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Mincer - SPINE > Week 3 Thu 1.28.16 Lumbar Obj Exam > Flashcards

Week 3 Thu 1.28.16 Lumbar Obj Exam Flashcards

1
Q

Components of lumbar exam in standing (9)

A
  • general observation and baseline vitals
  • functional activity such as squatting, putting on shoes or socks
  • gait
  • balance
  • neurological exam: MMT, toe/heel walk L4- L5, S1-S2
  • posture (iliac crest, PSIS, ASIS, leg length, lordosis, kyphosis, lateral shift, scoliosis, atrophy, skin inspection
  • lateral shift correction
  • AROM ( F, E, LF) overpressure as needed
  • combined movement testing, lumbar quadrant as needed
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2
Q

Components of lumbar exam in sitting (5)

A
  • Sitting posture
  • AROM: rotation as indicated with overpressure
  • neurologic screening (L2- S2)
  • MMT, DTRs, sensation as needed
  • slump test
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3
Q

Components of lumbar exam in supine (9)

A
  • Observe ability to transition to supine
  • Repeated movements: repeated F in lying
  • SLR plus sensitizing maneuvers: DF, ADD, IR
  • Palpation: iliac crest, ASIS, pubic tubercle symmetry, hip, abdomen as needed
  • Screen hip: F/ IR, also prone ER, overpressure; ABB/ADD overpressure, F, ABD, ER
  • screen knee: F, E, overpressure
  • Muscle length: piriformis, hamstring , (SLR or 90/90, latissimus, Thomas test ( iliopsoas, rectus femoris, IT band)
  • TA/ multifidus : palpation, biofeedback cuff/ rehab ultrasound imaging
  • SIJ distraction/compression, thigh thrust, Gaenslen’s test, sacral thrust
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4
Q

Components of lumbar exam in prone (8)

A
  • repeated movements: sustain or repeated 10X, assess response
  • prone on pillow, prone, prone on elbows
  • repeated E in lying (REIL)
  • REIL with sag
  • REIL with mobilization belt
  • REIL with hips offset
  • prone knee bend/ femoral nerve stretch
  • hip E: MMT ( gluteus max, hamstrings), hamstrings DTR

hip IR ROM bilaterally

palpation: PAIVM: central and unilateral (sacrum to T10)

prone instability test

passive lumbar E test

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5
Q

Components of lumbar exam in sidelying (3)

A
  • PFIVM - F/E/Side bend/ rotation
  • Ober’s test
  • hip ABD/ADD: strength
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6
Q

What activities should be included in the section of the exam for functional activity?

A

from the pt’s history that reproduce or increase the symptoms, such as: walking, sit-to-stand, putting on socks and shoes, bending, reaching, lifting, stair climbing, stepping up and down, getting into the car, hopping or squatting.

**Not all are necessary and be aware of SINSS

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7
Q

The relationship between gait speed and fear avoidance

A

fear avoidance is a strong predictor of gait velocity

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8
Q

The relationship between gait speed and LBP

A
  • patients with LBP walk slower and take shorter asymmetrical steps
  • If asked to walk faster, they simply increase their cadence
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9
Q

What are typical gait deviations for a patient with severe LBP?

A
  • LBP pt walk slower and take shorter asymmetrical steps
  • when asked to walk faster will increase cadence; rather than stride length
  • compensate affected side by taking shorter steps with the opposite side
  • trunk muscle activity is affected; visualized clinically as trunk rigidity (limited transverse rotation between thorax and pelvis)
  • loss of motor control can be seen as lateral pelvic tilt in the lateral plane (Trendelenburg sign)
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10
Q

What could be going on is bony pelvic landmarks are asymmetrical? (2)

A
  • ↑ height of the ASIS, PSIS and iliac crest on the same side suggest an apparent LLD
  • asymmetrical heights of ASIS, PSIS and iliac crest (eg. low PSIS on left, high PSIS on left, and high ASIS on left ) suggest apparent pelvic girdle asymmetry
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11
Q

What is the appropriate next step in the assessment for a patient who has, a leg length discrepancy (based on pelvic landmarks) and otherwise normal LE alignment and fairly good trunk posture whose worst LBP occurs in standing?

