Final

Question 1

What are the seated tests for lumbar spine?

Answer 1

Valsalva
Bechterew’s Test (seated straight leg raise)
Slump Test

Question 2

What are the supine leg tests?

Answer 2

Straight Leg Raise
Sicard’s Test
Bragard’s Test
Well Leg Raise

Question 3

What is Bechterew’s test?

Answer 3

Seated straight leg raise
passively OR actively straighten on leg at a time.

SX - down posterior thigh (possible L4, L5 or S1 radiculopathy)

could be due to:

• herniated disc
• stenosis
• osteophytes
• tumors
• infection
• fracture

Question 4

What is the slump test? what does it test for?

Answer 4

1. Patient sits upright, arms behind back
2. Pt slumps, cervically extends
3. cervical spine, fully flexed and released.
4. Extend one knee maximally, cervical spine flexed and released
5. dorsiflex ankle (cervical spine fully flexed and released)

IF CHANGE IN SX
6. both legs may be extended simultaneously

Question 5

How do you perform the straight leg raise (SLR)?

Answer 5

Patient supine, practitioner PASSIVELY elevates straight leg.
NOTE ANGLE OF ONSET OF PAIN

Question 6

What is a positive SLR? Hard? Soft? Negative?

Answer 6

Hard positive:

• sharp, burning electrical pain past knee - hip flexed 35-70
• sciatic nerve irritation (L4-S1); nerve root radiculitis (herniation, tumor, spinal canal stenosis, osteophytes)

Soft Positive:

• Pain radiates, but NOT PAST KNEE
• meaningful IF evidence of other sciatic nerve rt inflammation/compression
• insignificant if other evidence is absent

Question 7

what is the “alarm sign” for SLR?

Answer 7

focal point of pain in the leg or pelvis

-suggestive of tumor

Question 8

Sicard’s test is performed when? how?

Answer 8

IF passive SLR is positive, then lower the leg 5-10 deg or to just below point of pain and DORSIFLEX FOOT*

• positive if duplicates or increases radicular leg pain
• SCIATIC RADICULOPATHY
• disc herniation,
• encroachment,
• space occupying lesion

Question 9

Bragard’s test is performed when? how?

Answer 9

IF passive SLR is positive, then lower the leg 5-10 deg or to just below point of pain and DORSIFLEX Big TOE*

• positive if duplicates or increases radicular leg pain
• SCIATIC RADICULOPATHY
• disc herniation,
• encroachment,
• space occupying lesion

Question 10

Well leg raise is

Answer 10

SLR, or passive straight leg raise of the unaffected side.
- positive IF increases sx on the AFFECTED side

• nerve root irritation
• disc herniation
• encroachment by osteophytes

Question 11

What is the diagnostic cluster for lumbar stenosis?

Answer 11

• Relief during immediate sitting is strongly suggestive of spinal stenosis (Sensitivity 0.46; Specificity 0.93).

The most diagnostic combination included a cluster of:

1. BL sx;
2. leg pain more than back pain;
3. pain during walking/standing;
4. pain relief upon sitting;
5. age >48 years.

Meeting any one of five positive findings demonstrated a high sensitivity of 0.96 (95% CI = 0.94-0.97) and a low negative likelihood ratio (LR-) of 0.19 (95% CI = 0.12-0.29).

Meeting four of five findings yielded a LR+ of 4.6 (95% CI = 2.4-8.9) and a post-test probability of 76%.

Question 12

What is the Diagnostic cluster for Cauda Equina syndrome?

Answer 12

• Rapid symptoms within 24 hours 89% sensitivity
• History of back pain 94% sensitivity
• Urinary retention 90% sensitivity
• Loss of sphincter tone 80% sensitivity
• Sacral sensation loss 85% sensitivity
• Lower extremity weakness or gait loss 84%sensitivity

Question 13

What is the diagnostic cluster for lumbar radiculopathy?

Answer 13

• Dermatomal pattern (OR = 4.1)
• Pain on cough, sneezing, straining (OR = 3.2)
• More pain Sitting (OR=1.9)
• Subjective muscle weakness (OR = 2.2)
• Subjective Sensory loss (OR = 2.1)
• Paresis/Motor Loss (OR = 3.7)
• Positive SLR (OR = 3.9)
• UL Ankle reflex (OR = 3.9)

Question 14

Diagnostic cluster for lumbar compression fracture

Answer 14

• age >50 (sensitivity 0.84, specificity 0.61)
• age >70 (sensitivity 0.22, specificity 0.96)
• trauma (sensitivity 0.30, specificity 0.85)
• Adequate trauma, although in elderly trauma can be minor
• corticosteroid use (sensitivity 0.06, specificity 0.995)

Question 15

Diagnostic cluster for Spine cancer

Answer 15

• Age > 50 (sensitivity 0.77, specificity 0.71)
• previous history of cancer (sensitivity 0.31, specificity 0.98)
• failure to improve in 1 mo. of therapy (sensitivity 0.31, specificity 0.90)
• no relief with bed rest (sensitivity >0.90, specificity 0.46)
• duration of pain > 1 mo (sensitivity 0.50, specificity 0.81)
• COMBO: age >50 or cancer hx or unexplained wt loss or failure of conservative tx (sensitivity 1.00, specificity 0.60)
• Insidious onset (no stats)
• constitutional symptoms (no stats)

Question 16

Diagnostic cluster for Ankylosing Spondylitis?

