The

SPINE

Review of Relevant
Anatomy
Functional
Components:
1. Anterior Pillars
2. Posterior Pillars
Functional Unit:
Motions:

Sagittal
Frontal
Transverse
Ant/ Post shear
Lateral shear
Distraction

The Vertebral Column

> central bony pillar of the body
> provides a base of support for the head
and internal organs; a stable base for the
attachments of ligaments, bones, and
muscles of the UE, rib cage, pelvis,
> a link between the UE and LE
> protects the spinal cord

Structure
33 short bones called
vertebrae and 23 IV
disks
5 regions
> cervical (7)
> thoracic ( 12)
> lumbar ( 5)
> sacral ( 5)
> coccygeal ( 4)

Primary and Seconday

Curves

Primary curves ( thoracic and sacral)

posterior convexity, anterior concavity
( kyphotic curves)
Secondary curves (cervical and lumbar)
posterior concavity, anterior convexity
( lordotic curves)

General characteristics
of vertebra

Typical vertebra has

Anteriorly : rounded body
Posteriorly: vertebral arch

a. pedicles (sides of the arch)

B. laminae ( posteriorly located)
7 processes
( 1 spinous, 2 transverse, 4 articular)

Vertebral foramen

General characteristics
of vertebra

7 processes

4 articular and 3 nonarticular

NONARTICULAR
A. (1) spinous process or spine (directed
posteriorly )
B. (2) transverse processes ( directed laterally)
> arise from the junction of pedicles and
laminae
> serves as levers
> receives attachments of muscles and
ligaments

7 processes
ARTICULAR ( vertically arranged)
A. (2) superior articular
B. (2) inferior articular
2 superior articular processes of one arch
articulate with the 2 inferior articular processes
of the arch above forming two synovial joints
IV foramen formed by superior notch of one
vertebra and inferior notch of an adjacent
vertebra; transmits the spinal nerves and blood
vessels

Characteristics of a
typical cervical vertebra
Transverse processes has a foramen
transversarium for passage of vertebral artery
and veins
Spines are small and bifid
Body is small and broad from side to side
Vertebral foramen is large and triangular
Superior articular processes have facets that
face backward and upward; inferior have facets
that face downward and forward

Typical cervical
vertebra

Characteristics of the
atypical cervical vertebrae
( C1, C2, and C7)

C1 atlas ( supports the globe of the head)

> s body and spinous process
> has anterior and posterior arch
> has a lateral mass on each side with
articular surfaces on its upper surface for
articulation with the occipital
condyles(atlanto-occipital joints)

Characteristics of the
atypical cervical vertebrae
( C1, C2, and C7).

C2 axis ( epistropheus)
> has peglike odontoid process

C7 (vertebra prominens)
> has the longest spinous process and not bifid
> transverse process is large
> foramen transversarium is small and
transmits the vertebral vein or veins.

Atypical vertebrae

Characteristics of a
Typical Thoracic Vertebra
Body is medium size and heart shaped
Vertebral foramen is small and circular
Spines are long and inclined downward
Costal facets are present on the sides of the
bodies for articulation with the head of the ribs
Costal facets are present on the transverse
processes for articulation with the tubercles of
the ribs( T11 and 12 have no facets on the
transverse processes)
Superior articular processes facets backward
and laterally
Inferior articular processes facets forward and
medially

Typical thoracic
vertebra

Characteristics of a
Typical Lumbar Vertebra
Body is large and kidney shaped
Pedicles are strong and directed backward
Laminae are thick
Vertebral foramina are triangular
Transverse processes are long and slender
Spinous processes are short, flat, and
quadrangular and project backward
Articular surfaces of the superior articular
process face medially
Inferior articular processes face laterally

comparison

Regional variations in
vertebral structure
Body
Arch

cervical
thoracic
lumbar
small
heart-shaped kidney

Slant and Direction of Facet Joints

A. Cervical- frontal plane
B. Thoracic

Upper thoracic: frontal plane

Lower thoracic: sagittal plane

C. Lumbar- sagittal plane

Sacrum
5 vertebrae fused together to form
wedge-shaped bone
Concave anteriorly
Upper border articulates with L5
Inferior border articulates with coccyx
Lateral border articulates with 2 iliac
bones ( sacroiliac joints)

