1. MANAGEMENT GUIDELINES BASED ON IMPAIRMENTS
Dr. Wajeeha Mahmood
BSPT, PPDPT

2. Principles of management for the Spine
Examination and Evaluation
History, systems review, and testing. A history and systems review of the patient is conducted to rule out any serious conditions, red flag signs are ruled out, Neurological symptoms should be explored in an attempt to relate them to spinal cord, nerve root, spinal nerve, plexus, or peripheral nerve patterns, Pain patterns should be explored to determine if they relate to a known musculoskeletal pattern or signal a medical condition

3. Stage of recovery: the acute stage usually lasts less than 4 weeks; the subacute stage is 4 to 12 weeks; and the chronic stage is greater than 12 weeks. Chronic pain syndromes generally are conditions that extend beyond 6 months.
Acute inflammatory stage. The patient experiences constant pain, and there are signs of inflammation. No position or movement completely relieves the symptoms
Acute stage without signs of inflammation. Symptoms are intermittent and related to mechanical deformation. Delitto and associates classified patients as being at this stage if they cannot stand longer than 15 minutes, sit longer than 30 minutes, or walk more than one-quarter mile without their status worsening.
Subacute stage. Usually at this stage, certain movements and postures with some instrumental activities of daily living (IADLs) still provoke symptoms, activities requiring repetitive movement of loads
Chronic stage. When this stage is reached, emphasis is placed on returning the patient to high-level demand activities

4. Diagnosis, prognosis, and plan of care

9. Management Guidelines: Nonweight-Bearing Bias
This patient is often more comfortable lying down and may have partial or full relief with a traction test maneuver to the painful region of the spine
Management of Acute Symptoms
Traction: Traction has the mechanical benefit of temporarily separating the vertebrae, causing mechanical sliding of the facet joints in the spine, and increasing the size of the intervertebral foramina, reduce circulatory congestion and relieve pressure on the dura, blood vessels, and nerve roots in the intervertebral foramina, there is stimulation of the mechanoreceptors that may modulate the transmission of nociceptive stimuli at the spinal cord or brain stem level.
Harness
Various unloading devices or body weight support systems may be used, such as partially suspending the patient in a harness while he or she performs ambulation on a treadmill or gentle extremity exercises.
Pool
If a person is not fearful of being in a pool, supporting the individual with a buoyant life belt in deep water reduces the effects of gravity on the lumbar spine

10. Management Guidelines: Extension Bias
Patients with an extension bias often assume a flexed posture or a flexed posture with lateral deviation of the trunk or neck, but during the examination, sustained or repetitive extension maneuvers reduce or relieve their symptoms
Management of Acute Symptoms If symptoms are severe, bed rest is indicated with short periods of walking at regular intervals.
Extension
Patient position and procedure: Prone. If the flexion posture is severe, place pillows under the abdomen for support. Gradually increase the amount of extension by removing the pillows and then progress by having the patient prop himself or herself up on the elbows, allowing the pelvis to sag

12. Lateral Shift Correction
Patient position and procedure: Standing with flexed elbow against the side of the deviated rib cage. Stand on the side to which the thorax is shifted and place your shoulder against the patient’s elbow. Then wrap your arms around the patient’s pelvis on the opposite side and simultaneously pull the pelvis toward you while pushing the patient’s thorax away

14. Once the shift is corrected, immediately have the patient backward-bend

16. Lumbar Traction
Traction may be tolerated by the patient during the acute stage and has the benefit of widening the disc space and possibly reducing the nuclear protrusion by decreasing the pressure on the disc or by placing tension on the posterior longitudinal ligament. Use less than 15 minutes of intermittent traction or less than 10 minutes of sustained traction. High poundage; more than half the patient’s body weight is necessary for separating the lumbar vertebrae.
Joint Manipulation
Grades I through IV joint mobilization/manipulation may be utilized preceding the prone press ups

17. Kinesthetic Training, Stabilization, and Basic Functional Activities
Teach simple spinal movements in pain-free ranges using gentle pelvic tilts.
Teach the patient basic stabilization techniques utilizing the core trunk muscles while maintaining control of the extended spinal position and performing simple extremity motions.
Encourage activities, such as walking or swimming, within the tolerance of the individual.
Initiate passive, straight-leg raising with intermittent dorsiflexion and plantarflexion to maintain mobility in the nerve roots of the lumbar spine.

