** Due to congenital vertebral malformations. * **Neuromuscular:** Associated with neurological or muscular disorders (e.g., polio, cerebral palsy). * **Symptomatic:** Due to other underlying conditions (trauma, tumors, inflammatory diseases). #### 2.13.7 Evolution of scoliosis Scoliosis can progress, especially during growth spurts. Factors influencing progression include the curve's severity, location, and the patient's remaining growth potential. Treatment (bracing, physiotherapy, surgery) is determined by the risk of progression and curve magnitude. ### 2.14 Treatment considerations Treatment for scoliosis depends on the risk of progression, curve size, and skeletal maturity. * **Bracing:** Aims to prevent progression. * **Physiotherapy:** Focuses on strengthening spinal and abdominal muscles, improving motor control, manual mobilization for stiffness, and stretching for tightness. * **Surgery:** Indicated for severe curves, typically above 45–50 degrees, especially in skeletally immature patients with significant growth potential. The table below summarizes muscle involvement in postural deviations: | Lateral cervical deviation | Thoracic extension (hyperkyphosis) | Lumbar flexion (hyperlordosis) | Lumbar extension (hypolordosis) | | :------------------------ | :--------------------------------- | :----------------------------- | :------------------------------ | | Trapezius pars descendens (contralateral) | Pectoralis major (bilateral) | Iliopsoas (bilateral) | Hamstrings (bilateral) | | Levator scapulae (contralateral) | Pectoralis minor (bilateral) | Rectus femoris (bilateral) | Piriformis (bilateral) | | Sternocleidomastoideus (contralateral) | Latissimus dorsi (bilateral) | Tensor fasciae latae (bilateral) | | | | Erector spinae lumborum (bilateral)| | | The distinction between static and structural scoliosis is critical: | Static scoliosis or scoliotic posture | Fixed or structural scoliosis | | :------------------------------------ | :---------------------------- | | Disappears with active muscle contraction, lying down, or forward bending. | Primary curve does NOT disappear (secondary may partially). | | No wedged vertebrae, no rotation, no gibbus. Spine remains symmetrical. | Wedged vertebrae, rotation, and a unilateral gibbus (dorsal/lumbar/cervicodorsal) are present. | | No superimposition of curves. | Superimposed curves may exist. | | No further X-ray follow-up required. | X-ray follow-up is necessary. | --- # Clinical assessment and diagnostics of the spine This section outlines the principles and structure of spinal examination, focusing on history taking, risk assessment, red flags, and basic functional examination to identify serious underlying conditions. ### 3.1 Functional anatomy of the spine The spine is the central link for human function, requiring both stability and mobility. It has three primary functions: 1. Protecting the central nervous system (spinal cord and cauda equina). 2. Providing support, stability, and load-bearing capacity. 3. Serving as an attachment point for muscles, enabling movement between body parts. Functional stability involves the balance between stability and mobility. Adequate mobility is necessary for proper movement, sufficient muscle tone is needed to counteract gravity, and correct neuromotor patterns are essential for optimal posture and quality of movement. **Regions of the spine:** * Cervical * Thoracic * Lumbar * Sacral **Sagittal curves:** The spine has an S-shape. * **Lordosis:** Convexity towards the ventral side (cervical and lumbar regions). * **Kyphosis:** Convexity towards the dorsal side (thoracic and sacral regions). Pathological increases or flattening of these curves can affect overall posture and cause back pain. **Cervical functional zones:** * **C0–C2 (high cervical):** Highly mobile, with specific and extensive movement capabilities. * **C3–C7 (mid-low cervical):** Typical cervical movements. * **C7–T3 (cervicothoracic junction):** Rigid fulcrum. **Vertebral column structure:** * **Vertebrae:** * 7 cervical * 12 thoracic * 5 lumbar * 5 fused sacral * 3-4 fused coccygeal * A functional segment consists of two vertebrae and the intervening intervertebral disc and facet joints. * **General vertebral components:** * **Corpus vertebrae (vertebral body):** Flattened distally and proximally at lumbar and thoracic levels. * **Arcus vertebrae (vertebral arch):** Posteriorly located, composed of lamina (posterior) and pedicle (connecting to body). * **Processes:** Spinous (dorsal), transverse (lateral), articular superior/inferior (joint surfaces). * **Foramen vertebrale:** Together form the canalis vertebralis, housing the spinal cord and emerging nerves. **Cervical region characteristics:** * **Foramen transversarium:** Passage for the vertebral artery (except C7). * **Processus spinosus:** Bifid (split) at C3–C7, generally horizontal. * **Atlas (C1):** No body or spinous process; two lateral masses connected by short anterior and long posterior arches. Has a fovea dentis for articulation with the dens of C2. * **Axis (C2):** Dens axis projects cranially; articulates with C1. * **Joints:** * Atlanto-occipital (C0-C1) * Atlanto-axial (lateral and medial, C1-C2) * **Uncovertebral joints of Luschka:** Synovial joints formed by the uncinate processes on the superior edges of C3–C7 vertebral bodies. * **C7 (vertebra prominens):** Long spinous process, easily palpable. **Thoracic region characteristics:** * **Vertebrae:** Most resemble the typical vertebral type. T1 is more cervical-like, T11-T12 are more lumbar-like. * **Processus spinosi:** Mid-thoracic spinous processes are angled caudally, overlapping like roof tiles. They are more horizontal towards the cervical and lumbar regions. * **Costal facets:** On the sides of vertebral bodies (superior and inferior) and transverse processes for articulation with ribs. * Includes ribs, sternum, clavicles, and scapulae. * **Joints:** Intervertebral, costovertebral/costotransverse, sternocostal, acromioclavicular, sternoclavicular, scapulothoracic. **Lumbar region characteristics:** * Large vertebral bodies. * **Processus spinosi:** Thick and horizontal at their ends. * **Processus costalis:** Replaces transverse processes; rudimental ribs. * **Processus