Lumbar Spine Flashcards
Reflexes
(5)
L3-L4 - Patellar
L4-L5 - Tibialis Posterior
L5-S1 - Medial Hamstring
S1-S2 - Lateral Hamstring
S1-S2 - Achilles
SLUMP
Lumbar Radiculopathy
Patient in sitting w/ legs unsupported
Procedure:
- PT instructs the patient to place hands behind back, go into slump posture (rounded shoulders) bringing thier chin to their chest
- PT passively extends the uninvolved knee then repeats the test on the involved side
- If symptoms have not been reproduced ankle DF is added
- If symptoms of low back pain/ radiating pain in posterior leg are recreated, ask patient to extend their neck while maintaining a rounded back
(+) =
- relief of symptoms when patient extends neck indicates neural tension/restriction of lumbosacral roots
- It can also be interpreted as a restriction of the dura/neural tissues
- If symptoms are reproduced at any stage futher sequential movements are not attempted
Special Test: Straight Leg Raise (SLR)
Lumbar Radiculopathy
Patient lying in supine
Test unaffected side first
Procedure:
- PT slightly adducts & medially rotates patient’s hip, keeping the knee in full extension
- PT flexes patient’s hip (w/ knee in full extension) until the patient indicates pain or rightness in posterior thigh
- Therapist slowly lowers leg slightly until pain or tightness disapears
- PT dorsiflexes the foot or alternately asks the patient to flex their neck to verify if are symptoms reproduced
ROM explained:
- Before 35 degree nerve slack bring taken up
- At 35 root is under tension
- At 60-70 sciatic roots tense over disc
- > 70 degree pain is likely MSK (hamstring stretch)
LLTT
(Lower Limb Tension Test)
Bias (3) Nerves
Sural nerve = Inversion + DF (SID)
Tibial nerve = Eversion + DF (TED)
Peroneal nerve = Inversion + PF (PIP)
Crossover sign
When performing a SLR, on the unaffected side, the patient experiences pain in the affected leg
Indicates a LARGE disc buldge - pulling nerve root INTO disc buldge - causeing compression > S/S
Also known as Well Leg raising test of Fajersztajn or Lhermitt’s Test (test & sign are different)
Sign of the Buttock
Procedure:
- the PT performs a SLR until the point of restriction
- The PT proceeds to flex the knee to see whether an increase in hip flexion may be achieved
(+) =
- Hip flexion does NOT increase when the knee is flexed
- Indicates pathology behind the hip joint in the buttocks
Ex. bursitis, tumor, or abscess
REFERRAL - could be something sinister
Bow-string Test
Lumbar Radiculopathy
Follows a positive SLR
- While maintaining the SLR position which reproduced symptoms, the PT slighly flxes (20 degrees) the patient’s knee to reduce symptoms
Procedure:
- The PT then puts pressure into the popliteal area using his/her thumbs or giners
(+) = Reproduction of radicular symptoms
Indicates pressure or tension on sciatic nerve
Spinal Stenosis
Narrowing of the central canal (central stenosis) &/or interverterbral foramen (lateral stenosis)
- Common age of onset > 60 years old
- Insidious onset
- May be d/t osteophytes, spondylosis, or ligament thickening (ligamentum flavum)
- Stenosis may or may not be symptomatic
- May compress nerve roots or spinal cord
- May result in neurogenic claudification
Better w/ Flexion (opening IVF)
- Ie. Sitting, leaning forward, “shopping cart sign”, foot on stool (hip flexion = post. pelvic tilt = L/S flexion
Worse w/ Extension (closing IVF)
- Ie. standing, walking
Cook’s Rule
(5)
Spinal Stenosis
- > 48 years old
- Bilateral symptoms
- Leg pain worse than back pain
- Pain w/ walking or standing
- Sitting relieves pain
3 out of 5 positive
Spinal Stenosis: DDx - Intermittent Claudification
(4)
Page 142
- Pain or cramping that occurs in the buttock or legs (especially calves) as a result of poor circulation to the affected area
- INC pain with INC activity d/t increased energy demands on the mm which has poor circulation
Anaerobic > aerobic = INC lactic acid = INC uncomfortable = cramping - DEC pain at rest (even in standing positon) - catch up their metabolism
- Must differentiate between Intermittent Claudification & Neurogenic Claudification
SEE CHART ON 142
Spinal Stenosis: Intervention
(2)
PT Management:
- Flexion based exercises & positioning (knees towards chest)
- Avoidance of aggravating movements & positions
Prone: aggravating so maybe more supine/ crook-lying / z-lying (legs up on the chair)
Surgical Management
- Laminectomy (spinal decompression)
MAXIMUM protection - limit rotation - “log-rolling”
Disc Herniaton
Description & Types (4)
Migration of nucleus polposus away from its typical positon (central - slightly posterior
- Common age of onset is 30-50 years of age
>60 yo - less likely they have a disc bulge b/c as we age out discs dry out - dehydrates & annulus fibrosis becomes more fibrotic = less mvmt & less likely to herniate - ACUTE onset
- Disc herniations may or may not be symptomatic (PCE = symptomatic)