Structure and Function of the IV Disk

The Annulus Fibrosus
fibrocartilage and collagen
provides tensile strength
restrain various spinal motion
fibers of the inner layer blend with the nucleus
pulposus
firmly attached to the adjacent vertebra and to
one another
Supported by ligaments

Structure and Function of the IV Disk

The Nucleus Pulposus
gelatinous mass
with loosely aligned fibers.
high concentration of proteoglycans
Fluid Mechanics In the Spine

evenly distribute pressure

transport for nutrients
normally: NP does not move in a healthy disk

The Cartilaginous End-Plates

encircled by the apophyseal ring of the respective
vertebral body
nutrition diffuses from marros of the vertebral bodies to
the disk via the endplates

Ligaments

Intervertebral disk

Ligaments
1. Intersegmental
binds a anumber of
vertebrae into a unit
2. Intrasegmental
binds an individual or
adjacent vertebrae
together

Intersegmental
ligaments

Anterior Longitudinal ligament

Dense band along anterior and lateral surface
of the vertebral bodies from sacrum to C2
Atlanto-occipital ligament extension from C2
to occiput
Tensile strength
High cervical, lower thoracic, lumbar regions
Compressed in flexion, stretch in flexion and
slack in neutral position
2x as strong as the PLL

Intersegmental
2. Posterior Longitudinal ligament
Runs within the vertebral canal along
posterior surfaces of the vertebral bodies
from C2 to sacrum
Tectorial membrane ligament that
extends to the occiput
Stretched in flexion, slack in extension

Intersegmental
Supraspinous ligament
Runs along the tips of the spinous process
from C7 to sacrum
Ligamentum nuchae in the cervical region
Ligaments on the lumbar level merge with the
insertion of lumbar muscles
Stretched in flexion
Its fiber resist separation of the spinous
processes during forward flexion

Intrasegmental
ligaments
Ligamentum flavum
thick, elastic ligament on the posterior
surface of vertebral canal
Runs from C2 to sacrum connecting
laminae of adjacent vertebrae
Strongest in the lower thoracic and
weakest in midcervical

Intrasegmental
ligaments

Interspinous ligament
Well developed only in lumbar area from
base of spinous process to another
Stretch in forward flexion and slack in
extension
Intertransverse ligament
Well developed only in lumbar area
Stretch in lateral bending

Thoracolumbar Fascia

OTHER FACTORS THAT INFLUENCE

MOVEMENT
Slant and Shape of Spinous Process
Relative size of IV and Body
Ribs in the thoracic Region
Muscles

NEUROMUSCULAR
FUNCTION: DYNAMIC
STABILIZATION
Muscle control in the Lumbar spine
Functions primarily as prime movers and secondary stabilizers
Functions as primary stabilizers

Transversus abdominis and IO- isometric contraction,

valsalva maneuver and drawing in maneuver
IO and EO- rotation and side bending
Rectus abs- flexion and post tilting
Quadratus Lumborum- stabilize the spine and ribs
Multifidus
Intersegmental mm
ES
Iliopsoas mm

Small muscles at the

back

FEEDFORWARD AND SPINAL STABILITY

there are feedforward postural responses
of all trunk preceding activity in muscles
that move the extremity
speed or not direction of arm movements
directly affects activation of TA and IO
EFFECTS OF BREATHING ON POSTURE
AND STABILITY
Effect of Valsalva maneuver

POSTURE
Equilibrium
ankle
Knee
hip
Trunk
Head

Etiology of Postural Impairments

Mechanical stress

PAIN SYNDROMES RELATED TO IMPAIRED

POSTURE
Postural Fault: deviates from normal alignment but
has no structural limitations
Postural Pain Syndrome: pain that occurs from
mechanical stress when a person maintains a
faulty posture from prolonged period
Postural Dysfunction: with adaptive shortening of
tissues and mm weakness
Postural Habits

COMMON FAULTY POSTURES

Kypholordotic Posture
Potential sources of pain
Potential mm
impairments
Common Causes