A
  • after all other LE landmarks (ischial tuberosities, greater trochanters, fibular head and medial malleoli) are measured, standing block to level the pelvis may be tried and symptom response assessed.
  • want to determine if findings are relevant, incidental, or simply bony asymmetry
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12
Q

How and why should a therapist assess the relevance of trunk postural abnormalities and deviations during AROM?

A
  • Clinician should correct deviations from the expected movement plane either during or at end range to determine the relevance of the deviation.
  • If correction alters the pt.’s symptoms, then the relevance is established.
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13
Q

How does the direction of lateral shift usually relate to the painful side?

A

shift is contralateral, away from the pain

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14
Q

How are lateral shifts named?

A
  • The direction that the shoulders and upper T-spine are headed toward.
  • Below is an example of a right lateral shift
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15
Q

What does the presence of a lateral shift suggest?

A
  • widely believed to be associated with: symptomatic dics pathology such as disc protrusion, space occupying lesions, tumors, or painful nerve root compression
  • typically classified as a mechanical derrangement using MDT terminology
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16
Q

What is peripheralization what is the appropriate responses when performing shift correction?

A
  • Pain coming from the spine is produced distally, spreads distally or increases distally, and remains in the extremity after testing.
  • when it occurs, procedure is stopped and attempted in unloaded position
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17
Q

What is centralization and what is the appropriate responses when performing shift correction?

A
  • Pain in the extremity coming from the spine is abolished, progressively moves in a proximal direction, and remains abolished after testing. At the same time, proximal pain may develop or increase in the spine.
  • when it occurs, the correction procedure is continued until the side gliding motion is fully achieved across midline or to the possible extent in the first session
  • the procedure is continued with restoration of lumbar lordosis
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18
Q

What are the typical aberrant movements observed during trunk flexion? (5)

A
  • Painful arc during flexion or on return
  • High climbing or pushing on thighs to assist return to upright
  • Instability catch or a sudden acceleration or deceleration of the trunk movement
  • movement occurring out of the primary plane of motion
  • reversal of lumbopelvic rhythm. (ie flexion and shifting the pelvis anteriorly to return to upright from flexion)
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19
Q

What does the presence of aberrant movements observed during trunk flexion suggest?

A

Observation of aberrant movement is a key finding that supports the stabilization classification of LBP with movement coordination impairment.

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20
Q

When and why might we use overpressure applied to trunk ROM?

A
  • If indicated and is safe for the pt and if AROM is in full range and painless, passive OP is performed in an oscillatory manner and the limit of the movement confirms the end feel and effect on symptoms.
  • If AROM with OP is normal, the clinician should try repeated movements, sustained movements or combined movements to reproduce or alter the patient’s symptoms.
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21
Q

How does centralization relate to prognosis?

A

Centralization is associated w/ a good prognosis and good outcomes of reduced pain, greater functional improvement return to work, and decreased health care usage.

Failure to centralize is associated w/ poor outcome at 1 yr. Pts who fail to centralize are classified as non centralizers and at high risk for delayed recovery, chronic disability and greater healthcare usage.

22
Q

What is indicated when centralization and partial centralization occurs as a result of repeated motion testing?

A
  • suggests a subgroup classification within the direction-specific classification or derangement syndrome.
  • The direction of the repeated movement that results in centralization indicates that specific ex in that direction is an appropriate initial intervention.
23
Q

How many times do you have a pt. repeat a motion to determine symptom respone?

A

typically 10-15 times

24
Q

What is the very first thing to do when trying out repeated motions?

A
  • get baseline symptoms (this is much easier to forget than you would think)
  • will monitor symptom response throughout movements to determine if the patient has a directional preference
25
Q

What is the best use of the lumbar quadrant test?