- 80-90% of disc bulges/herniations are postero-lateral
- May compress nerve root in the direction of herniation potentialy causing radicular signs & symptoms
Types:
1. Protusion (Pro-T)
2. Prolapse (Pro-L) - Little bit more migration BUT still contained
3. Extrusion - has gotten out of fibers - free nuclear materal
4. Sequestration (symptoms resolve faster)
Postero-Lateral Disc Herniation:
Symptoms
(6)
- Flexion mechanism of injury
- Worse w/ flexion
Ie: lifting from floor, sitting - Better w/ extension
Ie: standing, walking, lying prone < may still be a load toleramce - Worse in morning - sleeping = unloaded position - no gravity influencing HYDROSTATIC pressure > refills disc > “more bulgy = more pressure on nerve root
- Worse w/ coughing, sneezing, or Valsalva manuever
- May present with lateral shift (listing) AWAY from the side of buldge
- LABEL top segment - Bulge is LT but shifting to the RT
- More w/ LATERAL than posterior
Dynamic Disc Theory - High > Low
FLEXION = Anterior > posterior
Disc Bulge: Interventions
2 Types - 4 + 1
PT Management:
- Directional perference exercises & positioning (MDT - Mackenzie approach)
Postero-lateral bulge (posterior derangement)
- Typically perfer extension-based exercises & mvmt such as reapted extension in (prone) ling (REIL)
- May use lumbar roll to promote extension in sitting - cobra
Not causing extension BUT less flexion
- Typical progressions:
Prone lying > Prone w/ 1-2 fists under chin > prone on elbows > extensions in lying > extensions w/ OP > extensions in standing
Lateral bulge (lateral derangement)
- Typically perfer movements in lateral direction (side glides) TOWARDS the direction of the bulge
- Hips to wall w/ pt who have poor kinesio-awareness
Anterior bulge (anterior derangement)
- Typically prefer flexion-based exercises & movements such as repeated knee to chest in (supine) lying (RFIL)
- No nerves to impede BUT annulus fibrosis have nocicptors that can be damaged / refer pain (Never down the leg)
- Exercises may be painful initially but must complete entire set in order to evaluate its effect on the patient’s symptoms - looking for CENTRALIZATION - priority
- Green / yellow / red light systems
- Green: keep going w/ the exercises - got centralization
- Yellow: intensity is more BUT still achieved centralization
- Red: peripheralization - STOP May have showed preferential direction in clinic BUT may not be ready for the load, etc - Avoidance of aggravating mvmt & positions
Surgical Management:
- Surgery (laminectomy, discectomy) if necessary - avoid spinal mvmt early in post-op
- Anything surgeon recommends - log-rolling, etc
Posture Dysfunction: Pelvic (Lowered) Cross Syndrome
Imbalance pattern which promotes increased lumbar lordosis
- Overactivity of hip flexors compensate for weak abdominals leading to anterior pelvic tilt
- Overactivity of hamstring & erector spinae mm compensate for weak glutes to assis in hip extension\
- Hamstrings also become tight in an attempt to posteriorly rotate the anteriorly rotated pelvic
- Short spinal mm (ie. multifidus, rotators) show weakness < inner unit mm
Abominals (lengthened & weak)
ASIS low
Iliopsoas (tight)
Erector spinae (tight)
PSIS higher
Gluteals (lengthened & weak)
Hamstring tension (tight)
Spondylosis
Description & Characteristics (6) & Insidious Onset Details (5)
Degenerative changes in spinal motion segment (vertebral body & disc)
- Increased incidence w/ age
- Typically, age > 50 (natural part of aging)
- Typically presents with loss of lordosis - flat L-spine indicates degeneration
- Results in INC stiffness & potentially mm spasms & back pain (ache)
- Worse with prolonged FLEX, EXT, sitting & standing = prolonged & loaded
- Better with lying in unloaded positions (ie supine, side-lying), positon changes, and gentle movement & activity
Insidious onset:
- Loss of disc height (DDD)
- Approximation of vertebral bodies
Dehydration of discs > vertebral bodies get closer > PSEUDO-laxity - ligaments on either side of bone are temporarily longer > lexity until osteophyte formation
- Degeneration of plates
- Fibrosis in disc
- Osteophyte formation - bone laid down > fusing together = stiffness
Facet Syndrome
(4)
- Syndrome caused by the facet joints
- Typically, pain is worse w/ compressive stress on the facet joints
- Pain may refer to low back, glutes, hips, groin, or thighs (never below the knees)
- May be tested using coupled or combined movements (physiological & non-physiological)
** Any psotions that close the facet (CPP)
Facet Syndrome:
Coupled Movements
Physiological Coupled Movements Lumbar Spine (normal)
- Rotation & side flexion occur in the SAME direction with FLEXION
Flexion + R SB + R ROT
Flexion + L SB + L ROT
- Rotation & side flexion occur in the OPPOSITE direction with NEUTRAL or EXTENSION
Extension + R SB + L ROT
Extension + L SB + R ROT