Answer 16

• age at onset < 40 (sensitivity 1.00, specificity 0.07)
• pain not relieved by supine position (sensitivity 0.80, specificity 0.49)
• morning back stiffness 0.64 0.59
• pain duration >3 months 0.71 0.54

4 of 5 questions above positive also:
-improved by exercise 0.23 0.82 +LR = 1.27

Question 17

Reflex testing of the Patella, Hamstring and Achilles test which Nerve roots, respectively?

Answer 17

Patella - L4
Hamstring - L5 (semitendinosus tendon)
Achilles - S1

Question 18

Which nerve root level does Iliopsoas test?

Answer 18

L1, L2

• Ventral Rami
• Femoral N

Question 19

Which nerve root level does Quadriceps test?

Answer 19

L3

- femoral N

Question 20

Which nerve root level does Tibialis Anterior test?

Answer 20

L4

Deep peroneal N

Question 21

Which nerve root level does Peroneous longs/brevis AND ext. hallucis longus test?

Answer 21

L5

deep peroneal n

Question 22

Which nerve root level does gastrocnemius/soleus test?

Answer 22

S1

tibial n

Question 23

Which nerve root level does Flexor Hallucis Longus test?

Answer 23

S1

tibial n

Question 24

How do you perform the horrible test that is KEMPs?

Answer 24

Kemps:
Extension, lateral flexion and rotation toward affected side
– compress spine and push in on the concave side (Horrible Test)
- IF positive, get radicular symptoms down the symptomatic side (the side they are laterally flexed to)

Question 25

what are the three MC ways to acquire cauda aquina?

Answer 25

• Fracture
• Disc Herniation
• Space Occupying Lesion

Question 26

PIR for Tensor Fascia Lata

Answer 26

Patient Position:

• Sidelying with target (involved) muscle up
• Patient’s posterior trunk positioned close to the edge of the table.
• *Upside leg (target muscle): the hip and knee are extended
• leg is lowered over the edge of the table until the barrier of resistance is palpated.
• *Downside leg: hip and knee flexed on the table for stability.

Doctor Position: Ipsilateral to dysfunction, standing behind the patient.

Procedure:

• With the superior hand (cephlad) stabilize the patient’s pelvis in a sidelying position.
• The inferior (caudal) hand is placed on the lateral thigh/knee of the upside leg.
• Adduct (lower toward the floor) and extend the leg to the position where the “barrier of resistance” can be palpated.
• Direct the patient to push their thigh/knee upward and forward against your contact hand as you apply isometric resistance to the patient’s hip abduction and flexion (20-75%).
• Use “as little force as possible or as much as necessary”. Avoid Valsalva.

Question 27

PIR for piriformis

Answer 27

Patient Position:

• Supine
• Contralateral leg (target muscle): knee flexed. Hip flexed, adducted and internally rotated to the position where the “barrier of resistance” is palpated
• Ipsilateral leg: extended and relaxed on the table

Doctor Position:
-Contralateral to dysfunction, facing the patient.

Procedure:

• The contralateral hip (target muscle) is placed as follows:
• hip flexion < 60º
• hip adduction across the midline of the body
• The superior (cephalad) hand is placed on the contralateral knee (over the patella)
• The inferior (caudal) hand is placed on the medial malleolus (inside) of the contralateral ankle.
• Place your sternum/epigastrium/abdomen on the top of your superior hand contact on the patient’s knee.
• Put compression into the hip joint by pushing and maintaining your body weight down the shaft of the femur.
• With your inferior hand (ankle contact) gently push the hip into internal rotation until the “barrier of resistance” to hip external rotation can be palpated.
• Direct the patient to push their foot against your contact hand (ankle) as you apply isometric resistance to the patient’s external rotation (20-75%).

-Use “as little force as possible or as much as necessary”.
• Avoid Valsalva.
• Hold 8-10 seconds.

• Slowly increase the hip internal rotation within patient’s comfort zone (the joint should move smoothly without muscle resistance).
• Repeat PIR stretch 3-5 times total.

Question 28

PIR for iliopsoas

Answer 28

Patient Position:

• Sitting on the edge of the foot of the table.
• Ipsilateral leg: patient pulls their knee-to-chest (flexion) and reclines the upper trunk backwards onto the table, leaving the contralateral leg (target muscle) hanging off the foot of the table.
• The doctor places his/her lateral hip against the sole of patient’s foot to help stabilize the leg in flexion.
• Contralateral leg (target muscle): allowed to hang over the foot of the table with the thigh resting as close as possible to the table top and the knee passively flexed as much as possible over the edge of the table.

Doctor Position:

• At the foot of the table standing contralateral to and facing the leg with the target muscle.
• The doctor places his/her lateral hip on the sole of the foot of the patient’s ipsilateral leg, stabilizing it in flexion.

