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MSK II FINAL > Lumbar Spine Examination > Flashcards

Lumbar Spine Examination Flashcards

1
Q

Subjective History:

A

Recently had a major trauma, MVA or fall from a height?

Has a medical professional told you that you had OA?

History of cancer?

Pain at night that wakes you up?

Pain ease when you rest in a comfortable position?

Recently had a fever?

Lose any weight without attempting?

Taking any antibiotics or medications for infection?

Recent onset of difficulty with urine retention?

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2
Q

inflammation of zygapophyseal joints =

A

can cause local back pain or buttock pain

also, with pain referred to the buttocks even below the knee

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3
Q

Functional measures – self-reported inventories

A

Oswestry Disability Index

Roland-Morris

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4
Q

Biopsychosocial considerations

A

Hx of depression or anxiety

Evidence of fear-avoidance (FABQ, Tampa Scale of Kinesiophobia)

Catastrophizing (PCS)

STarT Back Tool (best for screening high risk), OSPRO

Social determinants of health, barriers to Rx (access)

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5
Q

Standing:

A

Observation of movement/posture, LQ screen (ROM, heel/toe walking), Quadrant (Kemp) test

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6
Q

Sitting:

A

Continue LQ screen, Slump test

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7
Q

Supine:

A

Continue LQ screen, abdominal ms strength, LE ms length (HS, hip flexors), SIJ tests

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8
Q

Side Lying:

A

ms length – Ober, ms strength – hip abductors, lateral trunk flexors, palpation, PPIVMs

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9
Q

Prone:

A

Finish LQ screen, accessory motion/PAIVMs (mobility) testing (L1-L5) – central and unilateral PA’s/spring (pain provocation), ms strength – trunk/hip extensors, palpation

Prone instability, passive lumbar extension test

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10
Q

Clinical Examination – Standing

A

Observe: Posture, Gait, Heel walking (L4), Toe walking (S1), Functional movement

Lumbar AROM:
> Quantity, quality (aberrant movement), pain provocation

> Watch lumbopelvic rhythm, Assess response to OP, Measure (inclinometer)
- Flexion, extension, side bending

> Lumbar Flexion – add neck flexion at end range to test for neural irritability

> Quadrant test* = special test

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11
Q

Clinical Examination – Sitting

A

(thoraco) Lumbar rotation ROM

Myotomal testing (L2-L5)

Dermatomal testing (L1-S1)

DTR – Patellar (L3-4), Achilles (L5-S1), Babinski

Slump test*

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12
Q

Slump:

A

-Ask the patient to flex down from the neck
-Stop flexion at the lumbar spine

-Extend the knee, DF the ankle (or DF the ankle and slowly extend the knee)

-Patient may report exacerbation of radicular pain or local LBP

-Ask the patient to extend at the cervical spine only to assess for reduction in symptoms

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13
Q

Clinical Examination – Supine

A

PROM of the hips, knees and ankles

SLR

Vascular tests – palpate pulses, screen for AAA

Abdominal strength

Muscle length (hamstrings, hip flexors)

Rule out SIJ if indicated – compression, distraction, thigh thrust

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14
Q

SLR =

A

Crossed straight leg raise = raise uninvolved leg, reproduce LBP
Indicates lumbar disc herniation

0-35 = slack in sciatic arborization taken up during this range

tension applied to the sciatic roots at this angle

35-75 = sciatic roots tense over the IVD, during this range
> rate of deformation diminishes. as the angle increases

over 75 = practically no further deformation of roots occurs during further SLR

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15
Q

Clinical Examination – Side lying

A

Muscle length – Ober
Muscle strength – hip abductors, lateral trunk flexors
Palpation
PPIVM – passive intervertebral movements

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16
Q

Clinical Examination – Prone

A

Passive knee flexion with hip extension – femoral nerve (prone knee bend – PKB)

Resisted knee flexion (S2)

Accessory motion (mobility) testing (L1-L5) – central and unilateral PA’s/spring
*Pain provocation

Muscle strength – trunk extensors, hip extensors

Prone Instability, Passive Lumbar Extension Test*

Palpation

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17
Q

Clinical Examination – Special Tests

A

The most amount of information from the least amount of testing

Quadrant test
Slump test
Prone Instability test
Passive Lumbar Extension test

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18
Q

Quadrant or Kemp test:

A

Patient stands with feet shoulder width apart

Therapist stands behind the patient, grasping the patient’s shoulders

Patient extends as far as possible, then sidebends, then rotates toward the affected side

Therapist provides OP through the shoulders

Sensitivity 85-100% = if painfree = low chance of lumbar facet problems

A positive test is reproduction of symptoms. If pain is local, unilateral – high sensitivity for facet joint dysfunction.

