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Thoracic and Lumbar Spine Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C.

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Presentation on theme: "Thoracic and Lumbar Spine Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C."— Presentation transcript:

1 Thoracic and Lumbar Spine Clinical Evaluation Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2 Clinical Evaluation History: History: Location of Pain: Location of Pain: Pain radiating into extremities Pain radiating into extremities Peripheral paresthesia or numbness: Peripheral paresthesia or numbness: Result of impingement or pressure on nerve root exiting intervertebral foramen or dural irritation proximal to pain site Result of impingement or pressure on nerve root exiting intervertebral foramen or dural irritation proximal to pain site Pain Locations: Pain Locations: Lumbar pain – possible ambiguous cause Lumbar pain – possible ambiguous cause Sacroiliac pathology – pain around PSIS or radiating pain in hip/groin Sacroiliac pathology – pain around PSIS or radiating pain in hip/groin Piriformis spasm – symptoms of sciatic nerve dysfunction Piriformis spasm – symptoms of sciatic nerve dysfunction

3 Clinical Evaluation

4 History: History: Onset of Pain: Onset of Pain: Acute Acute Chronic Chronic Insidious pain onset Insidious pain onset Note: Patient may describe a single incident that initiated pain, although trauma is probably an accumulation or repetitive stresses/microtrauma Note: Patient may describe a single incident that initiated pain, although trauma is probably an accumulation or repetitive stresses/microtrauma Clinical Evaluation

5 History: History: Mechanism of Injury: Mechanism of Injury: Movement: Flexion, Extension, Lateral Bending, Rotation Movement: Flexion, Extension, Lateral Bending, Rotation Blunt Trauma: Direct blow to lumbar/thoracic area Blunt Trauma: Direct blow to lumbar/thoracic area Contusions Contusions Compressive Stress: Compressive Stress: Hyperextension of spine Hyperextension of spine

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7 History: History: Pain Consistency: Pain Consistency: Constant Pain: Unyielding (does not improve with various position of patient’s spine) Constant Pain: Unyielding (does not improve with various position of patient’s spine) Example pathology – Inflammation of dural sheath Example pathology – Inflammation of dural sheath Clinical Evaluation

8 History: History: Pain Consistency: Pain Consistency: Intermittent Pain: Intermittent Pain: Mechanical Origin – certain spinal positions may ↑ or ↓ pain symptoms Mechanical Origin – certain spinal positions may ↑ or ↓ pain symptoms Compression/stretching of nerve root – Increase pain Compression/stretching of nerve root – Increase pain Positioning (flexion, traction) – lessen the pressure on involved structure Positioning (flexion, traction) – lessen the pressure on involved structure Clinical Evaluation

9 History: History: Bowel or bladder signs: Bowel or bladder signs: Does the patient have any bowel or bladder problems? Does the patient have any bowel or bladder problems? Incontinence: Loss of bowel or bladder control Incontinence: Loss of bowel or bladder control May indicate lower nerve root lesions (cauda equina syndrome), or spinal cord injury May indicate lower nerve root lesions (cauda equina syndrome), or spinal cord injury Description: urinary incontinence may range from occasionally leaking urine (during cough/sneeze) to having sudden episodes of strong urinary urgency Description: urinary incontinence may range from occasionally leaking urine (during cough/sneeze) to having sudden episodes of strong urinary urgency Clinical Evaluation

10 History: History: Bowel or Bladder Signs: Bowel or Bladder Signs: Cauda Equina Syndrome: Cauda Equina Syndrome: Nerves within the spinal canal have been damaged Nerves within the spinal canal have been damaged Result: nerves supplying the muscles of the legs, bladder, bowel and genitals do not function properly Result: nerves supplying the muscles of the legs, bladder, bowel and genitals do not function properly Patients experience numbness, loss of sensation and pain in the legs, buttocks and pelvic region (damage usually permanent) Patients experience numbness, loss of sensation and pain in the legs, buttocks and pelvic region (damage usually permanent) Causes: Causes: Spina bifida (abnormality in closure of spinal canal) Spina bifida (abnormality in closure of spinal canal) Tumors Tumors Injury (spinal fractures) Injury (spinal fractures) Intravertebral disc herniation Intravertebral disc herniation Vascular (blood vessel) problems or infections of the cauda equina Vascular (blood vessel) problems or infections of the cauda equina Clinical Evaluation

