lectre 2b: lumbar spine examination and evaluation Flashcards by sophia carrasco

• L-spine physical exam MUST include thorough assessment of NMSK and vascular structures at what 4 regions

• Lumbar spine
• Pelvic region
• Hip region
• Lower extremities

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if the patient has a deep ache and boring pain what is the origin

bony tissues

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if the patient has a dull , achy , sore , burning and cramping pain what is the origin

muscle/fascia

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if the patient has a sharp , life liking shooting , lancinaitng , tingling, burning , numbness and weakness pain what is the origin

nerve

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if the patient has a burning ,stabbing , throbbing , tingling and cold pain what is the origin

vascular

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if the patient has a deep pain , cramping and stabbing pain what is the origin

visceral

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if someone comes in with back pain and they are in their 10-20’s what is a common diagnoses

Spondylolisthesis

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if someone comes in with back pain and they are .> 65 y/o what is a common diagnoses

cancer , compression fx, stenosis or AAA

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if someone comes in with back pain and they are in their 15-40’s what is a common diagnoses

disc hernimation/ dysfunction

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if someone comes in with back pain and they are > 45 y/o what is a common diagnoses

OA/ spondylosis

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if a patient comes in w back pain adn they are over 50 years old , has a hx of cancer , has unexplained weight loss and has had failure of conservative therapy what condition do we suspect?n

back related tumor

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if a patient comes in w back pain and has had a recent infection , is an intravenous drug user and has a concurrent immunosuppressive disorder what condition can we suspect

bac related infection (spinal osteomyelitis)

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if a patient comes in w back pain and they tell us they have urine rention or incontinence , fecal incontinence , saddle anesthesia , global or progresssive weakness in the LE and sensory deficits in the feet… what condition do we suspect?n

cauda equina syndrome

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if a patient comes in w back pain and has had a hx of trauma and is between 50-70 y/o what condition do we suspect?n

fracture

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what are a structure based (Cyriax) evaluation and interventions

-selective tissue tension test
-intervention based on treating pathologic strucutre

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what is the treatment based (McKenzie and Maitland) intervention based solely on

response to tissue loading and symptom response

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what is the ultimate goal for evaluation and intervention

self management by the pt

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what syndrome is typically a dx of exclusion

piriformis syndrome

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if a pt presents w

• Hx of trauma to SIJ and gluteal regions
• Pain around SIJ/piriformis mm
• Symptoms worsened w/ stooping or lifting
• Palpable tension (i.e. rope-like) in piriformis mm belly
• (+) SLR test
• Gluteal atrophy (depending on length of symptoms)

what can we suspect

piriformis syndrome

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if a patient has piriformis syndrome what makes the symptoms worse , and is the SLR postivie or negative and what does it feel like if u palpate it

symptoms worsens w stooping or lifting and SLR is positive

feels rope like

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what is spondylolysis and is it symptomatic or asymptomatic

defects in the pars interarticularis , often asymptomatic

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where does spondylolysis typically occur

L5 but can happen anywhere

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what position does patients prefer if they have spondylolysis

flexion (walking can make it painful)

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what is the tx for spondylolysis

conservative management first then sx if that has failed

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what is spondylolisthesis

when there is a fx in the pars interarticularis w an anterior slippage of the body

what is the grading system used for in spondylolisthesis

measure degress of anterior slippage for lateral view

what is the tx for spondylolisthesis

surgical intervention only indicated when • Conservative management has failed • NeuroS&Sprogressing

pertaining to the spine what is the order of susceptibility to compression injury

1. End-plate 2. Vertebral body 3. Disc

explain the process of disc herniation (11)

1. End-plate fx d/t excessive compression 2. Lesion heals OR disc DEGRADATION 3. Exposes NP to blood supply 4. Inflammatory response 5. NP progressively loses H2O and disc height 6. ↓ ability to resist loads 7. ↑ load to AF (load on outer AF may be painful) 8. Osteophyte formation on VB 9. ↑ load on facet joints and more osteophyte formation 10. Radial fissure in AF 11. Internal disc disruption

what is it called if a disc bulges w/o AF rupture

protrusion

what disc pathology is it when only the outer layers of the annulus fibrosis go out and NP is contained

prolapse

what disc pathology is it when AF perforated and disc material moves into epidural space

extrusion

what disc pathology is it when disc fragments from AF and NP disconnect

sequestattration

what is the clinical presentation of a **end plat fx**

- trauma or specific MOI - acute pain - (-) SLR -(+) compression test

• Trauma or specific MOI • Acute pain/spasm • (-) SLR • (+) compression test what disc pathology is this the clinical presentation for

end plate fx

what disc path is this a clinical presentation for • Separation of inner layers • LBP and/or referred hip/upper leg pain • (-) SLR • Dx made: discogram

internal disc disruption

what disc path is this a clinical presentation for • Some AF and PLL are intact • LBP and/or referred hip/upper leg pain • Pain w/ cough and sneeze • (-) SLR

disc protrusion and prolapse (contained)

what disc path is this a clinical presentation for • LBP • Pain w/ cough and sneeze • True sciatica (radicular pain) • (+) SLR

disc extrusion and sequestration (uncontained)

what is the main clinical presentation difference for disc protrusion and prolapse (contained and uncontained)

for uncontained the SLR test is positive and for contained it is negative for uncontained the patient has true sciatica bc disc is in epidural space now

what nerve would be compressed at L3-L4 nerve toor and wha this the motor deficit and sensory deficit

nerve root: L4 motor: quads sensory: anterolaterla thigh

what nerve would be compressed at L4-L5 nerve root and wha this the motor deficit and sensory deficit

