Human Injury Prevention Ch. 25

Which regions of the spinal column is in correct order from inferior to superior?
Coccyx, sacrum, lumbar, thoracic, cervical
Intervertebral discs are found only in the lumbar spine. True or false
There are 7 cervical vertebrae and 8 cervical nerves. True or false
C-1 is known as the axis. True or false
Using proper tackling technique will decrease incidence of spinal cord injury. True or false
Movements of the spine include:
Flexion, extension, right and left lateral flexion, and right and left lateral rotation. (Minimal movement in the thoracic region)
1. Muscle strengthening: Muscles of the neck resist hyperflexion, hyperextension and rotational forces. Variety of exercises can be used to strengthen the neck
2. ROM: Must have full ROM to prevent injury. Can be improved through stretching
3. Using correct technique: Athletes should be taught and use correct technique to reduce the likelihood of cervical spine injuries. Avoid using head as a weapon, diving into shallow water
Prevention of cervical spine injuries
1. Avoid stress: Avoid unnecessary stresses and strains of daily living. Avoid postures and positions that can cause injury.
2. Correction of biomechanical abnormalities: Establish corrective programs based on patient’s anomalies. Basic conditioning should emphasize trunk flexibility. Spinal extensor and abdominal musculature strength should be stressed in order to maintain proper alignment.
3. Using correct lifting techniques: Weight lifters can minimize injury of the lumbar spine by using proper technique. Incorporation of appropriate breathing techniques can also help to stabilize the spine. Weight belts can also be useful in providing added stabilization. Use of spotters when lifting
4. Core stabilization: Core stabilization,dynamic abdominal bracing and maintaining neutral position can be used to increase lumbopelvic-hip stability. Increased stability helps the athlete maintain the spine and pelvis in a comfortable and acceptable mechanical position (prevents microtrauma). No evidence that sit ups or crunches will reduce back injury
Prevention of lumbar spine injuries
1. Mechanism of injury (rule out spinal cord injury)
2. Other general questions
1. Body type
2. Postural alignments and asymmetries should be observed from all views
3. Assess height differences between anatomical landmarks (shoulders, nipple line, anterior/superior iliac spine, hands, patellae, shoulders, scapulae, elbows, posterior dimples, hands, popliteal fossae
– Assess position of head and neck
*Symmetry of shoulders (levels)
*Will the patient move the head and neck freely?
*Assess active, passive and resisted ROM
Cervical Spine Evaluation
– Pain in upper back and scapular region
– Lower thoracic region pain
– Facet joint involvement
Thoracic Spine Evaluation
– Coordinated movement of the low back involves the pelvis, lumbar spine and sacrum
– Equal levels (shoulders and hip)
– Symmetrical soft tissue structures bilaterally
– Observe patient seated, standing, supine, side-lying, and prone (leg position – contractures)
Lumbar Spine and Sacroiliac Joint Observations
– Spinous processes
*Spaces between processes – ligamentous or disk related tissue
– Transverse processes
– Sacrum and sacroiliac joint
– Abdominal musculature and spinal musculature
– Assessing for referred pain
– Assess hip musculature and bony landmarks as well
– Cervical Spine
* Brachial plexus test
* Cervical compression and Spurling’s test
– Lumbar Spine
* Tests done in standing position (forward bending, backward bending, side bending, rotation)
* Tests done in sitting position (slump test)
* Tests done in supine position (straight leg raise, well straight leg raising test, FABER and FADIR tests, knees to chest test, SI compression and distraction tests)
Special Tests
Special test of the cervical spine. Application of pressure to head, neck and shoulders to re-create MOI. Lateral flexion of the neck w/ same side pain indicates a compression injury. Lateral flexion of the neck w/ opposite side pain indicates stretch or traction injury
Brachial plexus test
Special test of the cervical spine. Compression of cervical spine compresses facets and spinal roots. Level of pain determines specific nerve root impingement. Spurling’s adds a rotational component to the cervical compression
Cervical compression and Spurling’s tests
Special test for the lumbar spine done in a standing position. Observe movement of PSIS, test posterior spinal ligaments
Forward bending
Special test for the lumbar spine done in a standing position. Anterior ligaments of the spine. Disk problem.
