LS Anatomy, Exam, Subgrouping Flashcards
Some LBP stats….
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
LBP choice of Tx
reflects skill of professional rather than needs of pt
GO BACK TO ANATOMY REVIEW
SLIDES 4-26
LS exam sequence…
Always take thorough Hx
Always have pt complete SRO
When it comes to LBP
DO LESS in….
LESS in pts w/ high irritability/acute injury
*avoid irritating pt OR worsening pathology
When it comes to LBP…
DO MORE OR ALL in…
MORE OR ALL in..
Less irritable/subacute/chronic pts
when it comes to LBP
Do “Enough”
to make sound tx decisions and classify pt into subgroup
LB pain
As pts are improving….
DO:
high lvl functional testing– sport, work
GOAL of LBP Exam:
Be able to “classify” pt into subgroup
LBP Exam Sequence
see pics
LBP Exam:
General questions
- onset/MOI?
- onset/when? since onset are sx’s same, better, worse?
- Where is your pain? Pain or radation of sx’s down leg? where?
- Peripheralization vs. centralization
- numbness, tingling leg, foot, toes? where?
- weakness? clumsiness in legs?
- past episodes or similar probs in past?
- 0-10 pain rating–now? worst? avg over past week?
LBP Exam
Gen Questions cont’d…
- constant or intermittent? on and off?
- makes it better?
- makes it worse?
- pain @ night? –discs hydrate (swell) @ night
- B&B problems? Saddle or pelvic floor parasthesia or numbness?—-RED FLAGS!! –Cauda Equina Syndrome
- Is pain worse w/ cough or sneeze?
- what acts are difficult? problems w/ functionally?
LBP Exam:
Gen Questions cont’d…
- better or worse w/ sitting? standing? walking?
- working now? what do you need to get back to?
- prior exercises/fitness/PLOA
- Any tx so far?
- any meds?
- any dx studies? imaging?
- What are your goals??? *****
Fear Avoidance Behavior Questionnaire
FABQ
covers psychosocial aspects
- 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
LS Observation/Inspection
- 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
- LOOK @:
LQS
DTRS
L3, 4==patellar tendon
S1,2==achilles
LQS
Abnormal reflexes
Babinski==UMN
Clonus==UMN
LQS
Myotomes
- 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)
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”
- 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)
NOTE: Dermatomes
Dermatomes overlap
This is why radiculopathies typ may cause PARTIAL numbness or parasthesias, but unlikely to result in complete anasthesia
Peripheral Joint Screening:
Look for sx repro/aggravtion and/or limtd or abnormal motion
What does this entail?
- 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)
AROM: Single Rep Motions
Flex
EXT
LF
Rot
% 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*
Single rep AROM testing sequence:
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
AROM: Repeated Motions
aka Directional Preference
Why???
- 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
AROM: Repeated Motions
Order of Testing
- Repeated FLEX in standing (RFIS)
- Repeated EXT in standing (REIS)
- Repeated FLEX in lying (RFIL)
- Repeated EXT in lying (REIL)
What should you remember in terms of Repeated Motions Outside Sagittal Plane
the Shift is named in terms of Shoulder Direction
which way are the shoulders leaning?
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:
- Repeated EXT w/ hips offset contralateral to sx’s
- Repeated EXT w/ hips offset ipsilateral to sx’s
- Flexion Rotation
RROM
isometric tests in neutral sitting:
Strong and painfree?
Strong and painful?
Weak and painful?
Weak and painless?
