L/S, SIJ and Pelvis Flashcards
Myotome
L2: hip flexion L3: knee extension L4: ankle dorsi-flexion L5: great toe extension S1: ankle plantar-flexion/ankle eversion/hip extension S2: knee flexion
Dermatome
L1 - Inguinal area.
L2 - On the anterior medial thigh, at the midpoint of a line connecting the midpoint of the inguinal ligament and the medial epicondyle of the femur.
L3 - At the medial epicondyle of the femur.
L4 - Over the medial malleolus.
L5 - On the dorsum of the foot at the third metatarsophalangeal joint.
S1 - On the lateral aspect of the calcaneus.
S2 - At the midpoint of the popliteal fossa.
S3 - Over the tuberosity of the ischium or infragluteal fold
S4 and S5 - In the perianal area, less than one cm lateral to the mucocutaneous zone
Spinal Fx (CPR)
Female
Trauma
>70 y/o
Chronic steroid use
Back Related Tumor
H/O CA
No relief with bed rest
*greatest indicators among red flags
Cauda Equina Syndrome
Urinary retention is the best indicator to R/I and R/O
Bilat. LE symptoms
Saddles anesthesia
Bowel/Bladder changes
This is a Medical Emergency
Infection
Fever is best to R/I
Spinal Compression Fx
Major Trauma is best to R/I
Ab. Aortic Aneurysm (AAA)
Current smokers, on statin drugs are high risk factor
Sx: Reports of throbbing and can’t get comfortable, best R/O by abdominal girth
MD referral if?
Findings suggest serious medical condition
Symptoms not consistent with a classification system
No resolved by intervention
Outcome measures
Oswestry (ODI) and Roland-Morris
*Roland Morris is better when small changes in function need to be detected
Manual Therapy indications for LBP
HVLA used for acute LBP, back related buttock/thigh pain
Non-thrust mobilization useful in sub-acute and chronic cases
MTT more effective when combined with exercise
Fitness
Promote Mod. to High. intensity exercise for patients with LBP and generalized pain. Low intensity exercise for chronic LBP.
Education
Promote early activity and discourage prolonged bed rest or in depth patho-anatomical explanations
Educate on pain pathways and referral systems, favorable prognosis, understanding structural strength of the spine (especially in cases with high FABQ scores)
Centralization
cases where radicular symptoms reduced with directional bias
Older patients
Flexion bias and lower quadrant nerve mobilization can be used with MMT to dec. chronic LBP and radiating pain
Traction
(+)SLR and peripheralization of symptoms without a directional preference (performed prone with intermittent force)
EXCLUSION criteria: Pregnant, osteoporosis, H/O fx in L/S, current Fx, SCI
Urogenital screening
Blood or changes in urinary patterns (frequency or retention)?
Pain or burning?
Recent kidney stones?
Previous treatment for CA?
Disc degenration
Should not directly cause pain because only the outer 1/3 is innervated. Pain is usually Nerve Root inflammation.
McNab classification of HNP
Protrusion (localized bulge)
Prolapsed (nucleus remains contained but migrates to outer ring)
Extruded (Nucleus pushes through the outer ring)
Sequestered (Nucleus leaks into spinal/intervertebral canals
Rehab after disc herniation (athletes)
Phase 1: (Non-rotation/Non-flexion bias) week 1
Phase 2: (Counter Rotation/Flexion Phase) week 2-3
Phase 3: Rotational Phase / Power development (from 9 days until return to sport ready)
Phase 4: Return to Sport
Tests of Nerve Root dysfunction
Best to R/O:
LE pain > LBP, SLR or slump, dermatomal distribution
Best to R/I:
Paresis
DDx for patients with potential nerve involvement
HNP:
Age 30-55, worse with flexion, pain @ or below single LE, diminished DTR (involved side)
Stenosis:
Age >60, worse with extension (standing/walking), sensorimotor changes (neuro claudication)
Cauda Equina:
Age 40-60, Insidious or chronic with bowel/bladder changes, Bilat. symptoms worse with flexion, Absent DTR Bilat., + SLR, effects S3-S4 (anal wink and perineal sensation)
Neural tension tests
Slump (false positive at 15 degrees of flexion)
SLR (+ test when 30-70 degrees flexion of the hip reproduces symptoms
X-SLR (indicates possibly large HNP, candidate for traction)
Femoral Nerve tension test (prone knee bend + if burning felt in the anterior thigh)
Slump stretch
Indicated as part of HEP for patient with a + slump and negative SLR (
Likelihood to succeed with P.T.