This test may also reproduce leg symptoms.

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19
Q

Slump:

A

-Ask the patient to flex down from the neck
-Stop flexion at the lumbar spine
-Extend the knee, DF the ankle (or DF the ankle and slowly extend the knee)
-Patient may report exacerbation of radicular pain or local LBP
-Ask the patient to extend at the cervical spine only to assess for reduction in symptoms

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20
Q

Prone Instability test:

A

Part 1: Pt position: relaxed with feet supported
PT provides a PA, If pain is reproduced continue to part 2.

Part 2: Patient lifts legs off the floor
Therapist repeats PA
(+) test = patients symptoms decrease with active muscle contraction

Sn = 61
Sp = 57
Reliability 0.69

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21
Q

Passive Lumbar Extension test

A

Patient prone
Therapist lifts the legs about 30 cm off the plinthe

(+) test = c/o strong pain, heavy feeling or apprehension in the low back

Sn = 84.2
Sp = 90.4

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22
Q

Segmental Mobility testing

A

Passive Physiological Intervertebral Movements (PPIVM)

”Movements performed by the therapist testing the available range of the client.”

Done in side lying

Passive Accessory Intervertebral Movements (PAIVM)
PA
Central
Cranial
Caudal
Unilateral

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23
Q

PPIVM: Lumbar Spine Extension

A

Patient side lying, lumbar spine neutral (use prop under waist if necessary)

Therapist: facing patient
> palpate adjacent spinous processes or interspinous spaces
> caudal hand grasps patient’s shins

passively extend lumbar spine using hips and pelvis as a lever to push away from you

lower spinous process will come towards upper, the interspinous space will get smaller

extending hips and spine further will create motion further up the lumbar spine

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23
Q

PPIVM: Lumbar Spine Extension Indications

A

Assess intersegmental extension
Treat intersegmental extension loss

Very small therapists with larger patients may use just the upper leg as the lever

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23
Q

PPIVM: Lumbar Spine Side Bending

A

Patient: side lying, lumbar spine neutral (use prop under waist if necessary)

Therapist: facing patient
> thread cranial arm through patient’s upper arm at elbow
> caudal arm on pelvis
> palpate adjacent spinous processes or interspinous spaces

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23
Q

PPIVM: Lumbar Spine Rotation
Procedure to rotate from above:

A

Use cranial arm on patient’s thorax as lever to rotate upper spinous process towards plinth

Stabilise lower spinous process and pelvis

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24
Q

PPIVM: Lumbar Spine Rotation
Procedure to rotate from below:

A

Use caudal hand on pelvis to rotate lower spinous process “up” away from plinth

Stabilise upper spinous process and thorax

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25
Q

PPIVM: Lumbar Spine Rotation
Indications

A

Assess intersegmental rotation

Treat intersegmental rotation loss

Left side lying rotate from above or below yields right rotation

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26
Q

Passive Accessory Intervertebral Movements (PAIVM)

A

These are joint gliding movements that test the accessory range of a joint’s movement.

These are movements that are an integral part of the overall joint movement but cannot be actively generated by the client.

They are performed on a specific joint level by the therapist.

They will give you information about the normal, hypo or hyper-mobility of the joint to be tested.

In the periphery these are your accessory joint mobilisations.

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27
Q

Passive Accessory Intervertebral Movements (PAIVM)

Lumbar spine

A

PA
Unilateral PA (on TP)
Cranially directed PA
Caudally directed PA

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28
Q

Aberrant Motion Observation during AROM

A

Purpose: To observe AROM flexion and extension of the lumbar spine for faulty movement.