accessorius:** Rudimental transverse processes dorsal to the costalis processes. * **Processus mamillaris:** Nipple-shaped projection cranial to the accessory process. * L4 marks the apex of lumbar lordosis. **Sacral region:** * Five fused sacral vertebrae. * **Crista sacralis mediana:** Fusion of spinous processes. * **Crista sacralis intermedia/medialis:** Fusion of articular processes. * **Crista sacralis lateralis:** Fusion of transverse processes. * Forms part of the pelvic ring, articulating with the ilium at the sacroiliac joints. **Facet joints (Zygapophyseal joints):** * Joint between the inferior articular process of the superior vertebra and the superior articular process of the inferior vertebra. * Each segment has left and right facet joints. * Strongly innervated, making them susceptible to degeneration and a common source of pain. * **Orientation:** * **Cervical:** Ventrocranial, 45°-70° to horizontal (C3: 45°, T1: 70°), 85° to sagittal. * **Thoracic:** Frontal orientation; superior facets are dorsal and lateral, inferior are ventral. * **Lumbar:** Sagittal orientation; lower lumbar facets rotate towards 45° frontal. Superior facets are dorsal and medial, inferior are ventral and lateral. **Intervertebral discs (Discus intervertebralis):** * Cartilaginous discs between vertebrae. * Most cranial: between C2 and C3. Most caudal: between L5 and S1. Absent in fused sacrum and coccyx. * **Structure:** * **Annulus fibrosus:** Outer fibrous ring. * **Nucleus pulposus:** Gelatinous inner core. * The nucleus dehydrates before age 30. * **Thickness:** Varies by region, age, and spinal load. Cervical discs are thinner and more vulnerable to trauma than lumbar discs. Lumbar discs are more prone to injury from heavy physical load. * **Total disc height:** Constitutes up to 25% of the total spinal length. **Ligamentous structures:** Connect bony structures. * **Ligamentum longitudinale anterior & posterior:** Connect vertebral bodies and discs. * **Ligamenta flava:** Connect ventral aspects of vertebral laminae. * **Ligamenta interspinalia:** Between spinous processes. * **Ligamentum supraspinale:** Borders dorsal aspects of spinous processes (ligamentum nuchae in cervical region). * **Ligamenta intertransversaria:** Between transverse processes. * **High cervical ligaments:** Ligamentum transversum atlantis (holds dens), alaria ligaments (connect dens to occipital condyles). ### 3.2 Myofascial system Muscles can be classified based on function (local/global), intrinsic properties (phasic/tonic), or anatomical location (ventral/dorsal/lateral). **Local muscle system (stability):** * **Function:** Maintains segmental stability. * **Anatomical:** Attachments close to vertebrae, stabilizing by lying near joints. * **Biomechanical:** Apply compression to joints without causing shear or movement, controlling neutral joint positions. * **Activity:** Continuous, regardless of movement direction. * **Histological:** High proportion of Type I fibers (endurance). * **Neuromotor:** Activated via a feedforward mechanism. **Global muscle system (strength and movement):** * **Function:** Provide force for daily activities, initiate and accelerate movement. * **Anatomical:** Attachments not directly to vertebrae. * **Biomechanical:** Span multiple segments; larger, more superficial muscles. * **Activity:** Not continuous; highly direction-sensitive. * **Histological:** High proportion of Type IIb fibers (fast, powerful contractions). * **Neuromotor:** Not activated via a feedforward mechanism. **Phasic vs. Tonic muscles (Janda):** * **Tonic muscles:** Predominantly red muscle fibers (Type I). Tend to shorten, leading to hypertonicity and shortening syndromes. * **Phasic muscles:** Predominantly white muscle fibers (Type II). Tend to lengthen and lose strength. * **Kinesiotherapeutic focus:** * Phasic muscles: Assess muscle strength. * Tonic muscles: Assess muscle length. ### 3.3 Neurogenic structures Pain can originate from any innervated spinal structure or from lesions of spinal nerves or ganglia. **Spinal cord:** * Cylindrical structure of white and gray matter. * Originates from the foramen magnum (medulla oblongata). * Terminates as the cauda equina at L1–L2. * **Gray matter horns:** * **Dorsal horn (posterior):** Interneurons for sensory information relay. * **Lateral horn:** Visceromotor neurons (sympathetic system). * **Ventral horn (anterior):** Motor neurons. * **White matter:** Contains myelinated nerve fibers (tracts) for ascending and descending pathways. **Meninges:** Protective spinal cord membranes (dura mater, arachnoid, pia mater). **Spinal nerves:** * Emerge from the spinal cord, one pair between vertebral arches. * Formed by the fusion of dorsal (sensory) and ventral (motor) roots. * Branch into: * **Ramus ventralis:** Mixed nerve, forms plexuses (cervical, brachial, lumbosacral). * **Ramus dorsalis:** Mixed nerve, innervates back muscles and skin. * **Ramus meningeus:** Innervates meninges. * **Ramus communicans:** Connects to sympathetic trunk. **Pain-sensitive structures ("nociceptive sources"):** * Intervertebral disc * Facet joints * Musculature * Dura mater * Skin ### 3.4 Clinical biomechanics of spinal movement **Spinal movements:** * Flexion, extension, lateral flexion, rotation. These can be combined. * **Mobility:** Cervical (most mobile) > Lumbar > Thoracic (least mobile due to rib cage). * **Attachment sites:** Cervicothoracic junction for shoulder muscles, lumbar spine for hip flexors, bears significant body weight. * **Pelvic movement:** Anteversion, retroversion; limited sacral movement relative to ilium. * **Factors influencing mobility:** Facet joints, ribs, intervertebral discs, ligaments, muscles. **Movement patterns by region:** * **Flexion:** Possible in all regions, most pronounced in cervical. * **Extension:** Most pronounced in cervical and lumbar. * **Lateral flexion:** Similar mobility in cervical, thoracic, and lumbar. * **Rotation:** Primarily cervical and high thoracic; least in lumbar. **Cervical region:** * Greatest mobility, allowing large ranges of motion. * Key joints for head movements: atlanto-occipital (flexion/extension) and atlanto-axial (rotation, flexion/extension, slight lateral flexion). * C2–C7 joints: allow flexion, extension, lateral