Patient to P.T. who wait 6 weeks to start P.T. more likely to develop depression (31%)
Back pain classification based on acuity of injury
Acute LBP 12 weeks
CPR for HVLA in acute LBP (4+/5)
pain 35 degrees hip IR
+ spring test (pain-hypomobile PA)
Cavitation is not required, most effective combined with exercise
HVLA improves nerve mobility in LBP treatment and multifidus activation
Systems of spinal stability (3)
Passive - ligaments and facets offer restraint at end ranges
Active - muscles control mid-range
NM - response to unexpected afferent feedback
Multifidus
Atrophy when LBP present, most important stabilizer in the sagittal plane @ L4-L5 (usually most involved L/S segment)
4 stages of motor control
Local (supine, progressed to sitting and prone), drawing-in maneuver
CKC (squat, step, dynamic sitting, lunge, trunk hinge)
OKC (while moving adjacent segment such as hips)
Functional (sport or work specific)
Lumbar Stabilization CPR (3+/4), indicates dec. recruitment of the lumbar multifidi
(+)Prone instability test
Aberrant motion
SLR (passive) > 90
Age
Plank Norms, significance of ratios
Low plank (2 minutes) Side Plank (1-2 minutes) Bridge (2 minutes, LS on non-dominant side for 1-2 additional minutes after 1st minute)
L to R ratios should be symmetrical (within .05)
Flexion to extension should be
Flag Colors
Red Flags (serious medical conditions) Yellow Flags (patient's personal beliefs) Blue Flags (Work, return-to-work related) Black Flags (secondary gain)
Stenosis CPR
Age > 48 with pain that is worse with standing/walking, relieved by sitting and more leg pain than back pain
LBP that would benefit from Pilates (CPR)
BMI > 25
no symptoms in the LEs
Duration of current symptoms
SIJ CPR (3+/5)
Thigh Thrust, compression, distraction, Gaenslen’s
sacral thrust or FABER
Best exercises for deep abdominal strengthening
TrA & IO (side plank and abdominal crunch)
TrA (Drawing-in maneuver & quadruped UE/LE
Chronic LBP treatment
Education + motor control exercises and graded activity
Extension treatment Bias
Preference for sitting or walking
Centralization with motion
Peripheralization opposite motion
*Not effective if no distal symptoms or status quo with all movements
Prone press-up 3x10 (5 sec hold)
Flow of classification algorithm
Specific exercise ->Manual based ->Stabilization
SIJ vs. L/S HVLA
SIJ mobilization used if 3+ present in Dx. cluster and pain at PSIS(+ Fortin)
L/S mobilization if localized pain that is unilateral
McKenzie classification
Posture Syndrome
Dysfunction Syndrome
Derangement Syndrome
Posture Syndrome
Age
Dysfunction Syndrome
Age > 30
Sedentary
Localized pain at end ranges
Restricted ROM from tissue shortening
Derangement Syndrome
Age 20-55
Sudden onset
Radicular symptoms
Pain can be constant and predictable with movements
Neurogenic vs. Intermittent claudication
Neurogenic claudication is worse with standing or walking, better with flexed trunk
Vascular claudication is worse with activity and only relieved by rest. can be treated by progressive interval walking at intensity that causes claudication after 3-5 minutes (common with PVD)
ABI should be 1:1, less than that is sign of PVD
Spondylolysis/Spondylolisthesis
Spondylolisthesis is common in cause of LBP in children usually due to hyperextension (i.e. gymnast) causes fracture of the pars and anterior translation of the vertebra
Males more prone to pars defects (spondylolysis).
Usually will present as LBP with symptoms in the LE (unilaterally), dull ache. Worse with extension and TTP at segment. Step-deformity. Most common at L5/S1 followed by L4/L5. Radicular symptoms will be at the nerve root level between the fracture site
SPECT is best diagnostic image for Pars defects
Tx:In acute cases bracing 3-6 months with anterior core stabilization. surgical gold standard is a posterolateral fusion.
Scoliosis
Functional may be due to spasms on discrepancy in limb length
Structural = idiopathic
Rib hump on convex side doesn’t disappear with forward flexion
Bracing is recommended after curve is >20 degrees and continues to progress by 5 degrees or more after a year. Immediate bracing is recommended if there is curve > 30 degrees.
MCID
ODI 6%
NDI 5-7%
NPRS > 2
PSFS > 2
GROC >5-10
LEFS 9
DASH 12.8 (14 in quickDASH)