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29
Q

Aberrant Motion Observation during AROM

Normal:

A

Initiate motion with hip flexion, 70 deg hip flex, 20 deg lumbar spine flexion, Reversal of lumbar spine curve, initiate hip extension first during return to standing

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30
Q

Aberrant Motion Observation during AROM

Abnormal:

A

observe for an instability catch, asymmetrical movement, use hands to walk up to extension (Gower’s sign), painful arc mid range, sudden knee flexion or pelvis shift

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31
Q

Aberrant Motion Observation during AROM

Indication:

A

an abnormal movement pattern can be indicative of lumbar instability

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32
Q

Muscle length Hamstrings: SLR excessive flexibility

A

Purpose: To observe hamstring flexibility

Normal: 70 degrees of hip flexion

Abnormal: greater than 91 degrees of hip flexion before posterior pelvic tilt is felt

Indication: can be indicative of lumbar instability

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33
Q

Capsular pattern –

A

ext>flex, SB and rot equally limited

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34
Q

Subjective Examination (suggesting SIJ dysfunction)

Common complaints:

A

Pain relief while standing

Pain rolling in bed, sit <-> stand or other transitional movements

Pain initiating LSP flexion

Pain at heel strike, one leg stand, ascending &/or descending stairs

Patient choosing asymmetrical sitting posture (e.g. legs crossed)

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35
Q

suggesting SIJ dysfunction
Mechanism of Injury:

A

Unexpected step down

Fall onto hip, especially with feet fixed (skis, bike …)

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36
Q

Pain location descriptions most useful in diagnosing SIJ dysfunction :

A

No LSP pain
Pain below L5
Pain in PSIS region
Pain in groin

SIJ symmetry are NOT useful
> Reliability for identifying positional faults is poor

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37
Q

SIJ Pain provocation tests are useful:

A

Patrick/FABER
Palpation of sacral sulcus (deeper on affected side)
Posterior shear/Thigh thrust
Resisted hip abduction
Iliac compression
Iliac gapping
ASLR

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38
Q

Ankylosing spondylitis

A

bilateral sacroiliac pain may refer to posterior thigh

morning stiffness
male predominance
stiff, controlled pelvis mvmnt
decreased active and pasive mvmnt

pain and weak resisted isometrics

sacral stress tests prob (+)
normal sensations and reflexes

x-ray diagnostic

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39
Q

sacroiliac arthritis

A

bilateral SO pain referring to gluteal area

S1-S2 dermatomes

morning stiffness (prolonged)

coughing painful

controlled pelvis mvmnt

side flexion and extension full AROM
slight limitation of flexion AROM
normal PROM

resisted isometrics - sacral stress tests prob positive

sensation and reflexes normal

palpation tender of SI joints

x-ray diagnostic

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40
Q

SIJ Special Tests

A

FABER’s / Patrick’s test
SIJ Gapping
SIJ Compression
SIJ AP shear (thigh thrust)
Active SLR (ASLR)
Resisted hip abduction

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41
Q

Accessory motion tests

A

Posterior rotation of ilium (on sacrum)

Modified Gaenslen – Nutation

Anterior rotation of ilium (on sacrum)

Modified Gaenslen – Counternutation

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42
Q

FABER’S test

A

(+) SIJ provocation if SIJ pain is reproduced

May also provoke pain at the pubic symphysis

43
Q

SIJ gapping

A

Compression at the ilium causes gapping at the SIJ

You may also seen this done in supine

Ventromedial load through the ilium
(+) if reproduction of symptoms

Low Sensitivity
High Specificity

44
Q

SIJ compression – Iliac gapping

A

Dorsolateral load through both ilia
(+) if reproduction of symptoms

Distraction or gapping of the ilia results in compression at the SIJ

45
Q

SIJ AP Shear / thigh thrust (Ostagaard)

A

Stand opposite the thigh you plan on thrusting

(+) if SIJ pain reproduced

Sn 80-88%Sp 81-89%

46
Q

Active SLR

A

Patient performs ASLR

if pain and compensatory movements noted

therapist provides compression to pelvic ring. If ASLR improves with compression, this indicates poor motor control of pelvic ring stabilizers

47
Q

Resisted hip abduction (SIJ test)