Extension done in stork- standing produces pain in the lumbar or sacral region may indicate a lesion in the pars interarticularis on the opposite side
Backward bending
Special test for the lumbar spine done in standing position. Lumbar lesion or sacroiliac dysfunction. An increase in pain with leaning toward a side will indicate a lumbar lesion or SI joint dysfunction. Patients with a herniated disc will tend to lean toward the herniated side to relieve the pressure on the disc.
Side bending
Special test for the lumbar spine done in standing position. Assessment of symmetrical motions w/out pelvic movement
Trunk rotation
Special test for the lumbar spine done in sitting position. Monitor changes in pain as sequential changes in posture occur
1. Cervical spine flexion C 1-8
2. Knee extension L3, 4
3. Ankle dorsiflexion L5 S1
4. Neck flexion released
5. Both legs extended S1
Assessment of neural tension at each stage
Slump test
Special test for the lumbar spine done in supine position. 0-30 degrees = hip problem or nerve inflammation
30-60 degrees= sciatic nerve involvement
W/ ankle dorsiflexion = nerve root
70-90 degrees = sacroiliac joint pathology
Straight leg raises
Special test for the lumbar spine done in supine position. Performed on the unaffected side, may produce pain in the low back on the affected side and cause radiating pain in the sciatic nerve. Positive test indicative of nerve root inflammation or disk herniation
Well straight leg raising test
Special tests for the lumbar spine done in supine position.
– FABER or Patrick’s test is used to assess anterior hip pathology or SI joint dysfunction
– FADIR is used to assess pathology of the lumbar spine with a positive test being increases in the low back pain
FABER and FADIR tests
Special test for the lumbar spine done in supine position. Bilateral – increases symptoms to lumbar spine
Single – pain in posterolateral thigh may indicate problem with sacrotuberous ligament
Pulling knee to opposite shoulder that produces pain in the PSIS region may indicate sacroiliac ligament irritation
Knee to chest test
Special test for the lumbar spine done in supine position. Used for pathologies involving SI joint
SI compression and distraction tests
Cervical spine condition.
– Etiology: Generally an axial load w/ some degree of cervical flexion, or forced hyperextension most common in 4,5, and 6
– Signs and Symptoms: Neck point tenderness, restricted motion, cervical muscle spasm, cervical pain, **pain in the chest and extremities, numbness in the trunk and or limbs, weakness in the trunk and/or limbs, loss of bladder and bowel control**
– Management: Patient should be stabilized, collared & spine boarded regardless of their level of consciousness. Use extreme care and caution
Cervical Fractures
Cervical spine condition. More frequent than a fracture.
– Etiology: Usually the result of violent flexion and rotation of the head 4, 5, and 6.
– Signs and Symptoms: Considerable pain, numbness, weakness, or paralysis. **Unilateral dislocation causes the head to be tilted toward the dislocated side with extreme muscle tightness on the elongated side**
– Management: Extreme care must be used – more likely to cause spinal cord injury than a fracture
Cervical Dislocation
Cervical Spine condition
– Etiology: Sudden turn of the head, forced flexion, extension or rotation. Generally involves upper traps, scalenes, splenius capitis and cervicis, SCM
– Signs and Symptoms: Localized pain and point tenderness, restricted motion, reluctance to move the neck in any direction
– Management: RICE and application of a cervical collar. Follow-up care will involve ROM exercises, isometrics which progress to a full isotonic strengthening program, cryotherapy and superficial thermotherapy, analgesic medications
Acute strains of the neck and upper back
Cervical spine condition.
– Etiology: Generally the same mechanism as a strain, just more violent. Involves a snapping of the head and neck – compromising **the anterior or posterior longitudinal ligament, the interspinous ligament and the supraspinous ligament**
– Signs and Symptoms: Similar signs and symptoms to a strain – however, they last longer. **Tenderness over the transverse and spinous processes.** Pain will usually arise the day after the trauma (result of muscle spasm)
– Management: Rule out fracture, dislocation, disk injury or cord injury RICE for first 48-72 hours, possibly bed rest if severe enough, analgesics and NSAID’s, mechanical traction
Cervical Sprain (Whiplash)
Cervical Spine condition.