11 History: History: History of spinal injury: History of spinal injury: Previous injuries: Previous injuries: Structural degeneration Structural degeneration Predisposition to injury Predisposition to injury Changes in activity: Changes in activity: Exercise habits (intensity levels, duration, frequency) Exercise habits (intensity levels, duration, frequency) Footwear, running surfaces Footwear, running surfaces New bed New bed Clinical Evaluation

12 General Inspection: General Inspection: Frontal Curvature: Frontal Curvature: Alignment of lumbar, thoracic, cervical vertebrae with patient lying prone or standing Alignment of lumbar, thoracic, cervical vertebrae with patient lying prone or standing Normal alignment – straight Normal alignment – straight Abnormal alignment: Abnormal alignment: Scoliosis – lateral curvature (lumbar and/or thoracic spine) Scoliosis – lateral curvature (lumbar and/or thoracic spine) Clinical Evaluation

13 General Inspection: Scoliosis General Inspection: Scoliosis Signs and symptoms: Signs and symptoms: Uneven shoulders Uneven shoulders One shoulder blade appears more prominent One shoulder blade appears more prominent Uneven waist / 1 hip higher vs. other Uneven waist / 1 hip higher vs. other Leaning to one side Leaning to one side Back pain and difficulty breathing (severe scoliosis) Back pain and difficulty breathing (severe scoliosis) Causes: Causes: Idiopathic (85% of cases) Idiopathic (85% of cases) Underlying neuromuscular disease, leg-length discrepancy, birth defect, fetal development (congenital) Underlying neuromuscular disease, leg-length discrepancy, birth defect, fetal development (congenital) Not caused by poor posture, diet, exercise, or the use of backpacks Not caused by poor posture, diet, exercise, or the use of backpacks Clinical Evaluation

14 Diagnosis: Diagnosis: Angle: X-ray Angle: X-ray Normal Spine (0 degrees) Normal Spine (0 degrees) Scoliosis: (> 10 degrees) Scoliosis: (> 10 degrees) Complications: (severe scoliosis) Complications: (severe scoliosis) Lung and heart damage: compression of rib cage against heart, lungs Lung and heart damage: compression of rib cage against heart, lungs > 70 degrees > 70 degrees Back problems Back problems Clinical Evaluation

15 General Inspection: General Inspection: Scoliosis Test: Adam’s Forward Bend Test Scoliosis Test: Adam’s Forward Bend Test Patient Position: Standing with hands held in front (arms straight) Patient Position: Standing with hands held in front (arms straight) Evaluation Procedure: Patient bends forward, sliding hands down the front of each leg Evaluation Procedure: Patient bends forward, sliding hands down the front of each leg Positive Test: Positive Test: Asymmetrical hump along lateral aspect of thoracolumbar spine Asymmetrical hump along lateral aspect of thoracolumbar spine One shoulder blade appears more prominent One shoulder blade appears more prominent Uneven hips Uneven hips Implications: Implications: Functional scoliosis: scoliosis present when patient stands straight, disappears during flexion Functional scoliosis: scoliosis present when patient stands straight, disappears during flexion Structural scoliosis: present during both standing and with flexion Structural scoliosis: present during both standing and with flexion Clinical Evaluation

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17 General Inspection: General Inspection: Sagital Curvature: Sagital Curvature: Normal Alignment: Normal Alignment: Lordotic cervical Lordotic cervical Kyphotic thoracic Kyphotic thoracic Lordotic lumbar Lordotic lumbar Kyphotic sacral Kyphotic sacral Clinical Evaluation

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19 General Inspection: General Inspection: Observation of GAIT: Observation of GAIT: Spinal pain – influence on walking and running gait Spinal pain – influence on walking and running gait Slouching Slouching Shuffling Shuffling Shortened gait Shortened gait Clinical Evaluation