flexion, and rotation, but lateral flexion and rotation are interdependent. * Uncovertebral joints guide all movements. * Mobility decreases caudally due to ribs and disc height. **Thoracic region:** * Least mobile due to: * Low disc height. * Facet joint orientation. * Long, overlapping spinous processes. * Rib cage and costovertebral/costotransverse joints. * Sternum and sternocostal joints. * **Primary movement:** Rotation. Flexion and extension are limited. **Lumbar region:** * **Upper lumbar (L1–L3):** Sagittal facet orientation allows primarily flexion and extension. * **Lower lumbar (L4–L5–S1):** Facets rotate towards the frontal plane (45°), allowing lateral flexion and rotation. **Sacral region:** * Minimal movement due to sacroiliac joints' irregular surfaces and strong ligaments. * **Nutations:** Forward tilting of the sacrum relative to the ilium. * **Counternutations:** Backward tilting of the sacrum relative to the ilium. * SI joint mobility temporarily increases during pregnancy. **Pelvic region:** * Acts as a pivot point between the spine and lower limbs. * **Movements:** * **Sagittal plane:** Anteversion and retroversion. * **Frontal plane:** Lateral tilt. * **Transverse plane:** Rotation. **Passive structures and pathology:** * **Hypomobility:** Loss of normal intervertebral mobility. * **Hypermobility:** Excessive intervertebral mobility. * **Instability:** Abnormal mobility in the mid-range. ### 3.5 Clinical diagnostics: General principles Back pain is a highly prevalent health issue, often work-related. * **Epidemiology of back pain:** 80% experience it at some point; 30-35% seek medical help; 55% recover within a week; 1 in 3 have a recurrence within a year; >10% develop chronic complaints. Prevention of recurrence is crucial. **Classification of back pain:** * **By cause/pathogenesis:** Congenital, traumatic, degenerative, postural, inflammatory, neoplastic, metabolic, neurogenic, psychogenic. * **By duration and prognosis:** * **Acute:** < 6 weeks. * **Subacute:** 6-12 weeks. * **Chronic:** > 12 weeks. * **By location:** * **Lumbalgia/lumbago:** Pain in the lower back. * **Lumbo-ischialgia:** Lower back pain with leg radiation. * **Sciatica:** Only radiating pain. **Aspecific low back pain:** 80-95% with unknown cause, often multifactorial. Imaging is not routinely recommended unless a serious underlying cause is suspected. **Specific spinal conditions:** * **Lumbar region:** * **Lumbalgia/lumbago causes:** Disc issues (bulging, protrusion, herniation, degeneration), facet joint problems (arthrosis, blockage), muscular issues (deconditioning, trauma, repetitive tasks, poor posture, stress). * **Lumbar spinal stenosis:** Narrowing of the vertebral canal (central or foraminal), leading to pain, fatigue, numbness, tingling, and altered reflexes in the legs. * **Spondylolysis and spondylolisthesis:** Stress fracture of the pars interarticularis (spondylolysis) and slippage of one vertebra over another (spondylolisthesis), often due to extension and rotation. * **Lumbo-ischialgia:** Referred pain in the pelvic/hip region and/or leg, potentially from non-radicular (somatic) sources (disc, facet, muscles) or radicular sources (nerve root irritation, e.g., disc herniation, lumbar stenosis). * **Thoracic region:** * **Tietze's syndrome:** Painful swelling of costochondral joints. * **Scoliosis:** Lateral spinal curvature, often in the thoracic region (idiopathic, congenital, neuromuscular, degenerative). Can lead to postural asymmetry, respiratory issues. * **Scheuermann's disease:** Kyphosis in adolescents due to vertebral development disorders. * **Ankylosing spondylitis (Bechterew's disease):** Chronic inflammatory disease affecting the spine, leading to stiffness and fusion. * **Aspecific issues:** Costosternal/costovertebral dysfunction, facet dysfunction, breathing mechanics. * **Cervical region:** * **Cervical syndrome:** Neck pain from facet, disc, or muscular issues. * **Cervico-brachial syndrome:** Neck pain with arm radiation (non-radicular or radicular). * **Cervico-cephalic syndrome:** Neck pain with head radiation, potentially causing headaches, dizziness, tinnitus. * **Other cervical conditions:** Vascular issues, malformations, inflammatory diseases, infections, tumors. ### 3.6 Principles and structure of spinal examination The spinal examination involves anamnesis (history taking), inspection, and clinical examination. **Anamnesis (History Taking):** * **Goal:** Formulate hypotheses and rule out serious underlying conditions (red flags). * **Key elements:** * **Onset, course, and current status:** Traumatic/idiopathic onset, time course, pain characteristics (location, severity on VAS, nature), neurological symptoms (tingling, weakness), instability. * **Symptom behavior:** Provoking and relieving factors, avoidance behaviors, 24-hour pattern. * **Previous episodes:** History of similar complaints. * **Belasting (Load):** Age, family history, occupation, hobbies. * **Medical interventions:** Investigations (X-ray, CT, MRI, EMG), medication, physiotherapy. * **General health:** Comorbidities, lifestyle. **Red Flags:** Clinical signs or symptoms indicating a high probability of a serious underlying cause. These require immediate referral to a physician. * **Examples:** Widespread neurological symptoms, progressive neurological deficits, saddle anesthesia, bowel/bladder dysfunction, severe motor deficit (<48h), severe pain post-trauma, vascular signs, pathological fracture, infection, tumor, inflammatory conditions, therapy-resistant pain (>6 weeks), HIV. **Risk Assessment (Yellow, Orange, Black, Blue Flags):** * **Yellow flags:** Psychological factors (pain beliefs, emotions, avoidance, dependency on passive treatment). * **Orange flags:** Psychiatric symptoms (depression, personality disorders). * **Blue flags:** Perceptions of work/health (feeling of insufficient support). * **Black flags:** Systemic and contextual factors (legal issues, financial disputes, overprotective family, demanding work). * Screening tools like STarT Back and Örebro Musculoskeletal Pain Screening Questionnaire can help identify patients at risk for chronic disability. * Low-risk patients require simple approaches; higher-risk patients need a complex, multimodal