Lumbar/PGP Practical mostly from Website and Pictures Flashcards
Lumbar Exam: Latissimus Dorsi (LD) Muscle Length Test
Practice/Describe/Think it through
- A short LD: facilitates a lumbopelvic lordosis, thoracic kyphosis, altered scapular and shoulder girdle movement, and increased glenohumeral internal rotation, extension, and adduction and lateral trunk flexion on one side.In subjects with neck pain interrater reliability is right side k=.80 (.53, 1.0) and left side k=.69 (.30, 1.0). Borstad and Briggs report on 6-week between-sessions measurements in healthy subjects. ICCs for all raters, novice and experienced were poor. These authors did not recommend this technique to assess within-subject change over time.
- Maintaining a posterior pelvic tilt, passively or actively flex the shoulder. The arms should lie flat on the table. ROM is measured at end of flexion. Palpate the medial & lateral humeral epicondyles to determine onset of IR which suggests the end of LD length.A firm end feel or IR ends the tests. A + test is side-to-side asymmetry. Relevance is based on clinical experience, the patient’s exam, and quality of movement.Normative data are not available.
PGP: PPIVM (also used as tx called Oscillatory Ileal Sidelying): Posterior Tilt of the ilium
Practice/Describe/Think it through
○ Posterior Tilt of the ilium
■ Passive physiological motion tests: Anterior and posterior tilt of the ilium commonly performed in sidelying; while supporting the uppermost knee in the clinicians abdomen or resting on top of the other leg table supported on a pillow, the SIJ is taken through full range of motion into anterior tilt and posterior tilt by gently grasping the ilium in both hands. Reliability and diagnostic accuracy are unknown. Can also perform standing behind pt, but I forgot the exact hand placements (It is easier that way though)
PGP: PAIVM: Pelvic girdle PA
Practice/Describe/Think it through
■ Anterior-to-posterior (Figure 4-140) is assessed in supine; apply an AP glide through the ASIS on one side and compare to the opposite side or apply bilaterally. Assess mobility and symptom response; compare sides for asymmetry. Posterior-to-anterior movement is assessed in prone; apply a PA glide through the PSIS on one side and compare to the opposite side. Assess mobility and symptom response.
Lumbar Exam: Trunk Muscle Endurance Tests: Side-Bridge or Lateral Musculature Test
Practice/Describe/Think it through
○ Full side bridge is with knees & hips extended & the top foot in front of the lower foot. If unable to maintain full side bridge, patients may flex the hips & knees. Subjects support on one elbow & both feet lifting their hips off the mat to maintain a straight line over the full body length. Uninvolved arm is across the chest, hand on the opposite shoulder. The test is timed and ends with loss of the straight back posture and the hips returned to the table. Dr. Mincer said important to pull the shoulder down with resting arm.
Make sure they get into and out of the position with the proper technique (see pictures)
Lumbar: RSGIS
Practice/Describe/Think it through
▪ Repeated Side Glide in Standing (RSGIS) to the right and left performed by the patient. The response to RSGIS is assessed when a lateral shift is present, sagittal plane movements are inconclusive or with asymmetrical or unilateral symptoms. The first movement is hips away from the painful side. For Left SGIS, the trunk moves to the left, hips to the right, & shoulders are parallel to the ground. May be done standing against a wall with therapist assist. Similar to the manual shift correction process, if centralization occurs, the patient is instructed to bend backwards to restore extension while the side glide is maintained.
Picture: with therapist assist
Lumbar: Flexion with OP
Practice/Describe/Think it through
▪ Flexion, OP: stabilize the pelvis and apply passive overpressure with the forearm across the lower thoracic spine into flexion.
What areas would you assess for a knee or ankle exam if you needed to go down the kinematic chain?
ROM/MMT
Accessory motion
Special tests
PGP: Motion Palpation; Modified Trendelenburg Test
Practice/Describe/Think it through
○ The patient stands on one leg and flexes the opposite hip with the knee at 90°. If pain is experienced in the pubic symphysis, the test is considered positive.
Lumbar Tx: Stabilization: Curl-up
Practice/Describe/Think it through
■ Beginner: Supine 1 knee flexed, the other leg extended. Hands support under the lumbar spine with elbows on the mat. The spine remains in neutral.Head & neck are stabilized on the trunk and move as a unit. Rotation occurs about the thorax by activating the rectus abdominus and obliques without lumbar spine motion. Head & shoulders raised slightly off the table. Breathing is normal; neck should not flex.
■ Intermediate:Same as for beginner except that the elbows are lifted slightly off the table. Prebracing and deep breathing become the advanced curl-up.
Hip: Accessory Motion: Hip lateral glide
Practice/Describe/Think it through
■ Hip lateral glide
● Lateral glide: In supine with the hip passively held at 90 ° flexion the clinician grasps the proximal thigh as close to the hip joint as possible and applies a laterally directed force. Perform in an oscillatory manner to assess onset of symptoms, stiffness through range, end feel and to assess a pain and stiffness relationship.
Practice/Describe/Think through
Lumbar: General Posture Assessment
▪ The history suggests which posture(s) to emphasize initially. For example, if sitting is a primary aggravating factor and standing and walking are not related to the patient’s symptoms, more time may be spent analyzing sitting posture as described in chapter 3. Observe anterior, posterior, lateral views in standing.
▪ Note global posture from all views gradually focusing on the lumbopelvic and lower extremity regions for the presence of scoliosis, lordosis, kyphosis, lateral shift, or patterns suggestive of muscle imbalance.
▪ In the neutral position of the pelvis with ASIS and PSIS relatively in the same planes, a normal lordosis is present. Excessive pelvic anterior tilts results in an increased lordosis or increased anterior curve. Excessive posterior pelvic tilt results in a flat back or decreased anterior curve.382 In the thorax, the manubriosternal junction should be in line with pubic symphysis and the ASISs. The femoral heads should be centered in the acetabulum without excessive femoral internal or external rotation.
Lumbar: AROM rotation with and without OP
Practice/Describe/Think it through
▪ Left and Right Rotation: Resting symptoms, quality, quantity, symptoms response, turn your body to the left/right performed in standing or seated. Manual pelvic stabilization (in standing) or make sure popliteal fossas stay on edge of table so legs don’t twist to remove the lower extremity contribution to rotation.
SIJ: Long Dorsal Sacroiliac Joint Test (LDL test)
Practice/Describe/Think it through
Posterior SI ligament (use 0-3 scale) (Long Dorsal Sacroiliac Ligament Test)
- Helps rule out a problem with SI joint.
- Palpate just inferior to the PSIS and if pt is not tender there, the problem is probably not with the SIJ
FRom Physiopedia: http://www.physio-pedia.com/Long_dorsal_sacroiliac_ligament_%28LDL%29_test
The LDL test in postpartum women
The patient lies prone and will be examined for tenderness on bilateral palpation of the LDL directly under the caudal part of the posterior superior iliac spine. The pain will be scored by a skilled examiner on a 4-point scale as positive or negative :
- 0 : no pain
- 1 : mild pain
- 2 : moderate pain
- 3 : unbearable pain
The sum score can be situated between 0-6 because the scores on both sides are added.
Lumbar: REIS
Practice/Describe/Think it through
▪ Repeated Extension in Standing (REIS): Repeat 10-15 repetitions, continually ask the patient about any change in symptoms, location, or intensity during movement or at end range and note any change in quantity of movement.
Lumbar Tx: Neurodynamics: Right leg passive neurodynamic silder tech
Practice/Describe/Think it through
○ A passive neurodynamic slider technique biasing the tibial branch of the sciatic tract with passive knee extension with ankle plantar flexion followed by passive knee flexion with passive ankle dorsiflexion.
