Lx spine Assessments

Question 1

What does PAIVMs stand for? function? directions?

Answer 1

Passive Accessory Intervertebral Movement

• mostly for spinal assessment but can be transferred into treatment
• assess quality and range of movement at IV levels > Early, Middle, Late range > pain or resistance?
• treat pain and stiffness > Maitland grades
• force applied PA ~ posteroanterior, AP ~ anteroposterior, and Transverse directions

Question 2

What does PPIVMs stand for?

Answer 2

Passive Physiological Intervertebral Movement

• level by level rather than whole spinal structure
• passively moving the spinal segment into each movement > perform flexion PPIMS, extension PPIVM and side flexion PPIVM
• assess if active or passive ROM differ; pain affects PROM; end feel? > comparing level above, below and opposite

Question 3

What are you looking for?

Answer 3

• reproduction of symptoms i.e. localised pain, pins and needles (paraesthesia), shooting pain
• pian
• resistance
• HYPO mobility
• HYPER mobility
• comparable differences in levels

Question 4

Where is the movement coming from in PPIVMs and PAVMs? angle of these in each spine?

Answer 4

the facet joints - the joint between the superior articular process of one vertebrae and the inferior articular process of the one below

• plane and direction of facet joints will help determine your angle of pressure in PAIVMs
  e.g. cervical - 45 degrees; Thx - 60 degrees; Lx 90 degrees

Question 5

Maitland assessment vs treatment?

Answer 5

ASSESSMENT:
- ranges; start to end
- early > middle > late ranges (x3)

TREATMENT:
- mobilisation grades (I-V)
used to EASE pain: (no resistance)
I - small amplitude out of resistance
II - larger amplitude out of resistance
used to RESTORE movement: (resistance)
III - larger amplitude into resistance
IV - small amplitude into resistance
V - high velocity thrust

Question 6

How do you perform PAIVMs in Lx spine? regions of movement?

Answer 6

1. Pt in prone (if lordotic - pillow under stomach)
2. consider direction of force linked to orientation of facet joints > stand directly above
3. use hypothenar eminence (fleshy muscle inferior to fifth digit - little finger), pisiform, ulnar side of hand or thumbs (for unilateral)
4. palpate spinal level and facet joints
5. sink slowly into early, middle and late range (3 oscillation at each range)
6. asking Pt for feedback; any pain? while sensing any resistance > stop on pain

• unilateral movements - on right or left side
• central PA movement - middle
• transverse - towards right to towards left

Question 7

How to locate T4, T7, L4, L5 and S2?

Answer 7

• T4 ~ in line with spine of scapular
• T7 ~ inferior angle of scapular
• L4 ~ in line with the iliac crest
• move one SP down for L5
• S2 is in line with PIIS

Question 8

What are the objective assessments of the Lx spine?

Answer 8

• observation
• palpation (looking for heat, tenderness, spasm, gaps, oedema/swelling)
• AROM
• PROM; PPIVM and PAVMs
• power/strength
• special tests (quadrant test)

Question 9

What are the contraindications x8 and precautions x4 of Lx assessment?

Answer 9

• NOT RED FLAGS - red flags cannot be treated with physio > refer on

Contraindications:
- active inflammatory disease local e.g. rheumatoid arthritis
- bone disease local e.g. osteoporosis
- malignancy local (active Ca/ Hx Ca)
- unhealed fractures local
- damaged skin local
- acute injury/inflammation or infection local
- active bleeding tissue/ haemorrhagic conditions
- active DVT

Precautions:
- hypermobility local
- pregnancy
- long term steroids
- recent anticoagulant therapy

Question 10

How to perform unilateral PAIVMs?

Answer 10

• more concentrated pressure on R or L side of facet joint
• both thumbs on the SP > treated from therapist standing on the same side
• sweep soft tissue away > 1cm and push down
• early, middle, late range > x3
• feedback for pain > sense any resistance at at what stage

Question 11

How would you carry out a Lx spine OBSERVATION?

