Week 3 Tue 1.26.16 General Obj.exam Flashcards
Name the 13 components of the standard objective examination.
- Observation
- Posture
- Gait
- Balance
- Functional Tests
- AROM
- PROM
- Neurological Screening
- Muscle length test
- Muscle performance
- Screen region/ joints above and below
- Special tests
- Palpations
Differentiate between protective, non-protective, structural and behavioral postural deviations.
-
Non-protective (structural or behavioral)- Long standing scoliosis is a non-protective structural deformity if it is not correctable by movement and attempts to correct it does not alter symptoms.
- A non-protective Behavioral deformity may be due to emotional state, personality, or poor body awareness. This type of posture is correctable actively or passively by the clinician without a change in symptoms, although it may still be relevant to the problem
- Protective posture- is an attempt by the pt either consciously or unconsciously to lessen symptoms. E.g. left lateral shift in a person with LBP is a protective posture. Correction of the shift and and the pts response determine the relevance and may guide the initial intervention.
What is a non-protective (structural or behavioral) postural deviation?
- Non-protective (structural or behavioral)- Long standing scoliosis is a non-protective structural deformity if it is not correctable by movement and attempts to correct it does not alter symptoms.
- A non-protective Behavioral deformity may be due to emotional state, personality, or poor body awareness. This type of posture is correctable actively or passively by the clinician without a change in symptoms, although it may still be relevant to the problem
What is a protective postural deviation?
- Protective posture- is an attempt by the pt either consciously or unconsciously to lessen symptoms. E.g. left lateral shift in a person with LBP is a protective posture. Correction of the shift and the pts response determine the relevance and may guide the initial intervention.
What is upper crossed syndrome? (include 4 parts of typical presentation)
A static standing postural deviation caused by muscle imbalance in the neck-shoulder region.
Typical postural deviations include
- Forward head
- Increased upper thoracic kyphosis
- Anterior translation of the c-spine
- Protracted, elevated scapulae.
Possibly affects all movements of the c-spine and UE.
Briefly describe the pattern of stiffness (4) and weakness (4) in the upper crossed syndrome
stiffness in the
- upper trapezius (UT),
- levator scapulae,
- pectoralis major, and
- sternoleidomastoid
Weakness in
- Deep neck flexors
- Lower trapezius
- Serratus anterior
- Stabilizers of the scapula
What is lower crossed syndrome? (include 3 parts of typical presentation)
A static standing postural deviation caused by muscle imbalance in the lumbopelvic hip region.
Typical postural deviation includes
- anterior pelvic tilt,
- increased flexion of the hips, and
- increase lumbar lordosis.
Briefly describe the pattern of stiffness (2) and weakness (2) in the lower crossed syndrome
Stiffness in the
- Hip flexors or
- Erector spinae
Weakness in
- Gluteal muscles
- Abdominal muscles
Describe the appearance of kyphosis-lordosis posture (what is weak [3], what is tight [3], what could be either [1]?)
Kyphosis-lordosis posture- is similar to the upper and lower crossed syndromes and is associated with
- weakness in the
- neck flexors,
- upper back erector spinae, and
- external oblique (EO);
- stiffness in the
- neck extensors,
- hip flexors, and
- lumbar ES; and
- hamstrings may or may not be weak.
Describe the appearance of flat back posture (what is weak [1], what is tight [1], what could be either [1]?)
Flat back posture- presents with a reduced or absent lumbar lordosis, posterior pelvic tilt, extension of the hip, slight PF of the ankle, a slightly extended cervical spine, flexion of the upper thoracic spine, and straight lower thoracic spine.
- Hip flexors are weak,
- hamstrings are stiff, and the
- lumbar paraspinals may be weak.
Describe the appearance of swayback posture
Swayback posture- presents as a forward head, extended cervical spine, increased flexion and posterior displacement of the upper trunk, flexion of the upper spine, posterior pelvic tilt, hyperextension at the hips with anterior pelvis displacement, hyperextension at the knees, and neutral at the ankles.
Describe the favored sitting position and why it is considered optimal.
- In considering an optimal posture for sitting, lumbopelvic sitting (ie, anterior pelvic rotation, lumbar lordosis, and thoracic relaxation) is favored for the lumbar and thoracic regions because it does not involve end-rage positions and results in preferential activation of local stabilizing muscles without high compressive loads of thoracic extensor spinae (TES).
- The favored posture for sitting is the lumbopelvic posture resulting in a relatively neutral head/neck alignment and diminished cervical erector spinae (CES) and thoracic erector spinae (TES) compared to slump sitting
- Note: Thoracic upright sitting (ie, shoulder blades slightly retracted and thoracolumbar spine extended) results in high compressive axial loads from the TES and EO.