approach. **Inspection:** * **Purpose:** Observe posture and symmetry from frontal, sagittal, and global perspectives, both standing and sitting. * **Frontal plane:** Assess symmetry of shoulders, scapulae, iliac crests, PSIS, waist triangles, and lower limbs. * **Sagittal plane:** Assess spinal curves (lordosis, kyphosis), pelvic tilt (anteversion/retroversion), head and shoulder alignment, and peripheral joint alignment. * **Sitting inspection:** Assess habitual sitting posture. * **Posture classification:** Normal physiological, non-structural (flexible, correctable), or structural (fixed, bony deformity). * **Sagittal plane deviations:** Anteroposition of head, thoracic hyperkyphosis, flat back, lumbar hyperlordosis, sway back, thoracic hypokyphosis. * **Frontal plane deviations:** Scoliosis (lateral curvature). **Basic Function Examination (Active and Passive Movement):** * **Purpose:** Assess global mobility, identify hypo/hypermobile segments, observe movement initiation and quality, and provoke pain. * **Active movement:** Patient performs movements; tests contractile and non-contractile structures. * **Passive movement:** Therapist moves the patient; tests non-contractile structures. Evaluates range of motion (ROM), pain, and end-feel. * **Parameters:** ROM, quality of movement (initiation, pattern, compensations), pain (recognizable pain), end-feel (passive). * **Functional examination:** Includes shoulder and hip assessment. **Specific Additional Examinations:** * **Articular examination:** Provocation tests to assess joint mobility and pain provocation. * **Neurogenic examination:** Provocation and functional tests for nerve root involvement. * **Myofascial examination:** * **Muscle length tests:** To identify shortened muscles prone to tightness. * **Muscle strength testing (Manual Muscle Testing - MMT):** Graded 0-5 based on resistance. * **Motor control examination:** Evaluates sensorimotor control, proprioception, postural control, and movement quality. * **Tests:** Positional correction tests, dissociation tests, tests for specific muscle recruitment (e.g., transversus abdominis, multifidus). * **Range of Motion (ROM) and Quality of Movement Assessment:** Detailed evaluation of joint movement quantity and quality, including segmental differences, pain arcs, and compensations. ### 3.7 Postural Deviations **Sagittal plane deviations:** * **Cervical posture types:** Chin poke (high cervical extension), anteroposition of head (low cervical flexion), combined anteroposition + chin poke. * **Thoracic posture types:** * **Thoracic hyperkyphosis:** Increased dorsal curvature, often compensated by cervical/lumbar lordosis. Can be flexible or fixed. * **Thoracic flat back:** Reduced kyphosis. * **Lumbar posture types:** * **Lumbar hyperlordosis:** Increased ventral curvature, often with pelvic anteversion, shortened hip flexors, weak abdominal muscles. * **Lumbar hypolordosis:** Reduced or absent lordosis, often with pelvic retroversion, weakened gluteal muscles. * **Global posture types (Kendall & Kendall):** * **Kyphotic-lordotic:** Pelvic anteversion, lumbar hyperlordosis, thoracic hyperkyphosis, anteroposition of head. * **Sway back:** Thorax shifts backward relative to the pelvis, pelvic retroversion, lumbar lordosis reduced. * **Flat back:** Reduced lordosis and kyphosis. * **Total kyphosis:** General rounded back, often seen in ankylosing spondylitis. **Frontal plane deviations (Scoliosis):** * **Definition:** Flexible or rigid deviation of the spine in the frontal plane. Named by the side of convexity. * **Causes:** Idiopathic (most common), congenital, neuromuscular, degenerative. * **Symptoms:** Can be asymptomatic or cause pain, stiffness, cosmetic concerns, functional limitations. * **Adolescent idiopathic scoliosis (AIS):** Most common type. * **Diagnostic tests:** * **Adams Forward Bend Test:** Assesses for a gibbus (hump) indicating structural scoliosis. * **Scoliometer:** Measures rib hump and spinal asymmetry. * **Imaging (X-ray, CT, MRI):** Used to measure Cobb angle, assess vertebral rotation, and evaluate spinal alignment. * **Cobb angle:** Measures the degree of the curve. * **Vertebral rotation:** Assessed via X-ray, visible as a gibbus on bending. * **Clinical Forms:** * **Static scoliosis (scoliotic posture):** Flexible, disappears with active muscle contraction, lying down, or bending forward. No vertebral wedging or rotation. * **Structural scoliosis:** Rigid, persists in all positions. Involves vertebral wedging and rotation, leading to a gibbus. * **Classification of structural scoliosis:** By number of curves, location (lumbar, thoracic, thoracolumbar), origin (congenital, idiopathic, neuromuscular, etc.), and severity (Cobb angle). * **Progression factors:** Age of onset, remaining growth, curve magnitude, curve pattern. * **Assessment includes:** Inspection and measurements in standing, sitting, and lying positions; muscle strength and length testing; motor control assessment. ### 3.8 Management of spinal conditions Treatment is determined by the risk of curve progression, curve magnitude (Cobb angle), and remaining growth. * **Bracing:** Used to prevent progression, particularly for curves >30° with remaining growth. * **Kinesitherapy:** Focuses on strengthening spinal and abdominal muscles, improving motor control, manual mobilization, and stretching. * **Surgical intervention:** Indicated for severe curves (e.g., Cobb angle ≥45° in skeletally immature, ≥50° in skeletally mature patients) with significant progression. --- # Spinal deformities and postural deviations This section delves into the identification, understanding, and management of spinal deformities and postural deviations, with a particular focus on scoliosis and its diagnostic evaluation. ### 4.1 Introduction to Spinal Function and Deformities The spine serves as the central link for human function, requiring both stability and mobility to balance opposing demands. Its primary functions include: * Protecting the central nervous system (spinal cord and cauda equina). * Providing support, stability, and load-bearing capacity. * Offering attachment points for muscles, enabling movement between body parts. Functional stability encompasses both stability and mobility, crucial