COMMON FAULTY POSTURES

Swayback
Potential sources of
pain
Potential mm
impairments
Common Causes

COMMON FAULTY POSTURES

Flat Low-Back
Potential sources of
pain
Potential mm
impairments
Common Causes

COMMON FAULTY POSTURES

Flat Upper Back and
Flat neck posture
Potential sources of
pain
Potential mm
impairments
Common Causes

COMMON FAULTY POSTURES

Forwardhead and
increased thoracic
kyphosis
Potential sources
of pain
Potential mm
impairments
Common Causes

COMMON FAULTY POSTURES

Lower Extremity Asymmetries
Characteristics

hip joint
SI joint
lumbar spine

Potential sources of pain

Shear forces in the SI and hip jt at LL
stenosis at IV foramina
facet compression
disc break down
Mm fatigue, spasm and tension
LE overuse

PATHOLOGY OF THE IV
DISK
INJURY AND DEGENERATION

INJURY AND DEGENERATION

1. Fatigue Loading and Traumatic Rupture
a. Fatigue Breakdown
b. Traumatic Rupture
2. Axial Load
3. Age
4. Degenerative Changes

DISC PATHOLOGIES

COMPRESSION FRACTURE

DISC HERNIATION AND TISSUE

FLUID STASIS

DISC HERNIATION

Etiology of S/Sx
1.
2.
3.

Pain
Neurologic s/sx
Variability of symptoms

Small posterolateral protrusion

Large posterolateral protrusion
Large posterior protrusion
Anterior protrusion

4. Shifting symptoms
5. inflammation

Herniation

Objective Clinical Findings

A. Lumbar Spine
Posture
Preferred position and activity
Forward bending and backward bending
special test
B. Cervical Spine

Pathology of the Facet Joint

Common Diagnosis of Facet Jt.

Pathologies

Sprain / Capsule Injury

OA, Degenerative Dse., Spondylosis
Rheumatoid Arthritis
Facet Jt. Impingement

Common Impairment
1. Pain
2. Mobility
3. Postural impairments
4. Activities and motions

Spondylolysis

Spondylolisthesis

Classification of Spondylolysis
1. Dysplastic: dysplasia in the superior
sacral facet and inferior facet of L5
2. Isthmic:
Lytic
Elongated
Acute Fracture

3.
4.
5.

Degenerative
Traumatic
Pathologic

S/ Sy of Spondylolysis/ Spondylolithesis
1.
2.
3.
4.
5.

Compression of nerve root

Compression of spinal cord
Exaggerated lumbar lordosis
Limited spinal ROM
Tightness of hip flexor, hamstring and
ankle dorsiflexors

On Xray: Meyerdings Classification

depending on degree of advancement

Meyerdings Classification

Treatment:

Posttraumatic cases: immobilization for 1012 wks

Chronic Back Pain
1. abdominal strengthening
2. stretching of tight structures
3. static and dynamic body strengthening
4. support
5. massage and modalities

Lumbar Stenosis
condition in which the nerves or the spinal
cord in the spinal canal are "closed in," or
compressed
Causes:
spur formantion
Facet hypertrophy
subluxation
spondyolisthesis
congenital presdeposition

Lumbar Stenosis

Lumbar Stenosis S/ Sx
Central Stenosis
1. Sx produced by standing and walking and
relieved by sitting or assuming a flexed
spine position
2. Pseudoclaudication
3. Weakness
4. Walks in a stooped manner
5. Walking uphill is easier than walking
downhill

Lumbar Stenosis S/ Sx
Lateral Recess Syndrome
1. Intense sciatic pain
2. Mild neurologic defecit
3. SLR usually negative
4. Little of no low back pain

TREATMENT
1.Strengtening
2. Stretching
3. Passive support

Pathology of Muscle and Soft

Tissue

Common Sites
a. Cervical
Flexion
Extension

b. Lumbar

Common Impairments
a. Acute
Pain and mm guarding
Pain c mm contraction and stretch
Interference c ADL

b. Subacute/Chronic

Mm weakness
Restricted mobility
Inadequate spinal control and stabilization
Poor postural awareness
Limited IADL, work and recreational act

Guidelines for Management of Soft Tissue

and MM Lesion
1. Modulate Pain and Control Edema and
Inflammation
a. Cervical
b. lumbar

