Week 1- L-spine Examination Flashcards
PART 1: CHART REVIEW/PATIENT INTERVIEW
PART 1: CHART REVIEW/PATIENT INTERVIEW
Screening Questions:
- Hx of ________, _________, _______, and ______.
- ______ loss
- Fatigue
- _______ and ________ dysfunction
- Sexual dysfunction
- LE dysesthesia/motor impairments
- Fever
- Abnormal sweating
- Concomitant DM
- Immunocompromization
- Hx of cancer, smoking, infection, and trauma
- Weight loss
- Bowel and bladder dysfunction
Common Red Flags with L-Spine:
- Age > ___
- No improvement in symptoms after ___ month(s)
- Previous Hx of _______
- No relief with _______
- Unexplained ____________
- Fever
- Thoracic pain
- “being systematically unwell”
- Age >50
- 1 month
- cancer
- bed rest
- weight loss
What are some outcome measures to use for Low Back? (3)
- PSFS
- Oswestry Disability Index (ODI)
- Roland Morris Questionnaire
What are some outcome measures to use for psychosocial limitations? (3)
- Fear Avoidance Beliefs Questionnaire (FABQ)
- Pain Catastrophizing Scale (PCS)
- Tampa Scale of Kinesiophobia (TSK)
PART 2: VISUAL INSPECTION
PART 2: VISUAL INSPECTION
Anterior View:
- What can we see with a visual inspection?
- What landmark palpations?
- weight shifting, pelvic asymmetry, LE alignment, distress
- ASISs
Posterior View:
- Visual inspection for soft tissue and bony contour general symmetry including what?
- Posture assessment with what landmark palpations?
- erector spinae mass, inferior angles in line with T7, tibial and fibular malleoli, popliteal crease
- vertical alignment of spine, iliac crest height, PSISs
Posterior View:
- What are (3) common abnormalities found when looking from posterior view?
- Lateral shift is often attributed to what?
- Unilateral muscle mass variance can be __________ (atrophy) or _________ (guarding, inhibition, spasm, volitional).
- Lateral shift, Scoliotic curvature, Unilateral muscle mass variance
- Lumbar lateral flexion “away” from laterality of pain source
- morphological or physiologic
Lateral View:
- Plumb line assessment with what 3 structures in line?
- Can observe lordotic curvature.
- Posture assessment with what landmark palpations?
- external auditory meatus, acromion, peak of iliac crest
- vertical alignment of spine, iliac crest height, PSISs
Lateral View:
- What are (3) common abnormalities found when looking from lateral view?
- Excessive lumbar lordosis is associated with the “tripod effect”, what is this? What is it possibly consistent with?
- Excessive lumbar lordosis may accompany _______ pelvic tilt.
- With pelvic cross syndrome, which muscles are shortened? Which are lengthened?
- Excessive lumbar lordosis, Diminished lumbar lordosis, “Sway Back” posture
- Z-joint become weight bearing, consistent with spondylolisthesis
- anterior
- shortened erector spinae and iliopsoas, lengthened abdominals and glute max
Lateral View:
- Diminished lumbar lordosis is known as “flat back” posture and may be consistent with what?
- Consider compressive loading on ________ vertebral body.
- May accompany __________ pelvic tilt.
- Often associated with shortening of _________, lengthening of ______________.
- lumbar stenosis
- anterior vertebral body
- posterior
- shortening of hamstrings, lengthening of hip flexors
Lateral View:
- “Sway Back” posture involves _________ thoracic kyphosis and __________ pelvic tilt.
- Sway back also associated with excessive hip ___________ and lengthened back extensors and hip flexors.
- excessive, posterior
- extension
Gait:
1
Gait
1
PART 3: SYSTEMS REVIEW
PART 3: SYSTEMS REVIEW
1
2
PART 4: ELIMINATION TESTS
PART 4: ELIMINATION TESTS
What are the (4) main parts of elimination testing?
- Lower Quarter Screen (LQS)
- Neuro Screening Tests
- Other Screening Tests
- Special Tests
What are the (5) main parts of a Lower Quarter Functional Screening?
- Lumbar AROM
- Squat
- Unilateral squat vs. Modified lunge
- Walking on Heels (10 steps)
- Walking on Toes (10 steps)
- What are the testing procedures for sensation? (3)
- What are the testing procedures for motor function? (3)
- light touch, pin prick, proprioception
- myotome, peripheral nerve distribution
- coordination
L1-S2 Sensory Testing:
- L1 = ________
- L2 = _________
- L3 = __________
- L4 = _________
- L5 = ________
- S1 = __________
- S2 = _________
- L1 = Proximal anterior thigh
- L2 = Middle anterior thigh
- L3 = Medial Knee
- L4 = Medial Foot
- L5 = Dorsum of Foot
- S1 = Lateral Foot and 5th Toe
- S2 = Medial Posterior Leg
L1-S2 Myotome Testing:
- L1 = ________
- L2 = _________
- L3 = __________
- L4 = _________
- L5 = ________
- S1 = __________
- S2 = _________
- L1 = Hip Flexion
- L2 = Hip Flexion
- L3 = Knee Extension
- L4 = Ankle DF
- L5 = Great Toe Extension
- S1 = Ankle PF
- S2 = Knee Flexion
DTR Nerve Roots:
- Quad = ____
- Extensor Digitorum Brevis = ____
- Achilles = ____
- Quads = L4
- Extensor Digitorum Brevis = L5
- Achilles = S1
What Pathologies can we use Elimination Special Tests on? (4)
- HNP/Lumbar Radiculopathy
- Z-Joint Pain
- Lumbar Stenosis
- Compression Fracture
What elimination tests are used to rule out HNP/Lumbar Radiculopathy?
