Lumbopelvic Spine Exam - Lecture 1 Flashcards
KNOW: Herniated discs / stenosis can both cause radiculopathy
Why might a tight iliopsoas cause back pain?
Because it originates on those lumbar discs
KNOW: Low back can refer down into the hip
Triple A can refer to the lower back and is a pulsatile force
Just to the left of the umbilicus
* IF I can feel a pulse more than 3 fingers out its greatly distended out
* Or if you can see it pulsing
1 organ visceral referal pattern for LBP
Kidney
(urinary track can also refer in the groin area)
KNOW: Cauda equina syndrome / Vascular claudication / limb threatning ischemia are all capiable of causing LBP (and are red flags)
All red flags for LBP
KNOW
KNOW: Fracture S/S (Low back)
* Midline tenderness at level of fracture
* Bruising
* LE neurological deficits (new or significantly worsened = red flag)
* Evidence of increased thoracic kyphosis (sets them up for a wedge fracture)
* Loss of function or mobility
* Most common at T11, T12, and L1
Organ refferal
KNOW: kidney refferal would be a good differential diagnosis for greater trochanteric pain syndrome
KNOW: If they have low back pain w/ LE symptoms think cauda equina but then quickly try and rule it out
How do we rule cauda equina in? (5)
Bowel and bladder disturbances (starting or stopping flow or fecal incontinence)
Saddle paresthesia (groin / medial thighs)
Sexual disturbances (inability to maintain and erection or inability to ejactulate)
Sensory motor deficits in the feet (bilatearl foot numbness)
Weak DF, toe extension, ankle PF weakness (gait disturbances)
* Note - the dysfunction is further down so they will have greater hip flexion to adjust for these weakened muscles that are lower down
* actively hip flex and throw leg out
Refer out if positive (this is a red flag)
check dermatomes and myotomes for these pts
Claduication is what?
Compressive event in vessle (narrowing or occulusion of vessels)
If its higher up then were going to have symptoms down the chain (cutting off the garden hose)
Vascular Claudication symptoms: (4)
Relieved w/ resting (never present when resting)
**Starts when exercising **
Aching or burning in leg muscles (not getting enough BF)
Sitting position does not change symptoms
* does not matter what positon they’re in when they’re exercising - its just moving for a certain amount of time brings on those symptoms
Normally its a set amount of time with movement that brings on symptoms
Is stenosis more about activity level or position of the spine?
Position of the spine
What makes spinal stenosis worse flexion or extension?
Extension - closes down on the spinal n
What makes disc issues worse flexion or extension?
Flexion
Two-Stage Treadmil test
* Level treadmil for 10 minutes
* Then incline treadmil 15 degrees for 10 minutes - this causes the lumbar spine to become more flexed
* If they have lumbar stenosis it should subside because they are in a flexed position (neurogenic claudication - something is occluding the n)
* If the symptoms don’t change were thinking its more vasculogenic (vasculogenic cluadication) in nature
If the pt is doing a two stage treadmil test and the treadmil is raised 15 degrees and symptoms go away what am I thinking they have and why? (test question)
Lumbar stenosis (neurogenic claudication)
Because extension makes it worse and we put them in a flexed position which took away their symptoms
If pt is doing a two stage treadmil test and the treadmil is inclined 15 degrees and the pts symptoms remain constant. What am I thinking it is? Why? (Test question)
Vasculogenic cluadication
Because if it was neurogenic cluadication that incline should’ve reduced symptoms (taken the perssure off the nerves) however relieve pressure meaning its more vasculogenic claudication in nature
What is acute limb threatening ischemia?
Some kind of ischemia that blocks the vessels quickly and causes blood not to flow down them
Is acute limb threatening ischemia rare?
Yes
Does Acute Limb threatening ischemia come on quickly or slow
Very quickly
Whats the best way to check for acute limb threatening ischemia?
