Lumber spine assessment and treatment

Question 1

red flags- cancer

Answer 1

history of cancer in themselves, strong family history, unexplained weight loss, general feeling unwell

Question 2

red flags- infection

Answer 2

recent surgery/ open wound, high temp, general feeling unwell

Question 3

red flags- myelopathy

Answer 3

central cord compression in cervical spine

Question 4

red flags-cauda equina syndrome

Answer 4

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

Question 5

how to know if neuro assessment needed

Answer 5

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

Question 6

lumber spine assessment

Answer 6

observations, AROM, PPIVM’s, PAIVM’s, muscle length testing, muscle strength testing, palpation of soft tissue, function

Question 7

observations

Answer 7

posture, offloading, asymmetry, COG, muscle bulk, guarding/bracing, fear avoidance, spinal curve, alignment, abnormal movement pattern

Question 8

AROM

Answer 8

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

Question 9

PPIVM’s- flexion and extension

Answer 9

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

Question 10

PPIVM’s- rotation and side flexion

Answer 10

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

Question 11

what does PPIVM’s and PAIVM’s stand for

Answer 11

passive physiological intervertebral movement

passive accessory intervertebral movements

Question 12

PAIVMS

Answer 12

central PA with caud/ceph
unilateral PA
transverse glide

Question 13

what of the surrounding muscles affect L spine and length testing

Answer 13

glut max, hamstrings (length testing), hip flexors (thomas test), abdominal muscles

Question 14

how can you assess motor control

Answer 14

good= control, smooth movement, gait

could be control of single leg stand, roll down= segment at a time (L, T, C)

Question 15

palpation of surrounding soft tissue

Answer 15

palpate- muscle tone, bulk, pain provocation, hyperalgesia

Question 16

functional assessment

Answer 16

aggs or limitations in their day to day function, what are their goals? observe them doing functional activity- look at modification

Question 17

common example of functional assessments

Answer 17

sit to stand, bending, twisting, lifting/reaching, standing/walking, sports or gym activity

Question 18

excluding other joints

Answer 18

SIJ, hip, knee

Question 19

indications for a neurological examination

Answer 19

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

Question 20

what can cause pain in dermatomal pattern

Answer 20

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,

Question 21

peripheral nerve distribution

Answer 21

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

Question 22

nerve conduction tests

Answer 22

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

Question 23

how to test dermatomes

Answer 23

use tissue paper or cotton wool test each dermatomal level systemically, then repeat with sharp object
ask if each leg feels the same

Question 24

LL myotomes- femoral nerve

Answer 24

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,

Question 25

LL myotomes- sciatic nerve and branches

Answer 25

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

Question 26

reflex testing

Answer 26

patella- palpate patelal tendon, achilles- place ankle in DF- using forearm

Question 27

what reflexes mean- hyper-reflexive, hyporeflexive

Answer 27

hyper- UMN lesion, hypo- LMN lesion or low tone

Question 28

what reflexes mean- normal, absent

Answer 28

absent- LMN lesion

Question 29

PKB test

Answer 29

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

Question 30

SLR

Answer 30

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)

Question 31

SLR- how to differentiate between the branches of the sciatic nerve

Answer 31

tibial nerve- DF and eversion, surreal nerve- DF and inversion, common perineal nerve- PF and inv, least range= problem

Question 32

Slump

Answer 32

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

Question 33

how to differentiate with slump

Answer 33

should get more movement when sitting up straight and take of DF- between nerve pain and muscle- same range= muscle problem

Question 34

UPN testing

Answer 34

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

Question 35

treatment options

Answer 35

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

Question 36

treatment options- examples

Answer 36

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

Question 37

what does MWM, SNAG, NAG, PMWM, SMWAM

Answer 37

MWM- mobilisations with movement, SNAG= sustained natural apophyseal glide, NAG= natural apophyseal glide, PMWM- peripheral mobilisations with movement, SMWAM= spinal mobilisations with arm movement

Question 38

principles of application- mannual therapy

Answer 38

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

Question 39

SNAGs

Answer 39

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

Question 40

MWM’s lumber flex

Answer 40

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

Question 41

MWM’s lumber extension

Answer 41

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