Practice/Describe/Think through
Lumbar: Heel Raise MMT
S1/2 may also be tested and graded in the manual muscle test position for the gastrocsoleus complex in standing. (S2 should be tested with knee flexion MMT)
Test Procedures from last year ortho lab: Ankle Plantarflexion
Because it is a big strong muscle and functionally very important this is the one muscle group that you will typically muscle test in weight bearing using the patient’s body weight as resistance. Give the patient something for balance purposes for the test. Watch for patient’s using arm to lift themselves up during the test though. The procedure is to do repetitive toe/heel raises, but no matter which name you prefer to use the goal is to lift the heel as high off the ground as possible. (Many consider 20-25 normal. – some recent literature has suggested more than that). We are going to do it first with knees straight for gastrocnemius and then with knees flexed to measure the soleus.
- Grade 5: 25 reps
- Grade 4: 10-19 reps
- Grade 3: 1-9 reps
- Grade 2: can’t get heels off of the ground
*What if they had 22 reps, and so without going into pluses and minuses they only get a 4.
Lumbar Tx: Quadruped arm and leg extension (bird dog) - two positions
Practice/Describe/Think it through
Quadruped arm and leg extension (bird dog)
- In quadruped and the spine braced in neutral. Motion begins with raising one hand or one leg. Neutral spine is maintained with normal breathing. The goal is to raise the arm or leg to the horizontal. An alternate beginner birddog exercise begins in standing leaning against a counter top and spine braced in neutral. Motion begins with raising one arm or one leg. Neutral spine is maintained with normal breathing. (start by lifting one leg at a time, and progress to coordinated lifts)
- Incline Position: In quadruped and the spine braced in neutral. Motion begins with raising one hand or one leg. Neutral spine is maintained with normal breathing. The goal is to raise the arm or leg to the horizontal. An alternate beginner birddog exercise begins in standing leaning against a counter top and spine braced in neutral. Motion begins with raising one arm or one leg. Neutral spine is maintained with normal breathing. (start with one limb at a time, progress to coordinated lifts)
Lumbar: Combined movements: Lumbar Quadrant
Practice/Describe/Think it through
▪ Patient reaches behind the uninvolved knee followed by comparison to the opposite side.A combined movement of extension, lateral flexion (LF), & rotation (ROT) to the same side. Theorized to result in maximal loading & narrowing of the IVF on the side of LF and ROT and may be useful in ruling out pain originating from the lumbar spine. Very provocative (Sn .70); not specific (i.e., unable to identify a specific structure). A strong predictor of clinically meaningful symptom severity, but not predictive of impaired function in degenerative LBP.
Hip: Adduction/Abduction AROM/PROM/OP
Practice/Describe/Think it through
■ ROM/OP for Abduction/Adduction (supine or sidelying): The patient actively abducts or slides the leg away or adducts toward midline. With the pelvis stabilized, the clinician passively moves through the range of ABD or ADD, OP is applied as indicated.
PGP: Motion Palpation; One Leg Standing Test
Practice/Describe/Think it through
○ On the WB side palpate the PSIS with one hand & S2 on the support side with the other hand; instruct the patient to flex the opposite hip (i.e., the side you are not palpating) & note the motion of the ilium (PSIS) relative to the sacrum on the WB side. The ilium & thus PSIS should either posteriorly tilt or remain still. A + test is recorded when the ilium or PSIS) anteriorly tilts relative to the sacrum implying a less stable position for load transfer through the pelvis.
PGP: Motion Palpation; Treatment; Asymmetrical motion: SIJ posterior distraction HVLA technique
Practice/Describe/Think it through
■ SIJ posterior distraction HVLA technique. In right side-lying with the lower leg extended and upper hip and knee flexed, the trunk is rotated to the left until L5-S1 is fully rotated to the left. With L5-S1 stabilized, the innominate is rotated internally about a horizontal axis, resulting in a distraction of the posterior aspect of the SIJ. The thrust technique can be focused through the stiffest segment of the sacrum (S1, S2, S3). Reassessment of the SIJ mobility and neuromuscular systems is mandatory to determine the response to the intervention.
Basically the same thing as the Sidelying Lumbar Thrust Manipulation (pictured) but you choose L5-S1 level
Lumbar: General Info about AROM
▪ Quantity (range of movement).Quality (control or ease of movement). Symptom response: during & at end range note a change in intensity or location from rest position and where in range symptoms change. Note deviation from plane of movement: correct to determine relevance; if relevant, symptoms are altered. Note aberrant movement: Painful arc, thigh climbing on return to upright, instability or catch or sudden acceleration or deceleration, reversal of lumbopelvic rhythm. Observe segmental motion for presence or absence of a smooth cure or a fulcrum or sharp angulation.
Lumbar Tx: Stabilization: Clamshell
Practice/Describe/Think it through
CLamshell: Gluteal activation using the clam shell. (Figure 103f) Accurate gluteal activation is needed for a healthy spine during activities such as getting in/out of a car. Substitution by the HS & erector spinae produce excessive spinal load in the presence of weak gluteals. To perform gluteal activation in sidelying with knees and hips flexed: Patient palpates gluteus medius with fingers posteriorly and thumb on the ASIS. With heels together the knees are separated. Assess for neutral spine, trunk stabilization & motion through range. Training may start here or progress to more advanced gluteal activation patterns such as hip abduction in sidelying or standing.
Can do with AB or ADIM
Practice/Describe/Think through
Lumbar: AROM Flexion with single and double inclinometer
Flexion (single and double inclinometer)
- Flexion: Resting symptoms: quality, quantity, symptom response. With your knees straight bend forward as if to touch floor.Quality, quantity symptom response.
- Single inclinometer
- Inclinometer at the T12 spinous process provides a measure in degrees of total flexion, extension. The amount measured combines motion available at the lumbopelvic and hip regions.
- Double inclinometer
- Other inclinometer goes over S2. Subtract the number you get at the S2 inclinometer (because it represents pelvic motion) from the T12 inclinometer (that represents lumbopelvic motion) - no picture or description on website.
Lumbar Tx: Mechanical Traction
Practice/Describe/Think it through (mostly just parameters we learned last year)
Mechanical traction is usually performed after a trial of manual traction
Clinical Guidelines for Lumbar Traction
Lumbar Spine - HNP:
- Weight: 30-40% body weight, no more than 50%
- Position: Supine hooklying
- ON:OFF time: 60:20
- Duration: Begin with 3-5 minutes progress to 15 minutes
- PT/PTA need to remain by patient for one full cycle
Lumbar Spine – Joint Dysfunction DDD:
- Weight: 30-40% body weight, no more than 50%
- Position: Supine hooklying
- ON:OFF time: 30:10 (intermittent)
- Duration: Begin with 10-12 minutes progress to 20 minutes
- PT/PTA need to remain by patient for one full cycle
Steps to Setting up Traction
- Apply stabilization harness:
- Place thoracic harness below ribs
- Place pelvic harness at ASIS
- Tighten:
- Harness
- Thoracic straps
- Weight rope
- Turn on unit and set:
- Duration
- ON/OFF time
- Choose: Progressive Intermittent option
- After 1st full cycle unlock table to prevent friction
- Remain by patient for one full cycle
Lumbar Exam: Trunk Muscle Endurance Tests: Extensor Endurance
Practice/Describe/Think it through
● Extensor endurance
○ Prone with the lower body fixed at the ankles, knees, and hips; upper body extended over the edge of the table. Table surface is 25 cm (9.8 inches) above floor. UE held across the chest with the hands resting on the opposite shoulders as the upper body is lifted off the floor to horizontal. Subjects maintain the horizontal position as long as possible. The endurance time is recorded in sec from the point at which the subject assumes the horizontal position until the upper body drops from horizontal.