A

Hip positioned at full extension and 50 degrees abduction

Sn 87%
Sp 100%

48
Q

Posterior rotation of ilium on sacrum(Passive physiological nutation)

A

Modified Gaenslen
Nutation

Patient:
in sidelying, bottom leg extended

PT:
> Blocks the bottom leg with knee
Grasps the top ilium at the crest and the IT
> Posteriorly rotates the ilium
> Results in a relative nutation of the sacrum

49
Q

Anterior rotation of ilium on sacrum(Passive physiological counternutation)

A

Modified Gaenslen
Counternutation

Patient:
in sidelying, bottom leg flexed

PT:
> Blocks the bottom leg with hip
> Grasps the top ilium at the crest and the IT
> Anteriorly rotates the ilium
> Results in a relative counternutation of the sacrum

50
Q

Test Clusters

A

Laslett’s
> Thigh thrust, Compression/gapping, Sacral thrust

Van der Wurff’s
> Compression/gapping, Thigh thrust, FABER, Gaenslen’s (passive physiologic nutation/counternutation)

51
Q

Most often primary hip pain is perceived as ____

A

inguinal or groin pain

Look for HIP capsular pattern (IR/Flx/AB»Ext)

52
Q

Posterior hip pain is often referred from ____

A

LSP

53
Q

Pain sitting – be suspicious of ____

A

LSP, don’t ignore ischial bursa

54
Q

Buttock Pain initiating hip or LSP motion especially reciprocal or asymmetrical motions – consider ____

A

SIJ

55
Q

Buttock pain with “one legged” sports (hurdles, high jump, pole vault, soccer, cricket fast bowler, football/rugby kicker …) ______

A

suggests SIJ however, r/o labral tear

56
Q

Recent pregnancy warrants special attention to ____

A

SIJ

57
Q

Pain walking, and eased with 10 + mins sitting, - be suspicious of _____

A

SIJ (BUT don’t forget spinal stenosis)

58
Q

Sign of the buttock (7 signs)

A

Rheumatic bursitis
* Osteomyelitis of the upper femur
* Neoplasm of the upper femur
* Neoplasm of the ilium
* Fractured sacrum
* Ischiorectal abcess
* Septic sacroilitis
* Septic gluteal bursitis

59
Q

sign of the buttock details:

A

Standard examination is performed which reveals the following 7 signs

Buttock large and swollen and tender to touch

Straight Leg Raise (SLR) limited and painful

Limited trunk flexion

Hip flexion with knee flexion limited and painful

Empty end feel on hip flexion

Non capsular pattern of restriction at hip (flex,abd,IR)

Resisted hip movements painful and weak esp hip extension

60
Q

Nerves may be irritated, damaged or constricted by:

A

Scar tissue /adhesions

Swelling

Stretch injury (tension)

other extra neural restrictions, like an osteophyte

close proximity to an unstable joint

61
Q

Neurodynamics

A

Adverse neural tension is an abnormal response of the neural tissue to mechanical stimuli.

Neurodynamic tests are used to understand the mechanical performance and sensitivity of the neural structures and their related interfacing and innervated tissues

62
Q

Neural provocation tests:

A

apply controlled mechanical and compressive stresses to dura and nerve

in a sequential and progressive manner

using longitudinal traction force attempting to reproduce patient symptoms

are performed as special tests towards the end of a full orthopedic evaluation

63
Q

During a joint movement:

A

Slack in the nervous system is taken up (eg SLR 0-35o)
> Whole peripheral nerve moves as does adjacent connective tissue

64
Q

In mid range, there is ___ nerve sliding

A

maximal
(eg SLR 30-70o)

Sliding occurs adjacent to and toward the moving joint (convergence)

65
Q

At end range, ___ builds as nerve sliding ends

A

tension
(eg SLR >70o)

Sliding occurs further from the moving joint

66
Q

When tension is released ____

A

(joint returns to resting position)

Sliding occurs away from the moving joint (divergence)

67
Q

The spinal canal is ___ longer in __ than in ___ (perhaps even longer in hypermobile individuals)

A

5-9cm
flexion
extension

68
Q

Median nerve gliding:

A

9mm median nerve GLIDE with wrist extension (tensioner)

12.6mm median nerve GLIDE with wrist extension and elbow flexion (slider)

69
Q

Does the order matter?