for everyday activities, maintaining an upright posture against gravity, and executing high-quality movements through proper neuromotor patterns. Understanding spinal pain necessitates knowledge of functional anatomy, clinical biomechanics, and diagnostic procedures. ### 4.2 Functional Anatomy of the Spine The trunk is divided into several regions: cervical, thoracic, lumbar, and sacral. The sagittal curvature forms an S-shape, with cervical and lumbar regions exhibiting lordosis (convexity anteriorly) and thoracic and sacral regions exhibiting kyphosis (convexity posteriorly). Pathological amplification or flattening of these curves can significantly impact overall posture and lead to back complaints. #### 4.2.1 Anatomical Structure of Vertebrae The vertebral column comprises: * 7 cervical vertebrae * 12 thoracic vertebrae * 5 lumbar vertebrae * 5 fused sacral vertebrae * 3–4 fused coccygeal vertebrae A functional spinal unit consists of two vertebrae and the intervertebral disc between them, along with the facet joints (zygapophyseal joints). General vertebral anatomy includes: * **Vertebral body (corpus vertebrae):** Flattened distally and proximally at lumbar and thoracic levels. * **Vertebral arch (arcus vertebrae):** Located dorsally, comprising laminae and pedicles connecting to the vertebral body. * **Processes:** Spinous (dorsal), transverse (lateral), and articular (superior and inferior). * **Vertebral foramen (foramen vertebrale):** Together, these form the vertebral canal, housing the spinal cord and exiting nerve roots. #### 4.2.2 Regional Spinal Anatomy * **Cervical Region:** * Characterized by the **foramen transversarium** for the vertebral artery (except C7). * **Atlas (C1):** Lacks a vertebral body and spinous process; consists of two lateral masses connected by anterior and posterior arches. It articulates with the occiput at the atlanto-occipital joint and the axis at the atlanto-axial joints. * **Axis (C2):** Features the dens (odontoid process) that articulates with the anterior arch of C1. * **Uncovertebral joints of Luschka:** Synovial joints located on the lateral edges of the vertebral bodies from C3 to C7. * **Vertebra prominens (C7):** Easily palpable due to its long spinous process. * **Thoracic Region:** * Features articular facets on the vertebral bodies and transverse processes for articulation with the ribs. * **Processus spinosi:** Directed obliquely caudally, creating an overlapping, "roof tile" appearance. * The thoracic cage, sternum, clavicles, and scapulae are integral to this region. * **Lumbar Region:** * Characterized by large vertebral bodies. * **Processus spinosi:** Thick and horizontal. * **Processus costalis:** Replaces the transverse processes, representing a rudimentary rib. * **Processus accessorius** and **processus mamillaris** are also present. * **Sacral Region:** * Comprises five fused sacral vertebrae. * Features **crista sacralis mediana**, **intermedia**, and **lateralis** resulting from the fusion of spinous, articular, and transverse processes, respectively. * Forms part of the pelvic ring and articulates with the ilia at the sacroiliac joints. #### 4.2.3 Facet Joints (Zygapophyseal Joints) These joints are located between the inferior articular processes of a superior vertebra and the superior articular processes of an inferior vertebra. Their orientation varies by region: * **Cervical:** Ventrocranially oriented (45°–70° to the horizontal), 85° to the sagittal plane. * **Thoracic:** Frontally oriented; superior facets face dorsally and laterally, inferior facets face ventrally. * **Lumbar:** Sagittally oriented; inferior facets face ventrolaterally. In the lower lumbar segments, they rotate towards 45° frontal. #### 4.2.4 Intervertebral Discs (Discus Intervertebralis) * Composed of the **annulus fibrosus** (outer fibrous ring) and the **nucleus pulposus** (gelatinous inner core). * They provide shock absorption and permit movement. * Disc height varies by region and age. Lumbar discs are thicker than cervical discs. * The nucleus pulposus loses water and hydration with age, affecting disc function. * Cervical discs are more vulnerable to trauma and degeneration due to less water content, while lumbar discs are more susceptible to heavy physical loading. #### 4.2.5 Ligamentous Structures Various ligaments stabilize the spine: * **Anterior and posterior longitudinal ligaments:** Connect vertebral bodies and discs. * **Ligamenta flava:** Connect the laminae of the vertebral arches. * **Interspinal and supraspinal ligaments:** Connect spinous processes. The supraspinal ligament is known as the nuchal ligament in the cervical region. * **Intertransverse ligaments:** Connect transverse processes. * **Transverse ligament of the atlas:** Stabilizes the dens of the axis. * **Alar ligaments:** Connect the dens to the occipital condyles. #### 4.2.6 Myofascial System Muscles of the spine can be categorized by function (local/global), intrinsic properties (phasic/tonic), or location (ventral/dorsal/lateral). * **Local Muscle System (Stability):** * Provides segmental stability by attaching close to the vertebrae. * Characterized by Type I muscle fibers, high endurance, and feedforward activation. * Examples: Deep spinal stabilizers. * **Global Muscle System (Force and Movement):** * Generates force for daily functions and movement initiation. * Spans multiple segments, are larger and more superficial, and exhibit directional, intermittent activity. * Rich in Type IIb fibers, facilitating rapid, powerful contractions. * Examples: Superficial back muscles, abdominal muscles. * **Phasic vs. Tonic Muscles (Janda):** * **Tonic muscles:** Predominantly Type I fibers, prone to shortening and hypertonicity. * **Phasic muscles:** Predominantly Type II fibers, prone to lengthening and loss of strength. * Therapeutic focus: strength for phasic muscles, length for tonic muscles. #### 4.2.7 Neurogenic Structures Pain can originate from innervated spinal structures or from lesions of spinal nerves or ganglia. Key neurogenic structures include: * **Spinal Cord:** Extends from the foramen magnum to the L1–L2 level. Grey matter comprises dorsal (sensory), lateral (visceral motor), and ventral (motor) horns. White matter contains ascending