Hip: FABER test (Patrick’s Test)
Practice/Describe/Think it through
● Flex, abduct, and ER the hip so that the lateral ankle rests on the opposite thigh just above the knee. While stabilizing the opposite side of the pelvis at the ASIS, the knee of the involved side is lowered toward the table until end range is reached. If no symptoms, OP is added. Inclinometer is 2.5 cm distal to the patient’s flexed knee. A + test is reproduction of the patient’s symptoms or limitation of motion.
Lumbar Exam Prone Palpation
Practice/Describe/Think it through
What are all the structures, how would you do it, etc.
- Palpation (can put pillow under hips/abs to help with feeling and/or if they do not tolerate prone well)
- Spinous Processes (PAVIM hand grip)
- Facet joints (~1 inch lateral to SP)/transverse processes (use thumbs, make sure you are palpating the side you are standing on)
- L5 vs S1:
- L5 is usually less prominent than L4
- Can look for drop off of sacrum by palpating startinglateral to S2 and moving fingers cephalically until you feel drop-off.
- PSIS/SIJ
- Posterior Dorsal SI ligament Test (use 0-3 scale)
- Sacrum (use same hand grip as PAVIM)
- Soft Tissue (make sure you are palpating perpendicular to the way the muscle runs so you can feel if it is ropey, etc). In general keep hands relatively flat, but also must tilt whole hand so the fingers dig in a bit to really feel the muscle fibers.
- Glut max
- Glut med/min
- Piriformis
- sciatic nerve is also there (halfway between ischial tubs and greater troch)
- Rotators
- Sciatic nerve on posterior thigh
- Palm flat on posterior thigh just below gluteal fold. Apply pressure and tilt hand down a bit (so fingers are digging in a little) and push hand medial and lateral while assessing for s/s.
- Greater trochanter
- Isch tube
- Palm flat on posterior thigh just below gluteal fold. Then slide hand on thigh in cephalic direction (towards fold) and will bump up and feel the Isch tub (much less invasive than how we palpated them before)
- Lumbar Soft tissue
- Multifidi and parapsinals
- Palpate perpendicular to fibers between the spinous process and transverse processes (will be palpating more than one level at a time)
- Erector spinae
- Quadratus Lumborum
- Multifidi and parapsinals
Lumbar Tx: Stabilization: AB with cat and camel
Practice/Describe/Think it through
AB with Cat and camel exercise in quadruped: A range of motion exercise focusing on flexion and extension of the spine. Teaching abdominal bracing: The patient is asked to contract the muscles to make them stiff. The abdominal wall is not drawn in or pushed out. Bracing is used to encourage co-contraction of the abdominal wall and paraspinals at low levels (i.e., 10-15% of maximum voluntary isometric contraction) in supine and then used in functional activities such as getting in and out of car and on off the toilet.
PGP: Motion Palpation; Prone Knee Bend
Practice/Describe/Think it through
■ This test compares apparent leg lengths with the patient prone when both knees are extended to when both knees are flexed to 90° by visually examining the left and right soles of the heel with shoes on. When the patient prone with both knees fully extended, a finding of a shorter leg compared to the opposite side suggests but does not confirm a posteriorly rotated innominate. While both heels of the patient’s shoes are held, the patient’s knees are passively flexed to 90°. An observable minimum difference estimated visually at 2.54 cm between the prone knee flexed and prone knee extended position is a positive test. Theoretically, an observed difference indicates a posteriorly rotated innominate.
What are the general rules for interpretingf trunk muscle endurance tests? (3)
Trunk Muscles Imbalance suggested if
- Flex:Ext endurance > 1.0. (Values <1.0 are desirable with 0.84 normal for healthy young males)
- Right-side-bridge:Left-side-bridge endurance >0.05
- Either side-bride:extension endurance > 0.75
Lumbar Tx: CPA PAIVM Mobilization
Practice/Describe/Think it through
- Non-Thrust Manipulation: Prone, Lumbar Central Posterior-to-Anterior (CPA) Mobilization. Central PA mobilization is similar to central PA PAIVM assessment. In Clelandthe central PA was directed at L4 & L5 using a low-velocity high amplitude oscillation at 2 Hz, a total of 60 sec for 2 sets. The therapist selects the level or chooses the L4/L5 segment because previous research suggests procedures directed toward the lower lumbar region are more effective. The position can be varied in flexion over a pillow, extension (prone on elbows), or lateral flexion.
Practice/Describe/Think through
Lumbar: Gait Screen
10MWT
From Book:
10 Meter walk test is an easy, reliable test to measure walking speed. A straight, level 20 m path is used beginning with 5 m for acceleration, 10 m for timed walking at a comfortable pace, and ending with 5 m for deceleration. the average of 2 trials is scored. The amount of change needed for a small but meaningful improvement is 0.04 to 0.06 m/s and for a substantial change 0.08 to 0.14 m/s. Gait speed of less than 1 m/s identifies well functioning older person at high risk of adverse health outcomes within 1 year.
Gait speed is a standards measure that has the potential to predict functional decline and future health status. Because self-selected walking speed is slower in pts with CLBP, walking speed should be assessed when appropriate to provide data relevant to the pt’s future functional ability and safety. While variations exist related to age and gender, the normal range for walking speed is 1.2 to 1.4 m/s
Lumbar Tx: Neurodynamics
general information
● ND mobilization procedures are passive or active movements centered on regaining the neural tissue’s ability to move & withstand normal daily stresses. Non-provocative gliding techniques are thought to result in a larger longitudinal excursion with a minimal increase in strain and to produce sliding movement between neural structures and adjacent non-neural tissue. These techniques are performed in an on and off or oscillatory manner and not performed as stretching techniques.
Lumbar Tx: Neurodynamics: Active slump neurodynamic slider technique
Practice/Describe/Think it through
○ Slump Sliding Technique: Step 1: Knee extension/knee flexion.Step 2: cervical & thoracic flexion and return to neutral.Repeat in an on/off manner.Pain free.Tensile loading techniques, as performed in the Cleland et al738 slump stretching study (Figure 4-121), are more aggressive since tension is taken up from both ends of the nervous system at the same time. ND mobilization is not indicated in patients with neurological signs of impaired conduction such as weakness, impaired sensation, and diminished DTRs.
○ With minimal improvement, impairments associated with NPNS were first addressed through seated slump in knee extension adding ankle dorsiflexion as a HEP & progressing to adding cervical flexion. At the 4th session prone PAIVM and sidelying PPIVM (Figure 4-128) in combination with SLR neurodynamic mobilization were initiated with full resolution of symptoms by the 6th session.
Hip: Abduction MMT
Practice/Describe/Think it through
■ MMT Abduction: While stabilizing the pelvis in side lying or supine with the hip at end range active abduction, the clinician provides a force directed into adduction. The patient is asked to resist this force.
PGP: Motion Palpation; standing flexion
Practice/Describe/Think it through
■ Monitor the inferior slope of the PSIS bilaterally. Patient is asked to bend forward. The clinician maintains palpation with the inferior slope of the PSIS/ilium bilaterally and monitors movement of the PSISs and ilia during forward bending. The normal response is symmetrical anterior tilt of both ilium over the femoral heads without deviation from the sagittal plane. The side that moves further cranially is suggested as the dysfunctional side with an observable minimal difference between sides estimated at 2.54 cm or at least 1 inch.
