lower back assessment Flashcards
Objectives of physical examination
to find
- a mechanical basis for problem
- a comparable sign
- the structure at fault
- accurate/reproducible signs to allow monitoring of treatment response
- particularly to look at ways of off-loading painful structures / spinal segments
CAUTION++ IF PATIENT COMPLAINS OF
- difficulty passing bowels/urine (inability to know when to go
- urinary retention not just constipation due to pain on passing motion)
- saddle anaesthesia, A&E caution given
- muscle weakness in lower limbs
- specific dermatomal loss of sensation
- or bilateral pins needles and/or numbness
- severe night pain
- severe pain reproduced on cough/sneeze
STANDING
Observation from behind
6
- breathing pattern – diaphragmatic; lifting
- levels, lateral shift, scoliosis, Lx lordosis (pivot point), Tx kyphosis
- crease lines - areas of increased flexibility (extension, side flexion)
- lower limb rotation and foot posture
- muscle - activity of erector spinae &/or hamstrings; adductor muscle
- muscle - decreased gluteals; atrophy (wasting) e.g. OA hip = postero lateral aspect
Standing Observation from side
- breathing pattern – diaphragmatic; lifting
- muscle bulk – abdominals
- Lx lordosis, pelvic tilt, Tx kyphosis, Cx lordosis, knees locked & effect on spine, sway & effect on gluteals (see plumbline posture assessment)
Palpation- superficial
- temperature
- muscle - activity of erector spinae Lx & Tx, quadratus lumborum, latissumus dorsi, hamstrings
- lateral expansion lower & higher
Quick tests for other joints (hip, knee and ankle if needed)
- hip movement when taking trousers & socks off
- sitting hip flexion movement
Standing Neurological muscle tests
S1- standing test, unilateral toe raise x 5 each leg (hold patients hands)
- S1 – walking on tip toes
- L4 and L5 - Walking on heels
Active Lx movements (quantity & quality)
- instruct patient to move fingers down legs and record P and R as appropriate
- lateral side flexion – pivot points, spinal curve
- flexion – catching pains, return to neutral
- extension – pivot points
10
Dynamic posture
· walking
- lack of Tx rotation
. - lack of arm swing
. - pelvis shifting laterally on weight bearing each leg (possible gluteal weakness)
. - shoulder level on weight bearing each leg (possible gluteal weakness
. - palpate gluteal muscles on weight bearing leg
. - decrease contraction in compared to other side
. - decrease holding time in compared to other side
. - hip movements – decreased extension, quads tight, effect on pelvis & Lx
. - knee snapping into extension
. - heel toe gait, heavy landing, heel control
dynamic posture· standing 1 leg
- leaning
- pelvis shifting
- gluteals
- hand on side of pelvis & repeat
dynamic posture · ¼ squat
- picking up, front-on?, lx v’s hips & knees in both flexion & extension
- at sink, lx v’s hips & knees in both flexion & extension
· sitting
observation
- slump, neutral or extended – sitting bones / ischial tuberosities
- lateral expansion lower & upper
- Tx rotation, side flexion
Passive accessory intervertebral movements (PAIVMs)
- shapes & sizes of spinous processes
- transverse pressures
Palpation soft tissues & ribs
- activity of erector spinae mid-thoracic to lumbar, quadratus lumborum, latissumus dorsi, upper buttocks, lateral buttocks, ITB
- rib movement
- intercostal movement
Muscle length tests / Neuromuscular sensitivity test
· iliopsoas / femoral nerve stretch (FNS)
Neurological examination
- muscle tests
- sensation - light touch / sharp to upper leg and lower leg (circular checks), feet
- cord signs – Babinski, Hoffmann’s and clonus tests
Quick tests for other joints
- hip quadrant, knee, ankle as appropriate
- SI joint compression and distraction via iliac crests
- SI joint - hip flexion, palpate SI joint while compressing through the femur
Neuromuscular sensitivity tests
SLR
Passive accessory intervertebral movements (PAIVMs)
- uni-lateral postero-anterior pressures on tissue over articular pillar
- central postero-anterior pressures on spinous processes
- transverse pressures on spinous processes
DIFFERENTIAL DIAGNOSIS
- fracture if traumatic injury
- referred pain from abdomen
- secondary to cancer eg. prostate, testicular, pelvis region, lung,
- aortic aneurysm
Neural test myotome
one leg heel raise (repeat x 5) standing
S1,S2 (gastroc, soleus)
Neural test myotome
hip flexion at 90°
-
L1,L2,L3
(psoas L1,2,3; iliacus L2,3)
supine
Neural test myotome