- Slump Test
- Straight Leg Raise Test (SLR)
Slump Test:
- How is the Slump Test performed?
- What is a positive test?
- Patient locks arms behind back, slumps forward, flexes the neck, extends the leg, and dorsiflexes the foot. Patient is then asked to extend head when radicular symptoms are felt.
- Alleviation of radicular symptoms with neck extension.
SLR Test:
- How is the SLR test performed?
- What is a positive test?
- Have patient in supine, flex leg while keeping knee fully extended. Ask when patient feels symptoms occur. When felt, back off slightly and DF foot or ask patient to flex neck and see if symptoms come back.
- Pain reproduction when performing DF or neck flexion.
What elimination tests are used to rule out Z-joint Pain?
-Extension-Rotation Test
Extension-Rotation Test:
- How is the Extension-Rotation Test performed?
- What is a positive test?
- Ask patient to cross arms and examiner reaches across patients shoulder while also blocking mid L-spine with other hand. Extend patient over hand, then rotate each direction.
- Pain provocation with rotation toward involved facet arthropathy.
What elimination tests are used to rule out Lumbar Stenosis?
-Clinical Prediction Rule
Clinical Prediction Rule:
What are the (5) items of the CPR for lumbar stenosis?
- Bilateral symptoms
- Leg pain > back pain
- Pain with walking/standing
- Pain relieved with sitting
- Age >48 years
What elimination tests are used to rule out Compression Fractures?
-Percussion Test
Percussion Test:
- How is the Percussion Test performed?
- What is a positive test?
- With patient standing or sitting, lightly percuss along spine with closed fist.
- Patient reports sudden, sharp, severe pain.
PART 5: STRUCTURAL STRESS TESTING
PART 5: STRUCTURAL STRESS TESTING
What are the 3 components of Structural Stress Testing?
- AROM
- PROM
- Resistive Testing
What are the 4 things we are looking for with AROM, PROM, and Resistive Testing?
- Quality
- Quantity
- Provocation
- Willingness to move
What are the L-spine movements? (4)
- Flexion
- Extension
- Lateral Flexion
- Rotation
How do we instruct a patient to perform lumbar flexion?
- Instruct pt to place hands on anterior thighs and reach down anterior LEs by bending at the l-spine.
- Ensure patients do not weight bear through UEs.
With lumbar flexion, how do we give quartile percentages of motion?
- 25% = mid thigh
- 50% = knees
- 75% = mid lower leg
- 100% = feet/floor
What are some compensations seen with lumbar flexion?
- Hinging at hips
- Gower’s sign (walking hands up LEs to return to upright)
How do we instruct a patient to perform lumbar extension?
-Instruct pt to put hands on hips and lean back at the waist to look at the ceiling.
What are some compensations seen with lumbar extension?
- Knee flexion
- Localization of motion in spine (upper vs lower)
How do we instruct a patient to perform lumbar lateral flexion?
-Instruct pt to reach fingertips toward side of the knee without rotation or bending at the waist.
With lumber lateral flexion, how do we give quartile assessment of motion?
-Note distance toward/past lateral tibiofemoral joint line.
How do we instruct a patient to perform lumbar rotation?
-Instruct pt to cross arms across chest and rotate at the low back. May require blocking.
With lumbar rotation, how do we give quartile percentages of motion?
-Via visual estimation compared to normal patients.
What are the 2 combined motions that may be performed at the l-spine with structural stress testing?
- Flexion, rotation, and contralateral lateral flexion
- Extension, rotation, and ipsilateral lateral flexion
In what positioned is a lumbar PROM assessment performed?
-sitting at corner of table
Resistive Testing
1
PART 6: PALPATION AND JOINT MOBILITY TESTS
PART 6: PALPATION AND JOINT MOBILITY TESTS
What bone and joint structures are we going to palpate at the L-spine? (5)
- Spinous Processes
- Transverse Processes
- PSIS
- ASIS
- Symphysis Pubis
When palpating the spinous processes, what may a step-off deformity indicate?
-May indicate serious injury spondylolisthesis or compression fracture.
What soft tissue structures are we going to palpate at the L-spine?
- Erector Spinae
- Iliolumbar Ligament
- Glute Max muscle belly
- Glute med
- Area between ASIS and Symphysis pubis
What (3) things are we assessing for with our manual therapy assessment?
- Gross quantity
- End-feel (quality)
- Provocation
- What is traction?
- What is compression?
- What is gliding?