A

Yes!

If the neurodynamic sequence is slightly different, the test is completely different.

The direction of neural sliding is influenced by the order of tension build up

The region moved 1st or strongest is more likely to have a localized response

Greater strain in the nerves occurs at the site of 1st movement

70
Q

Contraindications to Neural provocation and mobilization

A

Malignancies of nervous system
Acute inflammatory infections
Instability in the area
Spinal cord injuries
Worsening neurological signs and symptoms
Cauda equina symptoms
CNS disorders
Suspected disc lesions
Dizziness related to CAD
Extreme pain!!

71
Q

Precautions to Neural provocation and mobilization

A

Do not over lengthen a nerve bed

Do not prolong neural tension

Sustained tension of the nerve bed will quickly lead to ischemia in the nerve

Within 7 seconds, all the beneficial effects of nerve mobilization have occurred, further hold of the position begins to cause ischemia of the nerve

Sit up (don’t slouch) to unload your nervous system AND intervertebral discs!

72
Q

Sciatic Nerve Pathway

A

Largest in body

Sciatic nerve passes through or anterior to piriformis muscle, lateral to ischial tuberosity, anterior to hamstring muscles, before dividing into tibial and fibular nerves somewhere in middle third of the posterior thigh

73
Q

Locations for sciatic nerve entrapment:

A

Low lumbar spine
> IVD
> spinal cord
> IVF

Piriformis muscle

Hamstring muscles

74
Q

Sciatic nerve sensitization:

A

Hip adduction and internal rotation

75
Q

Tibial Nerve Pathway

A

Largest terminal portion of sciatic nerve – popliteal fossa, between heads of gastrocnemius muscle, posterior compartment of shin, posterior to medial malleolus, through tarsal tunnel, plantar aspect of foot as medial and lateral plantar nerves

76
Q

Locations for tibial nerve entrapment:

A

Tarsal tunnel (posterior to medial malleolus, with Tom Dick and Harry)

77
Q

Tibial Nerve sensitization position of the foot and ankle:

A

Dorsiflexion and eversion

78
Q

Fibular Nerve Pathway

A

divides off sciatic tract somewhere in the distal ½ of hamstrings, wraps around fibular neck, through fibularis longus muscle

79
Q

Locations for fibular nerve entrapment:

A

Fibular neck and fibularis longus muscle

80
Q

fibular nerve entrapment: extrinsic factors

A

crossing legs
below knee cast that is too tight
knee high stockings that are too tight

81
Q

fibular nerve entrapment: intrinsic factors

A

fibula fracture
rupture LCL
biceps femoris tendon trauma

82
Q

Fibular Nerve sensitization position of the foot and ankle:

A

Plantarflexion and inversion

83
Q

Fibular nerve muscles:

A

Sup fib nerve: fib long, fib brev

Deep fib nerve: Tib ant, ENL, EDL, fib tertius, EDB

84
Q

Fibular nerve sensory supply:

A

Common fib nerve: lat knee and prox lat 1/3 calf

Sup fib nerve: lateral calf distal half, dorsum foot excluding 1st web space

Deep fib nerve: 1st web space

85
Q

Sural Nerve Pathway

A

emerges to the surface approximately 16 cm proximal to the lateral malleolus by piercing through the fascia (a potential site of entrapment),

enters the foot posterior to the lateral malleolus,

86
Q

Locations for Sural nerve entrapment:

A

compression (piercing fascia as exits posterior compartment)

posterior to lateral malleolus

anywhere along the lateral aspect of the achilles tendon and the foot where it lies against bone and tendon

87
Q

Sural Nerve Sensitization position of the foot and ankle is:

A

Dorsiflexion and inversion

88
Q

In ___ of SLR, the slack or crimp in sciatic nerve is taken up

A

1st 30o

89
Q

Pain provocation in 0-30o of SLR may indicate

A

Acute spondylolisthesis
Tumor in the buttock
Gluteal abscess
Very large disc protrusion
Acute inflammation of the dura
Sign of the buttock

90
Q

Between 30-70o of SLR the spinal nerves & dural sleeves and the roots of L4-S2 stretch ____

A

2-6mm.

