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MSPT II > LS Anatomy, Exam, Subgrouping > Flashcards

LS Anatomy, Exam, Subgrouping Flashcards

1
Q

Some LBP stats….

A

50-75% exp @ one pt in life

40% LBP in any one year

15-20% current LBP

LBP is presenting reason for 50% pts seeking care in OP PT

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2
Q

LBP choice of Tx

A

reflects skill of professional rather than needs of pt

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3
Q

GO BACK TO ANATOMY REVIEW

A

SLIDES 4-26

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4
Q

LS exam sequence…

A

Always take thorough Hx

Always have pt complete SRO

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5
Q

When it comes to LBP

DO LESS in….

A

LESS in pts w/ high irritability/acute injury

*avoid irritating pt OR worsening pathology

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6
Q

When it comes to LBP…

DO MORE OR ALL in…

A

MORE OR ALL in..

Less irritable/subacute/chronic pts

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7
Q

when it comes to LBP

Do “Enough”

A

to make sound tx decisions and classify pt into subgroup

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8
Q

LB pain

As pts are improving….

A

DO:

high lvl functional testing– sport, work

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9
Q

GOAL of LBP Exam:

A

Be able to “classify” pt into subgroup

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10
Q

LBP Exam Sequence

A

see pics

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11
Q

LBP Exam:

General questions

A
  1. onset/MOI?
  2. onset/when? since onset are sx’s same, better, worse?
  3. Where is your pain? Pain or radation of sx’s down leg? where?
    1. Peripheralization vs. centralization
  4. numbness, tingling leg, foot, toes? where?
  5. weakness? clumsiness in legs?
  6. past episodes or similar probs in past?
  7. 0-10 pain rating–now? worst? avg over past week?
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12
Q

LBP Exam

Gen Questions cont’d…

A
  1. constant or intermittent? on and off?
  2. makes it better?
  3. makes it worse?
  4. pain @ night? –discs hydrate (swell) @ night
  5. B&B problems? Saddle or pelvic floor parasthesia or numbness?—-RED FLAGS!! –Cauda Equina Syndrome
  6. Is pain worse w/ cough or sneeze?
  7. what acts are difficult? problems w/ functionally?
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13
Q

LBP Exam:

Gen Questions cont’d…

A
  1. better or worse w/ sitting? standing? walking?
  2. working now? what do you need to get back to?
  3. prior exercises/fitness/PLOA
  4. Any tx so far?
  5. any meds?
  6. any dx studies? imaging?
  7. What are your goals??? *****
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14
Q

Fear Avoidance Behavior Questionnaire

FABQ

covers psychosocial aspects

A
  • Score range Phys Act: 0-24
  • Score range Work: 0-42
  • Best Possible Score: NO FEAR:0
  • Worst Possible Score: HIGH amts
    • Phys Act: 24
    • Work: 42

Best==Low score

Worst==High score

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15
Q

LS Observation/Inspection

A
  • Posture
    • sitting
    • standing
      • ant
      • post
      • lateral
  • Antalgic gait? AD? Footwear?
  • scoliosis or lateral shift?
  • Observed leg length
    • LOOK @:
      • medial malleoli
      • popliteal creases
      • glute folds
      • greater trochs
      • PSIS
      • ASIS
      • illiac crests
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16
Q

LQS

DTRS

A

L3, 4==patellar tendon

S1,2==achilles

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17
Q

LQS

Abnormal reflexes

A

Babinski==UMN

Clonus==UMN

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18
Q

LQS

Myotomes

A
  • L1,2,3– hip flexion
  • L3,4– knee extension
  • L4,5– ankle DF (heel-walking)
  • L5–hallux EXT (EHL)
  • L5,S1– knee flex
  • S1, S2– PF (walk on MET heads)
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19
Q

LQS

Dermatomes

B/L light touch; pt eyes CLOSED

“tell me where you feel it”

“is it the same on left vs right”

“how is it different”

