IPHREHAB : HIP PAIN..

IPHREHAB Hip pain is common problem, and it can be confusing because there are many causes. It is important to make an accurate diagnosis of the cause of your symptoms so that appropriate treatment can be directed at the underlying problem. If you have hip pain, some common causes include: Arthritis 

Arthritis is among the most frequent causes of hip pain, and there are many treatments available. If conservative treatments fail, hip replacement surgery is an option.

 Trochanteric Bursitis Trochanteric bursitis is an extremely common problem that causes inflammation of the bursa over the outside of the hip joint. 

 Tendonitis Tendonitis can occur in any of the tendons that surround the hip joint. The most frequently encountered tendonitis around the hip is iliotibial band (IT band) tendonitis. 

 Osteonecrosis Osteonecrosis is a condition that occurs when blood flow to an area of bone is restricted. If an inadequate amount of blood flow reaches the bone, the cells will die and the bone may collapse. One of the most common places for osteonecrosis to occur is in the hip joint. 

 Lumbar Pain - Referred Symptoms Many back and spine problems can cause symptoms around the buttocks and hip. The most common problems that refer pain to the hip region are herniated discs and sciatica. 

 Snapping Hip Syndrome Snapping hip syndrome is a word used to describe three distinct hip problems. The first is when the IT band snaps over the outside of the thigh. The second occurs when the deep hip flexor snaps over the front of the hip joint. 

Finally, tears of the cartilage, or labrum, around the hip socket can cause a snapping sensation. 

 Muscle Strains Strains of the muscles around the hip and pelvis can cause pain and spasm. The most common strains are groin pulls and hamstring strains. 

 Hip Fracture Hip fractures are most common in elderly patients with osteoporosis. Treatment of broken hips requires surgery to either replace the broken portion or repair it with a metal plate and screws. 

 Stress Fracture Stress fractures of the hip are most common in athletes who participate in high-impact sports, such as long distance runners. Treatment usually is successful by avoiding the impact activities.

IPHREHAB : Vertebrae and Spinal Cord Segmental Levels

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Vertebral vs. Cord Segmental Levels

The spinal cord is situated within the spine. The spine consists of a series of vertebral segments. The spinal cord itself has "neurological" segmental levels which are defined by the spinal roots that enter and exist the spinal column between each of the vertebral segments. As shown in the figure the spinal cord segmental levels do not necessarily correspond to the bony segments. The vertebral levels are indicated on the left side while the cord segmental levels are listed for the cervical (red), thoracic (green), lumbar (blue), and sacral (yellow) cord.

Vertebral segments. 

There are 7 cervical (neck), 12 thoracic (chest), 5 lumbar (back), and 5 sacral (tail) vertebrae. The thoracic vertebrae are defined by The spinal cord segments are not necessarily situated at the same vertebral levels. For example, while the C1 cord is located at the C1 vertebra, the C8 cord is situated at the C7 vertebra. While the T1 cord is situated at the T1 vertebra, the T12 cord is situated at the T8 vertebra. The lumbar cord is situated between T9 and T11 vertebrae. The sacral cord is situated between the T12 to L2 vertebrae.

Spinal Roots. 

The spinal roots for C1 exit the spinal column at the atlanto-occiput junction. The spinal roots for C2 exit the spinal column at the atlanto-axis. The C3 roots exit between C2 and C3. The C8 root exits between C7 and C8. The first thoracic root or T1 exits the spinal cord between T1 and T2 vertebral bodies. The T12 root exits the spinal cord between T1 and L1. The L1 root exits the spinal cord between L1 and L2 bodies. The L5 root exits the cord between L1 and S1 bodies.

The Cervical Cord. 

The first and second cervical segments are special because this is what holds the head. The lower back of the head is called the Occiput. The first cervical vertebra, upon which the head is perched is sometimes called Atlas, after the Greek mythological figure who held up earth. The second cervical vertebra is sometimes called the Axis, upon which Atlas pivots. The interface between the occiput and the atlas is therefore called the atlanto-occiput junction. The interface between the first and second vertebra is called the atlanto-axis junction. The C3 cord contains the phrenic nucleus. The cervical cord innervates the deltoids (C4), biceps (C4-5), wrist extensors (C6), triceps (C7), wrist extensors (C8), and hand muscles (C8-T1).

The Thoracic Cord. 

The thoracic vertebral segments are defined by those that have a rib. These vertebral segments are also very special because they form the back wall of the pulmonary cavity and the ribs. The spinal roots form the intercostal (between the ribs) nerves that run on the bottom side of the ribs and these nerves control the intercostal muscles and associated dermatomes.

The Lumbosacral Cord. 

The lumbosacral vertebra form the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts at about T9 and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the buttocks and anal regions.

The Cauda Equina.