20 General Inspection: General Inspection: Skin Markings: Skin Markings: Café-au-lait spots: presence of darkened areas of skin pigmentation Café-au-lait spots: presence of darkened areas of skin pigmentation Normal (benign) Normal (benign) Collagen disease Collagen disease Neurofibromatosis 1 Neurofibromatosis 1 95% of patients will display spots 95% of patients will display spots Clinical Evaluation

21 General Inspection: General Inspection: Skin Markings: Sign of Neurofibromatosis-1 Skin Markings: Sign of Neurofibromatosis-1 Neurofibromatosis-1: Neurofibromatosis-1: Autosomal dominant disease Autosomal dominant disease Characterized by formation of neurofibromas (tumors involving nerve tissue) in the skin, subcutaneous tissue, cranial nerves, and spinal root nerves Characterized by formation of neurofibromas (tumors involving nerve tissue) in the skin, subcutaneous tissue, cranial nerves, and spinal root nerves Implications: growth of tissue along the nerves – puts pressure on affected nerves and cause pain and severe nerve damage Implications: growth of tissue along the nerves – puts pressure on affected nerves and cause pain and severe nerve damage Loss of nerve function (sensation, movement) Loss of nerve function (sensation, movement) Clinical Evaluation

22 General Inspection: General Inspection: Breathing patterns: Breathing patterns: Irregular breathing (i.e. shallow respirations, pain) Irregular breathing (i.e. shallow respirations, pain) Injury to thoracic vertebrae Injury to thoracic vertebrae Pressure on thoracic nerves Pressure on thoracic nerves Trauma to ribs, costal cartilage Trauma to ribs, costal cartilage Bilateral comparison of skin folds: Bilateral comparison of skin folds: Asymmetry of natural folds Asymmetry of natural folds Causes: muscle imbalance, ↑ or ↓ kyphosis, scoliosis Causes: muscle imbalance, ↑ or ↓ kyphosis, scoliosis Clinical Evaluation

23 General Inspection: General Inspection: Kyphosis: Kyphosis: Abnormal forward rounding of the upper back (> 40 to 45 degrees) Abnormal forward rounding of the upper back (> 40 to 45 degrees) Round back or hunchback Round back or hunchback Causes: Causes: Developmental problems, degenerative diseases (arthritis), osteoporosis with compression fractures, trauma Developmental problems, degenerative diseases (arthritis), osteoporosis with compression fractures, trauma Severe cases: Severe cases: Can affect lungs, nerves, causing pain and other problems Can affect lungs, nerves, causing pain and other problems Clinical Evaluation

24 General Inspection: Kyphosis Test: Forward bend test Patient bends forward from the waist while ATC views the spine from the side With kyphosis, the rounding of the upper back may become more obvious in this position Postural kyphosis – the deformity corrects itself when patient lies on their back Clinical Evaluation

25 Postural kyphosis: May improve on its own Exercises to strengthen back muscles, correct posture, and sleeping on a firm bed Structural kyphosis: Caused by spinal abnormalities Scheuermann's disease: Developmental disorder that causes a stooped forward or bent- over posture Affects between 0.5% and 8% of the general population Osteoporosis-related kyphosis: Multiple compression fractures Low bone density Clinical Evaluation

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27 General Inspection: General Inspection: Movement and Posture: Movement and Posture: Poor posture (standing, sitting, bending) Poor posture (standing, sitting, bending) Lordotic Curve: Lordotic Curve: Reduction: Reduction: Muscle spasm Muscle spasm Hamstring tightness Hamstring tightness Increased: Increased: Hip flexor tightness Hip flexor tightness Abdominal weakness Abdominal weakness Clinical Evaluation

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29 General Inspection: General Inspection: Standing Posture: Standing Posture: Lateral shift in trunk and pelvis Lateral shift in trunk and pelvis Nerve root impingement (lateral shift ↓ pressure) Nerve root impingement (lateral shift ↓ pressure) Erector Spinae Muscle Tone: Erector Spinae Muscle Tone: Unilateral hypertrophy or atrophy Unilateral hypertrophy or atrophy Faun’s Beard: Faun’s Beard: Spina bifida occulta Spina bifida occulta Clinical Evaluation

