FINAL: SPINE Flashcards
(248 cards)
1
Q
Cervical Vertebrae
spine
shape
#
A
Cervical LORDOSIS
Vertebrae CONCAVE
7 cervical vertebrae
2
Q
Thoracic Vertebrae
spine
shape
#
A
Thoracic KYPHOSIS
Vertebrae CONVEX
12 Thoracic Vertebrae
3
Q
Lumbar Vertebrae
spine
shape
#
A
Lumbar LORDOSIS
Vertebrae CONCAVE
5 Lumbar vertebrae
4
Q
COCCYX vertebrae
A
3-5
FUSED
5
Q
What are primary curves
A
convex curves that are present at birth
- -thoracic kyphosis
- -sacral convexity
6
Q
What are secondary curves
A
come in as we develop (not present at birth)
Cervical Spine Lordosis : righting rxns where capital extensors get stronger
Lumbar Spine Lordosis : formed due to upright WB
7
Q
Vertebral Body Parts
shape
size
blood supply
endplate
A
Shape: kidney, wider than height,
shape and size varies in the regions of the spine
bony outer layer and spongy medulla inside (good blood supply)
endplate on superior and inferior aspect –made of thin hylaine cartilage
8
Q
Wolfs Law:
A
as load is placed on bone it remodels and adapts
9
Q
Vertebral Arch
A
horseshoe shaped–foramen in the center that the SC travels through
Pedicles on lateral side face anteriorly
Facets are between the pedicles and lamina
Lamina posteriorly
PROCESSES:
- superior/inferior: articular process
- transverse process laterally
- Spinous process posteriorly
10
Q
Which vertebrae does not have an SP?
A
C1
11
Q
Which Vertebrae does not have a body?
A
C1
C2
12
Q
Cervical Spine
VB
SP
Articular Process
Special considerations
A
Vertebral body: small (weaker)
SP: short and bifid
Articular processes: have foramen (holes)for vertebral artery to supply blood to the brain –vulnerable to injury
*JOINT OF LUSCHKA (uncovertebral joint) [online it says they run form C3-C7!!!] C1-C2 has NO disc
13
Q
Thoracic Spine
VB
SP
Articular Process
Special considerations
A
Vertebral Body: slender / long, course downward
SP: long and slender, course POSTERIORLY DOWNWARD *wont be in line with TP on palpation
Articular process: slender and project up
*costovertebral and costotransverse joints for ribs
14
Q
Lumbar Spine
VB
SP
Articular Process
Special considerations
A
Vertebral Body: large/rectangular,
—–bulbous posterior tip, project posteriorly
SP: rectangular bulbous posterior tip, project HORIZONTALLY POSTERIOR
Articular Process: short and stout
** Largest Vertebral body
15
Q
What motion most at C1/C2
A
Rotation
16
Q
Which vertebrae no SP?
A
C1
17
Q
What vertebrae has an extra process?
A
odontoid process on C2: axis
18
Q
Articular Process:
where are they
where do they project from
A
paired on either side superior and inferior: project from junction of pedicle and lamina
each process has facet for articulation with corresponding facet of vertebrae above and below = ZYGAPOPHYSEAL JOINT
19
Q
ZYGAPOPHYSEAL JOINT
A
each process has facet for articulation with corresponding facet of vertebrae above and below
capsule around facet joint has mechanoreceptor nerve endings to give proprioception to CNS–if misalign muscles told to contract to fix
20
Q
Intervertebral Foramen
–what is its significance
A
NR exits here (it is btwn 2 vertebrae)
implication for injury:
- Disc bulge
- Degenerative disc disease
- Stenosis/facet hypertrophy–> spurring
boundaries of intervertebral foramen:
Superior: pedicle/arch of superior vertebrae
Inferior: pedcle/arch of inferior vertebrae
Anterior: dorsum of IV dis
***disc bulge can compress/irritate the exiting NR
Posterior: facet joint and ligamentum flavum
- **stenosis here can affect nerve root (facet hypertrophy)
- **DDD: if disc lose water content and foramen can collapse and issue and NR
21
Q
What is purpose of ligaments?
A
structural stability
proprioceptive information
–can fail with repeated loading
22
Q
ALL
purpose
attach
features
A
- Checks hyperextension
- High resistance to traction
- extensive NERVE FIBERS for proprioceptive feedback
*attach to annulus, loose attach to VB
base of occiput–>Sacrum
Features: starts NARROWS in cervical spine and become more BROAD in lumbar spine
23
Q
PLL
purpose
attach
features
A
- Checks forward bending
- extensive NERVE FIBERS for proprioceptive feedback
attach to annulus, NOT ATTACH TO VB**allows space for sinovertebral nerve / sinovertebral artery to feed VB with NERVE endings and BLOOD SUPPLY
base of occiput–>Sacrum
Features: thicker and stronger in CERVICAL SPINE and tapers and narrows in LUMBAR spine
**reason for POSTERIOR-LATERAL BULGE in lumbar spine instead of a central posterior bulge
24
Q
Iliolumbar Ligament
function
attachement
special feature
A
TAUT IN CONTRALATERAL SIDEBENDING
Two bands, only in adults:
- superior band: transverse process L4–>Iliac crest
- inferior band: transverse process L5–> iliac crest
Stability: transmit force from axial skeleton through pelvic girdle
*QL/Psoas contract and cause L4/L5 motion which transmits force to SI joint
25
Ligamentum Flavum
function
attachement
special feature
lamina C2-->S1
(yellow=elastic)
Elastic, prestrain in neutral (15%): allow more flexion ROM and assistance returning
* *elasticity reduce structures protrude into central canal
* *prevent impingement: pull facet capsule so capsule doesnt pinch synovium in flexion/extension
[online: elasticity preserve the upright posture, and assist the vertebral column resuming it after flexion. elastin prevents buckling of ligament into spinal canal during extension, which would cause canal compression.]
