Lumbar Spine Competency

Question 1

a. Perform the seated and prone evaluation for lumbar spine Type 1 somatic dysfunction and document appropriately.

Answer 1

• Type I dysfunction has no flexion/extension component, often a group of vertebrae, and side bending and rotation go to opposite sides.

PRONE (Neutral):
- Student places patient prone with the head in neutral, or in position of comfort.

• Student stands at side of table and locates the lumbar spine by moving inferiorly from the thoracic spine/ribs or superiorly from iliac crests (L4)/sacrum.
• Student palpates the transverse process (TP) of L1 with the pads of the thumbs.
• Examiner alternately presses on the L and R transverse processes for L1-5 (load and spring), evaluating for ease of motion and hard end feels/PTPs.
• States this is performed to evaluate R and L rotation.
• Student then places patient in lumbar flexion (“cat back” position) and repeats techniques as above.
• Student then places patient in lumbar extension (“propped/TV watching” position) and repeats techniques as above.
• Student states that if there is no change in end feel between flexed and extended positions, (i.e. doesn’t prefer flexion or extension), this is a Type I Dysfunction
  (grouped segments, side bending and rotation in opposite directions)
• States the group curve would be documented in the objective portion of the SOAP note as L_-_ N S_R_ (Ex: L1-5 N SRRL)

SEATED (Neutral):
- Segmental motion testing can also be assessed by seated loading and springing.

• Patient is seated while examiner stands behind to evaluate transverse processes.
• Student assesses L1-5.
• Passive Side bending (in seated position): examiner monitors the ipsilateral transverse process while pushing down on patient’s shoulder with his/her hand or forearm to induce side bending.
• Passive Rotation (in seated position): examiner contacts the anterior aspect of the patient’s shoulder and induces rotation by pulling the shoulder girdle posteriorly while simultaneously pushing anteriorly on the ipsilateral transverse process (load and spring the segment).
• Student asks patient to bend forward to assess the segment in flexion and performs the same technique as above noting if rotational end feel becomes more symmetric in flexion.
• Student asks patient to sit up straight to assess the segment in extension and performs the same technique as above noting if rotational end feel becomes more symmetric in extension.
• Student states they are able to diagnose a neutral dysfunction by noting no appreciable difference in ease of motion relative to the side bending and rotation in flexion and extension.
• Student states the group curve would be documented in the objective portion of the SOAP note as L_-_ N S_R_ (Ex: L1-5 N SRRL).

Question 2

b. Perform the seated and prone evaluation for lumbar spine Type 2 somatic dysfunction and document appropriately.

Answer 2

• Type II dysfunction has a flexion/extension component, often a single vertebra, and side bending and rotation go to same side.

PRONE (Non-Neutral):
- Patient placed prone with the head in neutral, or in position of comfort.

• Student stands at side of table and locates the lumbar spine by moving inferiorly from the thoracic spine/ribs or superiorly from iliac crest/sacrum.
• Student palpates the transverse process (TP) of L1 with the pads of the thumbs.
• Examiner alternately presses on the L and R transverse processes of L 1-5 (load and spring), evaluating for ease of motion and hard end feels/PTPs.
• States this is performed to evaluate R and L rotation.
• Student then places patient in lumbar flexion (“cat back” position) and repeats techniques as above.
• Student then places patient in lumbar extension (“propped/TV watching” position) and repeats techniques as above.
• States if the segment improves or rotational end feel becomes more symmetric in flexion (thus restricted to or becomes more asymmetric in extension), this is defined
  as a Flexion Type II Dysfunction.
• States if the segment improves or rotational end feel becomes more symmetric in extension (thus restricted to or becomes more asymmetric in flexion), his is defined
  as an Extension Type II Dysfunction.
• Student states the segment would be documented in the objective portion of the SOAP note as L_ F or E S_R_ (Ex: L2 F SRRR).

SEATED (Non-Neutral):
- Segmental motion testing can also be assessed doing seated loading and springing.

• Patient is seated while examiner is standing behind and evaluating transverse processes.
• Student assesses from L1-5.
• Passive Side bending (in seated position): examiner monitors the ipsilateral transverse process while pushing down on patient’s shoulder with his/her hand or forearm to induce side bending.
• Passive Rotation (in seated position): examiner contacts the anterior aspect of the patient’s shoulder and induces rotation by pulling the shoulder girdle posteriorly while simultaneously pushing anteriorly on the ipsilateral transverse process (load and spring the segment).
• Student asks patient to bend forward to assess the segment in flexion and performs the same technique as above noting if rotational end feel becomes more symmetric in flexion. If it does, it is a Flexion Type II Dysfunction.
• Student asks patient to sit up straight to assess the segment in extension and performs the same technique as above noting if rotational end feel becomes more symmetric in extension. If it does, it is an Extension Type II Dysfunction.
• Student states the segment would be documented in the objective portion of the SOAP note as L_ F or E S_R_ (Ex: L2 F SRRR).

Question 3

Motor Exam for Nerve Roots

Answer 3

1) L4 Nerve Root (L4-L5 Disc):
- Ankle DORSIFLEXION

2) L5 Nerve Root (L5-S1 Disc):
- Great Toe Dorsiflexion

3) S1 Nerve Root (S1-S2 Disc):
- Ankle PLANTAR FLEXION

***Spinous processes are on the same plane as the Transverse Processes

***Most Superior portion of the ILIAC Crest corresponds with SPINOUS PROCESS of L4!!!!

Question 4

Gross Motion Testing

Range of Motion

Answer 4

1) Forward Flexion: 105 Degrees
2) Backward Extension: 60 Degrees
3) Side Bending: 40 Degrees
4) Rotation: 90 Degrees

Question 5

Lateral Lumbar Flexion (Hip Drop Test)

Answer 5

• Patient instructed to bend one knee, keeping both feet on the ground, but DISPLACING WEIGHT to the leg that is not bending at the knee
• This causes a COMPENSATORY SHIFT in Body Weight
• Not the amount of Lumbar SIDE BENDING created by the drop in Iliac Crest Height in degree
• NORMAL LUMBAR SIDE BENDING = 25-30 Degrees
• Repeat with Contralateral Side and compare
• If the hop on the unsupported side drops 25 degrees, it is a NEGATIVE TEST (Normal)
• If it does not drop 25 degrees, it is a POSITIVE TEST on the UNSUPPORTED SIDE

Ex: Right Iliac Crest drops 10 Degrees = Positive Right Hip Drop Test ——-> Problem with LEFT SIDE BENDING!!!!!!!

Question 6

Straight Left Raising Test (Lasegue Test)

Answer 6

• Tests for SCIATIC NERVE IRRITATION
• Patient is placed in the Supine position
• With the knee EXTENDED, MEDIALLY ROTATE and ADDUCT to Patient’s Hip
• Then FLEX the hip while maintain Knee Extension
• Continue HIP FLEXION until the patient experiences pain in the BACK of the SYMPTOMATIC LEG
• Symptoms should not be felt until the leg is raised 30 to 35 Degrees
• If pain is felt at a LESSER ANGLE or in the OPPOSITE LEG, there may be a DISC PROTRUSION!!!!!
• The Dura stretches between 30 to 70 Degrees. Pain above this angle may indicate NERVE ROOT IRRITATION, but may also be released to Mechanical Low Back Pain SECONDARY to Muscle Strain or Joint Disease
• Check Seated and Supine for consistency