A
  • L1–prox medial thigh (groin)
  • L2–prox ant thigh
  • L3–dist anteromedial thigh + knee
  • L4–anteromedial leg and med border foot
  • L5–D1/D2 webspace, anterolateral leg, dorsal foot
  • S1– lateral dorsal foot, post thigh + calf (more lateral)
  • L5 and S1–plantar surface of foot
  • S2– post thigh + calf (more medial)
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20
Q

NOTE: Dermatomes

A

Dermatomes overlap

This is why radiculopathies typ may cause PARTIAL numbness or parasthesias, but unlikely to result in complete anasthesia

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21
Q

Peripheral Joint Screening:

Look for sx repro/aggravtion and/or limtd or abnormal motion

What does this entail?

A
  • quick gait assess.
    • hip, knee, ankle, foot, toes
  • quick observation/inspection
    • hip, thigh, knee, lower leg, ankle, foot, toes
  • HIP
    • deep squat
    • FABER —static, let sit
  • KNEE
    • deep squat
    • ROM
  • ANKLE/FOOT
    • deep squat
    • active sup/pro (open chain)
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22
Q

AROM: Single Rep Motions

Flex

EXT

LF

Rot

A

% of Normal

If NO PAIN @ rest: “let me know if this brings on or provokes pain”

If PAIN @ rest: “let me know if this mvmt worsens, relieves, or has no effect on you pain”

*if worsens or relieves, ask about centralization/peripheralization*

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23
Q

Single rep AROM testing sequence:

A

Standing FLEX

Standing EXT

LF R/L

Rotation (stabilize pelvis w/ hands)

NOTE:

  • pts willingness to move/face/non-verbals
  • pain? where? referral/radiation?
  • if pain–painful arc or @ end range?
  • “instability jog—sudden mvmt shift
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24
Q

AROM: Repeated Motions

aka Directional Preference

Why???

A
  • baseline sx’s before beginning
  • 10-15 reps to tolerable end ROM
  • see if same, better, worse from baseline
  • Centralization or peripheralization?
    • if NO–> move to next movement on list
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25
Q

AROM: Repeated Motions

Order of Testing

A
  • Repeated FLEX in standing (RFIS)
  • Repeated EXT in standing (REIS)
  • Repeated FLEX in lying (RFIL)
  • Repeated EXT in lying (REIL)
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26
Q

What should you remember in terms of Repeated Motions Outside Sagittal Plane

A

the Shift is named in terms of Shoulder Direction

which way are the shoulders leaning?

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27
Q

Repeated Motions Outside of Sagittal Plane

*may be dealing w/ relevant lateral component to derangment

ex. disc (NP) protrudes more laterally

Do Rep’d motions outside of sagittal plane

ORDER OF TESTING:

A
  • Repeated EXT w/ hips offset contralateral to sx’s
  • Repeated EXT w/ hips offset ipsilateral to sx’s
  • Flexion Rotation
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28
Q

RROM

isometric tests in neutral sitting:

A

Strong and painfree?

Strong and painful?

Weak and painful?

Weak and painless?

*Defined on another card

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29
Q

Strong and Painless

A

No lesion or neuro deficit involved in mm or tendon

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30
Q

Strong and Painful

A

Minor lesion of the tested muscle or tendon

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31
Q

Weak and Painless

A

Disorder of the NS, NMSK junction, complete rupture of the mm or tendon, disuse atrophy

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32
Q

Weak and Painful

A

Serious, painful pathology such as fx or neoplasm

OTHERS: acute inflammatory process that inhibits mm contraction, exercise induced mm damage, partial rupture of mm or tendon

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33
Q

Special Tests:

SLR

A

see pics

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34
Q

+ Brudzinski’s

A

Cervical flexion INC pain

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35
Q

+Brogards

A

DF foot INC pain

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36
Q

Special Tests:

Sign of the Buttock Test

A

see pics

37
Q

Special Tests:

Slump Test

*indicates nerve root involvement*

*biases pons, cord, meninges, sciatic tract

A

see pics

38
Q

Special Tests: Prone Knee Bending Test

*biases femoral tracts, mid and upper lumbar roots, meninges, cord

A

see pics

39
Q

Special Tests:

Quadrant Test

A

see pics

40
Q

Manual Traction Tests

Positions

A

Prone—flat

Supine—knees bent, hips in slight flexion

41
Q

2 Special Tests for Instability

Standard Tests:

A
  1. Prone Instability Test (legs off table one)
  2. Passive Lumbar Instability Test (PASSIVELY check instability)
42
Q

Special Tests for Instability

Prone Instability Test

A

see pics

43
Q

Special Tests for Instability

Passive Lumbar Instability Test

A

see pics

44
Q

Specialized Group of Instability Tests

Post-partum women w/ pelvic girdle pain

5 tests

A
  1. P4 Test (Posterior Pelvic Pain Provocation
  2. +Active SLR (ASLR) test
  3. Provocation of Long Dorsal SI Ligament
    1. pain must last longer than 5s AFTER palpation
  4. Provocation of pubic symphysis w/ palpation
    1. pain must last longer than 5s AFTER palp
  5. Modified Trendelenburg test
    1. standing on 1 leg, if they lean hips TOWARD pain side === + test

*Criteria to define this sub-group==positive composite of tests

45
Q

Specialized Group

Post-partum women w/ pelvic girdle pain

P4 Test

A

see pics

46
Q

Specialized Group

Post-partum women w/ pelvic girdle pain

ASLR Test

*have them just lift leg and try to get to your hands

A

see pics

47
Q

Specialized Group

Post-partum women w/ pelvic girdle pain

Provocation of Long Dorsal SI Ligament

Provocation of Pubic Symphysis w/ Palpation

A

see pics

BOTH BELOW

*NOTE: just remember pain sx’s must last longer than 5s AFTER palpation

48
Q

Specialized Group

Post-partum women w/ pelvic girdle pain

Modified Trendelenburg Test

A

see pics

49
Q

Special Tests for the SIJ:

which is the most USEFUL type of test?

A

PROVOCATION TESTS

*Highest reliability and validity

50
Q

Of all studied, 4 tests contributed to making the dx of SIJ pain and dysfunction

What are they?

A
  1. SI Distraction
  2. Thigh Thrust
  3. SI Compression
  4. Sacral Thrust

*NOTE: Robinson et al. found that reliability of PAIN PROVOCATION was GOOD while reliability of palpation tests was POOR

51
Q

SIJ dysfunction Tests

SI Distraction

A

see pics

52
Q

SIJ Dysfunction Tests

Thigh Thrust

*hand under buttcheek (middle of sacrum) one

A

see pics

53
Q

SIJ Dysfunction Tests

SI Compression

A

see pics

54
Q

SIJ Dysfunction Tests

Sacral Thrust

A

see pics

55
Q

HOOVER TEST

tests for suspicion of…

A

malingering

56
Q

Hoover Test

For malingering

The one where you hold under calcaneus and when they lift one leg up, the other foot should push DOWN on your hand!!

A

see pics

57
Q

Accessory Motion Testing

2 of them:

A
  • PIVM (Passive Intervertebral Motion)
    • ​Flexion in sidelying
      • ​bring their knees off table
  • PAIVM (Passive Accessory Intervertebral Motion)
    • ​P-A central vertebral pressure
      • ​push directly on SP
    • PA U/L vertebral pressure
      • ​pressing on R/L TP

*Pushing on R. TP induces what motion–> L. ROTATION!!

58
Q

FUNCTIONAL TESTS

A

Basic ADLs

Work-related

Sports-Performance

59
Q

LB Exam

Important landmarks/structures to PALPATE

A
  • L1-S2 (use landmarks!!)
    • L1– after 12th rib
    • L5–iliac crests
    • S1– PSIS
  • Iliac crests
  • PSIS
  • ASIS
  • Erector Spinae–I Love Soup
    • Iliocostalis–most lateral
    • Longissimus
    • Spinalis–most medial
60
Q

AFTER basic LS exam:

What is BEST to do?