– Etiology: Result of stretching or compression of the brachial plexus – disrupts peripheral nerve function w/out degenerative changes
– Signs and Symptoms: Burning sensation, numbness and tingling as well as pain extending from the shoulder into the hand. Some loss of function of the arm and hand for several minutes. Symptoms rarely persist for several days
Repeated injury can result in neuritis, muscular atrophy, and permanent damage. Severity of injury may vary. Partial rupture with only myelin sheath damage. Complete tear or avulsion
– Management: Return to activity once S&S have returned to normal. Strengthening and stretching program. Padding to limit neck ROM during impact
Brachial Plexus Neuropraxia (Burner)
Cervical Spine condition.
– Etiology: Herniation that develops from an extruded posterolateral disk fragment or from degeneration of the disk. MOI involves sustained repetitive cervical loading
– Signs and Symptoms: Neck pain w/ some restricted ROM. Radicular pain in the upper extremity and associated motor weakness
– Management: Rest and immobilization of the neck to decrease discomfort. Neck mobilization and traction to help reduce symptoms and regain motion.
**If conservative treatment is unsuccessful or neurological deficits increase surgery may be needed**
Cervical Disk Injuries
Lumbar spine condition.
– Etiology: Congenital anomalies. Mechanical defects of the spine (posture, obesity and body mechanics). Back trauma . Recurrent and chronic low back pain
– Signs and Symptoms: Pain, possible weakness, **antalgic gait**, propensity to ligamentous sprain, muscle strains and bony defects. Neurological signs and symptoms if it becomes disk related
– Management: Correct alignments and body mechanics
Strengthening and stretching to ensure proper segmental mechanics
Low back pain
Lumbar Spine condition.
– Etiology: Sudden extension contraction overload generally in conjunction w/ some type of rotation. Chronic strain associated with posture and mechanics
– Signs and Symptoms: Pain may be diffuse or localized; pain w/ active extension and passive flexion. No radiating pain distal to the buttocks; no neurological involvement
– Management: RICE to decrease spasm; followed by a graduated stretching and strengthening program. Complete bed rest may be necessary if it is severe enough. NSAID’s and modalities are also useful.
Low back muscle strain
Lumbar Spine Condition
Sharp aching pain in low back, referred to upper buttocks and posterior sacroiliac region and abdominal wall; increased pain with standing, coughing, sneezing and sit to stand motions; pain increases with side bend toward the trigger point.
– Management: Stretching and strengthening of the involved muscle. Return muscle to normal length. Electric stimulation and ultrasound can be used to treat discomfort and pain
Quadratus Lumborum
Lumbar Spine Condition
– Etiology: Forward bending and twisting can cause injury. Chronic or repetitive in nature
– Signs and Symptoms: Localized pain lateral to the spinous process. Pain becomes sharper w/ certain movements or postures. **Passive anteroposterior or rotational movements will increase pain**
– Management: RICE, joint mobs, strengthening for abdominals, stretching in all directions. Trunk stabilization exercises. Braces should be worn early to provide support
Lumbar Sprains
Lumbar spine condition
– Etiology: Inflammatory condition of the sciatic nerve. Nerve root compression from intervertebral disk protrusion, structural irregularities w/in the intervertebral foramina or tightness of the piriformis muscle
– Signs and Symptoms: Arises abruptly or gradually; produces sharp shooting pain, tingling and numbness
Sensitive to palpation while straight leg raises intensify the pain
– Management: Rest is essential acutely. Treat the cause of inflammation; traction if disk protrusion is suspected; NSAID’s
Lumbar spine condition
– Etiology: Caused by abnormal stresses and degeneration due to use (forward bending and twisting)
– Signs and Symptoms: Centrally located pain that radiate unilaterally in dermatomal pattern. Symptoms are worse in the morning. Onset is sudden or gradual, pain may increase after the athlete sits and then tries to resume activity. Forward bending and sitting increase pain, while back extension reduces pain. **Straight leg raise to 30 degrees is painful.**Decreased muscle strength and tendon reflexes; Valsalva maneuver increases pain
– Management: Initial treatment should involve pain-reducing modalities (ice and stim). Manual traction and extension exercises to reduce protrusion of disk. As pain and posture return to normal additional strengthening exercises can be added. If disk is extruded or sequestrated pain modulation is key. Flexion exercise and lying supine in a flexed position may help with comfort. Surgery may be required with signs of nerve damage (Used to eliminate pain and dysfunction).