26
Intertransverse Ligament
function
attachement
special feature
check contralateral lateral flexion + rotation
attach superior and inferior TP [like iliolumbar]
* well developed in thoracic spine (they are round cords there)
* conected to deep back muscles
27
Interspinous Ligaments
function
attachement
special feature
check forward bending
attach root of apex of adjacent SP**distinct in cervical spine
highly innervated: proprioception and pain if injury
28
Supraspinous Ligament
function
attachement
special feature
check forward bending + some rotation
attach apex of each SP **C7-->:4
**above C7 it is ligamentum nuchae***
highly innervated: proprioception and pain if injury
29
Ligamentum Nuchae
function
attachement
special feature
keep erect posture in cervical spine, support cranium in upright position
sternal occipital protuberance-->spinous process of C7
homologous with interspinous and supraspinous ligaments
***some peopel have thicker that pop out when flex head and limit forward flexion
30
Orientation of facet joint
Horizontal plane and Frontal plane
Cervical Spine
Thoracic Spine
Lumbar Spine
Cervical Spine
- -Horizontal: 45
- -Frontal: 82
Thoracic Spine
- -Horizontal: 60
- -Frontal: 20
Lumbar Spine
- -Horizontal: 90
- -Frontal: 45
31
Cervical
Orientation of facet joint
Horizontal plane and Frontal plane
motion most here
Cervical Spine
- -Horizontal: 45 degrees from the horizontal
- -Frontal: 82
ROTATION
32
Thoracic
Orientation of facet joint
Horizontal plane and Frontal plane
Thoracic Spine
- -Horizontal: 60
- -Frontal: 20
so most have is: flexion/extension/sidebending
33
Lumbar
Orientation of facet joint
Horizontal plane and Frontal plane
Lumbar Spine
- -Horizontal: 90
- -Frontal: 45
**restricts rotation
L5 IS AN EXCEPTION TO THIS RULE BECAUSE IT IS A TRANSITIONAL VERTEBRAE
34
Motion in the spine is from what three joint?
2 facet joints
| 1 intervertebral joint
35
Cervical spine:
where does superior facet face?
BUM
backwards, upwards, and medial
most free in rotation: transverse horizontal plane
36
Thoracic spine
where does superior facet face?
BUL
backwards, upwards, lateral
facet surface is superior and lateral
37
Lumbar spine
where does superior facet face?
BM
medially
restricts rotation
so most have is: flexion/extension/sidebending
38
Disc Joint: between IV bodies
| role
**disc doesnt have blood supply: it comes VB-->endplate-->disc
1. dissipate forces/stress
2. resist compression
3. maintain size of foramina
4. restrict motion
5. ensure midrange position of facets during WB
6. CERVICAL + LUMBAR: create lordosis secondary to wedge shape--anterior disc is taller than posterior disc
**allow 6 degrees of motion
disc attached to each VB through endplate
39
How many discs in the body?
23 (NO DISC AT C1/C2)
so 7-1 = 6 cervial
12 thoracic
5 lumbar
= 23
40
Endplate
superior inferior border between disc and subchondral bone
*hyaline cartilage
resembles disc:
* center: *more proteoglycans and water*
* periphery: *more collagen*
0.6mm thick
vascular supply from VB --> endplate --> disc
41
Annulus fibrosis
1. what is it made of and what is its orientation
2. what does it attach to
3. what covers it
1) Made of:
- ---*fibrocartilage
- ---12-15 concentric rings in criss-cross oblique fashion at 30 degrees from horizon--> this makes it resist ROTATION
- ---*outer layer it vertical
2) attachments:
- ---**inner 1/3 attach ENDPLATE
- ---**outer 1/3 attach VB: SHARPEYs FIBERS
- ---ALL and PLL attach to annulous fibrosis: this helps contain bulges
3) covered by sheath:
--- SINOVERTEBRAL NERVE innervation: outer 1/3
spinal NR exit through foramen (split to dorsal and ventral ramus): the sinnovertebral nerve doubles back and has pain and mechanoreceptors on outer 1/3 of annulous fibrosis
*pain can be from another level
(remember: inner disc is nucleous propulses and outer is annulus fibrosis)
42
Nucleus Prupolsus
% water
why affinity for water
nutrition source
in case of herniation, what causes the pain
how does it pressure on nucleus prupolsus decreased
1) 88% water
* ***Lose water with age: matrix changes and lose affinity
2) due to monopolysaccharide matrix: high affinity for water
3) nutrition from endplate: no vascularity
4) *herniation, the pain comes from outside and not from inside the disc
5) *central portion is hydrostatic cushion: distribute forces evenly: if compressed water seeps to annulus (decreases pressure on the nucleus pulposus)
- -when remove load disc should return to original position
43
Intervertebral Disc
1. what is the pressure on it with no load?