and descending tracts. * **Meninges:** Protective membranes (dura mater, arachnoid mater, pia mater) surrounding the spinal cord. * **Spinal Nerves:** Formed by the fusion of dorsal (sensory) and ventral (motor) roots, exiting the vertebral canal. They branch into dorsal and ventral rami, which form various plexuses (cervical, brachial, lumbosacral). * **Pain-sensitive structures:** Intervertebral discs, facet joints, muscles, dura mater, and skin. ### 4.3 Clinical Biomechanics of the Spine #### 4.3.1 Spinal Movements The spine allows for flexion, extension, lateral flexion, and rotation, often in combination. Mobility varies significantly by region: * **Cervical:** Most mobile. * **Thoracic:** Least mobile due to the rib cage. * **Sacroiliac joints:** Very limited movement. Movement is influenced by facet joint orientation, the thoracic cage, intervertebral discs, ligaments, and muscles. #### 4.3.2 Regional Mobility Characteristics * **Cervical Region:** High mobility, particularly at the atlanto-occipital and atlanto-axial joints, which are critical for head movements. * **Thoracic Region:** Limited mobility due to the rigid rib cage, short intervertebral discs, overlapping spinous processes, and costovertebral/costotransverse articulations. Primarily allows for rotation. * **Lumbar Region:** Upper lumbar segments (L1–L3) facilitate flexion and extension due to sagittal facet orientation. Lower lumbar segments (L4–L5–S1) allow for more lateral flexion and rotation as facets approach a frontal orientation. * **Sacral Region:** Very limited mobility due to the strong sacroiliac joints and ligaments. Nutation and counternutation are the primary movements. * **Pelvic Region:** Acts as a hinge between the spine and lower limbs, allowing for anteversion, retroversion, and lateral tilting. #### 4.3.3 Passive Structures and Pathology * **Hypomobility:** Reduced normal intervertebral movement. * **Hypermobility:** Excessive intervertebral movement. * **Instability:** Abnormal movement in the mid-range. ### 4.4 Clinical Diagnostics of Spinal Conditions #### 4.4.1 General Principles Spinal complaints, particularly low back pain, are highly prevalent. A significant percentage of individuals experience back pain at some point, with a considerable proportion developing chronic issues or experiencing recurrences. Therefore, prevention is a crucial aspect of management. Classification of spinal conditions can be based on: * **Cause/Pathogenesis:** Congenital, traumatic, degenerative, postural, inflammatory, neoplastic, metabolic, etc. * **Duration and Prognosis:** Acute (< 6 weeks), subacute (6–12 weeks), chronic (> 12 weeks). * **Location:** Lumbalgia (low back pain), lumbo-ischialgia (low back pain with leg radiation), ischialgia (leg pain only). **Aspecific low back pain (80–95%)** often has multifactorial causes, and imaging is generally not recommended unless there's suspicion of a serious underlying condition. #### 4.4.2 Specific Spinal Conditions * **Lumbar Spine:** * **Lumbar spinal stenosis:** Narrowing of the vertebral canal (central or foraminal), often due to degeneration, arthritis, or ligament hypertrophy. Symptoms include back and leg pain with activity, numbness, and paresthesias. * **Spondylolysis and Spondylolisthesis:** Pars interarticularis defects (spondylolysis) that can lead to vertebral slippage (spondylolisthesis), often resulting from extension and rotation. * **Lumbo-ischialgia:** Referred pain in the pelvic/leg region originating from the lumbar spine, which can be somatically or radicularly referred. * **Thoracic Spine:** * **Scoliosis:** Lateral curvature of the spine, most commonly in the thoracic region. Causes include idiopathic, congenital, neuromuscular, or degenerative factors. * **Scheuermann's disease:** A developmental disorder affecting vertebral shape, leading to thoracic kyphosis in adolescents. * **Ankylosing Spondylitis (Bechterew's disease):** A chronic inflammatory condition primarily affecting the spine, leading to stiffness and eventual fusion. * **Cervical Spine:** * **Cervical syndrome:** Neck pain originating from facet joints, discs, or muscles. * **Cervico-brachial syndrome:** Neck pain with radiation into the arm(s), potentially somatically or radicularly referred. * **Cervico-cephalic syndrome:** Neck pain with radiation to the head, potentially causing headaches, dizziness, and tinnitus. #### 4.4.3 Principles of Spinal Examination The examination follows a structured approach: anamnesis (history taking), inspection, and clinical examination. A key component is risk assessment for chronicity, utilizing tools like the STarT Back or Örebro Musculoskeletal Pain Screening Questionnaire. * **Anamnesis:** Aims to identify "red flags" indicating serious underlying pathology. It gathers information on symptom onset, progression, aggravating/easing factors, past medical history, and psychosocial factors. * **Red flags** include neurological deficits, bladder/bowel dysfunction, severe pain after trauma, signs of infection or malignancy, and persistent, therapy-resistant pain. * **Yellow flags** (psychological factors), **orange flags** (psychiatric symptoms), **blue flags** (work-related factors), and **black flags** (systemic/contextual factors) are assessed to predict chronicity. * **Inspection:** Observes posture in frontal and sagittal planes, global movements, and sitting posture. * **Frontal Plane:** Assesses symmetry of the shoulder girdle, pelvic alignment, and presence of scoliosis. * **Sagittal Plane:** Evaluates the natural spinal curves (cervical lordosis, thoracic kyphosis, lumbar lordosis), pelvic tilt, and alignment of the head and lower limbs. Postural types include kyphotic-lordotic, sway back, flat back, and total kyphosis. * **Sitting Posture:** Assesses habitual sitting patterns and potential postural adaptations. * **Functional Movement Assessment:** Evaluates active and passive range of motion (ROM) for each spinal region to identify hypomobility, hypermobility, and quality of movement, including compensatory strategies. * **Active ROM:** Tests contractile and non-contractile structures. * **Passive ROM:** Primarily tests non-contractile structures, assessing end-feel and limitations. * **Specialized Examinations:** * **Articular