Role is to provide reinforcement to ligaments by limiting motion and stabilizing spine
Sacroiliac joints
Role is stabilizing the sacroiliac joint, limiting its movement, and protecting the joint by distributing biomechanical loads.
Nerves
Spinal nerves are mixed nerves that connect the spinal cord to the rest of the body. They carry both sensory (dorsal rami) and motor (ventral rami) information between the central nervous system (brain and spinal cord) and the peripheral nervous system (body and muscles).
Location of spinal nerves
Cervical: exit at the level above the associated vertebrae
Thoracic/lumbar: exit below the level of associated vertebrae
Spinal and pelvis movements
General rules regarding facet joint opening and closing
Flexion (bending forward):
When you bend forward, the facet joints on the back of the spine open up, allowing for more space between the vertebrae.
Extension (bending backward):
Conversely, when you bend backward, the facet joints close together, creating a more stable and compressed position.
Sidebending:
During sidebending, the facet joints on the side you are bending towards close, while the facet joints on the opposite side open.
Rotation:
During rotation, the facet joints on the ipsilateral side compress together, while the facet joints on the opposite side tend to open.
Joint movements (arthrokinematics)
Flexion
Upper facets move anterior and proximally while tilted anteriorly
Extension
* Upper facets move down and posterior while tilted posteriorly
Lateral bending
Right lateral bending
Upper facet moves down and anterior
Causing facet closure on right side and opening on left side
Left lateral bending
Upper facets moves upward and posterior
Causing facet closure on left side and opening on right side
Cervical rotation
Right rotation
Facets glide down and posteriorly- causing facet joint closure
This would be how therapist would close facet
Left rotation
Facets glide anteriorly- causing facet opening
This would be how therapist opens facet
Coupled movements
Cervical spine
C1: lateral bending and rotation occur in different directions (occurs if spine in neutral, flexion, and extension)
C2-C7: lateral bending and rotation occurring in the same direction (occurs if spine in neutral, flexion, and extension)
Lumbar/thoracic spine
If spine in flexion: side bending and rotation will occurring in same direction
If spine in extension/neutral: side bending and rotation will occur in opposite directions
Lumbopelvic joint
When in flexion: lumbar spine flexes followed by pelvis rotation anteriorly, ending with hip flexion
When in extension (when coming from flexed position): hips extend followed by pelvis rotating posteriorly, and spine extending
Sacroiliac joint
Nutation: flexion of sacrum causes posterior tilt of ilium (in frontal plane)
Counternutation: extension of sacrum causes anterior tilt of ilium (in frontal plane)
Anterior innominate: anterior superior iliac spine (ASIS) moves downward (in sagittal plane)
Posterior innominate: anterior superior iliac spine (ASIS) moves upward (in sagittal plane)
Special tests spine and pelvis
Cervical spine
Vertebral artery test
Patient supine with head supported and over edge of mat; therapist passively extends head/neck and hold for 30 seconds, progress to passively rotate and side-bending with extension-holding each position for 30 seconds
Tests the integrity of vertebrobasilar vascular system
Positive: symptoms of dizziness, dysphagia diplopia, ataxic gait, nystagmus- red flag and therapist does not progress with any movements of cervical spine
Vertebral artery test should always be performed prior to cervical spine mobilization- if not performed, this is considered sub-standard care and can be life-threatening
Flexion rotation test
Patient in supine with maximal flexion of neck performed with rotation to let and right
Provocative test for atlantoaxial dysfunction or cerviogenic headache
Positive: reproduction of headache symptoms or loss of 10 degrees of mobility when comparing left and right rotation (when compared to each side)
Spurling’s test (foraminal compression)
Patient sitting with head laterally bending towards involved side while therapist applies pressure straight down
Confirms cervical root dysfunction
Positive: pain and paresthesia in dermatomal pattern of cervical root
Cervical compression test
Patient sitting and neck passively moved into lateral flexion and rotation to the non-painful side, followed by extension. Repeat the painful side.
Positive: decrease in symptoms or decrease in upper limb pain
Lhermitte’s sign
Patient long sitting on mat; therapists passively flex patient’s head and hip while keeping knee in extension. Repeat with the other hip.