30 General Inspection: Spina Bifida General Inspection: Spina Bifida Birth defect that occurs when the tissue surrounding the developing spinal cord doesn't close properly Birth defect that occurs when the tissue surrounding the developing spinal cord doesn't close properly Spina Bifida Occulta: Spina Bifida Occulta: Mildest form, results in a small separation in one or more of the vertebrae of the spine (spinal nerves usually not involved – most patients have no signs/symptoms or neurological problems) Mildest form, results in a small separation in one or more of the vertebrae of the spine (spinal nerves usually not involved – most patients have no signs/symptoms or neurological problems) Inspection: Faun’s Beard, a collection of fat, a small dimple or a birthmark on the newborn's skin above the spinal defect Inspection: Faun’s Beard, a collection of fat, a small dimple or a birthmark on the newborn's skin above the spinal defect Complications: Complications: Minor physical disabilities Minor physical disabilities Mental strain Mental strain Severity: Severity: Size and location of the neural tube defect Size and location of the neural tube defect Does skin cover the area? Does skin cover the area? Do the spinal nerves come out of the affected area of the spinal cord? Do the spinal nerves come out of the affected area of the spinal cord? Clinical Evaluation

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32 Palpation: Thoracic Spine Palpation: Thoracic Spine Spinous Processes Spinous Processes Supraspinous Ligaments: Supraspinous Ligaments: Fills space between the spinous processes Fills space between the spinous processes Costovertebral Junction: Costovertebral Junction: Articulation between ribs and thoracic vertebrae Articulation between ribs and thoracic vertebrae Only palpable on slender individuals Only palpable on slender individuals Trapezius: Trapezius: Origin to insertion Origin to insertion Rhomboids and levator scapulae lie deep to middle/upper traps Rhomboids and levator scapulae lie deep to middle/upper traps Paravertebral Muscles Paravertebral Muscles Scapular Muscles Scapular Muscles Clinical Evaluation

33 1 – Spinous Processes 2 – Supraspinous Ligaments 3 – Costovertebral Junction 4 – Trapezius 5 – Paravertebral Muscles 6 – Scapular Muscles

34 StructureLandmark Cervical vertebral bodies Same level as spinous processes C1 transverse process One finger’s breadth inferior to mastoid process C3-C4 vertebrae Posterior to hyoid bone C4-C5 vertebrae Posterior to thyroid cartilage C6 vertebrae Posterior to cricoid cartilage; moves during flexion and extension of cervical spine C7 vertebrae Prominent posterior spinous process T1 vertebrae Prominent protrusion inferior to cervical spine T2 vertebrae Posterior from jugular notch of the sternum T3 vertebrae Even with the medial border of the scapular spine T7 vertebrae Even with the inferior angle of the scapula L3 vertebrae Posterior from the umbilicus L4 vertebrae Level with the iliac crest L5 vertebrae Typically demarcated by bilateral dimples, but variable from person to person S2 At level of the posterior superior iliac spine

35 Clinical Evaluation C7 T1 T2 T3 T4 T5

36 1 – Spinous Processes 2 – Step-off Deformity 3 – Paravertebral Muscles

37 Clinical Evaluation Spondylolisthesis: Spondylolisthesis: Forward slippage of a vertebrae on the one below it Forward slippage of a vertebrae on the one below it L4 and L5 / L5 and S1 L4 and L5 / L5 and S1 Affects 5-6% of males, 2-3% of females Affects 5-6% of males, 2-3% of females Causes: Causes: Strenuous physical activity (weightlifting, gymnastics, football) Strenuous physical activity (weightlifting, gymnastics, football) Types: Types: Developmental: Developmental: May exist at birth, or may develop during childhood (generally not noticed until later in childhood/adult life) May exist at birth, or may develop during childhood (generally not noticed until later in childhood/adult life) Acquired: Acquired: Degeneration: caused by the daily stresses that are put on spine (i.e. carrying heavy items, physical sports) Degeneration: caused by the daily stresses that are put on spine (i.e. carrying heavy items, physical sports) Connections between the vertebrae weaken Connections between the vertebrae weaken Single or repeated force Single or repeated force