knee extension
- L2,3,4 (quadriceps)
supine
Neural test myotome
knee flexion with knee flexed to 90°
*** L5,S1 **
* (hamstring med more L5; lat more S1)
supine
Neural test myotome
dorsiflexion & inversion (feet up & in)
**L4,L5 **(tibialis anterior)
supine
Neural test myotome
extension of big toe
L5 (ext hallucis longus)
supine
Neural test myotome
eversion
L5,S1 (peroneus longus)
supine
Neural test myotome
curl toes around therapist’s finger
**S2,S3 **(flex digitorum; flex hallucis longus)
supine
Neural test myotome
hip abduction
L5,S1 (gluteus medius)
supine/side
Reflex Neural test
(gluteus medius)
Test-tap hammer over therapist’s hand/thumb
* on muscle
* L5,S1
* side lying
Reflex Neural test
(adductor longus)
Test-tap hammer over therapist’s hand/thumb
* L2,3,4
* side lying
* on musculotendon junction
Reflex Neural test
(biceps femoris)
Test-tap hammer over therapist’s hand/thumb
- L5,S1
- side lying
- on musculotendon junction
Reflex Neural test
(knee jerk)
Test-tap hammer over therapist’s hand/thumb
- side lying
- on patella tendon
* L2,3,4
Reflex Neural test
(ankle jerk)
Test-tap hammer over therapist’s hand/thumb
- side lying
- on Achilles tendon
- S1,S2
reflex grading
· increased - hypereflexia (UMN)
· brisk - normal
· poor - hyporeflexia (LMN)
· nil - areflexia
Cord signs test
babinski
run blunt object on plantar aspect of foot from heel along lateral border of foot across MTP heads to head of 1st MT.
* Great toe ext & splaying of toes = +ve response.
* Great toe flex = -ve response
Cord signs test
clonus
quick repeated passive ankle dorsiflexion.
* Repetitive tremor = +ve response
Cord signs test
Hoffman’s
Flick middle finger distal phalanx into flexion.
* Index finger & thumb start to move together = +ve response
Tests for sensation
- light touch - use cotton wool
- sharp - use sterile needle/pin wheel in case break skin
- Perform each of the above on the low back, legs (circular checks) and feet
Areas of altered sensation are related to dermatomal spinal origin (nerve root or sleeve) or to peripheral sensory nerve
Test and then map any area of altered sensation by moving from area of altered sensation to areas of normal sensitivity
sensory assessment findings
· increased - hyperalgesia
· dulled - hypoalgesia
· nil - analgesia
· altered - dysaesthesia
vascular changes observation
colour
* white/blanched - arterial
* cyanosed/bluish - venous
.
* engorgement of superficial veins of limb - venous
* slow response to nail pressure - arterial
* deep vein thrombosis - pain, tenderness, hot, red, pain on stretch, pain weight bearing
find the L5 spinous process
- slide up off the sacrum until a spinous process is located deep at the centre of the lumbosacral depression
- to reconfirm that this is the L5 spinous process find the PSIS and draw an imaginary line at a 300 angle (from the horizontal) and the same spinous process should be located
Feeling of spinous processes
- L5
- L4-1
- L3
- T12
- the apex of the spinous process of L5 is small and rounded
- L4 to L1 are quadrilateral
- with L3 being the longest
- T12 is rounded
Aim of PPIVMs and PAIVMs
- assess the physiological and accessory glide movements of each spinal segmental level in an attempt to diagnose the segmental origin of the patient’s complaint.
The criteria for segmental diagnosis
is the detection of abnormal quality of intervertebral movement, associated with the perceived presence of through range and end range alterations in tissue resistance (such as that provided by muscle spasm / guarding) and the reporting of pain provocation during the process of manual examination.
difference in tissue resistance feeling
Older changes in tissue resistance may feel thicker, whereas more recent changes may feel softer
accessory glides on acute injury segment may cause
In acute injury segmental muscle spasm may be provoked during gentle accessory glides.
Hypermobile accessory
Hypermobile or unstable joints may feel “boggy”, with a noticeable increase in accessory movement unless prevented by alterations in tissue resistance such as muscle spasm / guarding.
pain reproduction - manual therapy
The pain reproduced may be local to the area where the technique is being performed or pain could be referred to an area where the patient is complaining of symptoms eg. in the buttocks/legs.
Reproduction of the exact symptomatic complaint of the patient assists greatly in deciding the segmental origin of a patient’s complaint.