*Defined on another card
Strong and Painless
No lesion or neuro deficit involved in mm or tendon
Strong and Painful
Minor lesion of the tested muscle or tendon
Weak and Painless
Disorder of the NS, NMSK junction, complete rupture of the mm or tendon, disuse atrophy
Weak and Painful
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
Special Tests:
SLR
see pics
+ Brudzinski’s
Cervical flexion INC pain
+Brogards
DF foot INC pain
Special Tests:
Sign of the Buttock Test
see pics
Special Tests:
Slump Test
*indicates nerve root involvement*
*biases pons, cord, meninges, sciatic tract
see pics
Special Tests: Prone Knee Bending Test
*biases femoral tracts, mid and upper lumbar roots, meninges, cord
see pics
Special Tests:
Quadrant Test
see pics
Manual Traction Tests
Positions
Prone—flat
Supine—knees bent, hips in slight flexion
2 Special Tests for Instability
Standard Tests:
- Prone Instability Test (legs off table one)
- Passive Lumbar Instability Test (PASSIVELY check instability)
Special Tests for Instability
Prone Instability Test
see pics
Special Tests for Instability
Passive Lumbar Instability Test
see pics
Specialized Group of Instability Tests
Post-partum women w/ pelvic girdle pain
5 tests
- P4 Test (Posterior Pelvic Pain Provocation
- +Active SLR (ASLR) test
- Provocation of Long Dorsal SI Ligament
- pain must last longer than 5s AFTER palpation
- Provocation of pubic symphysis w/ palpation
- pain must last longer than 5s AFTER palp
- Modified Trendelenburg test
- standing on 1 leg, if they lean hips TOWARD pain side === + test
*Criteria to define this sub-group==positive composite of tests
Specialized Group
Post-partum women w/ pelvic girdle pain
P4 Test
see pics
Specialized Group
Post-partum women w/ pelvic girdle pain
ASLR Test
*have them just lift leg and try to get to your hands
see pics
Specialized Group
Post-partum women w/ pelvic girdle pain
Provocation of Long Dorsal SI Ligament
Provocation of Pubic Symphysis w/ Palpation
see pics
BOTH BELOW
*NOTE: just remember pain sx’s must last longer than 5s AFTER palpation
Specialized Group
Post-partum women w/ pelvic girdle pain
Modified Trendelenburg Test
see pics
Special Tests for the SIJ:
which is the most USEFUL type of test?
PROVOCATION TESTS
*Highest reliability and validity
Of all studied, 4 tests contributed to making the dx of SIJ pain and dysfunction
What are they?
- SI Distraction
- Thigh Thrust
- SI Compression
- Sacral Thrust
*NOTE: Robinson et al. found that reliability of PAIN PROVOCATION was GOOD while reliability of palpation tests was POOR
SIJ dysfunction Tests
SI Distraction
see pics
SIJ Dysfunction Tests
Thigh Thrust
*hand under buttcheek (middle of sacrum) one
see pics
SIJ Dysfunction Tests
SI Compression
see pics
SIJ Dysfunction Tests
Sacral Thrust
see pics
HOOVER TEST
tests for suspicion of…
malingering
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!!
see pics
Accessory Motion Testing
2 of them:
-
PIVM (Passive Intervertebral Motion)
-
Flexion in sidelying
- bring their knees off table
-
Flexion in sidelying
-
PAIVM (Passive Accessory Intervertebral Motion)
-
P-A central vertebral pressure
- push directly on SP
-
PA U/L vertebral pressure
- pressing on R/L TP
-
P-A central vertebral pressure
*Pushing on R. TP induces what motion–> L. ROTATION!!
FUNCTIONAL TESTS
Basic ADLs
Work-related
Sports-Performance
LB Exam
Important landmarks/structures to PALPATE
- 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
AFTER basic LS exam:
What is BEST to do?
Based on exam findings, classify pt into a tx group–> match tx to subgroup characteristics/predictors
Sub-Groups of pts w/ LBP
What was the Traditional Medical Model?
- 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
Sub-Groups of pts w/ LBP
NOW
Guide to PT Practice (2001) recommend…
- Classify pts based on S/S….NOT presumed pathoanatomical causes
- Sub-group pts to ultimately direct tx decisions
Who proposed a classification structure for pts w/ LBP
Delitto et. al 1995
*research supports this process as resulting in better outcomes in PT tx
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???