A
  • MAX loading of spinal structures and narrowing of the IVF on the side of the LF and rotation
  • may be useful in ruling out pain originating from the lumbar spine.
26
Q

Purpose of the slump test

A

test neurodynamics of neuromeningeal structures in the vertebral canal & IVF and mobility of the PNS of the LE in pts with spinal & LE pain

27
Q

A positive slump test occurs when the test results in what 3 responses?

A
  1. Reproduction of the pts symptoms
  2. Asymmetry between uninvolved to involved side
  3. A positive sensitizing maneuver
28
Q

The mechanics and interpretation of sensitizing maneuvers used in neurodynamic testing.

A
  • Sensitizing maneuver is movement at site distant to location of symptoms- attempts to preferentially load neural tissue w/out placing stress on other tissues that could be related to the production of symptoms.
  • A positive sensitizing maneuver (i.e. release of neck flexion): altering symptoms help to differentiate between neural and non neural structures
29
Q

How are repeated motions in lying mechanically different from repeated motions in standing?

A
  • Unloaded position in lying vs a loaded position in standing.
  • If loaded position does not centralize symptoms, it will sometimes be more effective in an unloaded position
  • REIL produces a greater mechanical effect than REIS, pg 201 (This is the position my CI always tried extension.)
30
Q

What is the best interpretation of a negative ipsilateral SLR?

A

rule out disc herniation

31
Q

What 3 things are present for a +SLR?

A
  1. reproduction of the pt.’s familiar symptoms reproduced between 30-70 degrees or less of hip flexion
  2. limited motion compared to teh uninvolved side
  3. altered symptoms with a sensitizing maneuver
32
Q

What did Mincer say about the sensitizing maneuver with the SLR test

A

Only rules in neuroynamics, does not rule out anything

33
Q

What is the best interpretation of a positive contralateral SLR?

A

most likely disc herniation

34
Q

What is the best interpretation of a positive active SLR?

A
  • A positive test suggests a lack of dynamic stabilization and impaired load transfer (between lumbopelvic region and LEs).
  • ASLR assesses ability of lumbopelvic region to transfer loads between the trunk and LEs- requires both articular stability or form closure and adequate neuromuscular control or force closure.
35
Q

Some patients you would use ASLR with (3)

A
  • non-specific LBP
  • postpartum pelvic pain (PPPP)
  • SI disorders.

**Pts with these disorders show changes in movement patterns and force closure during the ASLR.

36
Q

What are the two reasons a PT should examine the hip in patients who are being evaluated for LBP?

A
  1. Overlapping refferal patterns
  2. Are there 2 different biomechanical issues going on?
37
Q

What common subjective and objective symptoms would make one suspect hip OA? (5 and 2)

A

Objective

  1. Pain aggravated with squatting
  2. Lateral and anterior hip pain with the scour test
  3. Active hip flexion causing lateral hip pain
  4. Pain with active hip extension
  5. Passive range of hip IR less than 25 degrees

Subjective

  1. complaint of morning stiffness under an hour
  2. over age 50
  3. strong desire to wear bell bottom pants
38
Q

What is the primary reason for performing Patrick’s (Figure4/FABIR) test?

A

pain provocation test assess for the presense of lumbopelvic and hip pathology

39
Q

Differentiate between stabilization that emphasizes TrA contraction with abdominal bracing

A
  • Abdominal brace (AB) is a low-level stiffening or isometric contraction of the muscles around the trunk (ie. abdominals, paraspinals, and TrA). The spine or pelvis should not move and the abdominal wall is not sucked in or pushed out. According to McGill, the AB stabilizes the spine in bending and twisting perturbations where the ADIM does not.
  • From a mechanical perspective, bracing appears to provide patterns of greater stability, while the ADIM does not appear to enhance stability.
  • Training of the TrA and MF (multifidus) are related to motor control aspects of segmental spinal stability, initially de-emphasizing the use of the global stabilizers.
  • AB appears to function by providing dynamic spinal stability through all muscles of the trunk, both deep and superficial.
  • Exam of the pt, the amount of load his or her spine will tolerate, and the specific tasks he or she needs or desires to perform will help the clinician determine whether to start with AB or ADIM.
40
Q

What is the best use of the SIJ test cluster? (5)

A
  1. distraction
  2. compression
  3. thigh thrust
  4. Gaenslen’s
  5. Sacral thrus
41
Q

How do you process the information regarding positive and negative results for the SIJ tests?