A

Based on exam findings, classify pt into a tx group–> match tx to subgroup characteristics/predictors

61
Q

Sub-Groups of pts w/ LBP

What was the Traditional Medical Model?

A
  • Indiv’s based on pathoanatomical dx and source of sxs
  • relevant pathology ID’d in LESS THAN 10% of cases
  • *matched tx to clusters of s/s
62
Q

Sub-Groups of pts w/ LBP

NOW

Guide to PT Practice (2001) recommend…

A
  • Classify pts based on S/S….NOT presumed pathoanatomical causes
  • Sub-group pts to ultimately direct tx decisions
63
Q

Who proposed a classification structure for pts w/ LBP

A

Delitto et. al 1995

*research supports this process as resulting in better outcomes in PT tx

64
Q

These are the original tx-based classifications as proposed by Delitto

*NOTE: intended for pts w/ acute or subacute exacerbation of LBP

What are the 4 classifications???

A
  1. Specific Exercise AKA Directional Preference
    1. ​Flex
    2. EXT
    3. Lateral shift patterns
  2. Stabilization
  3. Manipulation
  4. Traction
65
Q

Evidence-Based Exam/Intervention Strategies for Pts w/ LBP

revised by Alrwaily 2016

3 big topics w/ subtopics

A
  1. Symptom Modification
    1. ​directional preference
    2. manipulation/mobilization
    3. traction
    4. active rest
  2. Mvmt Control
    1. ​sensorimotor
    2. stabilization and flexibility ex’s
  3. Functional Optimization
    1. ​work/sport specific
    2. strength, conditioning, aerobic and gen. fitness ex’s
66
Q

4 Subgroups of Tx-Based Classification

WE LEARNED:

A
  1. Manipulation
  2. Specific Exercise AKA Directional Preference/Rep’d Motions
  3. Instability
  4. SI-Provocative
67
Q
  1. Specific Exercise (Directional Preference) Sub-group

*popularized by Robin McKenzie 1989

Explain…

A
  • Pts classified based on response to repeated mvmts
  • Focuses on centralization/peripheralization

See Pics

68
Q

Traditional hallmark findings for specific exercise classification

AKA directional preference

4:

A
  1. Dec or abolish pain/parasthesia
  2. Centralization
  3. Centralization MAY cause symptoms proximal to intensify
  4. INCd ROM
69
Q

Directional Preference

DEFINED

(Kilpkowski, 2002)

A
  • Mvmt in one direction IMPROVES pain and ROM
  • Mvmt in the opposite direction will cause s/s to WORSEN
70
Q

Directional Preference and pts exhibiting centralization

2 things to remember about pts w/ directional preference

A
    1. Pts exhibiting centralization will also demonstrate a directional preference

BUT…

    1. Pts w/ a directional preference DO NOT ALL demonstrate centralization
71
Q

*Strong correlation exists b/w centralization and disc pathology seen via positive discography

See Study:

A
  • Laslett et al. 2005: Centralization as predictive of disc pathology
    • _​_Sn: True Positive (SnNOUT)= 37%-40%
      • this means observation of centralization picks up disc pathology <50% of time—-LOTS of pts w/ disc patho. that do NOT centralize
    • ​SP: True Negative (SpPIN)=94%-100%
      • this means pts that DO centralize most likely HAS disc pathology

*Donaldson et al. –> Centralization was more accurate than MRI in detecting symptomatic discs when using discography as reference standard

72
Q

TREAT THE PATIENT, NOT THE IMAGES!!!!!!!

A

!!!!!!!!!!