Answer 11

looking for…
~ asymmetry between R and L sides
~ deviation from midline
~ inflammatory signs - redness, heat, swelling, bruising
~ bony deforming

posterior observation:
- lateral shifts R/L
- side flexions
- spinal curvature > s-shaped scoliotic curve (check if postural or structural)
- PSIS levels, crease of gluteal fold, knee creases

lateral observation:
- optimal view of postures; kyphosis, lordosis, sway back, flat back
- pelvic tilts; anterior or posterior

sitting posture observation:
- slouched or right at front of chair
- lx roll (tactile feedback)
- WB on one side

Question 12

How do you perform flexion PPIVMs?

Answer 12

• wanting to understand more about Pt after performing PAIVMs > how vertebrae moving in a physiological/functional way rather than just accessory
• assessing the movement of Lx vertebrae into flexion > a Pt in side lying bringing knees towards chest, creates flexion in Lx spine, opening the space between vertebrae posteriorly > this assesses from the bottom of the spine to the top i.e. pelvis to L5,4,3 etc.
• looking for sequential opening and closing; vertebrae above moving too soon > hypermobile, or the delay is in the below vertebrae > hypomobile

1. Pt in SL, test flexion and back to neutral by bringing knees to and from their chest > Pts legs against you, cusp under ankles palpating the Lx with other hand, fingers across IV space

Question 13

How do you perform SIDE flexion PPIVMs? issues? assessment? as treatment?

Answer 13

• movement dysfunction in SF (assess fingertips to knee)
  ~ SF to left: closing on left side and opening on the right, left structures are compresses and right are stretched (vice versa)
  ~ muscle on stretched side could be tight, not long enough, restricting movement
  ~ joints on SF side could be inflamed, closing the space and loading the joints causes pain
• ask Pt to perform SF in standing (unaffected side first) > slide hand down side of leg as far as possible, recording where in relation to the knee their fingertips are > obs anteriorly and posteriorly, comparing side creases
• Pt in side lying > palpate Lx SP with fingers underneath (inferiorly) as opening will occur on this side of the spine
• other hand on the pelvis/ around greater trochanter and oscillate SF movement OR bringing their knees and hips into flexion, grasping around ankles to move pelvis (precaution in Pt has knee problems)
• assess gapping at each level e.g. decreased gapping at L4/5 level

into treatment:
- find point in affected spinal level where gap is largest (most movement)
- introduce Maitland I-V
- grade I and II in standard SF, apply oscillations to the pelvis
- grade III and IV (resistance) > can use bed as assistance to bring Pt into more Sf range, therefore more stretch and add more resistance: (as able) bring Pts treated level in line with crease of bed, keeping hand on Pts hip and lift the head of the bed slightly (introduces SF without beginning Rx)
- find the level and its opening again > performing grade III and IV - checking in with Pt
* Rx pain - grade I and II OR Rx stiffness grade III and IV > 30s of oscillations for 3 sets if no pain as a treatment in one of the grades - RETEST side flexion as per start to assess change in ROM

Question 14

How do you perform ROTATION PPIVMs technique?

Answer 14

• Pt in SL with knees and hips bend
• block the Pts torso with forearm to stabilise, using that hand to palpate Lx spine
• other hand on pelvis, creating movement
• rocking the pelvis back and forth > when rotating pelvis back/ posteriorly, you should feel contact of the palpated SP > rotating forward the SP should move away
• as with SF, the movement should feel sequential on your fingers e.g. L4 > L3 > L2 (like ringing a towel)
• move up each spinous level to gauge rotation movement

~ e.g. L4 moves after L3 - L4 hypomobility; can go back to PAIVMs and assess L4 > finding stiffness > mobilise

into treatment…
- grades I and II ~ oscillate in SL with knees up from a downward diagonal force at the pelvis
- grades III and IV ~ put Pt into higher state of rotation, leg under brought back and the one over bent dropped over the bed with upper torso twisted in opposite direction, Pts arms crossed

Question 15

How would you manage the types of LBP? x3

Answer 15

1. non-specific LBP - advice
2. simple LBP with identifiable pathology - treat
3. serious spinal pathology - treat/refer on

Question 16

Role of a physio in LBP?

Answer 16

• screen for red flags (if identified refer on)
• diagnose non-specific LBP
• minimise becoming chronic condition > identifying and managing risk factors
• minimise risk of recurrence
• identify if a movement pattern exists > treat
• management plan

Question 17

What is non-specific LBP? (NSLBP) complains of? presents in? level of condition?