- Note: As expected, Slump sitting results in greater head/neck flexion, anterior head translation and increased cervical erector spinae activity.
- Additional info: Simply telling a pt. to “sit up straight” does not facilitate an optimal position of the spine. There is increased deep neck flexor and lumbar multifidus activity in a therapist-facilitated (ie, manually and verbally) lumbopelvic posture compared to non-facilitated thoracic upright sitting posture.
What happens if you tell a pt to “sit up straight”?
- Simply telling a pt. to “sit up straight” does not facilitate an optimal position of the spine. There isincreased deep neck flexor and lumbar multifidus activity (a good thing) in a therapist-facilitated (ie, manually and verbally) lumbopelvic posture compared to non-facilitated thoracic upright sitting posture.
- You should teach lumbopelvic sitting
List the procedure for assessing the effect of sitting posture correction on spinal symptoms.
- First, the pt.’s unsupported sitting posture is observed with the feet flat on the floor and hips in 80° of flexion.
- Next, the clinician manually assists anterior rotation of the pelvis, which results in neutral spinal posture as follows:
- a) restoration of the normal low lumbar lordosis;
- b) kyphosis in the thoracic spine adjusted with a slight sternal lift or depression;
- c) scapulae sitting flush on the thoracic wall;
- d) head-on-neck posture adjusted with gentle occipital lift away from cervical extension
- The clinician manually repositions the scapulae as needed.
- The pt. is asked to actively maintain this position.
- The effect of postural correction on the patient’s symptoms is assessed to determine relevance. Symptoms may increase, decrease, or remain the same or pt.’s may have difficulty assuming the desired position, perhaps due to impaired spinal mobility.
Should we try to fix all deviations from what is considered “normal” or “ideal” when teaching sitting posture?
Not all deviations from what is considered “normal” or “ideal” should be considered pathological, and some faulty postures should not always be corrected. For example, a pt. w/symptomatic lumbar spinal stenosis necessarily has a reduced lumbar lordosis.
Describe briefly the typical gait of a patient with spinal pain, and the relationship between gait speed and fear related to physical activity. (4 points)
- Most individuals with LBP walk slower, take shorter steps, and have asymmetrical step lengths.
- Altered gait strategies in persons w/LBP may also be affected by factors such as intensity of pain, level of disability, distribution of pain, and fear related to physical activity. In LBP, the level of perceived disability accounts for more variance of walking ability than pain intensity.
- Fear related to physical activity is a strong predictor of gait velocity.
- The 10-meter walk test is an easy, reliable test to measure walking speed. Gait speed of less than 1 m/s (ie, 6 sec to complete a 6-m course) identifies a well-functioning older persons at high risk of adverse health outcomes within 1 year.
Describe how to progressively assess standing balance?
Balance is progressively challenged as follows:
- Eyes Open on a firm, level surface utilizes the visual, vestibular, and somatosensory systems for postural control.
- Eyes Closed on a firm, level surface increases challenge to the vestibular and somatosensory systems through elimination of the visual system.
- Eyes Open on an unstable or foam surface changes the somatosensory input, placing greater reliance on the visual and vestibular systems.
- Eyes Closed on a foam surface requires greater reliance on vestibular input since vision is eliminated and somatosensory is altered.
***all of these are standing with both feet.
Someone 45 or under should be able to do all of these for 30 seconds (I think)
T or F: Individuals w/LBP have poorer standing balance w/altered postural adjustment strategies (reduced hip strategy) and increased visual dependence.
True
Describe the AROM testing procedures (everything)
- Test uninvolved side first and compare to the involved side.
- Explain what you want the pt. to do and ask for a response to the movement.
- The pt. should indicate where in the range symptoms are felt or increased if resting symptoms are present and which symptoms are affected by the movement.
- Establish symptoms at rest prior to movement.
- Assess pain or symptom response – seek to reproduce pt.’s symptoms.
- Note pain rating using the NPRS.
- Note behavior of symptoms through movement: local or referred, type and location, and where in range the symptoms were produced (eg., pain at end-range, mid-range, painful arc).
- Re-establish symptom baseline between tests to prevent a cumulative effect.
- Assess quality of movement by observing from front, back, or sides as needed.
- Note smoothness, ease of movement, and control of movement.
- Note deviations from normal otherwise known as aberrant movements or substitutions.
- Deviations are corrected to observe the pt.’s response. If symptoms change with the correction, then the deviation is relevant to the problem. For example, if lumbar flexion occurs asymptomatically with deviation to the left, relevance is supported if correction produces part or all of the pt.’s symptoms. If no change occurs with correction, the deviation is initially deemed not relevant.
- Note intervertebral movement.