73
Q

FLEXION SPECIFIC Exercise Classification

Key things to remember

A
  • MOST COMMON in older pts
    • ​*anterior derangement is the exception!
  • Correlates w/ medical dx of Spinal Stenosis

Whitman et. al 2006

  • Subjects >50yo w/ directional preference for FLEX
    • Group A did better:
      • mob/manip of spine and/or LE
      • ex’s to address impairs of strenght and/or flexibility
      • BW-supported TM walking
  • WHY?
    • Multimodal intervention protocol precludes conclusions on any indiv procedure
    • results suggest that interventions for older pts w/ FLEX-specific class. should include several components OTHER THAN just flex-oriented ex’s
74
Q

Examination of Pts w/ Directional Preference

Things to include…

A
  • Look @ Lateral Shift
    • when relevant?
    • most of time its AWAY from sx’s, contralateral shift, shoulders go OPP to pain
  • Hx
    • standing?
    • sitting?
    • walking?
  • Diff standing erect after sitting?
  • Loss of lumbar lordosis
  • Key elements of basic LS exam critical in determining inf pt has directional preference?
    • ​REPEATED MOTIONS!!!
75
Q

Force Progression Concepts for Pts w/ Directional Preference

What is the progression you learned in Lab for these Ex’s?

A
  1. Pt. generated movement
  2. Pt. overpressure using EXHALE
  3. Clinical overpressure
    1. PT pushes on LS as pt goes into motion (follow them)
  4. Manipulation/Mobilization
76
Q

Force Progression Concepts for Pts w/ Directional Preference

Basic concept of McKenzie based tx

2 things to remember:

A
  1. Starts w/ pt generated forces, progressing to therapist generated as needed
  2. MAY include changing plane of motion
    1. ​FROM sagittal TO coronal (frontal)

ADVANTAGES

  • gives clinician a formula for eval’ing and treating spine
  • encourages pt self-tx
  • empowers pts to treat their own condition
77
Q

Force Progression** **Concepts for Pts w/ Directional Preference

List the order of progression again

A

Pt gen’d forces

Pt overpressure (use exhale)

Clinician overpressure (mob as they move)

Clinician mobilization (P-A)

Clinical manipulation

78
Q

Force Progression Concepts for Pts w/ Directional Preference

More details…

A
  • Pt enters @ stage that produces improvement
  • ONLY progress when NO improvement OR stasis point
  • Ultimately move toward patient independence
79
Q

Force Progression Concepts for Pts w/ Directional Preference

Traffic Light Analogy

A

SEE PICS

80
Q

Force Progression Concepts for Pts w/ Directional Preference

Traffic Light Analogy

GREEN==

A

Progress Force

  • Sxs improving BUT not at a stasis point
  • reduction of sx’s NOT MAINTAINED after tx
81
Q

Force Progression Concepts for Pts w/ Directional Preference

Traffic Light Analogy

YELLOW==

A

Progress force w/ Caution

  • Sx’s INCd, but NO WORSE
  • NO change in status when performed
  • Ex. worse @ top of press-up, but better @ rest
82
Q

Force Progression Concepts for Pts w/ Directional Preference

Traffic Light Analogy

RED==

A

STOP Tx

  • Peripheralization of sx’s
  • Loss of ROM in other planes​​
83
Q

Directional Preference/Specific Ex’s

Ex. For pts w/ Directional Preference of EXT

EXT Ex’s

A

see pics

YOU KNOW THIS!!!

84
Q

EXT W/ LATERAL COMPONENT

EXT EX’S w/ Lateral Component

Progressions:

A

see pics

  • REIL w/ hips offset
    • hips going OPP DIRECTION of pain
  • Roadkill
    • LIFTING leg of side W/ PAIN
85
Q

EXT type Ex’s

When should you incorporate “functional activities?”

A

Once sx’s are Stable

86
Q

LS “Box” Tape Technique

A

For pts w/ EXT preference who need to Avoid FLEX

87
Q

Flexion Directional Preference Ex’s

A

See pics

88
Q

**Pts w/ FLEX preference and/or OLDER pts w/ STENOSIS

What should you use?

A

FLEISHMAN MANEUVER

*IVF OPENING MOBILIZATION

  1. NOTE: NOT for pts w/ Ant. Derangement
89
Q

This is for pts who DO NOT centralize w/ FLEX OR EXT

USE:

A

Flexion/Rotation Mobilization

see pics

MSPT II (20 decks)

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