2. Morning
3. Evening
4. Aging
1) preloaded state: pressure is never zero
when it is decreased, flexibility is decreased
2) Morning: increased disc height: resorb water in supine and draw in nutrients [more pressure]
3) Evening: decreased disc height: pressure from WB all day --water seep out into lamellae
4) Aging: decreased disc height: decreased water content
***diseased disc wont do the norm of water seep out with pressure and water resorbed when pressure removed
44
Which ligament has 10-15% preload for flexibility/prevent impingement during motion?
ligamentum flavum
45
what time of day a disc herniation will hurt most?
morning
more pressure and bulging in the morning
46
Disc thickness to VB height?
Cervical
Thoracic
Lumbar
where is there more mobility in the spine?
Cervical: 2:5: most mobility in cervical: mosts disc thickness to VB height
Disc 2: VB 5
Thoracic: 1: 5: least mobility in thoracic: smallest disc thickness to VB height
Disc 1: VB 5
Lumbar: 1:3
Disc 1: VB 5
47
Which section of spine has most disc thickness to VB height?
Which section of spine has least disc thickness to VB height?
Most: Cervical
Least: Thoracic
48
Where is the nucleus propulses in each section of the cervical spine?
Cervical spine: 4-7/10 of anterior posterior depth of VB superior surface IN LINE WITH AXIS OF MOTION
Thoracic spine: 4-7/10 of anterior posterior depth of VB superior surface BEHIND AXIS OF MOTION
Lumbar spine: 4-8/10 of anterior posterior depth of VB superior surface IN LINE WITH AXIS OF MOTION
49
Is the nucleus propulses on the vertebral body in line with the axis of motion in the
Cervical Spine
Thoracic Spine
Lumbar Spine
Cervical Spine: IN LINE WITH AXIS OF MOTION
Thoracic Spine: posterior
Lumbar Spine: IN LINE WITH AXIS OF MOTION
50
What doesnt the disc do in osteoarthritis that is should do?
fail to recuperate after unloaded (the return to normal after the load taken away)
51
Where does the disc move in:
Flexion
Extension
Lateral Flexion
Rotation
Flexion: posteriorly
(superior vertebrae moves anterior with respect to inferior vertebrae, anterior aspect gets smaller and posterior aspect gets bigger)
Extension: anteriorly
**someone with posterior lateral disc bulge should do extension exercises to reduce the disc bulge
Lateral Flexion: side bend to the right: DISC MOVES LEFT
(superior vertebrae moves right with respect to inferior vertebrae)
**ALL and PLL push to maintain disc in flexion / extension
Rotation: compressive forces : twisting cause compression and shearing/stress torsion
**annulous fibrosis has cross fibers that resist torsion with rotation: 30 degrees alternating each layer from horizon, rotation to right : right annulous fibrosis will be taut and left will be slack
52
Motion: Flexion
Movement of upper vertebrae
change in space
Nucleus propulsus migration
IV foramen
Movement of upper vertebrae: anterior
change in space: more space posterior
Nucleus propulsus migration: posterior
IV foramen: opens : facet joints seperate
53
Motion: Extension
Movement of upper vertebrae
change in space
Nucleus propulsus migration
IV foramen
Movement of upper vertebrae: posterior
change in space: more space anterior
Nucleus propulsus migration: move anterior
IV foramen: SMALLER: facet joints close --especially with hypertrophy
54
Motion: Lateral Flexion
Movement of upper vertebrae
change in space
Nucleus propulsus migration
IV foramen
Movement of upper vertebrae: ipsilateral side
change in space: more space contralateral side
Nucleus propulsus migration: contralateral side
IV foramen : more open on contralateral side, more small on ipsilateral side ??
55
Motion: Rotation
Motion: Lateral Flexion
Movement of upper vertebrae
change in space
Nucleus propulsus migration
IV foramen
Movement of upper vertebrae ?
change in space: DECREASED JOINT SPACE DUE TO COMPRESSION
Nucleus propulsus migration ?
IV foramen
smaller on ipsilateral side, more space on contralateral side
56
Histamine Scratch Test
scratch and see response
no reaction or decreased: can be due to chronic injury , stagnation, lack of BF
hyper-reaction: increased inflammation due to injury
57
where in spine is nucleus propulses in line with axis of motion
cervical and lumbar spine
NOT THORACIC SPINE: behind axis of motion
58
if you turn R, what happens to annulus fibers?
R: taut
L: slack
59
What happens to load in disc in:
supine, sit, stand, lean forward, lifting
Disc pressure in supine less than standing
Leaning forward (sit and stand) increases pressure
Lifting with poor mechanics increases pressure
60
Nachemson et al laod in disc
*sit vs stand
least to most
SUPINE--> sidelie --> STAND --> unssuported SIT --> stand lean forward -->sit lean forward --> stand holding load --> unsupported sit leaning forward with load
**SITTING MORE THAN STANDING
61
Wilke et al load in disc
*sit vs stand
Less in sitting than in standing
less pressure when hold load with bent knees correctly
lying supine increased pressure (fluid comes in)
**STANDING MORE THAN SITTING
62
Sato et al
intradiscal pressure between positions and disc degeneration
SITTING MORE THAN STANDING
spinal load increased in the following order of body positions: prone --> lateral-->upright standing--> upright sitting
Intradiscal pressure significantly reduced according to the degree of disc degeneration
respiration affected disc pressure in prone (more with valsalva)
63
Sinnovertebral Nerve:
where it goes
recurrent meningeal nerve:
off ventral ramus and doubles back to innervate structures in the canal and annulus fibrosis then wraps around to anterior of annulus fibrosis (can go up and down and innervate different levels)
64
Medial branch of the posterior ramus
where it goes
to facet joint capsule and ligaments
65
Lateral branch of posterior ramus
where it goes
to muscles in back and skin
66
vertebral Artery
supplies brain with blood and O2
vulnerable to injury!!