Lumbar: RFIS
Practice/Describe/Think it through
▪ Repeated Flexion in Standing (RFIS). Repeat 10-15 repetitions, continually ask the patient about any change in symptoms, location, or intensity during movement or at end range and note any change in quantity of movement.
Picture: we asked the person to slide hands on legs to help them feel more stable (not out in the air like in picture)
Hip: Adduction MMT
Practice/Describe/Think it through
■ MMT Adduction: ■
Adduction: With the hip at end range active adduction, stabilize the pelvis and provide a force into abduction. The patient resists. Observe for poor trunk control. If the hip flexes during abduction, the TFL is overactive; may be substituting for a weak gluteus medius, poor trunk control, or stiff adductors.
● In the past, we performed this in side-lying with the leg we are testing down. We stood behind the pt, held the top leg up, asked the pt to use the bottom leg to meet the top leg, let it drop a bit and then applied pressure and asked pt to resist us pushing their bottom leg down.
SIJ Profocation Tests: Gaenslen’s Test
Practice/Describe/Think it through
■ Gaenslen’s test: With one hip flexed toward the patient’s chest & the other extended over the edge of the table, apply overpressure to both sides at the same time. Perform on both sides to create a posterior SIJ rotational load of the flexed hip and an SIJ anterior rotational load of the extended hip.
Repeate on both sides (each side is considered 1 test for the 6-test cluster to rule out SIJ problem). The pain would just be reproduced on the same side whether you tested with right leg up or down)
Lumbar: Sitting posture
Practice/Describe/Think it through
- Book (chapter 3)
- Lumbopelvic sitting is preferable (anterior pelvic rotation, lumbar lordosis, and thoracic relaxation). Simply telling a pt to “sit up straight” does not facilitate an optimal position of the spine.
- First the pt’s unsupported sitting posture is observed with the feet flat on the floor and hips in 80 degrees flexion. The clinician manually assists anterior rotation of the pelvis in neutral spinal posture as follows: (a) restoration of the normal low lumbar lordosis; (b) kyphosis in the thoracic spine adjusted with a slight sternal lift or depression; ( c) scapulae sitting flush on the thoracic wall; and (d) head -on-neck posture adjusted with gentle occipital lift away from cervical extension. The clinician manually repositions the scapulae as needed. The patient is asked to actively maintain this position. The effect of postural correction on the pt’s symptoms is assessed to determine relevance. Symptoms may increase, decrease, or remain the same or pts may have difficulty assuming the desired position, perhaps due to impaired spinal mobility. Note: not all deviations from what is considered normal or ideal should be considered pathological, and some faulty postures should not always be corrected. (example pts with LSS)
PGP: Supine direct mob
Practice/Describe/Think it through
■ Performed by the therapist with oscillatory techniques between the ilium and sacrum (Figure 4-154) The knee is flexed and brought to the axilla with one hand placed under the ischial tuberosity and the other on the top of the patient’s knee. The pelvis is rotated posteriorly by pushing down on the shaft of the femur and lifting up firmly with the thenar eminence hand on the ischial tuberosity.
Lumbar Tx: Side-support (same as side bridge), Beginner Level 2; Beginner level 2; Intermediate.
Practice/Describe/Think it through
○ Beginner Level 1: Performed against the wall with the elbows flexed feet close together. Alternate position with elbows straight. With the spine braced the patient pivots on the balls of the feet from the left side-bridge position to the front plank position and then to the right plank position in a slow controlled manner with no motion in any plan occurring in the spine and normal breathing.
○ Beginner Level 2 side bridge: In right sidelying with knees flexed and hips in neutral, the left hand grasps the right shoulder. The right hip and right elbow support the side-flexed trunk. The start position for hip and knee angles varies, but the end position does not. With the spine braced, the trunk is straightened until the body is supported on the elbow and knee in line with the hips and shoulders.
○ Intermediate level Side-bridge: Performed the same as beginner except now the lower extremities are extended. The upper leg is slightly in front of the lower leg. The trunk is straightened until the body is supported on the elbow and feet and in line with the hips and shoulder. Video shows plank progression from side to prone to sid
Lumbar Exam; Ober’s Test (original and modified)
Practice/Describe/Think it through
○ Side lying, lower leg flexed, stabilize the pelvis & passively place the hip in abduction and extension. Knee flexed to 90° or extended. Keep the hip in line with the trunk, lower the thigh into adduction. A + test is if the hip does not adduct past the horizontal or when symptoms or complaints of tightness are reproduced. Modified Ober’s test allows significantly more hip adduction than the original Ober’s test; the two procedures should not be used interchangeably
Lumbar Tx: General Stabilization: Abdominal Brace
Practice/Describe/Think it through
■ Teaching abdominal bracing: The patient is asked to contract the muscles to make them stiff. The abdominal wall is not drawn in or pushed out. Bracing is used to encourage co-contraction of the abdominal wall and paraspinals at low levels (i.e., 10-15% of maximum voluntary isometric contraction) in supine and then used in functional activities such as getting in and out of car and on off the toilet.
PGP: Motion Palpation; Treatment; Asymmetrical motion: Supine lumbopelvic regional thrust manipulation
Practice/Describe/Think it through
■ Supine lumbopelvic regional thrust manipulation (also used in lumbar tx). Preliminary CPR has been developed to identify postpartum women with LBP or PGP who are likely to respond to a supine lumbopelvic thrust manipulation technique followed by 10 repetitions of a hand-heel rock ROM exercise in quadruped.
PGP: Self-mob MET (3 ways)
Practice/Describe/Think it through
■ Supine: In supine the patient grasps the knee with both arms, holds firmly, and pushes hard against the arms for 5-10 seconds. In supine the patient uses a belt to hold the knee and pushes hard against the belt for 5-10 seconds. The patient contracts the abdominal muscles while pushing with the knee to encourage posterior rotation of the pelvis and when lowering the leg. The exercises are repeated alternately on each side at least 3 times. If pain is severe, the patient performs the exercises every few hours throughout the day for 4 to 5 days, then 3-4 times daily for a week, and then as needed.
■ Sitting: Performed in sitting. The patient contracts the abdominal muscles while pushing with the knee to encourage posterior rotation of the pelvis and when lowering the leg. The exercises are repeated alternately on each side at least 3 times. If pain is severe, the patient performs the exercises every few hours throughout the day for 4 to 5 days, then 3-4 times daily for a week, and then as needed.
■ Standing: Performed in standing using a stable surface.The patient contracts the abdominal muscles while pushing with the knee to encourage posterior rotation of the pelvis and when lowering the leg. The exercises are repeated alternately on each side at least 3 times. If pain is severe, the patient performs the exercises every few hours throughout the day for 4 to 5 days, then 3-4 times daily for a week, and then as needed.
Picture: note external rotation in the supine example (good)
PGP: PAIVM: CPA scarum to coccyx
Practice/Describe/Think it through
■ Central posterior-to-anterior movement is also assessed directly on the sacrum to the coccyx. (same positions as nutation and counternutation)
SIJ Profocation Tests: Distraction
Practice/Describe/Think it through
■ Distraction: apply a posteriorly directed force through both ASISs purported to distract the anterior aspect of the SIJ.
Hip: Accessory Motion: Hip inferior glide in supine
Practice/Describe/Think it through
● Inferior glide: In supine with the hip passively held at 90° flexion the clinician grasps the proximal thigh as close to the hip joint as possible and applies an inferiorly directed force.
Picture: PT is on ipsilateral side. Put leg over shoulder (unlike picture) to avoid stressing knee.