38 Clinical Evaluation Spondylolisthesis: Spondylolisthesis: Grade 1: Grade 1: 25% of vertebral body has slipped forward 25% of vertebral body has slipped forward Grade 2: Grade 2: 50% 50% Grade 3: Grade 3: 75% 75% Grade 4: Grade 4: 100% 100% Grade 5: Grade 5: Vertebral body completely fallen off (i.e.,spondyloptosis) Vertebral body completely fallen off (i.e.,spondyloptosis)

39 Clinical Evaluation Symptoms: Symptoms: May be asymptomatic May be asymptomatic Low back pain (especially after exercise) Low back pain (especially after exercise) ↑ lordosis ↑ lordosis Pain/weakness in one or both legs Pain/weakness in one or both legs ↓ ability to control bowel/ bladder functions ↓ ability to control bowel/ bladder functions Tight hamstrings Tight hamstrings Advanced spondylolisthesis: changes may occur in the way patient stands/walks Advanced spondylolisthesis: changes may occur in the way patient stands/walks

40 Clinical Evaluation Palpation: Sacrum and Pelvis Palpation: Sacrum and Pelvis Median sacral crests Median sacral crests Iliac crests: Iliac crests: Palpate laterally from PSIS to find iliac crests and anteriorly to locate ASIS (level of symmetry) Palpate laterally from PSIS to find iliac crests and anteriorly to locate ASIS (level of symmetry) Posterior superior iliac spine Posterior superior iliac spine Gluteals Gluteals Ischial tuberosity Ischial tuberosity Greater trochanter Greater trochanter Sciatic nerve: Sciatic nerve: Place thumb on ischial tuberosity and 3 rd finger on the PSIS. 2 nd finger will fall into sciatic notch (nerve most superficial as it passes by ischial tuberosity) Place thumb on ischial tuberosity and 3 rd finger on the PSIS. 2 nd finger will fall into sciatic notch (nerve most superficial as it passes by ischial tuberosity) Pubic symphysis Pubic symphysis

41 1 – Median sacral crests 2 – Iliac crests 3 – PSIS 4 – Gluteal muscles 5 – Ischial tuberosity 6 – Greater trochanter 7 – Sciatic nerve 8 – Pubic symphysis

42 1 – Iliac crest 2 – Tensor fascia latae 3 – Gluteus medius 4 – Iliotibial band 5 – Greater trochanter 6 – Trochanteric bursa

43 1 – Pubis 2 – ASIS 3 – AIIS 4 – Sartorius 5 – Rectus femoris

44 Clinical Evaluation Active Range of Motion: Active Range of Motion: Flexion and Extension: Flexion and Extension: Measured with patient standing Measured with patient standing Distance from the fingertips to the floor can be measured (accuracy affected by tightness of hamstrings and calf muscles and scapular protraction) Distance from the fingertips to the floor can be measured (accuracy affected by tightness of hamstrings and calf muscles and scapular protraction) Gravity assists with movement Gravity assists with movement More accurate than hook-lying position More accurate than hook-lying position Abdominal muscles have to overcome weight of the trunk Abdominal muscles have to overcome weight of the trunk

45 Clinical Evaluation Active Range of Motion: Active Range of Motion: Lateral Bending: Lateral Bending: Patient standing (feet shoulder width apart and the hand opposite the direction of the movement resting on the ilium) Patient standing (feet shoulder width apart and the hand opposite the direction of the movement resting on the ilium) Patient bends trunk laterally (attempt to tough fingertips to the ground) Patient bends trunk laterally (attempt to tough fingertips to the ground) Distance between the ground and fingertips is measured Distance between the ground and fingertips is measured Rotation: Rotation: Patient is sitting position (stabilizes pelvis and lower extremity) Patient is sitting position (stabilizes pelvis and lower extremity) Patient rotates shoulder girdles and spinal column (attempt to look behind one’s back) Patient rotates shoulder girdles and spinal column (attempt to look behind one’s back) Movement primarily occurs in thoracic spine Movement primarily occurs in thoracic spine