comes up through neural foramina on either side of cervical column and takes serpintine course through C1/C2 vertebrae to enter the skull
**Check integrity to make sue with patient and not get injury
67
Spinal Movement
degrees of freedom
by region
coupled motions
fryette's laws of motion
68
Spinal movement and degrees of freedom
1. axial compression / distraction
2. rotation: transveres plane
3. forward/backward bend: saggital plane
4. Lateral flexion: frontal/coronal plane
5. forwar-backbend sliding/translation: rib mobilization
6. lateral glide/translation: rib mobilization
69
Spinal Movement By Region
CERVICAL MOST ROTATION
LUMBAR MOST FLEXION
Rotation: Cervical most
then thoracic, then ( lumbar least )
Side Bend: Cervical then Thoracic
Forward Bend: Lumbar has the most
Backbend: depend on study if cervical or lumbar (both say thoracic has the least)
70
Rotation
which spinal segment has the most rotation
C1/C2 has the most
diminishes as you go down the spine
hardly any in lumbar spine except L5/S1 because it is a transitional segment so more than the other of the lumbar spine
71
Flexion/extension
which spinal segment has the most
more cervical and lumbar
less thoracic
72
Lateral flexion
which spinal segment has the most
not much variation but in thoracic there is less mobility
73
Yellow flags
Beliefs, appraisals and judgements, Emotional Responses, Pain behavior:
Catastrophising – thinking the worst
Finding painful experiences unbearable, reporting extreme pain disproportionate to the condition
Having unhelpful beliefs about pain and work – for instance, ‘if I go back to work my pain will get worse’
Becoming preoccupied with health, over-anxious, distressed and low in mood
Fear of movement and of re-injury
Uncertainty about what the future holds
Changes in behaviour or recurring behaviours
Expecting other people or interventions to solve the
problems (being passive in the process) and serial visits to various practitioners for help with no improvement.
74
Blue flag
Perceptions about the relationship between work and health
75
Black flags
outside the immediate control of the employee and/or the team trying to facilitate the return to work.,
Legislation restricting options for return to work.
Conflict with insurance staff over injury claim.
Overly solicitous family and health care providers.
Heavy work, with little opportunity to modify duties.
76
Special questions to ask in upper quarter exam
```
Sleeping position
Dizziness
difficulty swallowing
bilateral numb or tingling
gait disturbances
overt weakness (dropping objects)
BECAUSE: these can all be from vsiceral or central (neuro) disorders
```
we want to rule out red flags (bowel, lung, cancer)
77
Yellow Flags
psychosocial components to their pain
fear avoidance, catastrophizing
these will complicate PT, require referral to CBT therapist
78
insidious onset
they dont know when it started, bothering them over time (ie an overuse injury)
79
what we want to ask in upper quarter about injury
1. when did it start--mechanism, did they hear or feel something in particular
2. did it start with pain or stiffness
```
3. what aggrevates the pain: 24 hour clock
morning vs evening
sitting vs standing
ADL
sport
```
4. what alleviates it / makes it better: if it never fluctuates we are concerned about a systemic or sinister source of pain
if pain is constant then it is not an indication for a musculoskeletal source of pain
80
Upper quarter:
| QUICK TESTS
A) AROM: if painfree apply overpressure
- shoulder
- -apley's scratch test and apply overpressure
- elbow
- wrist
Cervical spine: if full and painfree overpressure except EXTENSION (if FHP, put in neutral first)
we are looking for:
1. quality of motion
2. ranges
3. willingness to move
4. does it cause pain
B) If decreased ROM we go to PROM
supine on table, support occiput and assess endfeel as do flexion, sidebend, rotation (not extension, we have special tests for it)
81
Apley's Scratch Test
+ overpressure: use combining motio and overpressure: bring hand behind the back and see where middle finger hits-see if it is the same bilaterally : do this for ER and IR
82
What do we look for in AROM test of upper quarter?
we are looking for:
1. quality of motion
2. ranges
3. willingness to move
4. does it cause pain
83
Upper Quarter Examination
Neuro Exam
- -when?