Hip: Accessory Motion: Hip Long Axis Distraction
Practice/Describe/Think it through
● Long-axis distraction: In supine the clinician grasps the patient’s ankle passively moving the hip into 20-30° of hip flexion and 30° of abduction. A longitudinal distraction force is applied. Perform in an oscillatory manner to assess onset of symptoms, stiffness through range, end feel and to assess a pain and stiffness relationship.
Picture: grab proximal to malleoli (not like in picture)
Hip: Accessory Motion: Hip posterior glide at various ranges
Practice/Describe/Think it through
■ Hip posterior glide at various ranges
● Posterior glide: In supine with variations in hip flexion and adduction ranges, the clinician applies a posteriorly directed force in line with the long axis of the femur.
Picture: example of one position
Hip: Accessory Motion: hip inferior glide or medial glide sidelying
Practice/Describe/Think it through
- hip inferior glide or medial glide sidelying
- In sidelying with the lower leg in 45° of hip flexion, an inferior or medial glide is performed through the greater trochanter while supporting the leg in abduction.
Lumbar Exam: Musscle length tests: Piriformis (Hip ER) Muscle Length Test
Practice/Describe/Think it through
■ The piriformis muscle length test also assesses the other hip external rotators, but it is commonly known as the piriformis muscle length test. The piriformis is primarily an ER of the hip and assists with abduction and extension. When the gluteal muscles are weak or inhibited, the piriformis may overwork to assist hip extension and abduction resulting in a short muscle. With the hip above 60° of flexion, the piriformis acts a hip internal rotator. The diagnostic utility is unknown.
■ Piriformis Test Above 90 degrees: in supine flex the hip to 90 and add ER. While maintaining Flex and ER, adduct the hip toward the opposite shoulder.
■ Piriformis Test Less than 90 Degrees: In supine place the foot of the tested LE just lateral to the untested knee if the pelvis remains in neutral. If the pelvis elevates from the table, place the foot of the tested LE just medial to the untested knee. While manually stabilizing the pelvis on the tested side, passively move the hip into ADD and IR by moving the knee toward midline. A + test is side-to-side asymmetry. Relevance is based on clinical experience. A normal test response is unknown.
Hip: Extension AROM/PROM/OP
Practice/Describe/Think it through
■ ROM/OP Extension (prone): With the knee extended or flexed, the patient raises the leg off the table, OP may be applied if the lumbar spine, pelvis, and hip are controlled. The clinician stabilizes the pelvis at the PSIS or ischial tuberosity, grasps the distal thigh with the knee extended or flexed and passively moves the hip into extension, OP is added as indicated.
Can use a pillow if needed (if pt has reduced hip extension or lumbar extension is agg)
Lumbar Exam: CPA PAIVM
Practice/Describe/Think it through
○ Central PA PAIVM. In prone with arms at the side place hypothenar eminence just distal to the pisiform over SP. Place the other hand on top. Keep elbows straight and sternum directly over the SP. Progress in an oscillatory manner to assess symptom response & quality of movement through range and at end range. Do not push on the spine; lean forward to translate the weight of the trunk to the spine.
Lumbar Tx: Prone UPA PAIVM Mobilization
Practice/Describe/Think it through
○ Non-Thrust Manipulation: Prone, Lumbar Unilateral Posterior-to-Anterior Mobilization. Technique performance is the same as for assessment. Treatment of the painful and dysfunctional level is more effective in pain reduction than a randomly selected level. In asymptomatic subjects no difference was found between amplitudes or grades of mobilization as measured by pressure pain thresholds. Variations or progressions include positioning the patient in flexion, extension or lateral flexion.
Lumbar Tx: Positional Traction
Practice/Describe/Think it through
Lumbar lateral flexion in sidelying away from the painful side
Can add rotation
Lumbar Exam: UPA PAIVM
Practice/Describe/Think it through
○ Unilateral Posterior-to-Anterior PAIVM (Figure 4-85b). In the same position as described for central PA PAIVM the clinician uses both thumbs to produce the passive accessory movement. The thumbs are placed in the area of the zygapophyseal joints, 2-3 cm lateral to the SP, beginning on the uninvolved side making a side-to-side comparison.
PGP: SIJ traction (two ways)
Practice/Describe/Think it through
■ SIJ Traction with knee extended: The ankle is grasped at about 45° of passive SLR providing a strong pull on the leg in the long axis for about 5 sec. During distraction the patient tightens the abdominal muscles to facilitate posterior pelvic rotation. Traction is done on each leg one at a time for 4-5 reps. Reassess frequently.
■ This technique is used to traction the leg if unable to traction through the ankle. For the right side place the left forearm under the right knee and the left hand over the front of the left knee. Stabilize the right ankle with the right hand holding the knee in flexion. The clinician tractions the leg through the left forearm using the left hand to lever the traction which lifts the buttock on that side. Reassess frequently.
Picture: be sure to pull above the malleoli
Practice/Describe/Think through
Lumbar: AROM Extension with inclinometer
Extension: Resting symptoms: quality, quantity, symptom response. With your knees straight, hands on your hips, bend backwards
Inclinometer at the T12 spinous process provides a measure in degrees of total flexion, extension. The amount measured combines motion available at the lumbopelvic and hip regions.
Lumbar Exam: Prone Instability Test
Practice/Describe/Think it through
○ Trunk supported feet on floor. Perform a central PA PAIVM on the symptomatic segment. Patient lifts the legs < 6 inches Central PA PAIVM is repeated. Patient note change in symptoms. Test: + if the symptoms on first part of the test disappear on the second part of the test. Pain present with the initial central PA PAIVM, but not present with lifting the legs (activating spinal extensors) suggests that stabilizing the symptomatic segment.
Picture: part 2
Lumbar Exam: Trunk Muscle Endurance Tests: Flexor Endurance
Practice/Describe/Think it through
○ Subjects sit on the table with the upper body against a support with angled at 55°. Both the knees & hips are flexed to 90° with arms folded across the chest, hands placed on the opposite shoulder; feet stabilized manually or under straps. Subjects maintain the body position while the wedge is pulled back to begin the test. The test ends when the upper body falls below 55°.
SIJ Profocation Tests: Thigh Thrust (P4)
Practice/Describe/Think it through
■ Thigh thrust: Hip flexed to 90 ° and knee comfortably flexed, apply a downward vertical force through the femur. Stabilize the sacrum with one hand & encircle the flexed knee. The force provides a posterior SIJ shearing force on that side.
Picture: PT is standing on contralateral side. Don’t forget to put a towel or hand under sacrum!!
Hip: Scour Test
Practice/Describe/Think it through
To assess for hip OA475 or determine hip joint irritability. +LR 2.4 and -LR 0.51 for OA. Flex and adduct the hip until resistance to movement is noted. Maintaining the flexion, the hip is gently moved into abduction bringing the hip through 2 full arcs of motion. If the patient has no pain, repeat the test while applying long-axis compression through the femur. Use good communication so as not to exacerbate symptoms. Patient rates pain on a 1-10 NRS. A + test is provocation
Hip: Accessory Motion: Hip anterior glide
Practice/Describe/Think it through
● Anterior glide: In prone with the hip extended to neutral or near end range the clinician applies an anteriorly directed force over the posterior aspect of the greater trochanter or over the proximal femur just distal to the ischial tuberosity. The knee may be flexed or extended.
Lumbar: Lateral Flexion with OP
Practice/Describe/Think it through
▪ Lateral Flexion, OP: stabilize the pelvis on the side opposite the lateral flexion and applies OP through the opposite shoulder into lateral flexion.