- Assess quantity of movement grossly as normal, hypomobile, or hypermobile.
- Measurement with gravity/bubble inclinometer has acceptable reliability for neck pain and LBP
- If AROM is normal, apply overpressure (OP) and assess the end-feel and the effect on symptoms. Symptoms may stay the same, increase, or decrease.
- If AROM with overpressure is normal and symptoms have not been reproduced, try repeated movements, sustained movements, or combined movements.
AROM testing: which side should you test first?
Test uninvolved side first and compare to the involved side.
AROM testing: What are 4 things should you note when assessing quality of movement?
- smoothness
- Ease of movement
- Control of movements
- Deviations from normal (otherwise known as aberrant movements or substitutions)
AROM testing: If you note any deviations in movement when assessing quality of movement, what should you do? What does the response mean?
Deviations are corrected to observe the pt.’s response. If symptoms change with the correction, then the deviation is relevant to the problem. For example, if lumbar flexion occurs asymptomatically with deviation to the left, relevance is supported if correction produces part or all of the pt.’s symptoms. If no change occurs with correction, the deviation is initially deemed not relevant.
AROM testing: when could you provide overpressure and why?
If AROM is normal, apply overpressure (OP) and assess the end-feel and the effect on symptoms. Symptoms may stay the same, increase, or decrease.
AROM testing: if AROM with Overpressure is normal and symptoms have not been reproduced, what should you do? (3)
If AROM with overpressure is normal and symptoms have not been reproduced, try repeated movements, sustained movements, or combined movements.
Describe Repeated Movement/Motion Testing Procedure (everything)
- Establish baseline resting symptoms and explain what you want the patient to do.
- During the repeated movements, continually ask the pt. about any change in symptom behavior (location or intensity during movement or at end-range).
- This history may provide clues as to the movement that will worsen symptoms.
- Sagittal plane movements are performed first (eg., flex or ext)
- Frontal plane or horizontal plane movements are tested as needed for lateral or rotational directional preference (DP) for the cervical, thoracic, or lumbar spine.
- After 10 to 15 movements or one set, the pt. relaxes and reports current symptoms.
- If the pt.’s response is worsening or peripheralization occurs, the movements are discontinued prior to completing all repetitions. A different loading strategy may be performed in an attempt to obtain centralization or a DP.
- If the pt. is centralizing or getting better, additional repetitions may be required or a different loading strategy performed (eg., moving from extension in standing to extension in lying)
- the pt.’s response is detailed and recorded as centralized, peripheralized, better, no better, worse, no worse, or no effect.
What should you do first when assessing a pt for repeated motion?
Establish baseline resting symptoms
Repeated Motion testing: When should you do sagittal plane movement vs frontal or horizontal plane movements?
- Sagittal plane movements are performed first (eg., flex or ext)
- Frontal plane or horizontal plane movements are tested as needed for lateral or rotational directional preference (DP) for the cervical, thoracic, or lumbar spine.
Repeated Motion Testing: How may times should the pt perform a movement?
- After 10 to 15 movements or one set, the pt. relaxes and reports current symptoms.
- If the pt.’s response is worsening or peripheralization occurs, the movements are discontinued prior to completing all repetitions.
- If the pt. is centralizing or getting better, additional repetitions may be required or a different loading strategy performed (eg., moving from extension in standing to extension in lying)
Repeated Motion Testing: What could you do if the pt’s response is worsening or periphralization occurs?
If the pt.’s response is worsening or peripheralization occurs, the movements are discontinued prior to completing all repetitions. A different loading strategy may be performed in an attempt to obtain centralization or a DP.
Repeated Motions Testing: What is the main thing (s) you should document at the conclusion of the test?
the pt.’s response is detailed and recorded as centralized, peripheralized, better, no better, worse, no worse, or no effect.
Repeated Motions Testing: Define Centralized:
Centralized: 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.
Repeated Motions Testing: Define Peripheralized:
Peripheralized: The opposite of centralized. Pain coming from the spine is produced distally, spreads distally or increases distally, and remains in the extremity after testing.
Repeated Motions Testing: Define “better”
Better: Symptoms decreased or abolished and remain better after testing.
Repeated Motions Testing: Define “no better”
No better: Symptoms decreased or abolished but return to baseline after testing.
Repeated Motions Testing: Define “worse”
Worse: Symptoms produced or increased with movement and remain increased after testing.
Repeated Motions Testing: Define “no worse”
No worse: Symptoms produced or increased with movement but return to baseline after the test.
Repeated Motions Testing: Define “no effect”
No effect: symptoms do not change during or after testing.
What are three subgroups related to mechanical spine pain
- Derangement Syndrome
- Dysfunction Syndrome
- Postural Syndrome