Examination:** Provocation tests to assess joint play and pinpoint painful segments. * **Neurogenic Examination:** Provocation tests (e.g., straight leg raise) to assess nerve root irritation. * **Myofascial Examination:** Assesses muscle length and strength (manual muscle testing). * **Motor Control Examination:** Evaluates neuromuscular control, postural control, and coordination, including specific tests for lumbopelvic control and transverse abdominis/multifidus activation. ### 4.5 Postural Deviations in the Sagittal Plane These deviations involve alterations in the normal spinal curves: * **Anteroposition of the Head:** Often associated with forward head posture and altered cervical alignment. * **Thoracic Hyperkyphosis:** An increase in the normal thoracic curve. Can be flexible or fixed, often accompanied by muscle imbalances. * **Thoracic Flat Back:** Reduced thoracic kyphosis, leading to a flattened upper back. * **Lumbar Hyperlordosis:** An exaggerated lumbar curve, often associated with tight hip flexors and weak abdominal muscles. * **Lumbar Hypolordosis (Flat Lumbar Spine):** A flattening or reversal of the normal lumbar lordosis, often seen with pelvic retroversion. * **Overall Postural Types (Kendall & Kendall):** * **Kyphotic-Lordotic:** Increased thoracic kyphosis and lumbar lordosis, with anterior pelvic tilt. * **Sway Back:** Pelvis shifts posteriorly relative to the trunk, with a flattened or absent lumbar lordosis. * **Flat Back:** Reduced thoracic and lumbar curves. * **Total Kyphosis:** A generalized rounded spine, often seen in conditions like Ankylosing Spondylitis. ### 4.6 Postural Deviations in the Frontal Plane: Scoliosis Scoliosis is a lateral curvature of the spine in the frontal plane. #### 4.6.1 Definition and Diagnosis * **Definition:** A flexible or rigid deviation of the spine in the frontal plane. Named by the direction of the convexity (e.g., left lumbar scoliosis). * **Normal Spine:** Vertically aligned in the frontal plane due to vertebral shape and balanced muscle tone. * **Diagnosis:** * **Clinical Assessment:** Inspection for asymmetry, using a scoliometer to estimate the degree of curvature. The **Adams Forward Bend Test** is crucial for identifying structural scoliosis and the presence of a gibbus. * **Imaging:** Radiography (X-ray) is the gold standard for diagnosis and measurement. * **Cobb Angle:** The standard method for quantifying the severity of the curve, measured between lines drawn tangent to the superior endplate of the upper end vertebra and the inferior endplate of the lower end vertebra. * **Rotational Assessment:** Measuring vertebral rotation is essential, as it contributes to the deformity and gibbus formation. * **Neutral Vertebrae:** Vertebrae at the apex of the curve with minimal rotation. * **End Vertebrae:** The most tilted vertebrae at the upper and lower limits of the curve. * **Other Imaging:** CT scans provide detailed bony anatomy, while MRI can assess soft tissues and neurological involvement. Non-invasive methods like photographic analysis and raster stereography are used for monitoring. #### 4.6.2 Types of Scoliosis * **Scoliotic Posture (Static Scoliosis):** A non-structural, flexible deviation that corrects with postural correction, lying down, or hanging. There is no vertebral rotation or wedging. * **Structural Scoliosis:** A rigid, fixed deformity involving vertebral wedging and rotation. The primary curve does not fully correct. * **Idiopathic Scoliosis:** The most common type, with an unknown cause. Adolescent Idiopathic Scoliosis (AIS) is prevalent in adolescents and occurs more frequently in girls. * **Congenital Scoliosis:** Due to vertebral anomalies present at birth. * **Neuromuscular Scoliosis:** Associated with neurological or muscular disorders (e.g., cerebral palsy, muscular dystrophy). * **Degenerative Scoliosis:** Develops in adulthood due to disc degeneration and facet joint arthritis. #### 4.6.3 Mechanism of the Gibbus A **gibbus** (or voussure) is a dorsal prominence caused by vertebral rotation, most evident in structural scoliosis. * **Mechanism:** Due to asymmetric growth or loading, vertebrae become wedge-shaped and rotate. The spinous processes rotate towards the concave side, while the vertebral bodies rotate towards the convex side. * **Visibility:** The gibbus is more pronounced during the Adams Forward Bend Test and is typically located on the convex side of the curve. In the thoracic region, rotated ribs create a visible hump. #### 4.6.4 Clinical Forms and Progression Scoliosis is classified by the number of curves (single, double, triple) and their location (thoracic, lumbar, thoracolumbar). * **Severity (Cobb Angle):** * Mild: < 30° * Moderate: 30°–50° * Severe: > 50° * **Progression:** Scoliosis tends to progress during periods of rapid growth, particularly puberty. Factors influencing progression include: * **Severity of the curve:** Larger curves have a higher risk of progression. * **Age at onset:** Earlier onset generally leads to greater progression. * **Remaining growth potential:** Assessed by bone age (e.g., Risser classification). * **Treatment Considerations:** * **Bracing:** Used to prevent progression in growing individuals with moderate curves. * **Kinesitherapy:** Focuses on strengthening muscles, improving motor control, and addressing specific impairments. * **Surgery:** Indicated for severe, progressive curves (typically Cobb angle > 45°–50°). This summary provides a comprehensive overview of spinal deformities and postural deviations, emphasizing the diagnostic approach to scoliosis and the understanding of sagittal plane alterations. --- ## Common mistakes to avoid - Review all topics thoroughly before exams - Pay attention to formulas and key definitions - Practice with examples provided in each section - Don't memorize without understanding the underlying concepts

| Term | Definition | |---|---| | Vertebrae | The individual bones that make up the vertebral column, providing support and protection to the spinal cord. | | Spinal cord | The central nervous system structure extending from the brainstem down the back, protected by the vertebral column. | | Cauda equina | A bundle of spinal nerve roots extending from the lower end of the spinal