2. Maintain Mm integrity
a. Cervical Region
b. Lumbar Region
3. Maintain mm integrity when there is no mm injury
4. Traction

GENERAL GUIDELINES IN MANAGING

SPINAL PROBLEMS
Acute
1. Decrease Acute Sx
Modalities, massage, rest
Traction

2. Demonstrate awareness of neck and pelvic

position and movement
Establish the neutral position/ position of bias/
functional position
a. Flexion bias
b. Extension bias
c. Nonweight-bearing bias
Kinesthetic Training
a. cervical and scapular motions
b. Pelvic tilts and neutral spine

GENERAL GUIDELINES IN MANAGING

SPINAL PROBLEMS
3. Demonstrate safe postures
Teach awareness of safe postures and effects of
movement
Passive Positioning/ support

4. Initiate neuromuscular control of stabilizing mm

Drawing in Maneuver
Teach Basic Stabilization

5. Teach basic functional movements

6. Review Precautions

GENERAL GUIDELINES IN
MANAGING SPINAL PROBLEMS

Subacute
1. Learn self-management and decrease episodes
of pain
Ergonomics and safe act and postures

2. Progress awareness and control of spinal

segment
Practice spinal control in all positions and exercises

3. Increase mobility
Joint mob/ manipulation, inhibition
Stretching exercises

GENERAL GUIDELINES IN MANAGING

SPINAL PROBLEMS

4. Develop neuromuscular control, strength

and endurance in stabilizing mm
Progress stabilization ex, increase reps and
challenge

5. Increase dynamic trunk and extremity

strength
6. Develop general aerobic endurance
7. Learn technique of stress and relaxation
8. Learn safe body mechanics
9. Develop functional skills

GENERAL GUIDELINES IN
MANAGING SPINAL PROBLEMS
Chronic
progress exercises
Habitually use techniques of stress
relief/relaxation
return to high level/ high intensity activities
Develop healthy exercise habits

Guidelines for Management of

Impairments with an Extension
Bias
Principles of Mx:
1.
2.
3.
4.

Effects of Postural changes on IV disc

Effects of Bed rest
Effects of Traction
Effects of flexion and extension on IV and
Fluid stasis
5. Effects of Isometric and Dynamic Exercise
6. Effects of MM guarding

Guidelines for Management of

Impairments with an Extension
Bias
Indication for Extension Ex.
Precaution and CI to Extension Ex.
1. acute pain not influenced by changing the
patients position or movement
2. peripheralization of sy
3. CI:
No movement or position decrease the sy
Saddle anesthesia and bladder weakness
Extreme pain

4. Any activity or exercises that increases

intradiskal pressure , such as valsalva
maneuver, active pelvic tilt or trunk raising
exercise

Guidelines for Management of

Impairments with an Extension
Bias
Techniques
of Intervention Using an Extension
Approach in the Acute Stage
Lumbar Spine

Passive Extension
Lateral Shift
Traction
Patient Education
Position and motions increase and decrease pain
or other symptoms
Self-correction of lateral shift
Respect pain
Passive support during healing
Avoid flexion activities

Guidelines for Management of

Impairments with an Extension
Bias
Techniques of Intervention Using an
Extension Approach in the Acute Stage
Cervical spine
Passive Axial Extension
Patient Education
Traction
Kinesthetic Training for Posture

Mc Kenzie Regimen
Method of diagnosis and treatment based on
movement patterns of the spine
advocates position and movement patterns that
best relieve patients symptoms
Classified LBP based on spinal movement pattern,
each classification has a specific treatment that
includes postural correction and education
Approach:
Technique is a more passive form of spinal manipulation
which patient produces the motion , position and forces
Cyclic ROM to endrange- centralizes pain
Lumbar flexion ex maybe added later when patient has
full spinal ROM

McKenzie Regimen
1.
2.
3.
4.
5.
6.
7.

Lying prone 5 mins

Lying in extension ( prone on elbows)
Extension in lying ( prone on hands)
Extension in standing
Flexion in supine (knee to chest)
Flexion in sitting
Flexion in standing

McKenzie Regimen (New)

1.
2.
3.
4.
5.
6.
7.
8.
9.