Answer 17

• LBP than cannot be attribute to a recognised specific pathology i.e. infection, tumour, fracture, structural deformity, radicular/discogenic pain > defined as symptoms without clear specific cause
• complaints of muscle tension, stiffness localised below costal margin and above inferior gluteal fold WITHOUT leg pain
• fifth most common reason to visit a GP
• accounts for over 90% of Pts presenting to primary care
• most commonly presented > aged 45-64
• acute ~ less than 6 weeks; sub-acute ~ 6-12 weeks; chronic ~ over 12 weeks

Question 18

What can cause NSLBP? relationship with imaging?

Answer 18

~ any innervated structure has the potential to cause symptoms of LBP:
- muscles
- ligaments
- facet joints
- annulus fibrosis (outer IVD)
- fascia
- vertebrae
- dura mater and nerve roots

• imaging vs clinical presentation do not always correspond e.g. scans normal but Pt in pain OR Pt not in pain but scan shows abnormalities

Question 19

How can you sub-group NSLBP? x2

Answer 19

regular pattern of movement = pain is produced with COMBINATIONS of movements that have a MECHANICAL presentation…

1. CLOSING pattern - closing down of facet joints, compression, anterior stretch e.g. standing in extension
2. OPENING pattern - opening up of vertebrae, stretch, posterior stretch e.g. forward flexion

Question 20

How to diagnose NSLBP? (triaging)

Answer 20

1. screen for red flags
2. screen for nerve root problems (referred pain/neural pain)
3. risk assessment and risk stratification i.e. screen for risk of developing chronic/persistent condition > use STaRT back tool

Question 21

What are the red flags for BP? (TUNA FISH plus more)

Answer 21

T - trauma
U - unexplained weight loss
N - neurological symptoms
A - age 50 or more
F - fever
I - intravenous drug use (IV DU)
S - steroid use
H - Hx of Ca

~ cauda equina
~ SC impaired - bilateral disturbance
~ constant pain (unremitting, progressive)
~ thoracic pain

Question 22

LBP prognosis - course of condition?

Answer 22

• most episodes are self-limiting (resolve spontaneously without treatment or intervention)
• 50% recover in 2 weeks w no Rx; 70% at 4 weeks; 90% at 3-4 months
• 5% will not respond to conservative care e.g. physio
• 5% require our skilled management
• LBP recurrence is common ~ approx. 60% have recurrence with 3-6 months

Question 23

Physiotherapy management of LBP?

Answer 23

• teach Lx exercises
• strengthen globally and postural control
• aerobic exercise > encourage activity
• stretching
• mobilisation > Pt lead or therapist
• McKenzie
• manual therapy > massage
• don’t offer Lx braces, don’t give traction

Question 24

How do you perform Lx spine quadrant test? (special test) positive result?

Answer 24

• is a combination of movements to explore an area as compressed (combined movement - more than one plane) - if already reproduced symptoms and caused pain DO NOT keep exploring
• perform in standing hands across their chest > considering safety
• start with extension with over pressure > standing behind Pt holding shoulder slowing pull back into extension (while forcing hips up preventing falling back)
• therapist introduces full quadrant with handling and extends, side flexes and rotates Pt all to the same side (if able add compression, an over pressure at the end)
• perform movement in stages/sequentially
• compare both sides (unaffected side then affected)
• record the affect on Pts symptoms
• reproduction of pain, numbness or tingling locally in Lx - suggesting facet caused
• reproduction of referred pain into lower extremity - suggests nerve root irritation

Question 25

What are the types of neural injury?

Answer 25

1. DIRECT - traumatic overstretching, laceration(deep cut), blunt trauma
2. INDIRECT - mechanical interface, disturbance causing hypoxia (low o2) and/or mechanosensitive
   e.g. carpal tunnel (oedema, tendon thickening), fracture callus, postural distortion, disc compression or osteophyte (less IVF space), soft tissue spasm (e.g. piriformis), tumour

Question 26

Signs and symptoms of neuro problems?

Answer 26

SIGHNS:
- decreased ROM
- antalgic posture > structures may be sensitised so adopt an unnatural posture, shortens anatomical distances, lessen “pull” on nerves
- nerve trunk painful to palpate
- altered reflexes, sensation, power, proprioception

SYMPTOMS (complaints):
- paraesthesia > pins and needles
- anaesthesia > loss of sensation
- feels difficult to locate, not their body
- hurts themselves and doesn’t realise
- allodynia > very light touch hurts

Question 27

What are the types of neural pain?