- -how?
if they complain of changes in sensation, radiating pain, numbness, tingling, distal weakness, or any symproms are replicated in the neck exam
MYOTOME: check integrity of the NR going into the muscle
- -test for fatiguing weakness
* *contractile lesion or strain will be weak or painful with every repetition in the same way**
**if fatiguing weakness is due to nerve conduction it will be more weak with repetitions** because they cannot recruit from other fibers when fatigued
--if there is fatiguing weakness: differentiate it
Elbow: C5/C6 so test another muscle in the myotome (ie shoulder abduction and wrist extension)
84
Can you have sensory nerve involvement and not have fatiguing weakness?
motor nerves are in the center of the nerve so may not be deformed immediately
85
Myotomal Exam
Neck Flexion/Rotation
C1
here we do one isometric test because easy to flare up the cervical spine
hand on front of forhead and back of occiput
86
Myotomal Exam
Shoulder Shrugging
C2, C3, C4
87
Myotomal Exam
Diaphragm
C4
88
Myotomal Exam
Shoulder Abduction
C5
89
Myotomal Exam
Elbow Flexion
C5, C6
90
Myotomal Exam
Wrist Extension
C6
91
Myotomal Exam
Wrist Flexion
C7
92
Myotomal Exam
Elbow extension
C7
93
Myotomal Exam
Thumb extension, finger flexion
C8
94
Myotomal Exam
Finger abduction finger adduction
T1
95
Myotomal Exam
C1
Neck Flexion/Rotation
96
Myotomal Exam
C2, C3, C4
Shoulder Shrugging
97
Myotomal Exam
C4
Diaphragm
98
Myotomal Exam
C5
Shoulder abduction
99
Myotomal Exam
C5, C6
Elbow Flexion
100
Myotomal Exam
C6
Wrist extension
101
Myotomal Exam
C7
elbow extension, finger flexion
102
Myotomal Exam
C8
thumb extension, finger flexion
103
Myotomal Exam
T1
finger abduction, adduction
104
Dermatomal Exam
Occiput
C2
105
Dermatomal Exam
Jaw/Neckline
C3
106
Dermatomal Exam
supraclavicular fossa
C4
107
Dermatomal Exam
Lateral brachiam (side of arm)
C5
108
Dermatomal Exam
Lateral base of thumb
C6
109
Dermatomal Exam
Distal Phalanx digit 3
C7
110
Dermatomal Exam
Ulnar border digit #5
C8
111
Dermatomal Exam
Medial border forearm
T1
112
Dermatomal Exam
C2
occiput
113
Dermatomal Exam
C3
neck (jawline)
114
Dermatomal Exam
C4
supraclavicular fossa
115
Dermatomal Exam
C5
lateral brachium
116
Dermatomal Exam
C6
lateral base of thumb
117
Dermatomal Exam
C7
distal phalanx digit #3
118
Dermatomal Exam
C8
ulnar border digit #5
119
Dermatomal Exam
T1
medial border forearm
120
DTR
Biceps
C5, C6
121
DTR
brachioradialis
C6
122
DTR
Triceps
C7
123
DTR
0
ABSENT
124
DTR
1+
decreased/hyporeflexive
125
DTR
2+
normal
126
DTR
3+
brisk
127
DTR
4+
hyperreflexive with nonsustained clonus
128
Jendrassik
distract the patient to relax them to illicit the DTR
129
Which DTR grade means normal?
2+
130
Myotomal Test
Hip Flexion
T12, L1-L3
illiopsoas
131
Myotomal Test
Hip Flexion
(L2)
T12, L1-L3
illiopsoas
132
Myotomal Test
Knee Extension
L3
quads
133
Myotomal Test
Dorsiflexion
L4
anterior tibialis
134
Myotomal Test
Extend big toe
L5
EHL
135
Myotomal Test
PF
S1
peroneus longus and brevus
136
Myotomal Test
Heel Raises
S1-S2
Gastroc/Soleus
137
Myotomal Test
Foot intrinsics
S2-S4
138
Myotomal Test
Bladder
S2-S4
139
Myotomal Test
T12
L1-L3
illiopsoas
hip flexion
140
Myotomal Test
L2-L4
quads
knee extension
141
Myotomal Test
L4
anterior tibialis
142
Myotomal Test
L5
extensor hallucis longus
143
Myotomal Test
S1
peroneus longus and brevis
144
Myotomal Test
S2, S3, S4
bladder
foot intrinsics
145
Dermatomal
Inguinal line
L1
146
Dermatomal
anterior proximal tigh
L2
147
Dermatomal
anterior medial knee
L3
148
Dermatomal
medial leg
L4
149
Dermatomal
lateral leg
L5
150
Dermatomal
lateral foot / calcaneus
S1
151
Dermatomal
L1
inguinal line
152
Dermatomal
L2
anterior proximal thigh
153
Dermatomal
L3
anterior medial knee
154
Dermatomal
L4
medial leg
155
Dermatomal
L5
lateral leg
156
Dermatomal
lateral foot/calcaneus
S1
157
DTR
achilles tendon
S1
158
DTR
patella tendon
L4
159
Babinski
start plantar calcaneus and drag it up laterally and at MTP go medially
NORMAL: toes flex = negative
POSITIVE: toes fan out (sign for UMN)
in babies 6 months - 2 years have babinski
160
Clonus
stabilize at lower leg and give a quick stretch into DF at plantar foot
POSITIVE: patient kicks back at you: clonus (sign for UMN)
document # of beats
161
Hoffman Sign
stabilize their hand but leave fingertips free
FLICK 3rd digit into EXTENSION
POSITIVE: clawing thumb and 1st finger
162
Test Pec Minor Tightness
shoulder height from table
normal 1-2 inch
--if more see if pec minor causing scapula anterior tilt, palpate pec minor and see if hypertonic or tight and compare sides and see if we want to tx if fits with cheif complaint
163
Soto Hall Test
supine: flex neck up; chin to chest
Positive: lightening pain elicited (spinal cord issue, tumor, TB, fracture)
Brudzinski sign: respond with knee flexion to get slack in the spinal cord as a result of the Soto Hall Test
164
Brudzinski sign:
respond with knee flexion to get slack in the spinal cord as a result of the Soto Hall Test
165
Vertebral Artery Tests
| 4
they are performed after clear and no signs and sx from ROM tests
1. Quadrant test in supine
2. Hautards
3. Swallowing
4. Valsalva
166
Quadrant Test in supine
Supine: combine extension + rotation + sidebend
Wait between each layer to see if there is a change in blood flow (pick up the response)
1. EXTEND and wait 10 seconds: make sure no changes
2. add LATERAL FLEX: wait 10 seconds here
3. add ROTATE wait 30 seconds
+ dizzy, nystagmus, nausea, etc.