- Traction = Separation of joint surfaces with force direction perpendicular to joint plane.
- Compression = Approximation of joint surfaces with force direction perpendicular to joint plane.
- Gliding = Force direction parallel to joint surface.
What are the 2 types of joint mobility testing?
- PAIVM (Passive Accessory Intervertebral Mobility Testing)
- PPIVM (Passive Physiological Intervertebral Mobility Testing)
Are CPAs and UPAs PAIVMs or PPIVMs?
-PAIVMs
What are we looking for when performing UPAs or CPAs?
-Provocation of concordant symptoms or accessory motion.
What are the motions assessed with PPIVMs?
- Flexion
- Extension
- Lateral Flexion
- Rotation
PPIVM Flexion:
-How is flexion PPIVM performed?
- Patient starts in side lying with hips and knees flexed to mid-range.
- Examiner faces patient’s anterior and uses palpation finger at the interspinous space between levels being assessed.
- Starting at level L5/S1, examiner shifts weight in patients cranial direction to create flexion moment.
- After spinous processes have stopped gapping, examiner relocates palpation finger to interspinous space of the next segment above.
- As more cranial segments are assessed, process is repeated without returning to neutral lumbar flexion/extension.
PPIVM Extension:
-How is extension PPIVM performed?
- Patients starts in side lying with hips and knees slightly flexed.
- Examiner faces patient’s posterior with CAUDAL hand supporting patient’s distal lower leg. Palpation finger of CRANIAL hand is at the interspinous space between levels being assessed.
- Starting at level L5/S1, examiner shifts weight in rotary direction by “pulling” the LEs in the posterior direction. Approximation should b observed at spinous process.
- Once the segment has stopped approximating, the examiner relocates palpation finger to interspinous space of the next segment above.
- As more cranial segments are assessed, process is repeated without returning to neutral lumbar flexion/extension.
PPIVM Rotation:
-How is rotation PPIVM performed?
- Patient starts in side lying with hips and knees slightly flexed.
- Examiner faces patient’s anterior with cranial forearm between patients arm and trunk. CAUDAL forearm stabilizes patient’s posterior-lateral pelvis while palpating finger is placed off of spinous process at level being assessed.
- Starting at the level of T12/L1, examiner shifts weight so rotation occurs away from examiner. Once spinous process has been approximated, examiner will relocate to next segment below.
- As more caudal segments are assessed, process is repeated without returning to neutral lumbar flexion/extension.
PPIVM Lateral Flexion:
-How is lateral flexion PPIVM performed?
- Patient starts in side lying with hips and knees at approx 90 degrees.
- Examiner faces patient’s anterior with the CAUDAL hand reaching anteriorly to the distal lower legs. Palpation finger is at interspinous space between levels being assessed with the CRANIAL hand.
- Starting at the level of L5/S1, examiner shifts weight in cranial direction. Distal lower leg is lifted away from table, causing patients lower half to pivot. Once examiner observes that spinous processes have stopped gapping, palpation finger is relocated to segment above.
- As more cranial segments are assessed, process is repeated without returning to neutral lumbar flexion/extension.
PART 7: CONFIRMATION TESTS
PART 7: CONFIRMATION TESTS
What Pathologies can we use Confirmation Special Tests on? (3)
- Discogenic Symptoms
- HNP/ Lumbar Radiculopathy
- Instability
What confirmation tests are used to rule in Discogenic Symptoms?
-Centralization with Repeated Motions
What confirmations tests are used to rule in HNP/ Lumbar Radiculopathy?
- Well Leg Raise Test
- Femoral Nerve Tension Test
- CPA/Spring Testing
Well Leg Raise Test:
- How is the Well Leg Raise Test performed?
- What is a positive test?
- Raise non symptomatic LE keeping knee extended. Look for provocation of symptoms on problematic side.
- Positive test is concordant symptoms on contralateral side.
Femoral Nerve Tension Test:
- How is the Femoral Nerve Tension Test performed?
- What is a positive test?
- With patient in prone, slowly bend knee until symptoms felt. If no symptoms are felt then raise the hip off of the table.
- Concordant pain reproduction.
CPA/Spring Test:
- How is the CPA/Spring Test performed?
- What is a positive test?
- Provide CPAs to patient at each lumbar level.
- Concordant pain reproduction.
What confirmation tests are used to rule in Instability?
- Catch Sign
- Passive Lumbar Extension Test
- Prone Instability Test
Instability Catch Sign Test:
- How is the Instability Catch Sign Test performed?
- What is a positive test?
- Performed by asking patient to flex towards the ground and come back up.
- Any pain felt with catch or sudden LBP.
Passive Lumbar Extension Test:
- How is the Passive Lumbar Extension Test performed?
- What is a positive test?
- With patient in prone, legs are passively raised ~10 inches.
- Severe LBP or feeling of heaviness on lower back.
Prone Instability Test:
- How is the Prone Instability Test performed?
- What is a positive test?
- With patient prone hanging over the table apply PA pressure. If pain provoked, ask to lift legs and apply PA pressure once more.
- Pain provocation with PA reduced by actively bringing legs off ground.