 In human, the spinal cord ends at L2 vertebral level. The tip of the spinal cord is called the conus. Below the conus, there is a spray of spinal roots that is frequently called the cauda equina or horse's tail. Injuries to T12 and L1 vertebra damage the lumbar cord. Injuries to L2 frequently damage the conus. Injuries below L2 usually involve the cauda equina and represent injuries to spinal roots rather than the spinal cord proper.

In summary, spinal vertebral and spinal cord segmental levels are not necessarily the same. In the upper spinal cord, the first two cervical cord segments roughly match the first two cervical vertebral levels. However, the C3 through C8 segments of the spinal cords are situated between C3 through C7 bony vertebral levels. Likewise, in the thoracic spinal cord, the first two thoracic cord segments roughly match first two thoracic vertebral levels. However, T3 through T12 cord segments are situated between T3 to T8. The lumbar cord segments are situated at the T9 through T11 levels while the sacral segments are situated from T12 to L1. The tip of the spinal cord or conus is situated at L2 vertebral level. Below L2, there is only spinal roots, called the cauda equina.

IPHREHAB : SENSORY AND MOTOR LEVEL OF DERMATOME

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A dermatome is a patch of skin that is innervated by a given spinal cord level. Figure 2 is taken from the ASIA classification manual, obtainable from the ASIA web site. Each dermatome has a specific point recommended for testing and shown in the figure. After injury, the dermatomes can expand or contract, depending on plasticity of the spinal cord.

C2 to C4. The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle (the horizontal bone that goes to the shoulder. C4 covers the area just below the clavicle.

C5 to T1. These dermatomes are all situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the lateral aspects of the hand, and T1 covers the medial side of the forearm.

T2 to T12. The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

L1 to L5. The cutaneous dermatome representating the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

S1 to S5. S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Ten muscle groups represent the motor innervation by the cervical and lumbosacral spinal cord. The ASIA system does not include the abdominal muscles (i.e. T10-11) because the thoracic levels are much easier to determine from sensory levels. It also excludes certain muscles (e.g. hamstrings) because the segmental levels that innervate them are already represented by other muscles.

Arm and hand muscles. C5 represents the elbow flexors (biceps), C6 the wrist extensors, C7 the elbow extensors (triceps), C8 the finger flexors, and T1 the little finger abductor (outward movement of the pinky finger).

Leg and foot muscles. The leg muscles represent the lumbar segments, i.e. L2 are the hip flexors (psoas), L3 the knee extensors (quadriceps), L4 the ankle dorsiflexors (anterior tibialis), L5 the long toe extensors (hallucis longus), S1 the ankle plantar flexors (gastrocnemius).

The anal sphincter is innervated by the S4-5 cord and represents the end of the spinal cord. The anal sphincter is a critical part of the spinal cord injury examination. If the person has any voluntary anal contraction, regardless of any other finding, that person is by definition a motor incomplete injury.

It is important to note that the muscle groups specified in the ASIA classifications represent a gross over simplication of the situation. Almost every muscle received innervation from two or more segments.

In summary, the spinal cord segment serve specific motor and sensory regions of the body. The sensory regions are called dermatomes with each segment of the spinal cord innervating a particularly area of skin. The distribution of these dermatomes are relatively straightforward except on the limbs. In the arms, the cervical dermatomes C5 to T1 are arrayed from proximal radial (C5) to distal (C6-8) and proximal medial (T1). In the legs, the L1 to L5 dermatomes cover the front of the leg from proximal to distal while the sacral dermatomes cover the back of the leg.

IPHREHAB : INTERMITTENT & STATIC TRACTION

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INTERMITTENT & STATIC TRACTION
Mode of treatment

• Intermittent Most comfortable
• On times generally between 7-20 sec
• Off times 7 to 60 sec
• On/Off ratio may be 1:1 or 3:1 

Lumbar spine

• Positioning for inter vertebral encroachment is neutral for bilateral involvement.  Unilateral SB toward good side with trunk rotated toward the affected side.
• Facets are treated in flexion

• Position:  
• L5-S1= 45* hip flexion
• L4-L5 = 60-75* HIP FLEXION
• L3-l4 + 75-90* HIP FLEXION

Lumbar Traction

HARNESS

• Mechanical traction 
• Motorized unit
• Self-administered Autotraction
• Manual traction
• Belt 
• Thoracic stabilization harness
• Pelvic traction harness
• Clinician’s body weight

Lumbar Traction:  Tension

• Approximately ½ of body weight
• Published literature = 10-300% of patient’s body weight

• Patient Position & Angle of Pull
• Should maximize separation & elongation of target tissues
• Prone or Supine – depends on:
• Patient comfort
• Pathology
• Spinal segments & structures being treated

Lumbar Traction - Patient Position

Supine positioning 

Tends to increase lumbar flexion

Flexing hips from 45 to 60 increases laxity in L5-S1 segments

Flexing hips from 60 to 75 increases laxity in L4-L5 segments

Flexing hips from 75 to 90 increases laxity in L3-L4 segments

Flexing hips to 90 increases posterior intervertebral space

Prone Position

Used when excessive flexion of lumbar spine & pelvis or lying supine causes pain or increases peripheral symptoms

Lumbar Traction – Angle of Pull

Anterior angle of pull increases amount of lumbar lordosis

Posterior angle of pull increases lumbar kyphosis

Too much flexion can impinge on the posterior spinal ligaments

Optimal position & angle of pull – 

Often derived by trial & error 

Depends on patient & pathology of injury

Lumbar Treatment Set-up

Calculate body weight

Apply traction & stabilization harness

Position on table, drape for modesty

Set mode – intermittent or continuous

Set ON:OFF ratio time

Set tension

Set duration

Give patient Alarm/Safety switch

Explain everything to patient prior to beginning treatment!