Lumbar: SLR (ipsilateral and contralateral)
Practice/Describe/Think it through
- Patient supine; test uninvolved side first; 1 hand under ankle; 1 above knee. Passively lift into hip flexion; keep hip in neutral & knee extension until symptoms are produced or significant resistance is reached. Note onset of resistance, hip flexion angle, and symptoms. Use an inclinometer zeroed on proximal tibial crest to measure hip flexion angle. Avg ROM of the L and R sides > 91° is a key factor in a CPR to consider if a patient will benefit from a lumbopelvic stabilization program.413 Distinguish between familiar symptoms and symptoms due to HS tightness - which is not a positive test. (sensitizign manuver ankle DF or PF).
- Contralateral performed the same way, except s/s are reporduced in leg that stays on table
- Can use ipsilateral to rule in HNP; contralateral to rule out HNP.
Picture: do not use a head pillow (ulness you use it each time you reassess)
Lumbar Exam; PPIVM Flexion
Practice/Describe/Think it through
Assess passive physiological flexion, extension and segmental motion of L5- S1 through T10-12 and determine if movement at an appropriate spinal segment reproduces the patient’s symptoms and whether the segmental motion is normal, hypomobile, or hypermobile for purposes of diagnostic classification and guiding intervention. Diagnostic utility is discussed in chapter 3.
■ Flexion: Patient in sidelying in neutral lumbar spine with knees flexed. Face the patient supporting the uppermost leg or both legs at the ankle with the knees resting on the clinician’s thigh. Use the middle or index finger of the other hand to palpate the L5-S1 interspace. A neutral position for each segment is the starting position. Slowly bring the hips into flexion to recruit motion at each segment. Assess the amount of opening at the interspinous space.
Hip: Extension MMT
Practice/Describe/Think it through
■ MMT Extension: While stabilizing the pelvis in prone with the hip at end range active extension, the clinician provides a force directed into flexion. The patient is asked to resist this force. If poor trunk control is noted and to enhance the control of prone extension, performance of the abdominal drawing-in maneuver (ADIM) is advised to limit excessive anterior pelvic tilt and minimize over activity of the superficial spinal extensors.
Lumbar: ASLR
Practice/Describe/Think it through
○ Supine legs straight, feet 20 cm apart. Patient raises 1 leg at a time 8 inches without bending the knee Score the effort needed to raise the leg on a 6-point scale: not difficult at all = 0, minimally difficult = 1, somewhat difficult = 2, fairly difficult = 3, very difficult = 4; unable to do = 5. Both sides are added totaling score from 0-10. A score of 1 or higher is a positive test suggesting a lack of dynamic stabilization and impaired load transfer. Observe for poor motor control strategies such as breath holding, thoracolumbar rotation, pelvic rotation to stabilize the thorax, low back, and pelvis. ASLR is then repeated with manual or belt compression through the ilia and any change in effort or pain is noted.
Lumbar Exam: Passive Lumbar Extension Test
Practice/Describe/Think it through
Note: none of our professors use this
○ Patient prone: Passively elevate both LE at the same time about 12 inches from the table while keeping the knees straight & gently pulling the legs. Assess response during elevation of both legs and on return. During elevating both legs the test is + with complaint of strong LBP, or a feeling as if the low back is coming off; and if the pain goes away with leg lowering. Mild numbness or prickling sensations are not a + test.
Lumbar Exam: Neurodynamics/Muscle length: Prone Knee Bend
Practice/Describe/Think it through
■ If symptoms change, neural mechanosensitivity is implicated. If symptoms do not change, somatic tissues are implicated.432, 433 For both the prone and sidelying versions of this test: an increase or reproduction of the patient’s familiar symptoms, asymmetry between uninvolved to involved sides, a positive sensitizing maneuver describe a positive test. Symptoms of pulling or pain related to tension on the rectus femoris or quadriceps, or hip or knee somatic structures are normal responses. Symptoms may also refer from the lumbar spine or hip.
Prone knee bend
- Prone Knee Bend For neurodynamics: Perform in prone; or sidelying the slump knee bend test. In prone with the hip in neutral and the pelvis stabilized, passively flex the knee attempting to differentiate symptoms from the lumbar spine, hip, knee, quadriceps or neural tissue mechanosensitivity. The addition of hip extension may be used as sensitizing maneuver, but still allows movement of various somatic structures.
Lumbar Tx: Right Supine Lumbopelvic Manipulation
Practice/Describe/Think it through
○ Right Supine Lumbopelvic Regional Thrust Manipulation. Patient supine with fingers interlocked behind the head. PT opposite the side to be manipulated & passively moves the patient into lateral flexion toward the side to be manipulated.Maintain the laterally flexed position, place thrust hand on ASIS.Passively rotate the patient toward.Perform HVLA thrust to the ASIS in a posterior and inferior direction.
PGP: Motion Palpation; standing hip flex/Gillet/Stork
Practice/Describe/Think it through
■ Start position; palpate S2 spinous process with the left thumb; the right thumb is on the right PSIS and hand on ilium. In standing the patient is asked to raise the right knee toward the ceiling (i.e., flex the right hip). The clinician maintains palpation of the S2 spinous process with the left thumb; the right thumb on the right PSIS and hand on ilium & monitors movement of the right PSIS & ilium. The right ilium should move into posterior tilt relative to the sacrum. Compare left and right sides. Theoretically, the PSIS that does not move posteriorly and inferior relative to S2 is considered a positive test.
Lumbar Exam; PPIVM Extension
Practice/Describe/Think it through
■ Assess passive physiological flexion, and extension segmental motion of L5- S1 through T10-12 and determine if movement at an appropriate spinal segment reproduces the patient’s symptoms and whether the segmental motion is normal, hypomobile, or hypermobile for purposes of diagnostic classification and guiding intervention. Diagnostic utility is discussed in chapter 3.
■ Extension: In sidelying in neutral lumbar spine with hips and knees flexed. Facing the patient supporting the uppermost leg or both legs at the ankle with the knees resting on the clinician’s thigh. Use the middle or index finger to palpate the L5/S1 interspace. A neutral position for each segment Is the starting position. Slowly bring the hip or hips into extension to recruit motion at each spinal motion segment. Assess the amount of closing at the interspinous space.
Hip: Hamstring length at 90/90
Practice/Describe/Think it through
● Zero inclinometer on the upper tibial anterior border. In supine the untested LE is stabilized on table with the knee extended. The clinician holds the tested LE in 90° of hip flexion and passively extends the knee to end range of HS length. A + test is asymmetry from side-to-side. Relevance is based on clinical experience. Normative data are not available for either test position.
I found another note saying zero inclinometer on table, not on pt
Lumbar: Extension with OP
Practice/Describe/Think it through
▪ Extension, OP: the clinician steps behind the patient whose arms are crossed and places one hand at the lower lumbar region while the other hand reaches across the upper body to provide OP into extension.
Hip: ER MMT
Practice/Describe/Think it through
■ MMT External Rotation: In sitting with the hip at end range active ER, the clinician stabilizes the lateral knee and applies a force directed into internal rotation. The patient is asked to resist this force.
Lumbar Exam: Muscle Performance; Deep Trunk Muscles: TrA palpation and ADIM (include biofeedback and prone)
Practice/Describe/Think it through
TrA palpation and ADIM
- In supine hooklying & neutral spine posture, gently palpate 2 cm medial & inferior to the ASIS. At the end exhalation, the patient performs a slow, gentle TrA contraction (i.e, 15% of max) by drawing the navel in toward the spine & up toward the chest -AKA the abdominal drawing-in maneuver (ADIM). If the muscle contracts properly, an increase in deep tension is palpated. Hold the contraction for 10 sec. Cues for women: gently lift your pelvic floor; men: imagine gently lifting the testicles. Note: abdominal bulging an abnormal response during the ADIM
TrA activation with biofeedback pressure unit
- Supine: In hooklying the cuff is placed under the lumbar spine and inflated to 40 mm Hg. The procedure for TrA activation is the same as for palpation. A successful contraction is an increase of 0-5 mm Hg and the ability to maintain the change in pressure. A firm or hard surface is recommended to minimize measurement error. The addition of a series of leg loading activities such as unilateral heel slides may be used as a progression.