46 Clinical Evaluation Passive Range of Motion: Passive Range of Motion: Flexion: Flexion: Patient in hook-lying position Patient in hook-lying position Examiner brings the knees to the chest by lifting under the knees and thighs and flexing the hip and thoracic spine Examiner brings the knees to the chest by lifting under the knees and thighs and flexing the hip and thoracic spine Extension: Extension: Patient prone (hands flat on table at shoulder level – push-up position) Patient prone (hands flat on table at shoulder level – push-up position) Patient extends arms, lifting the torso (hips and legs remain of table) Patient extends arms, lifting the torso (hips and legs remain of table) Rotation: Rotation: Patient in hook-lying position Patient in hook-lying position Patient’s pelvis and legs are rotated to bring lateral portion of the knee towards the table (shoulders remain flat) Patient’s pelvis and legs are rotated to bring lateral portion of the knee towards the table (shoulders remain flat)

47 Motion Ligaments Stressed Flexion Posterior Longitudinal Ligament, Supraspinous Ligament, Interspinous Ligament, Ligamentum Flavum Extension Anterior Longitudinal Ligament Rotation Interspinous Ligament, Ligamentum Flavum Lateral Bending Interspinous Ligament, Ligamentum Flavum Spinal Ligaments Stressed During Passive Range of Motion Testing

48 Clinical Evaluation Beevor’s Sign: Beevor’s Sign: Test for thoracic nerve inhibition Test for thoracic nerve inhibition Patient performs an abdominal curl-up from hook-lying position Patient performs an abdominal curl-up from hook-lying position Normal Findings: abdominal muscles receive concurrent innervation from T5-T12 nerve roots (umbilicus does not move) Normal Findings: abdominal muscles receive concurrent innervation from T5-T12 nerve roots (umbilicus does not move) Positive Test: umbilicus is pulled toward the head Positive Test: umbilicus is pulled toward the head Characteristic of spinal cord injury between T6 and T10 levels Characteristic of spinal cord injury between T6 and T10 levels Upper abdominal muscles (rectus abdominis) are intact at the top of the abdomen but weak at the lower portion, patient is asked to do a sit up – only the upper muscles contract (umbilicus pulled toward the head) Upper abdominal muscles (rectus abdominis) are intact at the top of the abdomen but weak at the lower portion, patient is asked to do a sit up – only the upper muscles contract (umbilicus pulled toward the head)

49 Clinical Evaluation Resistive Range of Motion: Resistive Range of Motion: Flexion: Flexion: Patient position – supine with knees flexed and feet flat on table Patient position – supine with knees flexed and feet flat on table Stabilization – pelvis Stabilization – pelvis Resistance – applied to the superior sternum as patient lifts the scapulae off the table Resistance – applied to the superior sternum as patient lifts the scapulae off the table Muscles tested – rectus abdominis, internal oblique, external oblique Muscles tested – rectus abdominis, internal oblique, external oblique

50 Clinical Evaluation Resisted Range of Motion: Resisted Range of Motion: Extension: Extension: Patient position – prone with arms interlocked behind the head Patient position – prone with arms interlocked behind the head Stabilization – lower lumbar region Stabilization – lower lumbar region Resistance – applied to upper thoracic spine as patient lifts head, chest, and arms off table Resistance – applied to upper thoracic spine as patient lifts head, chest, and arms off table Muscles tested – iliocostalis lumborum, iliocostalis thoracis, longissimus thoracis, spinalis thoracis, semispinalis thoracis, rotators, latissimus dorsi Muscles tested – iliocostalis lumborum, iliocostalis thoracis, longissimus thoracis, spinalis thoracis, semispinalis thoracis, rotators, latissimus dorsi

51 Clinical Evaluation Resisted Range of Motion: Resisted Range of Motion: Rotation: Rotation: Patient position – supine (hands interlocked behind head) Patient position – supine (hands interlocked behind head) Stabilization – opposite ASIS Stabilization – opposite ASIS Resistance – anterior aspect of shoulder as it is rotated off the table Resistance – anterior aspect of shoulder as it is rotated off the table Muscles tested – internal oblique, external oblique (opposite side), rotators, multifidi Muscles tested – internal oblique, external oblique (opposite side), rotators, multifidi


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