ROOT: L5 motor: extensor hallucis longus snensory: lateral thigh

what nerve would be compressed at L5-S1 nerve root and wha this the motor deficit and sensory deficit

root: S1 motor: ankle PF sensory: posterior leg

what is the difference between nerve root compression and nerve root entrapment

entrapment is still compression but more bc of structural reasoning

what is spinal stenosis

narrowing of spinal canal causes nerve to pinch

what are the S&S of **spinal stenosis**

persistence buttocks pain, limping , lack of sensation in LE and decrease walking/stnading ability

what is **central stenosis** and what may it elicit

mid line sagittal spinal canal diameter decreases elicit neuro claudication or pain in butt , thigh or leg

what is **lateral stenosis** and what may it impinge

narroweing between superior facet and posteior vertebral margin may impinge nerve root and causes radicular pain

what is the main difference between central and laterla stenosis

lateral has more radicular pain

• Centralcanal • Peripheralcanal • Degenerative spondylolisthesis these are examples of what kind of spinal stenosis

acquired degenerative

what dysfucntion has **hypo mobility** at 1 or both facet joints at a lumbar segment and can have pain and potential restriction w specific lumbar AROM directions

z-joint (facet) dysfunction

what kind of pain is more common with z joint (facet) dysfunction

localized pain

what is the tx for **z joint (facet) dysfunction**

manual therapy techniques> mobility ex’s > strengthening ex’s ## Footnote bc it is hypomoble so u start w manual

is hypo or hyper mobility most likely to cause symptoms at the facet joints

hypo

what is the **hallmark** for any joint if they have **instability**

inconsistent symptomology

what test is positive with clinical lumbar spine instability

prone instability test

* Loss of normal passive restraints to motion * Loss of active NM control * Reports of recurrent back pain that‘ **catches**’ or ‘**locks**’ * Inconsistent symptomology * Structural instability: **(+)prone instability test** if a patient has this what condition is it

clinical lumbar spine instability

what does **Ankylosing Spondylitis** affect first

the spine and progresses to fusion of invovled joints

* Chronic inflammatory disease of **unknown origin** * **1st affects spine** & progresses to fusion of involved joints * **Males**, <30 y/o * Typically follows a 20-yr course * 90-95% of pts w/ AS have human leukocyte antigen B27 * “**Bamboo-spine**” in radiography what condition does this patient have

Ankylosing Spondylitis

what condition has a “bamboo spine” in radiography

Ankylosing Spondylitis

• Chronic condition • Causes pain, stiffness & tenderness of muscles, tendons & joints • Characterized by: • Pain (100%) • Restless sleep • Wake up feeling tired • Fatigue (90%) • Emotional disturbances (>50%) • Disturbances in bowel function • 1o women (80%) ages 35-55 y/o what condtion is this

fibromyalgia

is a patient is >60 has bilateral leg pina that is insidious and is increased q stnading and decreased with sitting and bending and has a positive SLR what condition is it

spinal stenosis

what positions make the pain worse and better for **spondylolisthesis**

standing anf bending make it better sitting makes it worse

what positions make the pain worse and better for **scoliosis**

stnading and bending make it better sitting makes it worse

what positions make the pain worse and better for **herniated nucleus pulposus**

standing makes it worse sitting and bending make it better positive SLR

• Impairments: • Segmental or global hypomobility • Pain in back, buttock, groin or thigh • Impaired functional movements (i.e. squatting, lifting) • (-) neuro tests • Onset of symptoms <3 months what ICF categories from low back pain does this fit into

Acute or Sub-acute LBP w/ Mobility Deficits

* Impairments: * Segmental or global instabilities * Pain in back, buttock, groin or thigh * Worsens w/ end range movements * ↓ NM control of voluntary movements * Muscle weakness * Fatigueable * Non-fatigueable * ↓ activity tolerance (i.e. sitting, standing, running) * Impaired functional movements (i.e. squatting, lifting) * (+) prone segmental instability test what ICF category does this fit into for LBP

Acute, Sub-acute or Chronic LBP w/ Movement Coordination Impairments

• Impairments: • Segmental or global hypomobility • Significant pain in back, buttock, groin or thigh or instabilities • Postural deficits • ↓ activity tolerance (i.e. sitting, standing, running) • Impaired functional movements (i.e. squatting, lifting) • Onset of symptoms <3 days • (+) repeated movements tests what ICF category does this fit into for LBP