Check for a pulse - if they don’t have one rule this in
6 P’s that come on w/ Acute Limb threatening ischemia
Not out practical just kind of know what these are for test
1) Pain at rest - not consisten w/ vasculogenic claudication
2) Pallor (paleness)
3) Pulseless
4) Parasthesia
5) Paralysis
6) Perishing cold - because they no longer have BF to that limb and won’t have the warmth fromt hat blood
KNOW: Will have an acute immediate onset - will proably be in an atheltic sport not out pt (because they won’t have time to make it to u in OP)
Red flag call 911
Whats a good way to differeintaite acute limb threatening ischemia from vascular claudication?
w/ limb threatening ischemia they will have pain at rest and but they will have no pain at rest w/ vascular cluadication
What would you do for someone w/ vascular claudication
Not a 911 call
We would put them on a walking program where they walk to the onset of symptoms then rest then walk again once symptoms leave
NOTE: This is something blocking the vessel - so the increased BF though the vessel needed won’t be able to make it when doing CV activity
Do this EX every single day without missing
Malls are the best place because of the bistanders around just incase something goes wrong
KNOW: When measuring lumbar spine to clear it we do AROM w/ OP
* Just like in the C-Spine we OP halfway through AROM and an axial load
KNOW: Oswestry Disability Index (ODI) is best for LBP
* Higher # = more distability
* out of 50
* 50% = 25 questions answered
Scoring system (very subjective)
Do we over press PT’s w/ pain?
No!!
Dermatone testing: (in neuro screen)
* NEVER DONE OVER CLOTHING
* Testing side to side back and forth
* have pt close eyes
* say when they feel
* always start on uninvolved side and touch then ping pong back and forth
* not just touch but doing small little arcs in the dermatome pattern
* Great quick screener
KNOW: for myotomes we have them do the action first then we load it
EX: To check L3 we would have them kick leg all the way out
* Then you load it for a period of time (not just one quick second)
* We are checking fatiguability - not just strength - nerves have stored potential energy (stored ACl)
* My goal is to see if it fatigues by slowly loading
* A compressed n is like a compressed garden hose - theres still going to be some water is the more distal end when its compressed - we have to get that water out then check it (thats the stored ACl that were getting out first then seeing if it fatigues)
How many relfexes do we check when doing reflexes for myotome testing?
6 reflexes - looking for it to diminish (getting rid of that stored potential)
KNOW: When doing reflexes make sure you’re supporting them so they’re fully relaxed (the muscle cant be contracting)
KNOW: For clonus were doing a quick extension then holding it in that position and seeing if we get MORE THAN 3 twitches (will happen very quickly)
KNOW: Inverted supinator sign is taken 1-2 finger widths proximal from the radial styloid process
KNOW: Very common ataxic gait pattern for LE is kicking leg out (because they dont get full extension)
Facet refferal patterns for LE
LE dermatomes
KNOW: Radicular pain is often sharp and shooting following a dermatomal pattern (doesnt have all the stuff that radiculopathy has)
* Radiculopathy = follows that dermatomal pattern but also has numbness / tingling reflex issues / deep tendin reflex issues / myotome issues / dermatome issues
Reffered pain = dull aching cant pinpoint
What is repeated motion testing?
repeating the same motion over and over (~10 times)
* Won’t do w/ high irritability pts
* Were trying to figure out what centrializes / peripheralizes the pain
* Goal is to get pt back to midline before doing this (make sure the latearl shift has been fixed)
What is a latearl shift?
pt shifting laterally AWAY from pain
KNOW: Whenever there is radicular or reffered pain we need to centralize that pain
* Not pts might report worse back pain after that LE is centeralized - this is good
* educate pts that this is a good thing
3 ways to do flexion
2 ways to do extension
KNOW: w/ repeated motion tests we want to start by getting that pain centralized
* so if flexion makes it better were doing flexion over and over
* However, life isnt lived all the time in flexion. So once we have those symptoms centralized (several weeks in) were going to start working into those extension movements as well
What is a flexion directional preference?
They like flexion (going into that motion allivates peripheral symptoms and centralizes them)
KNOW: lateral shift is shifting away from pain, however, in an acute phase they might shift towards pain
This is a lateral shift correction for lumbar spine (want to maintain about 50% of this from visit to visit - in the acute phase they are going to keep wanting to shift away from pain)
How many degrees of lumbar flexion do you need to get from sit to stand? (test)
35
How much lumbar flexion do you need to put on socks? (test)
55 deg
Picking up an object form the floor requires how much lumbar flexion (test)
60 deg
Average lumbar flexion
40-60 deg
Average lumbar extension
20-35
Average lateral flexion (lumbar spine)
15-20
Average lumbar rotation
3-18deg
What are aberrant movements?