cord. | | Lordosis | An inward curving of the spine, typically in the cervical and lumbar regions. | | Kyphosis | An outward curving of the spine, typically in the thoracic and sacral regions. | | Functional segment | The basic functional unit of the spine, consisting of two adjacent vertebrae and the intervertebral disc and facet joints between them. | | Corpus vertebrae | The main, weight-bearing part of a vertebra. | | Arcus vertebrae | The bony arch at the posterior aspect of a vertebra, enclosing the vertebral foramen. | | Processus spinosus | The posterior projection from the vertebral arch, serving as a muscle attachment point. | | Processus transversi | The lateral projections from the vertebral arch, serving as muscle attachment points and, in the cervical region, housing the vertebral artery. | | Foramen vertebrale | The opening in each vertebra that, when aligned, forms the vertebral canal. | | Canalis vertebralis | The vertebral canal, housing the spinal cord. | | Intervertebral disc | A cartilaginous disc located between adjacent vertebrae, acting as a shock absorber and allowing for spinal movement. | | Annulus fibrosus | The outer ring of tough fibrocartilage in an intervertebral disc. | | Nucleus pulposus | The gel-like inner core of an intervertebral disc. | | Facet joints (zygapophyseal joints) | The joints between the superior and inferior articular processes of adjacent vertebrae, guiding spinal movement. | | Ligaments | Strong fibrous tissues that connect bones to other bones, providing stability to joints, including those of the spine. | | Myofascial system | The interconnected network of muscles, fascia, tendons, and connective tissues that influence posture, movement, and function. | | Global muscles | Larger, superficial muscles that span multiple spinal segments, primarily responsible for powerful movements. | | Local muscles | Smaller, deep muscles that attach close to the vertebrae, primarily responsible for segmental stability. | | Fasic muscles | Muscles characterized by a tendency to lengthen and lose strength quickly, typically possessing a higher proportion of type II muscle fibers. | | Tonic muscles | Muscles characterized by a tendency to shorten and develop hypertonia, typically possessing a higher proportion of type I muscle fibers. | | Neurogenic pain | Pain arising from the nervous system, including spinal nerves or ganglia. | | Meninges | The protective membranes that surround the brain and spinal cord (dura mater, arachnoid mater, pia mater). | | Dorsal root | The sensory root of a spinal nerve, carrying afferent (sensory) information to the spinal cord. | | Ventral root | The motor root of a spinal nerve, carrying efferent (motor) information away from the spinal cord. | | Spinal nerve | A nerve formed by the fusion of a dorsal and ventral root, carrying both sensory and motor fibers. | | Plexus | A network of intersecting spinal nerves that serves a specific region of the body. | | Lumbar spinal stenosis | Narrowing of the vertebral canal in the lumbar spine, potentially compressing neural structures. | | Foraminal stenosis | Narrowing of the intervertebral foramen, through which spinal nerves exit the vertebral canal. | | Scoliosis | A lateral curvature of the spine, often accompanied by rotation. | | Kyphosis | An excessive outward curvature of the spine, typically in the thoracic region. | | Lordosis | An excessive inward curvature of the spine, typically in the lumbar or cervical region. | | Gibbus | A dorsal prominence or hump caused by structural scoliosis, resulting from vertebral wedging and rotation. | | Cobb angle | A measurement used to quantify the severity of a spinal curvature (scoliosis) on an X-ray. | | Red flags | Clinical signs or symptoms that suggest the possibility of a serious underlying medical condition requiring urgent medical attention. | | Anamnesis | The process of gathering a patient's medical history. | | Inspection | The visual examination of a patient's posture and body alignment. | | Basic functional examination (BFO) | A core set of tests to assess movement and function, including active and passive range of motion. | | Provocation tests | Diagnostic maneuvers designed to elicit or reproduce a patient's symptoms to identify the affected structures. | | Function tests | Tests used to assess the behavior of a specific spinal segment or joint under load. | | Neurogenic tests | Tests designed to assess the function of the nervous system, particularly nerve roots and peripheral nerves. | | Myofascial examination | Assessment of muscles, fascia, and related soft tissues for length, strength, and function. | | Muscle length testing | Assessing the passive range of motion to determine if muscles are excessively shortened. | | Muscle strength testing (Manual Muscle Testing - MMT) | A graded assessment of muscle power, typically on a scale from 0 to 5. | | Motor control examination | Evaluation of the interplay between sensory input and motor output for posture, movement, and stabilization. | | Proprioception | The sense of the relative position of one's own parts of the body and strength of effort being employed in movement. | | Spinal deformities | Abnormal shapes or alignments of the vertebral column. | | Postural deviations | Variations from the normal alignment of the body. | | Radiography (RX) | An imaging technique using X-rays to visualize the internal structures of the body, commonly used for spinal assessment. | | Computed Tomography (CT) | An imaging technique that uses X-rays and computer processing to create cross-sectional images of the body. | | Magnetic Resonance Imaging (MRI) | An imaging technique that uses magnetic fields and radio waves to create detailed images of organs and tissues. | | Adams Forward Bend Test | A clinical test where the patient bends forward to assess for a gibbus, indicative of structural scoliosis. | | Scoliometer | A device used to measure the angle of trunk rotation in scoliosis assessment. | | Risser classification | A system used to assess skeletal maturity based on the ossification of the iliac crest. | | Brace (orthosis) | A device worn externally to support, align, prevent, or correct the function of movable body parts, often used in scoliosis management. |