Procedure:
• Place the superior (cephalad) hand on the patient’s ipsilateral knee to stabilize it.
• With the inferior (caudal) hand push down on the contralateral (target) knee to stretch the iliopsoas muscle.
• Stretch the iliopsoas until the “barrier of resistance” can be palpated.
• Direct the patient to push their knee against your contact hand as you apply isometric resistance to the patient’s hip flexion (20-75%).
• Use “as little force as possible or as much as necessary”.
• Avoid Valsalva.
• Hold 8-10 seconds.
• Patient relax - wait for muscle resistance to let go (1-3 seconds)
• Slowly increase hip extension within patient’s comfort zone (the joint should move smoothly without muscle resistance).
• Repeat PIR stretch 3-5 times total.

Question 29

PIR for Rectus Femoris

Answer 29

Rectus Femoris

Patient Position: Same as the iliopsoas position

Doctor Position: Same as the iliopsoas position

Procedure:
• Place the superior (cephalad) hand on the patient’s ipsilateral knee to stabilize it.
• With the inferior (caudal) hand push on the contralateral tibia to induce knee flexion.
• Stretch the rectus femoris (quadriceps) until the “barrier of resistance” can be palpated.
• Direct the patient to push their lower leg against your contact hand as you apply isometric resistance to the patient’s knee extension (20-75%).
• Use “as little force as possible or as much as necessary”.
• Avoid Valsalva.
• Hold 8-10 seconds.

• Patient relax - wait for muscle resistance to let go (1-3 seconds)
• Slowly increase the knee flexion within patient’s comfort zone (the joint should move smoothly without muscle resistance).
• Repeat PIR stretch 3-5 times total.

Question 30

PIR for quadratus lumborum

Answer 30

Note: For stretching purposes the Quadratus Lumborum can be divided into an
anterior and a posterior division and each division can be stretched separately.
The procedure is similar for both divisions except for the following:
• when stretching the posterior division the patient’s trunk is positioned toward the back edge of the table and the hip is placed in extension.
• when stretching the anterior division the patient’s trunk is positioned toward the front edge of the table and the hip is placed in flexion.

Patient Position: Sidelying with target (involved) muscle up
Patient’s trunk is positioned close to the edge of the table.
♣ Upside leg (target muscle): the knee is straight (extended) and the hip is either flexed or extended (anterior vs. posterior divisions) with the leg lowered over the edge of the table.
♣ Downside leg: hip and knee are flexed on the table for stability.
♣ The patient’s upside arm reaches overhead and grasps the top of the table.
♣ A roll may be placed on the table under the patient’s waist.

Doctor Position:  	Ipsilateral to dysfunction; standing behind the patient to stretch 					the posterior division or in front of the patient to stretch the 						anterior division.

Procedure: •	The fingers of both hands are interlaced and placed over the upside iliac crest. •	The doctor straddles and lightly squeezes the patient’s leg between his/her knees. •	Pull on the iliac crest with both hands to the position where the “barrier of resistance” can be palpated.  •	Ask the patient to breathe in and look up with both eyes. •	Direct the patient to pull their iliac crest superiorly (cephalad) against your contact hands as you apply isometric resistance to the patient’s iliac elevation (20-75%). •	Use “as little force as possible or as much as necessary”. •	Avoid Valsalva. •	Hold 8-10 seconds. •	Instruct the patient to breathe out and release their eyes. •	Patient relax - wait for muscle resistance to let go (1-3 seconds) •	Slowly pull downward on the iliac crest, lowering it within the patient’s comfort zone (the iliac crest should move smoothly without muscle resistance). •	Repeat PIR stretch 3-5 times total.

Question 31

PIR for erector spinae?

Answer 31

Patient Position:
-Sidelying with a pillow or roll under their waist. The patient’s upper trunk is placed in a pronated position (hugging the table) and their downside hip and knee is flexed.

Doctor Position: Standing behind the patient near the patient’s pelvis.

Procedure:
Doctor’s hand position:
• Reach over to the patient’s posterior trunk and contact the iliac crest/ASIS with the superior hand. With the inferior hand contact the lower thoracic or upper lumbar erector spinae muscles.
Alternative hand placement:
• The doctor’s arms do not have to be crossed as illustrated here.

• The doctor uses the superior hand to pull the patient’s pelvis posteriorly while using the inferior hand to push superiorly and anteriorly on the erector spinae until the “barrier of resistance” is reached
• Ask the patient to breathe in and look up with both eyes.
• Direct the patient to push their trunk backward against your contact hand as you apply isometric resistance to the patient’s trunk extension (20-75%).
• Use “as little force as possible or as much as necessary”.
• Avoid Valsalva.
• Hold 8-10 seconds.
• Instruct the patient to breathe out and release their eyes.
• Patient relax - wait for muscle resistance to let go (1-3 seconds)
• Slowly increase the trunk flexion within patient’s comfort zone (the trunk should move smoothly without muscle resistance).
• Repeat PIR stretch 3-5 times total.