Movements that shift out of line w/ pain (think s curve - shifts out then back in)
* Can be seen on squatting and many other movements
* Think shifting around and back
KNOW: Aberrant movements are often because of lumbar functional instability (shifting out then shifting back in - like theres a catch)
What is a Gowers sign?
Having to push up on thighs to get back up
KNOW: Hip pts can have painful arc w/ flexion - somewhere in their flexion causes pain
KNOW: During lumbar AROM we are looking for reversal of lumbopelvic rhythm - which is over using hips or knees t
Yoib retyrb frin a firward bent position, pt suddenly bends their knees to extend the hips, shifting pelvis anteriorly as they return to standing position
KNOW: To do a lumbar CPA you put pisiform over SP and press down w/ other hand - mobilizing w/ body
KNOW: for lumbar UPA
* Go 1 thumb lateral = facet plane
* TP = 2 thumb widths over and just slightly superior to hit the same lvl TP
then use other hand to push down - or you can just use your pisiform to push down
KNOW: Lots of muscles here so might not really feel it well - will be uncomfertable for pt
Not using thumbs in this one
KNOW: Resisted procacation tests dont test for strength - they test for pain w/ contraction
What is the max closing down position of the lumbar spine?
What kind of pain are we looking to bring on?
called extension quadrent test
Extension
Lateral flexion
Ipsialtearl rotation
Brings on facet joint realted pain
This test being positive doesnt tell us much - its a negative test that tells us a lot
* If negative im thinking its not a stenosis issue / facet closing issue / not radiculopathy
Its not going to be comfertable but were making sure it doesnt reproduce the pain that they came into the clinic w/
4 tests to look for lumbar instability
* Prone Lumbar Extension Test
* Trendelenburg Test
* Active SLR
* Prone Instability Test
These 4 tests are all under the umbrella for LBP w/ movement coordination inpairments - makes me think some type of muscular weakness / instability
How to do Prone Lumbar Extension Test
Therapist Lifts both legs of pt passively about 2 feet off the table
They need to maintain that pure extension
While maintaing that extended position pull the legs out (distracting LE)
Positive = pain in the lumbar region that is relived when the legs are lowered back to the table
Dont fully understand positive but done in lab
How to do Active SLR
Therapist asks pt to slowly raise a straight leg off the treatment table 8 inches, pause then slowly lower the leg to the ttable and repeate on the other side
If pt admits to difficulty in raising the leg OR symptoms are proboked w/ the active straight leg raise, the ASLR is repeated w/ the therapist providing compression to the anterior pelvis (lateral to medial on IC) Or posterior pelvis (at the level of the PSIS)
* If symptoms are relieved or the ease of leg raising is improved w/ anterior or posterior pelvic compression, the test result is positive
So if compression helps them do it more easily im thinking it could be releated to functional/clinical instability
* Im compressing asis / psis into sacrum
Shows PT pushing anterior and posterior
Prone instability Test
He said it sucks
PA pressure applied to each targeted lumbar vertebrae
If provocation of pain is reporte, the patient lifts the feet off the floor and the pressure is reapplied at symptomatic level
Positive = pain is present in the first position but not reportuced to the same severity when pressure is reapplied to the symptomatic vertebra w/ the second position
checking for instability
LBP w/ radiating pain tests
* SLR
* Crossed SLR
* Slump Test
* Lateral Shift Correction (lumbar side glide)
* Ely’s Test (femoral n tension test)
How to do a SLR
* W/ radiating pain test
Hip is slowly flexed as the knee is maintained in full extension
Positive = reproduction of LE pain at <30 deg of hip flexion has been strongly correlated w/ herniated disc - because at that point I havent put any tension on the hamstring msuculature
* anything passed 70 degrees were def involving the hamstrings
Patient asked to respond to the movement, and the degree of hip flexion that is attained when their symptoms are reported. Now to play with proximal/distal sites
* Further sensitization can be applied by adding hip adduction Or ankle dorsiflexion before raising the leg (tighten sciatic n)
* Further sensitization can be added by passive neck flexion to increase dural tension (stretching the dura of the SC further sensitizing it)
* If moving the hd hurts the back of the leg im thinking thats def not connected to the HS so its proably nervey at that point (same thing w/ DF of foot???)