Acute LBP w/ Related (Referred) LE Pain

• Impairments: • Segmentalorglobalhypomobilityor instabilities • Radiating pain(often times below the knee) in a dermatomal pattern • Muscle weakness • Fatigueable • Non-fatigueable • ↓activity tolerance(i.e.sitting, standing, driving, running) • Impaired functional movements(i.e. squatting, lifting) • (+)neuro exam • (+)neuro dynamictests • (+)repeated movements tests what ICF caterogy does this fit into for LBP

Acute, Sub-acute or Chronic LBP w/ Radiating Pain

• Impairments: • Sensitivity to noxious stimuli • Displays range of emotions • Pain in back,buttock,groin or thigh,lower leg • Tendency to elaborate physical symptoms for emotional/affective reasons • High scores on FABQ and Pain Catastrophizing Scale • Impaired ADLs • ↓activity tolerance(i.e.sitting,standing, • Impaired functional movements(i.e. squatting, lifting) • Inconsistent MSK exam results • Onset of symptoms <3months • (+)Waddell’s test what ICF caterogy does this fit into for LBP

Acute or Sub-acute LBP w/ Related Cognitive or Affective Tendencies

• Impairments: • Generalizedpain(presentinback,other body structures or globally) • Inconsistentw/MSKdysfunction • Appropriatenessofemotion • △’sinbrainandsensorystructures • HighscoresonFABQandPain Catastrophizing Scale • ImpairedADLs • ↓activitytolerance(i.e.sitting, standing, running) • Impairedfunctionalmovements(i.e. squatting, lifting) • InconsistentMSKexamresults • Onsetofsymptoms>3months what ICF category does this go into for LBP

Chronic LBP w/ Related Generalized Pain

what are the treatment based categories for LBP

-manipulation/ manual therapy - stabilization exercises -direction specific exercises - traction

TBC: **manual therapy** classification criteria Anatomic location of sx: Duration of current episode of pain: Score on FABQ – work subscale: Results of segmental mobility testing in PA direction: Hip internal rotation ROM:

No sx distal to knee Less than 16 days Score of less than 19 At least 1 hypomobile segment in L- spine At least 1 hip w/ >35° of internal rotation

TBC for LBP: **stabilization** classification criteria Younger age: Greater general flexibility: Aberrant movements in lumbar spine: Lumbar instability: Patients who are post-partum:

Less than 40 years Post-partum, average SLR >91° Visible ‘instability catch’ or aberrant movements during lumbar flexion/extension ROM (+) prone instability test (+) posterior pelvic pain provocation, ASLR, modified Trendelenburg tests OR Pain w/ palpation of long dorsal SI ligament or pubic symphysis

Direction-Specific Exercise Classification for extension

• Sx centralize w/ lumbar extension • Sx peripheralize w/ lumbar flexion

Direction-Specific Exercise Classification from flexion

• Sx centralize w/ lumbar flexion • Sx peripheralize w/ lumbar extension

TBC for LBP: Direction-Specific (Extension): Classification Criteria Anatomic location of sx Sx response to lumbar ROM Sx response to lumbar ROM Subjective response to movement

Sx distal to buttock Symptoms centralize w/ lumbar ext Symptoms peripheralize w/ lumbar flex Directional preference for extension

TBC for LBP: Direction-Specific (Flexion): Classification Criteria Older age Subjective response to movement Imaging evidence

Greater than 50 years Directional preference for flexion Lumbar spinal stenosis

TBC for LBP: Direction-Specific (Lateral Shift): Classification Criteria Observation Subjective response to movement

Visible frontal plane shift of shoulders relative to pelvis Directional preference for lateral translation movements of pelvis

TBC for LBP: Traction: Classification Criteria Sx response to lumbar traction

Symptoms decrease w/ manual or autotraction

if your patient demonstrates (+) CPR for manual therapy what is the recommended interventions

• Lumbopelvic HVLAT • Lumbar and LE ROM exercises

If your patient demo (+) CPR (clinical practice rule) for stabilization what is the recommended interventions

• Promote isolated contraction and co-contraction of deep stabilizers (multifidi, TA) • Strengthen large spinal stabilizers (ES, internal/external obliques

if a pateitns fits >1 classification group u prioritize order of treatment based on what 3 things

• Level of risk • Psychosocial factors • Co-morbidities

Presence of psychosocial factors and co-morbidities ____ a treatment effect

weaken

what TBC category would u use if the ICF caterogry was acute or sub acute LBP w/ mobility deficits

Manipulation/Manual Therapy:

what TBC category would u use if the ICF caterogry was Acute, sub-acute or chronic LBP w/ movement coordination impairments

stabilization exercises

what TBC category would u use if the ICF caterogry was • Acute, sub-acute or chronic LBP w RADIATING pain and Acute LBP w/ related (referred) LE pain

direction specifici exercises

what 2 ICF categories for LBP do NOT fit not TBC category

• Acute or sub-acute LBP w/ related cognitive or affective tendencies • Chronic LBP w/ related generalized pain

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lectre 2b: lumbar spine examination and evaluation Flashcards

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