Static traction

Used less frequently.

Treatment times 8-25 minutes

Brief continuous for disc problems 10 minutes

Facet problems 15-20 minutes

Other duration considerations

HNP Decrease time 5-8 minutes

DJD, Spondylolithesis up to 20’

Frequency from 2-3 times per week up to daily

Allow the patient to rest a few minutes upon completion.  Ask the patient f they have any dizziness or headache post treatment

Document

A. Position

B. Angle of pull

C. Amount of force., hold and rest cycles

D. Static or intermittent

E. Duration

F. Pt. Response

Pain / changes

Functional changes

IPHREHAB : Lumbar Traction AND TREATMENT

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Lumbar Traction

• To be effective, lumbar traction must overcome lower extremity weight (¼-½ of body weight)
• Friction is a strong counter force against lumbar traction
• Split table is used to reduce friction

General Technique for Applying Lumbar Tx

• Traction harness use

– Clip buckle versus velcro

– Vinyl versus cotton

– Adjustable lengths, pads

– Placement of lumbar belts 

• skin versus clothes – dissipate traction force)

– Use of thoracic belts on lower, lateral ribs

• Not in axilla

– The thoracic belt is placed on after the pelvic belt

Mechanical Traction Application

• Motorized lumbar traction
• Assess body weight
• Remove material that may interfere with halter
• Adjust halter accordingly

1. Traction halter = Pelvis
2. Stabilization harness = 8th-10th Ribs

• Unlock split table and align target spinal segment over the opening in the table
• Secure and connect halter
• Align angle of pull to correspond with specific pathology
• Explain treatment to patient and give safety switch

Effects on Lordosis (prone)

• Patients with sever pain and muscle spasms may tolerate prone traction better

• Pillows and harness to control lordosis

• Rope angle

– Always low

– Pillows can decrease or increase lordosis

• Pelvic harness

– May be placed to effect lordosis, as with supine

– Harness is never placed posteriorly in prone

– Rarely anterior

– As a rule, it is placed laterally to maintain other positional effects

• Treatment in prone 

– Allows performance of other modalities without position changes 

– Allows for easy palpation of the interspinous spaces to determine the level and degree of spinal motion 

General Technique for Applying Lumbar Tx

• Patient position

– Prone versus supine (comfort, goals)

– Prone 

• Disc

• Pillows under abdomen to flatten lordosis, under thighs or chest to increase extension

– Supine

• Mobilization

• pillows under knees to decrease lordosis

– Initial soft tissue stretch on soft tissue should come from positioning 

Effects of Lordosis (supine)

• Leg Position

– Up on a stool, decreases lordosis

– Flat, normal lordosis is maintained

– 90/90 position should flatten back, less than that decreases in increments

• Rope Angle

– Flat low pull maintains

– With increased (elevated) rope angle, lordosis decreases

• Pelvic Harness

– Greatest effect on lordosis

– Posterior pull decreases lordosis

– Lateral pull maintains lordosis

– Anterior pull increases lordosis

– Positions between these will result in incremental changes 

Patient Positioning

Supine

Increases flexion

• Supine + Flexion

Further increasing flexion

46-60 = L5-S1

60-75 = L4-L5

75-90 = L3-L4

90 = Posterior inter vertebral space

• Extension

Opens facet joints and increases distraction in upper lumbar

Initiation of Treatment

• Set controls to zero and turn on unit
• Adjust ratio
• Tension

1. Approximately 25% of body weight
2. Radicular pain caused by disk herniation: 30 to 60% of body weight

• Duration

1. Corresponding to pathology

• Instruct patient to remain relaxed

Termination of Treatment

• Tension
• Gradually reduce over 3 or 4 cycles
• Gain slack and turn unit OFF
• Many units have an auto OFF sequence
• Remove halter from unit and patient
• Patient remains in position for 5 minutes after the treatment

Patient Positioning

Prone

• Used when excessive flexion or lying supine causes pain
• Beneficial

1. Allows other modalities to be used during traction
2. Effects the lower disk protrusions

• Optimal Position
• Experience
• Trial and error

Traction Technique

• Angle of pull
• C spine supine better.  25* flexion
• L spine Flex hip and knees, symmetrical or prone or unilateral technique