Used to rule out (negative = rule it out)
TESTS SCIATIC N
Crossed Straight LEg Raise (“well” SRL test)
* w/ raidation pain
How to perform
Same as the SLR just above except
If the SLR of the contralateral leg causes symptoms on the involved leg, a symptomatic herniated disc is suspected
Crossed just means other leg (how to remember)
TESTS SCIATIC N
Slump Test
* w/ radiating pain
* How to do
Assesses for neuropathic related symptoms
Positive test = LE symptoms reproduced and knee extension is limited in the slump sit position AND symptoms are alleviated and knee ROM is improved with a return to the neck neutral position
TESTS SCIATIC n
For a pt w/ increased irritability would I do the slump test or the SLR test? (test question)
SLR
doesnt bring on symptoms nearly as badly - slump test is much more aggresive
Femoral n tension test (Ely)
* W/ radiating pain
* How to do
Therapist passively flexes the patient’s test knee to 90 degrees flexion (whilst in prone) and then lifts the hip into full extension
* Positive = provocation of anterior thigh pain w/ the stretch position (compairable sign)
* obvisouly stertching femoral n
* can further it by extending the neck or plantar flexing the foot
TESTS FEMORAL N
Sacrioiliac Joint Related - special tests
* Supine to sit test
* Gillet Marching Test
* FABER
* SI Provocation Test Item Cluster
Supine to sit test
* sacroiliac joint related pain
* How to do
You check in a sitting position to see where their legs are at then have them lay down and see if they rotated
Supine to sit test
* sacroiliac joint related pain
* How to do
We would look at medial malleolus (because its part of an imovable position) and see if it they are level
* we then lift their legs up to the sky and set them back down and see if they’re level
* Anterior hip rotation would make the ipsialteral side longer
* Would strengthen hip extensors - if its pulled forward I would want to strngthen the muscles that would pull it backwards (note - its rotating in the sagital plane so an anterior rotation is what causes that lordosis)
Gillet Marching Test
* sacroiliac joint related pain
* How to do
if it does not move the thought is that its not moving w/ SIJ (during marching)
What population has more SIJ movement? (2)
1) pregnancy (relaxin)
2) hypermobility - marfan / downsyndrome / elhers danlos
laslets cluster: what are they
* Used to rule in SIJ Provocation
* Must have ruled out pts that have pain that centralizes (lumbar radiculopathy) before using these
1) Distraction Provocation (ASIS gap)
2) ASIS Compression Provocation
3) Thigh Thrust Provocation - basically dorsal glide for hip
4) Gaenslen’s Provocation
5) Sacral Thrust Provocation
Need 3/5
Distraction Provication ASIS Gap
* SIJ Provocation Tests
Essentailly distracting ASIS
Do it for 10 seconds
After 10 seconds if they don’t have pain quickly pulse (thrust)
Reproduces SIJ pain (can radiate down back of leg but were thinking its posterior thigh / butt)
ASIS Compression Provoation
* SIJ Provocation Tests
Essentially compressing ASIS
Slowly load 10 seconds (stop if theres pain)
Pulse
Thight Thrust Provocation (Ostgaards test)
* SIJ Provocation Tests
can do it w/ adduction / abduction
Gaenslen’s Provocation
* SIJ Provocation Tests
pt is off the edge of the table
forcefully flexing flexed hip and forcefully extending extended hip
Looking to see if pain is reproduced
Sacral Thrust Provocation
* SIJ Provocation Tests
Physical Performance Tests
Isometric abdominal test
Physical Performance Test
* Biering-Sorenson Fatigue Test (lumbar extension endurance test)
pain free should be around 77 seconds
LBP pain around 36-39 seconds
Physical Performance Test
* Side Plank
KNOW: He said don’t study these physical performance tests that much
