OSCE: BLT/FPR/Still's Screening for Thoracic and Lumbar Spine

Question 1

BLT Upper Thoracic, Supine

Answer 1

Position:

• Patient: supine
• Physician: at head of table

Hand Placement:

• With hand ipsilateral to PTP, place the index finger on the TP of the dysfunctional segment
• With hand contralateral to PTP, support the patients head

Technique:

1. Move patient into flexion with rotation and sidebending to the EASE of motion (indirect) until reaching the point of balanced ligamentous tension
2. Assess respiratory phases, have patient hold breath in inhalation or exhalation based on the position that best achieves ligamentous balance
3. Minor adjustments to flexion, rotation and sidebending may be needed to maintain ligamentous balance; repeat until best motion is obtained
4. Reassess

Question 2

BLT Upper Thoracic, Seated

Answer 2

Position:

• Patient: Seated
• Physician: Behind seated or standing

Hand Placement:

• Monitor the segment being treated with one hand.
• Place the other elbow on the patient’s shoulder, with hand on top of the patient’s head

Technique:

1. Place the patient in an indirect position, using small increments until all three planes achieve BLT.
2. Test the respiratory phases and instruct pt to hold breath as long as possible in phase that provides best BLT. Make minor adjustments in patient’s position to maintain tissue balance.
3. Repeat as needed.
4. Reassess for 2-4 TART findings.

Question 3

BLT Lower Thoracic, Seated

Answer 3

Position:

• Patient: seated
• Physician: behind patient

Hand Placement:

• Use thumb ipsilateral to PTP to contact the TP of the inferior vertebra in the vertebral unit
• Use thumb contralateral to PTP to contact the TP of the superior vertebra in the vertebral unit

Technique:

1. Instruct patient to lean back at the hips then sit up straighter or slouch forward to localize the sagittal plane at the dysfunctional unit.
2. Instruct patient to “lean a little towards” the ease of sidebending motion and “turn a little towards: the ease of rotation motion in small increments to achieve balanced ligamentous tension
3. Assess respiratory phases, have patient hold breath in inhalation or exhalation based on the position that best achieves ligamentous balance
4. Minor adjustments to flexion, rotation and sidebending may be needed to maintain ligamentous balance; repeat until best motion is obtained
5. Reassess

Question 4

BLT Thoracic/Lumbar, Prone

Answer 4

Position:

• The patient lies prone.
• Physician stands beside the table.

Hand Placement:

• The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12.
• The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1.

Technique:

1. The patient inhales and exhales, and physician encourages patient to hold the more relaxing of the two and follows the motion of these two segments.
2. The physician adds a compression force (long arrows) approximating T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier. (If the diagnosis is a flexion dysfunction you would push down and out to exaggerate the flexion component instead of down and in for the extension component)
3. Next, the physician’s thumbs approximate the left transverse processes of T12 and L1, which produces side bending left (horizontal arrows) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb, downward arrow).
4. When this total balanced position is achieved, the physician holds the position until air hunger. Repeat as needed (usually 3 times).
5. Reassess for 2-4 TART findings

Question 5

FPR: Upper Thoracic

Answer 5

Position:

• Patient Seated
• Physician behind

Hand Placement:

• Monitor segment with one hand.
• Other hand on top of head.

Technique:

1. Instruct patient to extend head to neutralize upper thoracic kyphosis.
2. Add <1lb of compression down to the segment you are monitoring.
3. Put patient into triplanar position of ease.
4. Hold 3-5 seconds.
5. Return to neutral and reassess.

Question 6

FPR: Lower Thoracic

Answer 6

Position:

• Patient Seated
• Physician behind

Hand Placement:

• Monitor segment with one hand
• Other rests across posterior aspect of the patients neck

Technique:

1. Instruct patient to extend head to neutralize thoracic kyphosis.
2. Add <1lb of compression down to the segment you are monitoring.
3. Put patient into triplanar position of ease.
4. Hold 3-5 seconds.
5. Return to neutral and reassess.

Question 7

FPR: Lumbar, Flexed (type 2), Prone

Answer 7

Position:

• Patient prone with pillow under abdomen
• Physician at side of table ipsilateral to PTP

Hand Placement:

• Monitor TP of affected segment with hand closest to table
• Other hand will maneuver the lower extremity

Technique:

1. Flex the leg ipsilateral to the PTP off the table
2. Internally rotate and adduct the lower extremity by moving the knee medially or by pulling the ankle laterally
3. Apply compression through the femur (distal to proximal)
4. Hold 3-5 seconds
5. Return to neutral and reassess

Question 8

FPR: Lumbar, Extended (type 2), Prone

Answer 8

Position:

• Patient prone with pillow under abdomen
• Physician at side of table ipsilateral to PTP

Hand Placement:

• Monitor TP of affected segment with cephalad hand
• Caudad hand will maneuver the lower extremity

Technique:

1. Abduct the leg ipsilateral to the PTP until motion is felt at the monitoring hand.
2. Induce internal rotation of the hip then extend the leg.
3. Add <1 lb of compression through your finger resting on the TP contralateral to the PTP you are monitoring.
4. Hold 3-5 seconds.
5. Return to neutral and reassess.

Question 9

Still’s: Upper Thoracic Seated

Answer 9

Position:

• Patient seated
• Physician behind

Hand Placement:

• Monitor TP of affected segment
• Other hand will maneuver the head

Technique:

1. Extend the head until motion is palpated at the affected segment that is being monitored.
2. Induce sidebending and rotation into the ease of motion until motion is felt at the monitoring hand.
3. Add gentle compression towards the segment.
4. Move through the triplanar restrictive barriers while maintaining compression.
5. Return to neutral and reassess.

Question 10

Still’s: Lower Thoracic, Seated

Answer 10

Position:

• Patient seated
• Physician behind

Hand Placement:

• Monitor TP of affected segment

Technique:

1. Initial Positioning: Extend to localize to T6, then add rotation left and sidebending left (monitor at TP for tissue texture normalization)
2. Localizing Force: Compression through shoulders to the segment
3. Activating Force: Move T6 through restrictive barrier through shoulder contact (FRRSR) while maintaining compression
4. Final Positioning: attained anatomic barrier
5. Return to neutral, reassess

Question 11

Still’s: Lumbar, Seated

Answer 11

Position:

• Patient seated
• Physician behind patient

Hand Placement:

• Monitor TP of affected segment.

Technique:

1. Initial Positioning: Extend to localize to L4, then add rotation left and sidebending left (monitor at TP for tissue texture normalization)
2. Localizing Force: compression through shoulders to the segment
3. Activating Force: Move L4 through restrictive barrier through shoulder contact (FRRSR) whiling maintaining compression
4. Final Positioning: attained anatomic barrier
5. Return to neutral, reassess