Answer 27

RADICULAR - nerve root compression and stretch injuries > axonal conduction loss > decreased neuro function, anaesthesia, paraesthesia, poor proprioception

NEUROGENIC - like radicular pain without axonal conduction loss > nerve trunk sensitised (deep ache), allodynia possible (light touch pain)

DYSESTHETIC - pathological changes in peripheral nerves due to excessive impulses from damaged or regeneration > cause unusual symptoms; burning, cool, crawling, electric, wet, paraesthesia, itching

CENETRAL SENSITISATION - abnormal processing e.g. mechanoreceptor input processed as pain when unpainful stimulus (allodynia)

Question 28

What are the tests of a neuro function assessment? what for? x4

Answer 28

• STRENGTH ~ myotomes (oxford scale)
• TONE ~ hypertonia/spasticity = UMN, hypotonia/flaccidity = LMN
• DEEP TENDON REFLEX > absent or decreased reflex = LMN lesion, increased
  reflex/hyperreflexia = UMN lesion
• SENSATION > dermatomes and peripheral nerves; light touch, hot/cold, sharp/blunt, vibration)

Question 29

What is the Hoffmans sign? used for?

Answer 29

• used to rule out a more serious neurological problem i.e. UMN lesion might present > check before moving on with Ax
• arm and hand relaxed, support the 3rd finger above the DIP
• flick the DIP into flexion (flicking down)

POSITIVE - if there is involuntary flexion and adduction of thumb and index finger

Question 30

What is the Colonus test? used for?

Answer 30

• an UMN test > checking for more serious neuro issues before continuing
• in supine, support the lower leg around the calf
• initiate brisk forcible DF on foot

POSITIVE - visible oscillations of foot in response

Question 31

What is the Babinski test? used for?

Answer 31

• UMN lesion test > high specificity, valid and reliable evidence of UMNL if positive (due to low sensitivity, further evaluation if negative test)
• Pt in supine
• run a pointed object (end of reflex hammer) from the heel along the lateral aspect of the foot and forwards towards the great toe

NORMAL REACTION - flexor reflex, toe flexion/toes moving down
POSITIVE - extensor plantar response (Babinski sign) > great toe extends, facing up and toes fanning out

Question 32

What are the reflexes of the LL for neurological function? nerve segment? innervation? muscle?

Answer 32

*help identify pathological disc level/ spinal level of issue
* 5 grade scale > 0-4 (0 - no reflex, 1 - slight, 2 - brisk, 3 - very brisk, 4 - hyperreflexia) - 1, 2 and 3 are most norm responses
* tap 3-6 times > diminution
* re-enforcement - Jendrassik manoeuvre

1. patella tendon reflex
   - L3/L4 segment
   - femoral nerve
   - quadriceps
2. achilleas tendon reflex
   - L5/S1 segment
   - tibial nerve
   - gastroc.

Question 33

What are the signs we use prior to full assessment to rule out UMNL?

Answer 33

1. Hoffmans > 3rd finger flick
2. Colonus > brisk DF
3. Babinski > plantar foot response

Question 34

What are the neural integrity tests? x3 what are the neuro-dynamic tests? x3

Answer 34

neural integrity:
1. myotomes - strength/power
2. dermatomes - sensation
3. reflexes

neuro-dynamics:
1. single leg raise (SLR) - sciatic nerve
2. slump test - sciatic nerve
3. passive knee bend - femoral nerve

Question 35

What are myotomes? how to test? myotomes of LL/ spinal level and muscle?

Answer 35

• muscles neurologically supplied by particular spinal level/segment
• assess using isometric tests - strength testing on oxford scale
• unaffected side then affected side ALL in supine

T2-L1 ~ NO muscle test/reflex

L2 ~ HIP flexion
L3 ~ KNEE extension (+ knee reflex) > one arm under testing leg resting on other leg to raise knee, push down on lower leg
L4 ~ foot DF (+ knee reflex)
L5 ~ GREAT TOE extension
S1 ~ PF and EVERSION of foot; KNEE flexion; contract buttock > PF test or ask Pt to rise on there toes
S2 ~ KNEE flexion, toe standing > Pts supine, knee bent to 45, grasp behind ankle and pull
S3-S4 ~ muscles of pelvis floor, bladder and genital function

Question 36

What are dermatomes? what to use? how to test LL?