Non-Physiological Coupled Movements Lumbar Spine (provocative)
- All movements are opposite to physiological coupled movements (closing space & trying to provoke S/S)
Coupled movements into EXTENSION may be used to rule out facet joint involvement
Lumbar Instability
Decription & 3 Systems
Excessive motion between 2 adjacent vertebra
- D/t ligament damage, fracture, dislocation, joint damage (stenosis, dehydrated discs - period before osteophytes are formed leading to stiffness)
- May be caused by trauma, congenital malformations, long-term corticosteriod use (weaken tissues), or secondary to pathologies (RA, DS, osteoporosis)
IF instability is suspected mobilizations &/or manipulations should not be performed (contraindicated)
Systems:
1. Control System: CNS
2. Active System: Muscles & Neural Tissue
3. Passive System: Ligaments & Congruency of Bones
Clinical Instability:
L/S Muscular Control
7 + 1
Inner Unit Muscles
- Attach segmentally
- Function as stabilizers (tonic mm) NOT prime movers
- Inner unit includes:
Transverse abdominis
Lumbar multifidus
Pelvic floor mm
Diaphragm
- Thought to be neurophysiologically contented - believed if the TA contracts then they all get activated w/ mvmt
- Can often become weak - d/t injury (most often) & pain - issues w/ coordination & timing
- Dysfunction in these muscles can lead to segmental (clinical) instability, potentially leading to aberrant movement between segments or at certain ROM causing pain
Aberrant OR micro mvmts that cause pain
- May also lead to increased recruitment of superficial global muscles in an attempt to maintain stability causing overuse of global musculature
Timing (motor control) & endurance more important than strength
- Anticipatory action prior to movement of limbs & spine
- 30 m/s prior to initation of mvmt > small amount of active stabilization that occurs w/ any INTERNAL perturbation
Active Muscle Systems
Local VS Global
Page 147
Local Muscle System (Inner Unit)
1. Deep muscles
2. Prime stabilizers (isometric endurance)
3. Type 1 fibers (slow twitch)
4. Tonic function
5. Helps control shear force
6. Muscles:
Transverse abdominis
Multifidus
Pelvic Floor MM
Diaphragm
Global Muscle System (Outer Unit)
1. Larger, superficial muscles
2. Prime movers
3. Type II (fast twitch)
4. Phasic function (happens in bursts)
5. Poor ability to control shear forces (no segmental attachments)
6. Muscles:
Rectus Abdominis
External Obliques
Internal Obliques
Erector Spinae muscles
Special Test: H & I Stability Test
Set of movements which tests for mm spasms or possible spinal instability
Procedure:
“H” movement:
- The patient begins in neutral standing positon
- the patient is asked to perform side flexion as far as possible (both are tested, start w/ pain-free direction first)
- The patient is then asked to perform flexion or extension as far as possible (both are tested, start with pain-free direction first)
- Repeat with side flexion to other side
“I” movement
- The patient begins in neutral standing positon
- The patient is asked to perform lumbar flexion OR extension as far as possible (both are tested, start with pain-free direction first)
- The patient is then asked to perform side flexion to one side as far as possible (both are tested, start with pain-free direction first)
- Repeated with side flexion to other side
(+) =
Hypomobility
- At least 2 momvements limited or painful in the SAME quadrant
Instability
- Only 1 movement into the quadrant is affected (may present with pain or instability “jog” > one moment when you feel instability & get pain in that moment BUT after you go past that you are good
- The direction of instability is the movement that is performed in the first phase of movement
- If the movement is performed in the second phase of movement it can be stabilized by the first movement & an instability would not be apparent
** IF “H” or “I” is painful & there other is not = INSTABILITY
Special Test:
Prone Segmental Instability Test
Position:
Patient lies with their upper body prone on the examination table while their legs are over the edge of the table resting on the floor
Procedure:
- PT applied PA pressure on the L/S
- The patient is instructed to lift their legs off the floor
(+) = pain is produced while the legs are resting on the floor, but not present when the legs are lifted off the floor
- Test indicates patient would benefit from core strengthening/stability exercises
Progression of Core Exercises
(4)
- Isolate inner unit
- Train the inner unit (inner unit control during light functional activities)
No trunk movement
Ie. alternate heel slides, alternate leg lifts, bent knee fall-outs - Maintain control of inner unit while training the outer unit
Ie. bridging, resisted trunk rotation - Integrate into function (functional retrianing)
Ie. golf swing
Examples & descriptions of exercises on page 148-149