91
Q

After 70o there is further tension but no further stretch, also ____ are now involved.

A

hamstrings, gluteus maximus, and the hip sacroiliac and lumbar spine joints

92
Q

Straight Leg Raise TestingSciatic Nerve (& terminal branches)

Test Sequence:

A

Passive hip flexion maintaining full knee extension

Hip must pass 35o to take up slack in the sciatic nerve

At 70o hip flexion sciatic nerve is at maximum length, symptoms after 70o flexion should be attributed to the hip jt, SIJ or lumbar spine (unless the patient is hypermobile, eg ballerina, gymnast, martial artist)

93
Q

Straight Leg Raise TestingSciatic Nerve (& terminal branches)

Positive Test:

A

SLR <70o limited by pain
Pain is neurologic in nature
Pain is “the patient’s pain”

94
Q

Straight Leg Raise TestingSciatic Nerve (& terminal branches)

Sensitization:

A

Cervical flexion may increase symptoms (pulling dura from above)

Hip adduction+internal rotation (sciatic nerve passes lateral to ischial tuberosity)

Ankle dorsiflexion (pulling dura from below)

Thoracolumbar side bend away may increase symptoms

Pre-positioning in cervical flexion

95
Q

Addition of DF+Ev =

A

tibial nerve bias

96
Q

Addition of DF+Inv =

A

sural nerve bias

97
Q

Addition of PF+Inv =

A

fibular nerve bias

98
Q

Slump TestSciatic Nerve (& terminal branches)

A

Slump test is considered a general test of neurodynamic mobility

Assesses excursion of neural tissues within the vertebral canal and IVF and detects impairments to neural tissue mobility from a number of sources.

During full spinal flexion the cauda equina becomes taut and the lumbosacral nerve roots and root sleeves are pulled into contact with the pedicle of the superior vertebra

99
Q

Advantages of Slump over SLR

A

Slump increases the compressive forces through the IVD

Slump highlights the presence of dural adhesions

Slump may reproduce the functional position in which the patient experiences symptoms

Slump may provoke symptoms in a patient with posterior instability of the lumbar spine

100
Q

Slump Testing:Sciatic Nerve (& terminal branches)

patient positioning

A

patient = Seated well back on plinth, hands behind back

therapist = Standing or sitting beside patient

Alternate Sequence = Passive lower extremity movement

101
Q

Slump Testing: Test Sequence

A

Slump (“best slouch you can do”), now adjust the upper body until sacrum is perpendicular to plinth

Guide (but do not push) head and neck into flexion (“chin to chest and keep it there”)

Active knee extension

Active ankle DF

102
Q

Slump Testing: Sensitization

A

Cervical extension should reduce symptoms

DF+Ev = tibial nerve bias

DF+Inv = sural nerve bias

PF+Inv = fibular nerve bias

103
Q

Femoral Nerve

A

Branch of lumbar plexus from ventral rami L2-L4, through psoas, between psoas and iliacus, under inguinal ligament into thigh

104
Q

Locations for femoral nerve entrapment:

A

IVD (L2-4)
Spinal canal
IVF
Psoas major
Between psoas and iliacus
Under inguinal ligament

105
Q

femoral nerve Sensitization:

A

Hip extension & knee flexion

106
Q

Prone Knee Bend TestFemoral nerve

A

Used to indicate presence of upper lumbar (L2-4) disc herniations or nerve root impairments

Dura is stretched at 80-100o knee flexion

Acute L4-S1 disc protrusions may yield a positive PKB

107
Q

Femoral Nerve Testing – 2 options

A

Prone Knee Bend

“Side lying Slump”

108
Q

Prone Knee Bend Test:

A

Passively flex knee
Passively extend hip

positive test = Unilateral pain in lumbar spine, buttock, anterior thigh at 80-100o of knee flexion

109
Q

“Side lying Slump” Test:

A

patient = Side lying, neck and trunk fully flexed, bottom hip and knee fully flexed

therapist = Behind patient’s pelvis

test sequence =
> Start hip and knee at 90/90
> Extend hip
> Flex knee

MSK II FINAL (13 decks)

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