- Prone: The cuff is placed under the abdomen with the navel in the center and the distal edge of pad in line with the ASIS on both sides. Inflate the cuff to 70 mm Hg and allow the reading to stabilize. The dial moves with normal respiration. TrA activation is the same as for palpation. A successful contraction lowers the reading by 6-10 mm Hg. A change of < 2 mm Hg, no change, or an increase suggests the person is unable to correctly contract the TrA. May also be used to monitor trunk stabilization with arm movement.
Lumbar Tx: Right Sidelying Lumbar Thrust Manipulation
Practice/Describe/Think it through
○ Right Sidelying Lumbar Spine Thrust Manipulation or Mobilization Targeting L4/L5 Segment. Patient side-lying, painful side up. Flex top hip until motion is felt at the L4-L5 interspinous space & place the patient’s foot in the popliteal fossa. Maintain position, grasp the lower shoulder/arm to introduce SB & rotation until motion is felt at L4-L5. Maintain the setup, position the patient’s arms around the clinician’s arm & log roll toward. Apply HVLA thrust manipulation to the pelvis in an anterior direction using the right arm. May be used as a rotational mobilization.
PGP: PPIVM (also used as tx called Oscillatory Ileal Sidelying): Anterior Tilt of the ilium
Practice/Describe/Think it through
○ Anterior Tilt of the ilium
■ Passive physiological motion tests: Anterior and posterior tilt of the ilium commonly performed in sidelying; while supporting the uppermost knee in the clinicians abdomen or resting on top of the other leg table supported on a pillow, the SIJ is taken through full range of motion into anterior tilt and posterior tilt by gently grasping the ilium in both hands. Reliability and diagnostic accuracy are unknown. Can be done from behind the pt too (easier that way) but I forgot the exact hand placements.
Hip: IR/ER AROM/PROM/OP
Practice/Describe/Think it through
○ Internal/External Rotation
■ ROM/OP Internal/External Rotation (sitting, supine, prone): In sitting with the hip in 90°of Flex and 0° abduction or adduction, ask the patient to bring the foot up and out/in, OP is applied as indicated. In supine, ask the patient to turn the foot out toward the side or the clinician passively performs IR/ER with OP. In prone, IR and ER can be assessed with the hip in neutral Flex, ABD, and ADD.
■ In prone, the hip on the side to be tested is in line with the body with the knee flexed to 90°. Inclinometer is zeroed on the distal fibula. IR measured at the point when the pelvis first begins to move.Interrater reliability (ICC 0.95- 0.97). At least one hip with > 35° of IR measured in prone is a key factor in a validated, CPR that identifies patients with LBP who may benefit from manipulation
SIJ Provocation: SIJ Sacral Thrust
Practice/Describe/Think it through
○ Sacral Thrust: In prone apply a posterior to anterior force to the center of the sacrum purported to produce an anterior shearing force of the sacrum on both ilia. A + test occurs when the patient’s familiar symptoms are reproduced or increased, but the test does not indicate a specific pathology or help direct treatment.
Hip: Accessory Motion: Hip posterior glide at 90 degrees flexion
Practice/Describe/Think it through
■ Hip posterior glide at 90 degrees flexion
● Posterior glide: In supine with the hip passively flexed to 90 °, the clinician applies a posteriorly directed force in line with the long axis of the femur.
Lumbar: Supine Palpation
Practice/Describe/Think it through
○ Area of pain and other structures PRN
○ Begin at the iliac crests and move anteriorly to the ASIS looking for symmetry. By flexing and abducting the hip, attachments of the rectus femoris and tensor fascia lata to the ASIS become easily palpable. With the thumbs on the ASIS the fingers will reach to the lateral aspect of the thigh for palpation of the greater trochanter and gluteus medius. From the ASIS to the pubic tubercle on each side, palpate the inguinal ligament and pubic symphysis. The superior border of the femoral triangle is the inguinal ligament. Below the inguinal ligament is medial border of the adductor longus and lateral border of the sartorius. Within the femoral triangle, from lateral to medial, are the femoral nerve, femoral artery with a palpable pulse, femoral vein, and lymph nodes. Includes any area of the patient’s symptoms: Areas or structures might include the iliac crest, ASIS, pubic symphysis, anterior hip or groin, and abdomen. For the abdominal area general inspection, observation of breathing patterns, palpation, percussion, & auscultation procedures may be needed.
Lumbar Exam: Modified Thomas Test
Practice/Describe/Think it through
■ Patient sits at end of table & lies down while bringing both knees to chest. The patient maintains one side in hip flexion keeping the lumbar spine & sacrum flat. The clinician passively lowers the tested limb over the end of the table towards the floor. The thigh should touch the table. Observe to see if the hip is in neutral or flexed in the sagittal plane and whether neutral or abducted in the frontal plane. The lower leg should be in neutral rotation with the knee flexed. Compare both sides and observe asymmetry. To differentiate between the 1- & 2-joint hip flexors when the thigh does not touch the table, extend the knee to place the 2-joint hip flexors on slack. If hip extension increases, the 2-joint hip flexors are implicated. If there is no change in hip extension, the 1-joint hip flexors are implicated. Abduction or ER of the thigh suggests TFL tightness. If the thigh is abducted, bring the thigh to neutral. If hip flexion increases, the TFL-ITB is short. If knee flexion is < 80°, a short rectus femoris is suggested.
Lumbar: REIL with clinician OP
Practice/Describe/Think it through
○ REIL with clinician overpressure: Use a cross-arm technique to place one hypothenar eminence of each hand over the transverse process of the same segment. Lean forward to produce a gentle, symmetrical pressure as the patient performs REIL. The clinician allows the motion to occur. If the pressure produces more pain, direction-specific) or mobility deficit classification may be present. If the pressure decreases symptoms or creates centralization, a direction-specific exercise classification is likely.
PGP: Motion Palpation; Supine to sit/long sitting
Practice/Describe/Think it through
■ Compare the lengths of the inferior aspects of medial malleoli. A shorter leg compared to the opposite side suggests a posteriorly rotated innominate. Theoretically, a posterior innominate rotates the acetabulum superior carrying the leg with it giving the appearance of a short leg while supine. Hold the inferior medial borders of the medial malleoli with the thumbs; the patient comes to a long-sitting position.Apparent lengthening of the short leg, an observable minimum difference between the supine & long-sitting position estimated visually at 2.54 cm is a positive test. The reverse would occur with an anteriorly rotated innominate.
Don’t Forget the Webber-Barstow maneuver before (pictured)
Lumbar Tx: Neurodynamics: Left leg neural mobilization
Practice/Describe/Think it through
○ After ruling out the presence of centralization or peripheralization, the patient started RFIL, plus left leg neural mobilization. With the hip at 90° flexion the knee was actively extended with the ankle in neutral to symptom onset (Figure 4-122) for 6-8 reps 5-6 x/day followed by 10 reps of REIL. Exercises progressed to repeated flexion in sitting with the left knee extended and then repeated flexion in standing. After 6 sessions & a 5-month follow-up the patient was asymptomatic for 4 wks.Flexion AROM significantly improved, sensation was normal, left SLR was 80° with hamstring tightness only, but the left Achilles reflex was still diminished.