A
  • If three or more tests are positive, Sn is 0.91 and Sp is 0.87
  • Using only 4 tests (distraction, thigh thrust, sacral thrust, and compression) only 2 out of 4 need to be positive for diagnosis of SIJ-related pain with Sn 0.88 and Sp 0.78.
  • If all 6 tests do not reproduce pain, SIJ problems can be ruled out.

(Each test position is held 7-10 seconds.)

42
Q

How does one progress a patient through prone extension activities?

A
  • Prone on pillow or pillows (sustained)- remove pillows gradually
  • Prone (sustained)
  • Prone on elbows (sustained)
  • REIL (Note: this is where the progression would start if there was no kyphotic shift)
  • REIL with sag:
  • REIL with clinician OP
  • REIL with mobilization belt fixation
43
Q

Why perform REIL with hips off?

A
  • This procedure is indicated when unilateral symptoms worsen or do not respond to sagittal plane movements of REIS or REIL.
  • The procedure is the same as for REIL except for the starting position with the hips off center, creating a lateral force in an extension procedure.
  • The hips are usually shifted away from the painful side and REIL is performed.
44
Q

What is/are the indication(s) for the Prone Knee Bend (PKB) test?

A
  • The PKB test places a tension load on the upper and mid-lumbar nerve roots (L2- L4) through tension of the femoral nerve during knee flexion.
  • The test is indicated for patients with hip, knee, thigh, or upper lumbar (L2-L4) symptoms
  • suggested to aid in the diagnosis of lumbar radicular symptoms at these levels.
45
Q

What is the advantage of performing PKB in sidelying instead of prone?

A
  • It is also known as the slump knee bend test which allows for differentiation of neural mechanosensitivity and symptomatic somatic structures.
  • Hip extension is a sensitizing maneuver.
  • Technique is similar to the other slump test and will allow clinician to determine femoral nerve involvement or somatic structures of the quadriceps
46
Q

What is the purpose of PAIVM testing

A

To determine whether movement at an appropriate spinal segment reproduces the patient’s symptoms and which spinal segments are normal, hypomobile, or hypermobile for purposes of diagnostic classification and guiding intervention.

47
Q

With PAIVM testing, what treatment is generally indicated by of segmental hypermobility?

A

Lumbar hypermobility assessed with a central PAIVM, a factor in multivariate CPR, is predictive of a successful outcome with a stabilization program

48
Q

With PAIVM testing, what treatment is generally indicated by segmental hypomobility?

A

Identified with a central PAIVM, combined with key history and physical exam findings is useful in predicting which patients are most likely to improve with manipulation.

49
Q

What is the purpose of the Two-stage Treadmill Test?

A

assists in differentiating between neurogenic, like spinal stenosis and vascular claudication.

50
Q

How does the two stage treadmill test differentiate between lumbar spinal stenosis (LSS) and vascular claudication?

A
  • TSTT compares the results of a patient’s walking tolerance with a level and a 15% incline setting at a self-selected comfortable pace.
  • A positive test is associated with an earlier onset of symptoms and prolonged recovery time with level treadmill walking.- vascular claudication
  • The presence of a longer total walking time during inclined walking is predictive of LSS. (in flexed position walking on incline)
51
Q

What are the indications for radiographs in acute LBP? (11)

A
  1. Recent significant trauma
  2. Milder trauma with age > 50
  3. Unexplained weight loss or fever
  4. Immunosuppression
  5. History of cancer
  6. IV drug use
  7. Prolonged use of corticosteroids
  8. Osteoporosis
  9. Age > 70
  10. Focal neurologic deficit with progressive or disabling symptoms
  11. Duration of longer than 6 weeks

Mincer - SPINE (16 decks)

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