19. Management Guidelines: Flexion Bias
Patients may present with a flexed posture and be unable to extend because of increased neurological symptoms and decreased mobility; these patients would benefit from early interventions that emphasize flexion of the involved segments to relieve symptoms. The patients may have a medical diagnosis of spondylosis or spinal stenosis (central or lateral), an extension load injury, or capsular impingement or swollen facet joints, so symptoms increase with extension
Management of Acute Symptoms
Rest and Support
With acute joint symptoms, a cervical collar or lumbar corset may help provide rest to the inflamed or swollen facet joints

20. Functional Position for Comfort
For flexion bias in the lumbar spine, the position is usually with the hips and knees flexed so the lumbar spine flexes.
In the cervical spine, the position is toward axial extension (upper cervical flexion) with some flexion also in the lower cervical region.
Cervical Traction
Gentle intermittent joint distraction and gliding techniques may inhibit painful muscle responses and provide synovial fluid movement in the joint for healing.
Dosages must be very gentle (grade I or II) to avoid stretching the capsules and are best applied with manual techniques during the acute stage.
Correction of Lateral Shift
Patient position and procedure: Standing with the leg opposite the shift on a chair so the hip is in about 90° of flexion The leg on the side of the lateral shift is kept extended. Have the patient then flex the trunk onto the raised thigh and apply pressure by pulling on the ankle

22. Management Guidelines: Stabilization
Patients with segmental instability including hypermobility; ligamentous laxity; diagnoses such as spondylolysis, spondylolisthesis, or poor neuromuscular control of the deep segmental and global stabilizing musculature require interventions that improve stability.
Passive Support
Braces or corsets may be necessary for external support to provide stability and reduce pain.
Deep Segmental Muscle Activation
Initially, the patient is taught to find and maintain a neutral spinal position using pelvic tilts (mid-range). The patient is then instructed in the “drawing-in maneuver” to activate the transversus abdominis, and he or she learns to contract the multifidus by bulging out the muscle.
Multifidus activation
Patient position and procedure: Prone or side-lying. Place your palpating digits (thumbs or index fingers) immediately lateral to the spinous processes of the lumbar spine. Palpate each spinal level so comparisons in the activation of the multifidus (Mf) muscle can be made between each segment as well as from side-to-side. Instruct the patient to “swell the muscle” out against your digits. Palpate for consistency of muscle contraction at each level.
Progression of Stabilization Exercises
Included are weight-bearing activities, such as wall slides, partial lunges, and partial squats, with emphasis on the “drawing-in” maneuver and spinal control in the neutral spinal position while doing the activities

24. Temporomandibular Joint Dysfunction
The function of the temporomandibular (TM) joint is closely related to the function of the upper cervical spine and posture. In 70% of patient cases, neck pain is associated with temporomandibular dysfunction (TMD)
Signs and Symptoms
The three cardinal (main) signs of TMJ impairments are
Pain in the TMJ region that is affected by movement.
Joint noise during movement.
Restrictions or limitations with jaw movement.
Etiology of Symptoms
1. Possible causes of TMJ pain: TM joint impairments are usually the result of trauma, poor posture, or faulty movement patterns. Additionally, symptoms can result from:
■ Poor oral hygiene.
■ Gum chewing.
■ Bruxism (grinding the teeth).
■ Smoking.
■ Inflammatory conditions such as rheumatoid arthritis.
■ Open mouth breathing.

25. 2. Relationship to Neck Pain
Causes may be:
A result of the neurophysiological influences from pain in masticatory muscles via the tonic neck reflex and/or the agonist/antagonist relationship of the anterior and posterior cervical muscles.
3. Mechanical Imbalances
Malocclusion, decreased vertical dimension of the bite, or other dental problems.
Faulty joint mechanics from inflammation.
Muscle spasm in the muscles of mastication, causing abnormal or asymmetrical joint forces.
Sinus problems, resulting in mouth breathing, which indirectly affects posture and jaw position.
Forward-head posture resulting in retraction of the mandible, which places the anterior throat muscles in a lengthened position

26. Principles of managment
Reduction of Pain and Muscle Guarding
Soft Tissue Techniques
Extra-oral massage. Perform using a circular motion technique in the region of either the masseter or temporalis muscle. Use a gentle massaging motion to facilitate muscle relaxation.
Intra-oral trigger point release. Identify a point of muscle tension within either the temporalis or masseter tendons. Maintain gentle finger point pressure until the muscle is felt to relax. Repeat at multiple areas of the muscle where muscle tension is identified.
A Petrous sinus release. Place one finger on the buccal side of the maxillary teeth and move posterior and cephalad. Once resistance is met, then maintain pressure until a “release” or softening of the muscle occurs.
Fascial Muscle Relaxation and Tongue Proprioception and Control
Place the tip of the tongue on the hard palate behind the front teeth and draw little circles or letters on the palate.
Place the tip of the tongue on the hard palate and blow air out to vibrate the tongue, making an “r r r r” sound.
Fill the cheeks with air (mouth closed); then let the air out in a puff.

27. Control of Jaw Muscles and Joint Proprioception
Teach control while opening and closing the jaw through the first half of the ROM. With the tongue on the roof of the mouth, the patient opens the mouth, trying to keep the chin in the midline.

28. Joint Manipulation Techniques
Unilateral distraction : Use the hand opposite the side on which you are working. Place your thumb in the patient’s mouth on the back molars; the fingers are outside and wrapped around the jaw. The force is in a downward (caudal) direction.
Unilateral distraction with glide : After distracting the jaw as described above, pull it in a forward (anterior) direction with a tipping motion. The other hand can be placed over the TMJ to palpate the amount of movement.