Lumbar spx Flashcards
Describe Lumbar Radiculopathy Physical Examination
Dermatome
Myotome
Reflexes
Special Tests
If there is decreased Sensation over the Patella wat Nerve root is impacted
L4
If there is Decreased senstion of the Pinky toe what Nerve root is impacted``
S1
How long should a therapist apply manual resistance when testing myotomes?
5-8seconds
Lumbar Myotomes and alternatives
L1-2: Hip Flexion
L3: Knee extension
L4: ankle Dorsiflexion
L5- Big toe extension
S1: Ankle plantar flexion (alternative: ankle eversion) (alternative: hip extension)
S2- Knee Flexion (alternative hip extension) (alternative: ankle plantar flexion)
What reflexes can be tested in LMN
L3-L4 Patellar
L4-L5 Tibialis post
L5-S1 Medial Hamstring
S1-S2 Lateral Hamstring
S1-S2 Achilles
What Special tests are used for Lumbar Radiculopathy
SLUMP
- HBB into slump posture (rounded shoulders) - bring chin to chest
- Therapist passively extends uninvolved knee, then repeats the test on involved knee
- if symptoms not reproduced –> add DF
- if symtpoms are reproduced - ask patient to extend nexk - should provide relief
+ = relief of S+S when extending neck back - indicates neural tension/restriction of lumbosacral roots
Describe the SLR for radiculopathy
- in supine
- unaffected side first
- therapist slightly adducts and internally rotates patients hip - knee fully extended
- flexes patients hip until patient indicates pain or tightness in posterior thigh -
ROM
- Before 35 degrees the nerve slack is being taken up –> at 35 degrees nerve roots under tension
- At 60-70 degrees Sciatic roots TENSE OVER |THE DISC
->70 degress is where hamstrings are under stretch –> most likely pain from MSK
How do you stress individual nerves
“SID” = Sural Inversion and DF
“TED” = Tibial Nerve Eversion DF
“PIP” - Peroneal nerve inversion Plantar flexion
What is the cross over sign
SLR on unaffected side - patient experiences pain in the AFFECTED leg
–> this indicates a LARGE DISC BULGE
AKA - Well Leg raising test of FAjerstajin or Lhermitts test
What is the sign of buttock test
- therapist performs SLR until point of restriction
- therapist proceeds to flex the knee to see if we can flex the hip a bit more
+ = Hip flexion does NOT increase when knee is flexed
- inidcates pathology behind the hip joint in the buttocks –> bursitis, tumor, abscess
What is the Bow-string test
- Follows Positive SLR test
- At the position where SLR reproduced symptoms - slight flex (20 degrees) of the knee to reduce symptoms
- Then places pressure into the popliteal area (irritate and compress sciatic N) using thumbs
+= Reproduction of radicular symptoms
Describe Spinal Stenosis
- Narrowing of the central canal (Central stenosis) or narrowing of the intervertebral foramen (Lateral stenosis)
- age of onset 60+
- Insidious
- maybe due to osteophytes , spondylosis, or ligament thickening (contibutes to central stenosis)
- compress nerve roots or spinal cord
- MAY CAUSE NEUROGENIC CLAUDICATION
- Better with flexion - opening up IVF
- worse with ext (walking, standing)
Difference between Neurogenic claudication and Vascular Claudication (intermittent)
-Cause
-Onset of S+S
-Distribution
- Pain characterisitc
- Agg factors
- Eases
Intermittent Claudication
* pain or circulation that occurs in buttocks or legs (especially calves) as result of poor circulation to affected area
* increased pain with increased energy demandson the muscle (ppor blood supply to meet demand)
*decreased pain at rest
Cause
NC: Nerve root compression due to LATERAL stenosis; IC: PAD
Onset
NC: Typically immediate; IC: Gradually increases with activity
Distribution
NC: proximal to distal, usually b/l; IC: distal to proximal, unilateral
Pain characteristic
NC: Burning and tingling; IC: cramping
Aggs
NC: Spine extension, standing, walking, walking DOWNHILL (lean back); IC: icnreased muscular activity of calves
Eases