Lying Prone
Lying Prone in Extension
Extension in Lying
Extension in Lying with Belt Fixation
Sustained Extension
Extension in Standing
Extension Mobilization
Extension Manipulation
Rotation Mobilization in Extension

McKenzie Regimen (New)

10. Rotation Manipulation in Extension
11. Sustained Rotation / Mobilization in
Flexion
12. Rotation Manipulation in Flexion
13. Flexion in Lying
14. Flexion in Standing
15. Flexion in Standing
16. Correction of Lateral Shift
17. Self Correction of Lateral Shift

Guidelines for Management of

Impairments with an Flexion Bias
Principles of Mx:
1. Effects of position
2. Effects of traction
3. Effects of Trauma and repetitive irritation
4. Effects of meniscoid tissue

Guidelines for Management of

Impairments with an Flexion Bias
Techniques of Intervention Using an Flexion
Approach in the Acute Stage
rest and Support
Functional position for comfort
Traction
Correction of lateral shift
Correction of meniscoid Impingement

1. Traction
2. Spinal mobilization and manipulation

Williams Exercise

Guidelines for Management of

Impairments with a NonWB Bias
Techniques of Intervention Using a NonWB
Approach in the Acute Stage
Traction
separate vertebra
mechanical sliding of facets
reduce circulation congestion
relieve pressure on the dura, blood vessels and
nerve root
stimulation of mechanoreceptors

Harness
Pool

NEURAL TENSION IMPAIRMENTS

Nervous System Mobility Characteristics

arrangement allows for mobility

Nerves are wavy
Connective tissue absorb tensile and compressive
forces

Positive Signs: Tension Signs

Causes of Sy
Mx
CI

Acute or unstable neurologic signs

cauda equina symptoms
SCI or sy

MUSCLE RELAXATION
TECHNIQUE
1. AROME
2. Conscious Relaxation Training in the
Cervical Region
3. Modalities and Massage

BODY MECHANICS

BODY MECHANICS
1. Lifting with a flexed spine

Support is from inert structures

Mm is elongated and relaxed

2. Lifting with an extended spine

Mm in the lumbar spine is active

3. Lifting with a neutral spine

PROPER LIFTING TECHNIQUES

DIAGONAL
LIFT

DIAGONAL LIFT.

PROPER LIFTING TECHNIQUES

SQUAT LIFT

SQUAT LIFT

PROPER LIFTING TECHNIQUES

Plan ahead before lifting.
Knowing what you're doing and where you're going will
prevent you from making awkward movements while
holding something heavy. Clear a path, and if lifting
something with another person, make sure both of you
agree on the plan.
Lift close to your body.
You will be a stronger, and more stable lifter if the object
is held close to your body rather than at the end of your
reach. Make sure you have a firm hold on the object you
are lifting, and keep it balanced close to your body.
Feet shoulder width apart.
A solid base of support is important while lifting. Holding
your feet too close together will be unstable, too far
apart will hinder movement. Keep the feet about
shoulder width apart and take short steps.

PROPER LIFTING TECHNIQUES

Bend your knees and keep your back straight.
Practice the lifting motion before you lift the object, and think about
your motion before you lift. Focus on keeping you spine straight-raise and lower to the ground by bending your knees.
Tighten your stomach muscles.
Tightening your abdominal muscles will hold your back in a good
lifting position and will help prevent excessive force on the spine.
Lift with your legs.
Your legs are many times stronger than your back muscles--let your
strength work in your favor. Again, lower to the ground by bending
your knees, not your back. Keeping your eyes focused upwards
helps to keep your back straight.
If you're straining, get help.
If an object is too heavy, or awkward in shape, make sure you have
someone around who can help you lift.
Wear a belt or back support.

PROPER LIFTING TECHNIQUES

Tips:
Never bend your back to pick something up.
It's just not worth the damage that improper
lifting technique can cause.
Hold the object close to your body.
You are a much more stable lifter if you're not
reaching for an object.
Don't twist or bend.
Face in the direction you are walking. If you
need to turn, stop, turn in small steps, and
then continue walking.
Keep your eyes up.
Looking slightly upwards will help you
maintain a better position of the spine.

1.
2.
3.
4.
5.
6.

ERGONOMICS

Lumbar support
Chair height
Desk height or table height
Mattress and pillows
Position
Reaching overhead