Identifies upper neuron lesions
Positive: electrical pain down spine and into upper or lower limbs
Alar ligament test
Patient seated and therapist palpates C2 spinous process; the therapist passively flexes the upper cervical spine with lateral flexion and rotation
Tests integrity of alar ligament
Positive: Inability to palpate C2 and/or inability to feel movement at C2
Thoracic spine
Rib sparing
Patient prone; beginning at upper ribs apply posterior/anterior force to rib moving through the entire rib cage. Also perform in a side-lying position.
Tests rib mobility
Positive: pain, excessive motion of rib, or restriction of rib
Lumbar spine
Slump test
Patient sits with knees flexed and neutral neck and head; progress through the following steps- passively flex head and neck, passively extend knee, passively dorsiflex ankle of limb- repeat with opposite leg
Therapist will stop at a step if reproduction of symptoms occurs
Tests for neurological dysfunction of lower extremity
Positive: pain, paresthesias, numbness/tingling, and other neurological symptoms
Prone instability test
Patient prone with torso supported on mate, legs off the edge with both feed supported on the ground. Therapist applies posterior/anterior springing throughout the lumbar spine to identify painful segments. Therapist then instructs patient to lift legs off floor and performs same posterior/anterior springing
Tests instability of lumbar spine
Positive: decreased pain during posterior/anterior springing with the legs raised compared to when the feet are supported on the ground
Quadrant test
Patient standing
Facet dysfunction: instruct patient to lateral bend to left, rotate to right, and maximally extend to compress facet joint on left. Repeat on the opposite side.
Intervertebral foramen: instruct patient to lateral bend left, rotate left, and maximally extend to close intervertebral foramen on left. Repeat on the opposite side.
Tests compression of neural structures at facet and intervertebral foramen
Positive: pain or paresthesias in dermatomal pattern or localized pain if facet dysfunction
Bicycle test
Patient positioned on stationary bike. In erect posture, patient rides bike at set pace/speed with time observed; patient then rides bike at set pace/speed in slumped position with time observed
Differentiates between intermittent claudication and spinal stenosis due to position
Positive: Individuals with spinal stenosis will tolerate riding bike with slumped posture longer than when in erect posture
Neurological dysfunction
Lower limb tension tests- assists with identifying peripheral nerve injury by placing the lower limb in positions of that will stress nerve
Sacroiliac
Gillet’s test
Patient standing; therapist places one thumbs under posterior iliac spine (PSIS) of unilateral extremity and other thumb in center of sacrum. The patient then flexes knee and hip while the therapist palpates PSIS and observes for movement.
Assess posterior movement of ilium
Positive: no movement of ilium or sacrum (ilium has lost mobility)
Gaenslens’s test
Patient side-lying at edge of mat with bottom leg maximally flexed at hip and knee. Therapist passively extends uppermost limb
Tests for sacroiliac dysfunction
Positive: pain in sacroiliac joint
Long sitting
Patient supine with therapist palpating medial mallelous- therapist observes alignment. The therapist then asks the patient to come to a long sitting position to observe if alignment at medial mallelous is still present.
Tests for leg length discrepancy due to sacroiliac joint
Positive: one leg observed longer when coming in long sitting position compared to supine positon
Sidelying compression test
Patient side-lying with side of dysfunction facing upward toward therapist. Therapist palpates iliac crest and then applies force down through ilium for up to 30 seconds
Identifies sacroiliac dysfunction
Positive: reproduction of pain
Supine iliac gapping
Patient supine with therapist crossing their arms and placing their hands on patient’s anterior superior iliac spine (ASIS)- each hand on the medial aspect of the ASIS and pushing out laterally
Identifies sacroiliac dysfunction
Positive: sacral symptoms relieved
Temporomandibular joint (TMJ)
Elevation (Closing):
Contraction of the masseter, temporalis, and medial pterygoid muscles raises the mandible.
Depression (Opening):
Relaxation of the elevator muscles and contraction of the digastric, geniohyoid, and mylohyoid muscles lowers the mandible.
Protrusion (Forward Movement):
Contraction of the lateral pterygoid muscles moves the mandible forward.
Retrusion (Backward Movement):
Contraction of the posterior fibers of the temporalis muscles moves the mandible backward.
Lateral Deviation (Side-to-Side Movement):
Contraction of the lateral pterygoid muscle on one side moves the mandible toward that side.
Special tests of TMJ
TMJ compression
Patient sitting or supine; therapist stabilized patient’s head with one hand while the other hand pushes mandible superiorly causing a compressive load to the TMJ