Answer 36

• area of skin innervated by sensory fibres of single nerve root
• paraesthesia is most likely to be found in the most distal part of the dermatome
• L2 to S1 are dermatomes most used in clinic
• use cotton wool or bed roll tissue > DAB rather than drag across skin
• assess PROXIMALLY to DISTALLY comparing both sides
• seek feedback > does this side feel the same to this side?
• Pt in supine, ask them to close their eyes
• using wool or tissue
• provide Pt with example of sensation on a central point > sternal angle OR forehead > “this is what it will feel like”
• L2 ~ distal to greater trochanter, down the lateral femur > dab middle top third of thigh
• L3 ~ half way down medial thigh, down to just distal of tibial condyle > dab medial area of patella
• L4 ~ 1/4 down medial tibia, all the way down, under medial malleolus, under medial arch to under sole to great toe > dab half way down medial tibia
• L5 - 1/4 down of lateral fibular, down diagonally to great toe on dorsal/top of foot > bad medial side of great toe CPJ
• S1 ~ from lateral malleolus, across lateral foot, to the lateral side of fifth digit > last third of lateral foot

Question 37

What are neuro-dynamics? relationship of elongating nerves?

Answer 37

• mechanical or physiological properties of neural tissues
• nerves slide against surrounding ‘tissue interfaces’ and pass through structures or go around
• spinal canal 5-9cm longer in Lx flexion > lengthening the system
• never stretch a nerve as elongation > mobilise the surrounding tissues relieving pressure;
  elongation > narrow the nerve > reducing lumen opening > restricting blood flow > therefore can lead to ‘tingling’

Question 38

How to perform the femoral nerve tension test in side lying? which spinal segments?

Answer 38

passive knee bend ~ FEMORAL nerve ~ mid Lx; L2, L3, L4

• assess unaffected side then affected side > see their norm
• Pt in side lying
• bring bottom leg up to their chest, there top arm in front to stabilise > neck into full flexion
• stabilise pelvis and grasp under the top knee in flexion
• extend the hip

~ if symptoms come on - stop (differentiate between soft tissue stretch or neural symptoms)
~ desensitise by removing cervical flexion > less ‘pull’ > does removal of neck flexion change pain or resistance? > lessens then could be myofascial restriction
~ symptoms ~ reproduction of pain, paraesthesia, shooting, resistance > over anterior thigh or mid Lx - L2, L3, L4

Question 39

How to perform the straight leg raise (SLR) neurodynamic test? which nerve and spinal segments?

Answer 39

straight leg raise - SCIATIC nerve - L4, L5, S1, S2
~ progressively add tension to structures
~ unaffected then affected

• Pt in supine, relaxed with a neutral head
• want to passively perform hip flexion while maintaining knee extension
• with Pts leg straight, increase hip flexion, bringing leg up, until end range or start of symptoms
• after max hip flexion > rest Pts leg on shoulder using same arm to bring foot into DF (if this INCREASES symptoms of paraesthesia or shooting from previous, this can confirm the pain is neural)

~ further sensitising movements to confirm - does this increase your symptoms?:
- cervical neck flexion
- hip adduction
- hip medial rotation
(with constant DF)

Question 40

How do you perform the slump test? which nerve and spinal segments?

Answer 40

slump test - SCIATIC nerve - L4, L5, S1, S2
~ unaffected then affected

• Pt in sitting on side of plinth, therapist on SAME side as tested leg
• ask Pt to bring arms behind their back, and chin to chest (cervical flexion) with Thx flexion ~ slump
• therapist gently places hand on back of Pts head and rest elbow on Pts shoulder to maintain the slump position
• ask Pt to actively extend their knee to end range or till neural symptoms start
• then further sensitise > ask Pt to actively DF

~ positive - reproduction of pain, paraesthesia, shooting

• ask Pt to extend cervical spine back to neutral > does this change or reduce your symptoms? if it DOES NOT change/reduce: the the dura mater is NOT involved however, if symptoms change or REDUCE this tells us the dura mater IS involved