Herniated Disk
Rehab technique for the neck. Can be extensively used in rehabilitating the neck for pain reduction, increasing ROM and restoring mobility
Joint Mobilizations
Rehab technique for the neck. Must restore the neck’s normal range of motion. All mobility exercises should be performed pain free. Perform exercises passively and actively (flexion, extension, lateral bending and rotation). Exercises should be performed 2-3 times daily, 8-10 reps and held for at least 6 seconds for each stretch
Flexibility exercises
Rehab tecnhique for the neck. Should be initiated when near normal range has been achieved, and should be performed pain free. Exercises should progress from isometric to isotonic exercises
Strengthening Exercises
There are a number of philosophical approaches to low back rehab. Initial treatment should focus on modulating pain (ice, electric stim, rest; avoid aggravating motions or positions). Analgesics for pain modulation or muscle relaxants to decrease muscle guarding. Progressive relaxation techniques
Rehab techniques for the low back
Rehab technique for the low back. With acute low back pain, the athlete can be limited for some time. Activity must be modified during the initial stages. Resume activity as pain can be tolerated. Aquatic exercise may be useful to maintain fitness levels
General Body Conditioning
Rehab technique for the low back. Can be used to improve joint mobility or to decrease joint pain by restoring joint accessory motion. Gradual progression from grade 1 and 2 joint modes to grades 3 and 4 as pain and muscle guarding subsides. Should be engaged in conjunction w/ manual traction for best results.
– Traction: Treatment of choice when there is a small protrusion of the nucleus pulposus. Distraction of vertebral bodies creates subatmospheric pressure that pulls protrusion back to normal position. Can be used daily for 2 weeks. Amount of traction used is a percentage of the patient’s body weight
Joint Mobilizations
Rehab technique for low back. Should be routinely incorporated into the rehab program. Used to reinforce pain-reducing movements and postures
– Extension exercises:
—- Should be used when pain decreases w/ lying down and increases w/ sitting
—- Backwards bending is limited but decreases pain — forward bending increases pain
—- STLR is painful
– Flexion exercises:
—-Used to strengthen abdominals, stretch, extensors and take pressure off nerve roots
—-Pain increases with lying down and decreases with sitting
—- Forward bending decreases pain
—- Lordotic curve does not reverse itself in forward bending
– PNF exercises:
—- Chopping and lifting patterns can be used to strengthen the trunk, re-establish neuromuscular control and proprioception
Strengthening exercises
Rehab technique for the low back. Must re-educate muscles to contract appropriately. Stabilization exercises can help minimize the cumulative effects of repetitive microtrauma. Core/dynamic stabilization.
— Control of the pelvis in neutral position
— Integration of full body movements and lumbar control
— Incorporation of abdominal muscle control is key to lumbar stabilization
Neuromuscular control
Rehab technique for the low back. Progression of stabilization exercises should move from supine activities, to prone activities, to kneeling and eventually to weight-bearing activities. Stabilization exercises must be the foundation and should be incorporated into each drill
Functional Progressions
Rehab technique for the low back. Acute sprains and strains of the back take the same amount of time to heal as most extremity injuries. With chronic or recurrent injuries, return to full activity can be frustrating and time consuming. Extensive amounts of time and education concerning skills and techniques of the patient will be required to achieve a full return to activity
Return to activity