167
Hautards
Part 1:
patient stand with shoulders flexion in front and supinated EYES CLOSED
-Arm loses position => this is not vascular source, it is vestibular/cerebellar source
Part 2:
OPEN EYES: rotate + extend cervical spine
to compress the vertebral artery
--Positive => this is vascular insufficiency, because compromised the bloodlfow
168
Swallowing
observe/palpate HYOID when patient swallows
--swallow dysfunction is cranial nerve (ie tumor pressing on CN)
169
Valsalva
space occupying lesion, cancer, disc bulge
they will say have sx when they bear down
170
Thoracic Outlet Syndrome Tests
btwn clavicle and first rib there is decreased space and this can compromise the vascular / nerve
1. ROOS
2. Adson
3. Halstead
4. Allens
5. Wright
171
Roos Test
Test for TOS
Patient if in shoulder 90-elbow 90
Open and Close hands for THREE MINUTES!!!
Positieve: ellicit symptoms (numb, tingling, heaviness that is ASSYMETRICAL)
172
Adson Test
TOS (pecs), Palpate radial pulse on snuffbox to see if it diminishes with
1. Shoulder Extension/Abduction/ER and SUPINATION
2. Patient holds breath (pulls up first rib)
3. Head rotated to IPSILLATERAL side (contract scalenes to see if compromising bloodflow to radial artery)
POSITIVE: weakens radial pulse
(adson loves looking at his arm in the sun)
173
Halstead Test
TOS, Palpate radial pulse on snuffbox to see if it diminishes with
1. Shoulder Extension/Abduction/ER and SUPINATION
2. Patient holds breath (pulls up first rib)
3. Head rotated to CONTRALATERAL side (lengthen scalenes to see if compromising bloodflow to radial artery)
POSITIVE: weakens radial pulse
(halstead looks the other way instead )
174
Allens Test
TOS, Palpate radial pulse on snuffbox to see if it diminishes with
***Shoulder 90/ Elbow 90 + Contralateral head rotation
POSITIVE: weakens radial pulse
(allen is a poser posing his muscle to you )
175
Wright
TOS, Palpate radial pulse on snuffbox to see if it diminishes with
*** Shoulder full abduction
POSITIVE: weakens radial pulse
(jesse wants to write graffiti on the wall)
176
Provocation Test
why
which (2)
rule in/out stenosis, disc bulge, NR impingement
**do slowly
1. Compression / Distraction
2. Spurlings
177
Compression Test
provocation test to rule in/out stenosis, disc bulge, NR impingement**do slowly
1. NEUTRAL: sitting, longitudinal force through the spinal column and see if illicit sx (bring pressure on slowly then slowly back off)
2. FLEXION: (FB) confirm posterior bulge:
hand on posterior cranium and thoracic back : apply compression through spine
3. EXTENSION: (BB): if OA or facet issue it will flare with this and dx:
hand on front of chest and head: apply compression through through spine
4: SIDEBEND: (SB): hand on top of head and on shoulder: apply compression through spine
If he has sx on contralateral side: DISC
If he has sx on ipsilateral side: NR IMPINGEMENT
178
Upper Quarter: distraction relieves after traction, what is dx?
Stenosis or arthritis
179
Compression Flexion: what it tells you
FLEXION: (FB) confirm posterior bulge:
| hand on posterior cranium and thoracic back : apply compression through spine
180
Compression test in Extension: what it tells you
EXTENSION: (BB): if OA or facet issue it will flare with this and dx:
hand on front of chest and head: apply compression through through spine
181
Compression test in sidebend: what it tells you
SIDEBEND: (SB): hand on top of head and on shoulder: apply compression through spine
If he has sx on contralateral side: DISC
If he has sx on ipsilateral side: NR IMPINGEMENT
182
Upper Quarter: distraction relieves after traction, what is dx?
Stenosis or arthritis
183
Spurlings Test
Provocation Test: FACET PATHOLOGY / STENOSIS
extension + lateral flexion + rotation
"look up over shoulder at me"
--if painfree, no sx with this, add compression through head
(or backbend + sidebend + rotation)
184
Diff Dx
C4/C5
Axillary (C5, C6) and Supraclavicular (C3, C4) Nerves
axillary doesnt go to biceps area but C5 goes to elbow
Check biceps
185
Diff dx
C5 vs Axillary
check biceps
186
Diff dx
C6 vs musculocutaneous nerve
musculocutaneous (anterior arm) - C5, C6, C7
check thumb sensation
peripheral nerves change at the wrist
187
Diff dx
C6 vs radial nerve
check thumb sensation
peripheral nerves change at the wrist
Radial nerve: C5, C6, C7, C8 & T1.