- Specific Exercise AKA Directional Preference
- Flex
- EXT
- Lateral shift patterns
- Stabilization
- Manipulation
- Traction
Evidence-Based Exam/Intervention Strategies for Pts w/ LBP
revised by Alrwaily 2016
3 big topics w/ subtopics
-
Symptom Modification
- directional preference
- manipulation/mobilization
- traction
- active rest
-
Mvmt Control
- sensorimotor
- stabilization and flexibility ex’s
-
Functional Optimization
- work/sport specific
- strength, conditioning, aerobic and gen. fitness ex’s
4 Subgroups of Tx-Based Classification
WE LEARNED:
- Manipulation
- Specific Exercise AKA Directional Preference/Rep’d Motions
- Instability
- SI-Provocative
- Specific Exercise (Directional Preference) Sub-group
*popularized by Robin McKenzie 1989
Explain…
- Pts classified based on response to repeated mvmts
- Focuses on centralization/peripheralization
See Pics
Traditional hallmark findings for specific exercise classification
AKA directional preference
4:
- Dec or abolish pain/parasthesia
- Centralization
- Centralization MAY cause symptoms proximal to intensify
- INCd ROM
Directional Preference
DEFINED
(Kilpkowski, 2002)
- Mvmt in one direction IMPROVES pain and ROM
- Mvmt in the opposite direction will cause s/s to WORSEN
Directional Preference and pts exhibiting centralization
2 things to remember about pts w/ directional preference
- Pts exhibiting centralization will also demonstrate a directional preference
BUT…
- Pts w/ a directional preference DO NOT ALL demonstrate centralization
*Strong correlation exists b/w centralization and disc pathology seen via positive discography
See Study:
- 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
-
__Sn: True Positive (SnNOUT)= 37%-40%
*Donaldson et al. –> Centralization was more accurate than MRI in detecting symptomatic discs when using discography as reference standard
TREAT THE PATIENT, NOT THE IMAGES!!!!!!!
!!!!!!!!!!
FLEXION SPECIFIC Exercise Classification
Key things to remember
- 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
- Group A did better:
- 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
Examination of Pts w/ Directional Preference
Things to include…
- 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!!!
Force Progression Concepts for Pts w/ Directional Preference
What is the progression you learned in Lab for these Ex’s?
- Pt. generated movement
- Pt. overpressure using EXHALE
- Clinical overpressure
- PT pushes on LS as pt goes into motion (follow them)
- Manipulation/Mobilization
Force Progression Concepts for Pts w/ Directional Preference
Basic concept of McKenzie based tx
2 things to remember:
- Starts w/ pt generated forces, progressing to therapist generated as needed
- MAY include changing plane of motion
- 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
Force Progression** **Concepts for Pts w/ Directional Preference
List the order of progression again
Pt gen’d forces
Pt overpressure (use exhale)
Clinician overpressure (mob as they move)
Clinician mobilization (P-A)
Clinical manipulation
Force Progression Concepts for Pts w/ Directional Preference
More details…
- Pt enters @ stage that produces improvement
- ONLY progress when NO improvement OR stasis point
- Ultimately move toward patient independence
Force Progression Concepts for Pts w/ Directional Preference
Traffic Light Analogy
SEE PICS
Force Progression Concepts for Pts w/ Directional Preference
Traffic Light Analogy
GREEN==
Progress Force
- Sxs improving BUT not at a stasis point
- reduction of sx’s NOT MAINTAINED after tx
Force Progression Concepts for Pts w/ Directional Preference
Traffic Light Analogy
YELLOW==
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
Force Progression Concepts for Pts w/ Directional Preference
Traffic Light Analogy
RED==
STOP Tx
- Peripheralization of sx’s
- Loss of ROM in other planes
Directional Preference/Specific Ex’s
Ex. For pts w/ Directional Preference of EXT
EXT Ex’s
see pics
YOU KNOW THIS!!!
EXT W/ LATERAL COMPONENT
EXT EX’S w/ Lateral Component
Progressions:
see pics
- REIL w/ hips offset
- hips going OPP DIRECTION of pain
- Roadkill
- LIFTING leg of side W/ PAIN
EXT type Ex’s
When should you incorporate “functional activities?”
Once sx’s are Stable
LS “Box” Tape Technique
For pts w/ EXT preference who need to Avoid FLEX
Flexion Directional Preference Ex’s
See pics
**Pts w/ FLEX preference and/or OLDER pts w/ STENOSIS
What should you use?
FLEISHMAN MANEUVER
*IVF OPENING MOBILIZATION
- NOTE: NOT for pts w/ Ant. Derangement
This is for pts who DO NOT centralize w/ FLEX OR EXT
USE:
Flexion/Rotation Mobilization
see pics