Lumbar Exam: Neurodynamics/Muscle length: Quadriceps Length
Practice/Describe/Think it through
■ Prone Knee Bend for Quadriceps Length: Performed in prone. While preventing anterior pelvic tilt & lumbar spine extension, passively flex the patient’s knee. Measure knee flexion with an inclinometer placed over the distal tibia & zeroed to the horizontal. A + test is side-to-side asymmetry. Relevance is based on clinical experience. Normative data are not available. ICC = .91 (.80, .96)
Lumbar Exam: Knee Flexion MMT
Practice/Describe/Think it through
PGP: PAIVM: Sacral Nutation and counternutation (PA glide at S1 through S5)
Practice/Describe/Think it through
○ Sacral nutation and counternutation (PA glide at S1 through S5)
■ Passive physiological motion tests: Sacral nutation (relative posterior tilt of the ilium); apply a PA force to the base of the sacrum centrally; assess mobility and pain response. Sacral counternutation (relative anterior tilt of the ilium): apply a PA force to the apex of the sacrum.
Lumbar Tx: Manual Traction
Practice/Describe/Think it through
Lumbar lateral flexion in sidelying and lumbar traction in supine (two versions)
- Lumbar lateral flexion in sidelying away from the painful side at the affected level for 60 sec at a frequency of 1 Hz to increase the size of the intervertebral foramen.
Picture: hold above the malleoli so you don’t traction the ankle joints too
Lumbar Tx: Right Sidelying Lumbar Mobilization
Practice/Describe/Think it through
○ Right Sidelying Lumbar Spine Thrust Manipulation or Mobilization Targeting L4/L5 Segment. Patient side-lying, painful side up. Flex top hip until motion is felt at the L4-L5 interspinous space & place the patient’s foot in the popliteal fossa. Maintain position, grasp the lower shoulder/arm to introduce SB & rotation until motion is felt at L4-L5. Maintain the setup, position the patient’s arms around the clinician’s arm & log roll toward. Apply HVLA thrust manipulation to the pelvis in an anterior direction using the right arm. May be used as a rotational mobilization.
Same position as Manip
Hip: Flexion MMT
Practice/Describe/Think it through
○ MMT Flexion: While stabilizing the trunk in neutral sitting and the hip at end range active flexion, the clinician applies an inferiorly directed force on the distal thigh. The patient is asked to resist this force.
(this is different from what we learned last year - we learned it last year with pt supporting self with hands back on table, PT only pushing on distal femur.)
Hip: IR MMT
Practice/Describe/Think it through
■ MMT Internal Rotation: In sitting with the hip at end range active IR, the clinician stabilizes the medial knee and applies a force directed into external rotation. The patient is asked to resist this force.
PGP: PAIVM: Pelvic girdle AP
Practice/Describe/Think it through
■ Anterior-to-posterior (Figure 4-140) is assessed in supine; apply an AP glide through the ASIS on one side and compare to the opposite side or apply bilaterally. Assess mobility and symptom response; compare sides for asymmetry. Posterior-to-anterior movement is assessed in prone; apply a PA glide through the PSIS on one side and compare to the opposite side. Assess mobility and symptom response.
Practice/Describe/Think through
Lumbar: Lateral shift correction (manual)
- Patient stands feet together shoulder-width apart , near side elbow is flexed to 90°. PT applies gentle repeated & sustained side gliding mobilization. Pulls patient’s hips and pelvis horizontally with counterpressure to the trunk in a horizontal plane to produce a lateral shearing motion rather than lateral flexion. Use a rhythmic oscillation interrupted by pressure sustained for a few seconds until obstruction to motion is achieved. A solid resistance to the side gliding pressure is felt at first, but over time (variable) the resistance appears to “soften” and a greater range of motion is achieved. Extension is added if centralization occurs.
- Once full correction of the lateral shift is achieved the second component of the procedure follows. Restoration of lumbar lordosis. The patient is asked to bend backwards while the manual shift correction is maintained. This is also repeated in a rhythmical fashion until as much extension is achieved as possible.
Picture: pt’s right elbow is bent at side.
Lumbar Exam: Multifidus Activation/Palpation
Practice/Describe/Think it through
- Multifidus palpation (prone)
- Palpate at each segment next to SP with the patient relaxed. Compare side-to-side at the symptomatic, segmental level because segmental atrophy has been noted on MRI.502To preferentially activate the MTF, gently & slowly contract & swell out the muscles under the clinician’s fingers without moving the spine; palpate for deep tension in the muscle. The goal is to hold for 10 sec while breathing naturally.If able to perform correctly test 10 reps with 10 sec holds for endurance. Incorrect activation occurs if no tension is palpated, rapid superficial tension develops, superficial thoracic erector spinae are activated and palpable resulting in stiffness or arching of the spine. Cues for MTF activation are asking the patient to draw the PSISs together, gently lift the pelvic floor, or perform the ADIM.
- Multifidus palpation using contralateral arm (prone)
- Activate & palpate MTF in prone through a contralateral, UE lift of 5 cm (2 inches) with the shoulder abducted to 120 degrees and the elbow flexed to 90 degrees. A small hand weight is normalized to the patient’s body mass. During fine-wire EMG this process engages about 30% of the MVIC of the multifidi.
Lumbar: Neurodynamics; Slump Test
Practice/Describe/Think it through
▪ Purpose: to test neurodynamics of neuromeningeal structures in the vertebral canal and intervertebral foramina & mobility of the PNS of the LE in subjects with spinal & lower limb pain. High interrater reliability (k=.83). Pain of non-neural origin (i.e., experimentally induced) was not exacerbated by the slump tests. Diagnostic accuracy: Sn .84 (.74-.90), Sp .83 (.73-.90), +LR 4.94, -LR .19 in patients with and without lumbar disc herniations on MRI.
▪ Care is required at each step to assess range of movement, quality of movement, and symptom response. If symptoms are produced at any step in the procedure, the clinician attempts to differentiate between neural and non-neural structures by assessing the patient’s response to the release of neck flexion.
▪ Patient: Sitting with thighs fully supported, knees together, hands behind back. Begin on uninvolved side. Explain procedure & establish resting symptoms. Assess response after each step. Ask patient to slump; do not allow neck flexion. Gently OP thoracic/lumbar spine keep sacrum vertical. Add active neck flexion, then OP. Add active left knee extension. Add active left ankle dorsiflexion. If no response at this step, add hip flexion which is generally not required. Repeat steps 5 & 6 with right leg (involved side). Repeat steps 5 & 6 with both legs PRN. When symptoms are reproduced, release neck flexion: assess response. If symptoms decrease or disappear, increase range of the limited side until symptoms are once again reproduced.
Practice/Describe/Think through
Lumbar: Functional Activity, Squating
During a functional squat such as sit-to-stand from a chair, the thoracic and pelvic spine alignment of a neutral pelvis and spinal curves should not change. Keeping the trunk over the base of support forward movement of the trunk occurs as the hips and pelvis move posteriorly. The pelvic girdle anteriorly tilts on the femoral heads; the hips, knees, & ankle flex. The knees remain centered over the foot without varus, valgus or rotational movements. Deviations from these positions suggest altered motor control strategies. For example, an increase in lumbar lordosis suggests over activation of the erector spinae. A loss of lumbar lordosis may suggest hip mobility deficits. Excessive forward trunk lean due to limited ankle dorsiflexion (Part 1). Increased range of ankle dorsiflexion results in improved forward trunk lean (Part 2).