The radial nerve and its branches provide motor innervation to the dorsal arm muscles (the triceps brachii and the anconeus) and the extrinsic extensors of the wrists and hands; it also provides cutaneous sensory innervation to most of the back of the hand. The ulnar nerve provides cutaneous sensory innervation to the back of the little finger and adjacent half of the ring finger.
188
Diff dx
C6 vs ulnar nerve
check thumb sensation
peripheral nerves change at the wrist
```
Ulnar Nerve
pinky, 1.5 ring finger
flexor carpi ulnaris
flexor digitorum profundis
lumbrical muscles
opponens digiti minimi
flexor digiti minimi
abductor digiti minimi
interossei
adductor pollicis
```
189
Diff dx
C7 vs median nerve
C7: 2nd and 3rd digits -median nerve
Compare to thumb to distinguish median vs C7
190
Diff Dx
C8 vs Ulnar nerve
C8 dermatome extends more proximally
Peripheral ulnar nerve does not extend far past the wrist
191
T1 vs Medial Antebrachial nerve
T1 extends to cubital fossa
Medial Antebrachial nerve doesnt
192
Relate Myotome, Dermatome, DTR
C1
dermatome: crown of head
myotome: cervical rotation
193
Relate Myotome, Dermatome, DTR
C2, C3
dermatome: neck
myotome: shoulder elevation
194
Relate Myotome, Dermatome, DTR
C5
Dermatome: lateral brachial
Myotome: biceps
DTR: Bicep
if have DTR here then do a test corresponding to a C5 muscle
195
Relate Myotome, Dermatome, DTR
C6
Dermatome: Thumb
Myotome: wrist extensors
DTR: Brachioradialis
196
Relate Myotome, Dermatome, DTR
C7
Dermatome: 3rd digit
Myotome: triceps
DTR: triceps
197
Relate Myotome, Dermatome, DTR
C8
Dermatome: ulnar border 5th digit
Myotome: finger flexion (intrinsics ie thumb and ulnar deviation)
198
Relate Myotome, Dermatome, DTR
T1
Dermatome: ulnar forearm
Myotome: palmar/dorsal interosseu: abduciton/adduction
199
Blue Flag
workers compensation
if not motivated to return to job this is a barrier to recovery
200
Black flag
barrier related to financial constraints or transportation
ie high copay / deductible that will limit their access to PT
201
What do we suspect if unrelenting pain?
cancer
202
What do we suspect if bladder in systems review? saddle numb? saddle parasthesia
cauda equina
203
what suspect if worse in the morning?
arthritis
herniated disc (bulges more in the morning)
matress
sleep position
204
effect of coughing, sneezing, bearing down on spine?
increase intraabdominal pressure so this can be a disc herniation
205
effect sit to stand increase pain in spine, how this can help us with herniated disc vs arthritis/posteriro structure
in a dynamic task may be motor control , enough to transition position vs static flexion can be herniated disc standing extended can relieve the herniated disc
but arthritis or postrerior structure involvement can get aggravated like this
206
back sx from what issue in systems review?
gallbladder refer to back
can be a GI dysfunction *so check if the pain fluctuates with position or body or nonmechanical movements
207
3 outcome measures for the back
1) McGill Pain Scale:
2) FABQ: investigate fear-avoidancebeliefs among LBP patients: see if PT alone isnt going to help and need to refer to CBT
3) Owestry Low Back Disability: for pt with LBP: percent of disability (ie pain intensity, how it affects ADL)--use for insurance
208
What we look at in postural exam
1) what we look at
2) what may indicate a disc bulge
1) head position, shoulder height, spinal alignment, iliac crest height, leg length, foot posture
2) if there is a lateral shift and may see increased arm space on one side and decreased on the other side
209
How to palpate L4
level of Iliac crest
210
How to palpate S1
?
211
how to palpate S2
?
212
Quick Tests for Lower Quarter
1. Full Squat: make sure symmetrical bilaterally, excessive pelvic tilt, angle of torso and thighs
2. Heel Raise: look at S1 myotome, 10 reps
3. Stand on Heels / walk on heels: L4 myotome
4. Gait: look for gait deviations (if more pelvic rotation this can put more motion in lumbar spine)
5. Balance: look for pelvic drop: week gluteus medius superior gluteal nerve (L4, L5, S1 nerve roots): look for lateral trunk lean, pelvic rotation, SLS 30 seconds eyes open
213
What can a squat tell you about spine?
