Lumber spine assessment and treatment Flashcards
red flags- cancer
history of cancer in themselves, strong family history, unexplained weight loss, general feeling unwell
red flags- infection
recent surgery/ open wound, high temp, general feeling unwell
red flags- myelopathy
central cord compression in cervical spine
red flags-cauda equina syndrome
retention of urine, loss of anal tone/bowel incont, saddle anaesthesia (ask about changes in sensation around groin or genitalia), bilat leg pain/ worsening neuro, erectile dysfunction
how to know if neuro assessment needed
numbness, pain down one leg, altered sensation, P and N, changes in bladder and bowel, sudden onset on pain in LL, nature of pain= burning pain, shooting pain, electric shock pain
lumber spine assessment
observations, AROM, PPIVM’s, PAIVM’s, muscle length testing, muscle strength testing, palpation of soft tissue, function
observations
posture, offloading, asymmetry, COG, muscle bulk, guarding/bracing, fear avoidance, spinal curve, alignment, abnormal movement pattern
AROM
flex- standing run hands down front of legs (marker could be where fingers reach), side flex- hands down side, rotation- sit down to fix pelvis- rotate whole UL- position of shoulders could be maker, extension- hand on hips
looking for pain reproduction, asymmetry
functional demo- show what movements that hurt
PPIVM’s- flexion and extension
flex- patient side lying, palpate lumber spine, rest patients legs on top of femur and move hips into flexion
ext- same position, and push legs backwards- push through femur
PPIVM’s- rotation and side flexion
side flex- side lying, lift lower legs off plinth whilst palpating L spine
rotation- forearm resting across ischial tuberosity fixing hip, other arm under armpit push upper body towards bed or push pelvis towards bed, whilst palpating L spine
what does PPIVM’s and PAIVM’s stand for
passive physiological intervertebral movement
passive accessory intervertebral movements
PAIVMS
central PA with caud/ceph
unilateral PA
transverse glide
what of the surrounding muscles affect L spine and length testing
glut max, hamstrings (length testing), hip flexors (thomas test), abdominal muscles
how can you assess motor control
good= control, smooth movement, gait
could be control of single leg stand, roll down= segment at a time (L, T, C)
palpation of surrounding soft tissue
palpate- muscle tone, bulk, pain provocation, hyperalgesia
functional assessment
aggs or limitations in their day to day function, what are their goals? observe them doing functional activity- look at modification
common example of functional assessments
sit to stand, bending, twisting, lifting/reaching, standing/walking, sports or gym activity
excluding other joints
SIJ, hip, knee
indications for a neurological examination
pain in dermatomal distribution- tells us which nerve route is affected, pain from L spine referred beyond the hip, altered sensation in LL, pain in LL that may be related to a lumber condition, complaints of weakness in LL
what can cause pain in dermatomal pattern
disc prolapse/foraminal (foreamen narrow)/ SC stenosis, narrow spinal canal- tumour and spondylitis, spondiolythesis (where vertebra above slip forward on vertebra below)
nerve route problem= radiculopathy,
peripheral nerve distribution
nerve irritated anywhere else= peripheral nerve distribution
sciatic nerve= posterior thigh, femoral nerve= anterior thigh, tibial nerve= posterior thigh, saphenous- medial side of lower leg, common peroneal- lateral
nerve conduction tests
myotomes, reflexes, tendon jerk, dermatomes- light touch (A beta fibres) and pin prick (sharp pain= A delta) (test first)- can test C fibres with hot/cold therapy
how to test dermatomes
use tissue paper or cotton wool test each dermatomal level systemically, then repeat with sharp object
ask if each leg feels the same
LL myotomes- femoral nerve
L2-3- illiopsoas- hip flexion, L3-4- femoral nerve- knee extension, L4-5- deep femoral nerve- TA- DF, L4-5, S-1- EHL- big toe extension,
LL myotomes- sciatic nerve and branches
L5/S1-2- tibial nerve- gastroc and soleus, L5-S1- common peroneal nerve- peroneus longus and brevis- eversion, L5-S1- sciatic nerve- hamstrings- knee flexion
reflex testing
patella- palpate patelal tendon, achilles- place ankle in DF- using forearm
what reflexes mean- hyper-reflexive, hyporeflexive
hyper- UMN lesion, hypo- LMN lesion or low tone
what reflexes mean- normal, absent
absent- LMN lesion
PKB test
sidelying, lower knee pulled up to chest with neck flex, full knee flex and hip ext(passive), then ext cervical spine- should have more movement, if not then muscle problem
femoral nerve
SLR
sciatic nerve, supine lying, MR hip slightly, passively flex hip and ext knee (wrap hand around calcaneus), could be differentiate between muscle tightness and nerve by adding DF (if same degrees of hip flex= muscles)
SLR- how to differentiate between the branches of the sciatic nerve
tibial nerve- DF and eversion, surreal nerve- DF and inversion, common perineal nerve- PF and inv, least range= problem
Slump
sciatic nerve and above, sit fully supported with thighs on the bed, hands held behind back, slump shoulders down, hold, neck flexion active, passive DF ankle and ext knee
how to differentiate with slump
should get more movement when sitting up straight and take of DF- between nerve pain and muscle- same range= muscle problem
UPN testing
babinski- run sharp end of reflex hammer on base of foot on lateral border and toes should curl, positive test- toes ext clonus- quickly force ankle into DF= positive- leg goes into spasm
treatment options
education/ reassurance/ reduce threat, address patients beliefs and yellow flags, exercise (strength, endurance, power, control, proprioception, stretching), mannual therapy (PAIVMs, MVM’s/ SNAG’s, NAGs), activity modification/function
treatment options- examples
stiff- PPIVM/ PAVIMs (give/roll/spine/glide)- both decrease pain/ exercise- AROM= stretches capsule and soft tissue
muscle length= stretch 30 secs- 3 times (90 secs)
strength= strengthening exercises (deadlifts, ab exercises)
reduced control of movement= use mirror or video or break down movement
reduced endurance- body weight exercise or dead lift
what does MWM, SNAG, NAG, PMWM, SMWAM
MWM- mobilisations with movement, SNAG= sustained natural apophyseal glide, NAG= natural apophyseal glide, PMWM- peripheral mobilisations with movement, SMWAM= spinal mobilisations with arm movement
principles of application- mannual therapy
functional technique- WB and/or combined with functional movement, subtle handling and directional changes, PILL (pain instantaneous and long lasting), if no change- change technique, use active movement towards restricted/symptomatic range with glide, hold glide & repeat (6-10), neuromodulatory response= decreased pain
SNAGs
sustained end range technique combined with active movement, movement induced symptoms, antero-superior, central or unilateral, severe but non-irritable, self-snags, active movement with passive, maintained to return, SNAG= increases ROM
MWM’s lumber flex
sitting- central/unilateral pressure to SP, belt below ASIS, put belt round therapist waist, aim- increase flex and decrease pain, X3 reps
standing- patient knees slightly flexed, use plinth for patient to place hand on for stability, might have to stand to the left to allow patient to bend forward
MWM’s lumber extension
sitting- pressure applied to the superior SP of vertebral segment involved, same position as flex
standing- may need to stand to side to give patient space