NC: spine flexion, sitting, leaning, one leg on stool, fetal position; IC: Rest
What is the intervention for Neurogenic Claudication
- Flexion based exxercises and positioning
- avoiding aggs
Surgical
- Laminectomy (spinal decompression)
–> remove laminae and make space for the nerve
Describe Disc Herniation
- MIgration of the NP from its typical position (central-slightly posterior)
- Age: 30-50yrs
- Acute onset –> bending down to tie shoes and quick pain
- 80-90% of disc bulges are postero-lateral
- may compress nerve root in direction of the herniation potentially causing radicular s+s
What are the 4 types of Disc Bulges/herniation
- Protrusion - sligtly protruted
- Prolapse: MIgration of the NP but still contained within the Annulus Fibrosis
- Extrusion - outside the annulus Fibrosis
- Sequestration - outside AF and broken up
(Symptoms of this resolve faster than less severe disc bulge)
Describe Postero-lateral Disc Herniation
MOI: Flexion (dynamic Disc theory)
Desk job
Lifting heavy
- intitally no issue but prolonged position and poor lifting leads to sudden pain.
Worse with flexion
E.g.: lifting from floot, sitting etc
Better with extension - standing, walking, lying prone (inc extension)
- Worse in the morning - sleeping at night in a more unloaded position the disc becomes more “bulgey”
Worse with coughing, sneezing, valsalva - may present with lateral sift (listing) away from side of bulge
What are the Interventions for Disc Herniations
- Directional preference exercises and positiong
POsterio-lateral bulge (posterior derangement)**
* typically prefer extension-based - repeated ext in prone lying in REIL (repeated extension in lying)
- LUMBAR ROLL to promote ext in sitting (extenuate lordosis)
Progression of Cobra - prone lying - prone on elbows - extensions in lying - extensions in lying with OP - extension in standing
What are the interventions for Lateral bulge (lateral derangement)
- movements in the lateral direction (slides-glides) towards the direction of the bulge –> INcrease pressure on the side of the bulge so it can go from High P to Low P
Anterior Derangement
- Flexion exercises and movements such as repeated knees to chest in supine (RIFL)
Surgery - laminectomy, discectomy)
What is the red/yellow/green system
- exercises might be painful initially but must complete entire set in order to evaluate its effect
LOOK FOR CENTRALIZATION
- ask them to monitor where pain is at the start “in my mid calves” - rate pain 0-10 (3/10)
- do exercises (10exts)
- After pain reassess - “pain is now in lower back” but pain (6/10)–> better so this is Green light (do every waking hour)
Yellow: Pain is 7/10 behind the knees –> proceed with caution
Red: 10 ext completed but pain gets alot worse and centralization goes down
Describe Pelvic (lower) crossed syndrome
- mm imbalance pattern that causes LUMBAR LORDOSIS
- OVERACTIVITY of hip flexors compensate for WEAK abs - anterior pelvic tilt
- Hamstrings tighten to Compensate (try to bring back pelvis) - erector spinae also tightens for weak glutes to help with hip extension
- short spinal mm (multifidus, rotatores) show weakness
What is Spondylosis
- degenerative changes in spinal motion segment (vertebral body and disc)
- age >50 (natural part of aging)
- Insidious
Physiological S+S of spondylosis
- Loss of disc height (DDD) - disc get dehydrated - annulus gets fibrotic
*Approximation of vertebral bodies
*degeneration of the plate
*instability - tight segmental ligaments when the disc height is lost carries slack - decreasing stability
*decreased lordosis - disc is thicker anteriorly if disc dehydrated and loses its lordosis
- Fibrosis in the disc
*osteophyte formation
S+S: increased stiffness and potentially mm spasm and back pain
- WORSE with prolonged flexion, extension, standing, sitting
- Better with lying in unloaded positions (supine, side lying) position chnages, and gentle movement with activity
