L22 - PRACTICE & CLINICAL REASONING IN NEURO-MSK PHYSIO 1 Flashcards
Training clinical case 1
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Training clinical case 2
Definition relative flexibility
tendency of joint or tissue to move more readily than others when subjected to force,
often due to differences in stiffness or resistance. Lead to compensatory movement patterns where more
flexible areas move excessively while stiffer ones remain restricted
Training on clinical case 3
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Training on clinical case 4
Rotation classification: description of primary rotation + content
Primary rotation
- Symptoms (Sx): acute pain (often)
- Rotation causing Sx
- Patient presents as shift
- Most often has Sx at rest particularly when weight bearing
- Correction of rotation reduces Sx
Diagnosis (Dx) example
- Flexion – rotation – type primary
Content
- Notable asymmetry in Lx region
- Have Sx at rest or be on verge of Sx
- Sx with side bending & rotation in standing
- Quadruped: rocking back, rotation in Lx spine increases
o Has Sx as lumbar region goes from flexion toward neutral (extension)
o Decreases in flexion & Sx as repeats rocking backward (slight manual correction)
- Asymmetry corrected with repeated rocking
- Remain susceptible to recurrent episodes of rotation of offending joints (rotation ext / flex)
Rotation classification: secondary rotation: description
Secondary rotation
- Asymmetry of thoracolumbar regions
- No Sx at rest even in weight bearing
- Rotated region / joints prevent motion at these joints
- Results in excessive motion at joints below rotated regions
- Rotated joints do not cause Sx, but cause excessive rotation at inferiorly situated joints
- Disc degeneration at these joints
Diagnosis example:
- Flexion-rotation – type secondary (more about structure as scoliosis => muscular & postural
adaptation)
Format of assessment: observed preferred postures & motions:
- primary test
- secondary test
Observed preferred postures & motions
Primary test
- Patient in preferred posture
- Patient performs motions in preferred pattern
And
- Note symptoms
- Assess movement pattern / alignment
Secondary test
- Modify / correct patient’s performance
And
- Note effect on symptoms
Key elements for assessment
Key elements for assessment
- Relationship to symptoms
- Pattern
o Consistent with optimal kinesiology
▪ Movement of spine itself: in total or within motion segments
▪ In relation to other adjacent regions: hip / thoracic spine
- Relationship to daily activities
- Implications for treatment
- Test of spinal movements
- Test of limb movements as affect spine
Alignement factors for assessment in standing position
Alignment factors
Standing position
- Observe subject on multiple planes
- Identify deviations from optimal alignment
- Consider implications with potential
o Structural contributing factors
o Functional contributing factors
Treatment principles
Treatment principles
- Stop motion in pain producing direction
o ADLs & recreational activities
- Instruct in correct movement of pain producing segment & in adjoining segments
- Instruct in how to alleviate pain
- Specific exercises for control of inadequately performing muscles
o Stiffen what is too flexible & shorten what is too long
o Improve specific muscle performance
Treatment guidelines
Treatment guidelines
- Modify daily work, leisure & self-care activities
- Change direction-specific movement & alignment strategies during regular activities
- Changes regular stimulus that is proposed to be related to LBP & adaptations contributing to LBP
o Decreased stress on tissue (short-term effects)
o Changes stimulus contributing to passive or active adaptations (long-term effects)
- Prescribe exercise / positioning to address contributing factors (changes in movement system
elements)
- Motor control
- Retain in appropriate movement strategy
- Redistribute motion
o Decreasing movement in lumbar spine
o Increasing movement in other segments
- Identify movement impairment
- Identify contributing factors
- Educate patient about impairment
- Help identify way patient is performing activities contributing to movement impairment
- Instruct patient in corrective exercises & movement patterns
Postural assessment: steps
Examination / observation
Movement factors
Description of examination / observation
EXAMINATION / OBSERVATION
Start with top-to-bottom visual inspection of patient’s posture, identifying any misalignments, asymmetries or deviations
1) General overview
- Observe overall body alignment & symmetry from anterior, posterior & lateral views
- Look for any obvious structural deformities, asymmetries or habitual postures
2) Head & cervical spine
- Check for protraction (forward head) or retraction (chin tuck) posture
- Assess cervical spine curvature for excessive lordosis or straightening
3) Shoulders
- Evaluate levelness of shoulders: depressed?
- Assess scapular alignment: protraction, retraction or winging
- Check alignment relative to hips (vertical line from acromion to greater trochanter)
4) Thoracic and Lumbar Spine:
- Examine spinal curves (kyphosis, lordosis, or flat back).
- Note any lateral deviations such as scoliosis.
5) Pelvis & Hips:
- Observe pelvic tilt: anterior or posterior tilt.
- Assess pelvic alignment: differences in levels of iliac crests or ASIS
- Check for rotational asymmetry.
- Angle between level of PSIS & ASIS: 15° between horizontal
- PSIS level = S2 more stable point to find level in spine
6) LL Alignment:
- Femoral orientation: Check alignment from the greater trochanter to the femoral condyles.
- Tibial orientation: Evaluate alignment from the femoral condyles to the medial and lateral
malleoli.
- Assess knee rotation (internal/external rotation) and valgus/varus alignment.
7) Knee:
- Evaluate angle between femur & tibia
- Check for hyperextension (genu recurvatum).
8) Ankle & Foot:
- Assess for excessive plantarflexion related to hyperextension.
- Check foot posture: inversion, eversion, flat feet (pes planus), or high arch (pes cavus).
- Observe weight distribution and arch height.
9) Leg Length & Muscle Imbalances:
- Investigate discrepancies in leg length or pelvic level.
- Consider potential causes: anatomical (leg length) or functional (muscle imbalances, abductors)
Description of movement factors:
- standing
- supine
Evaluate how movement patterns reveal mobility, stability or compensations
Standing
1) Forward Bending:
Check for:
- Pain during movement.
- Changes in spinal curves (smooth vs segmental stiffness)
- Adequacy of hip flexion contribution vs. spinal motion.
- Distribution of forces through feet (equal or uneven weight-bearing)
2) Side Bending:
Assess:
- Pain or stiffness on one side compared to the other.
- Smoothness and symmetry of the movement.
- Avoidance of compensations like trunk rotation, lateral sway, or forward bending.
3) Rotation:
- Observe differences between right and left rotations.
- Evaluate:
▪ Pain during rotation.
▪ Relative contribution of hips vs. spine.
▪ Sequence of motion (whether hips or spine initiate/lead movement).
4) Hip Flexion:
Identify:
- Any asymmetry or difference in flexibility between sides.
- Pain or compensatory strategies like lumbar extension.
5) Arm Elevation:
Look for:
- Contribution of scapular muscles like serratus anterior.
- Compensatory thoracic extension or overuse of lumbar spine.
Supine
Specific to chronic postural dysfunctions (not acute issues), perform tests like the Modified Thomas Test
- Assesses hip flexor tightness (iliopsoas, rectus femoris)
- Note differences in hip extension or knee flexion between sides