Initiate with Posterior Pelvic Tilt: disc herniation issue
Anterior tilt and lumbar Lordosis and using erector spinae: not using core
214
What can heel raisesies tell you about
Myotome S1: gastroc
215
What can standing on heels tell you about
L4 myotome
216
AROM of Lumbar Spine
what we look for
What motions
Look for:
1. quality of motion
2. ranges, excursion
3. willingness to move, does it cause pain
4. Muscle Power
Flexion: tuck chin and rolll to floor keep knees straight: overpressure: stabilize S5
- -look for reversal in lumbar curve and pelvis movement (if not hamstrings need to be checked)
- -tight erector spinae
- -catch/jutter
- -Gower's Sign: hard to come back up without using hands bc lack strength or control of dynamic stabilizers
Extension: put your hands on your buttock an keep your knees straight
--reproduce sx, excursion, mobility, motor control hinge at L4/L5 because not other segments giving motion
Lateral Flexion: hand on hip and slide down leg : one hand their ribcage and one on pelvis for overpressure
Rotation: stand cross arms across chest (we stabilize pelvis, but do overpressure in sitting: block pelvis with leg and hand on ribcage for overpressure)
217
Gower's Sign:
-hard to come back up without using hands bc lack strength or control of dynamic stabilizers
218
Lower Quarter: combo of motions
1. Extension, Sidebend, Rotation:
FACET ISSUE, NERVE IMPINGE
```
2. Flexion, Sidebend, Rotation
DISC ISSUE (probably posterior lateral)
```
219
Extension, Sidebend, Rotation:
what does pain indicate
FACET ISSUE, NERVE IMPINGE
220
Flexion, Sidebend, Rotation
what pain indicates
DISC ISSUE (probably posterior lateral)
221
T/F
Disc herniations rare for upper lumbar region
TRUE
--so on dermatome test she doesnt usually do L1/L2
222
What dermatome between 1st and 2nd toe?
L5
223
Which vertebrae common spondylolisthesis
L5
224
Lower Quarter Special Tests
1. Slump Test
2. passive SLR
3. Soto Hall Test
4. Femoral Nerve Stretch
5. Compression of the Trunk
6. Distraction
7. INTRATHECAL PRESSURE TESETS
- --Milgram Test
- --Nafzieger Test
- --Valsalva Test
8. SI Joint Special Tests
- --Anterior Gapping Test
- --Posterior Gapping Test
- --Gaenslens Test
- --Thrust Test
- --Spring Test
- --Faber
225
Lower Quarter: Intrathecal Pressure Tests
| 3
1---Milgram Test
2---Nafzieger Test
3---Valsalva Test
226
Lower Quarter: SI Joint Special Tests
| 6
```
1---Anterior Gapping Test
2---Posterior Gapping Test
3---Gaenslens Test
4---Thrust Test
5---Spring Test
6---Faber
```
227
Slump Test
Lower Quarter:
NEUROTENSION TEST:
1. herniated disc pressing on NR
2. NR adhesions along the nerve path
1) Sit, hands rest on table, patient SLUMP down (this may cause sx)
2) KNEE EXTENSION
3) DF
4) HIP FLEXION
5) If there is sx with any of them ask what he feels then to LIFT HIS HEAD UP
negative: lifting head doesnt change sx
POSITIVE: symptoms change when he lifts his head up--positive for nerve tension
228
pSLR/Lasegue Test
Lower Quarter:
disc bulge
sciatic nerve neurotension/limited mobility
(not so good at discriminate other causes with this test)
1) PT lifts pt leg into SLR:
2) Note if there are sx before 70 degrees of hip flexion
3) lift head up and see if this changes the symptoms
POSITIVE: symptoms increase with cervical flexion
Negative: symptoms dont change, may just be tight hamstrings
229
Soto Hall Test
Lower Quarter:
Central Cord Issue
Space occupying lesion
supine: flex neck up; chin to chest
Positive: lightening pain elicited (spinal cord issue, tumor, TB, fracture)
Brudzinski sign: respond with knee flexion to get slack in the spinal cord as a result of the Soto Hall Test
230
Femoral Nerve Stretch
Lower Quarter:
- upper lumbar herniated disc
- nerve tension restriction due to adhesion of NR as exit spine/ adhesions as travel through soft tissue
1) Patient prone, PT flexes knee
Positive: patient indicate pain is in upper lumbar spine (femoral nerve on stretch)
2) if not provocative enough do in sidelie
--head flexed
--hip extended
--flex knee
see if changes when lift head back up (if no change it is just tightness, if changes it is NR restriction)
231
Compression of Trunk Test
Lower Quarter:
1) Supine, hug knees to chest
2) compress spine through ischial tuberosities superiorly to load spine
Positive if this increases symptoms
232
Distraction
Lower Quarter
Hookline
pull distal thigh away and see if it ALLEVIATES symptoms
Positive: symptoms alleviated with trunk distraction
233
Tests for Intrathecal pressure
1. milgram
2. nafziger
3. valsalva
234
Milgram Test
--central cord lesion
bilateral passive SLR
positive: sx
235
Nafziger Test
palpate jugular vein until face flushes
we dont do this one
236
Valsalva
space occupying lesion
cancer
disc bulge
they will say have sx when they bear down
237
SI Joint Special Tests
3 out of 5 tests in the clinical prediction rule test positive indicate SI joint dysfunction
1. Anterior Gapping Test
2. Posterior Gapping Test
3. Gaenslens Test
4. Thrust Test
5. Spring Test
```
Faber Test (Flexion, Abduction, ER)
Patrick Test
```
238
Anterior Gapping test
SI joint dysfunction
pt supine
heel of palms on bilateral ASIS
distract laterally
Positive: sx reproduced
239
Posterior Gapping Test
Si joint dysfunction
pt supine
heel of palms on bilateral ASIS
compress medially
Positive: sx reproduced
240
Gaenslens Test
SI joint dysfunction
1) Supine, (R) Knee to Chest, Contralateral (L) leg off table
2) PT press (L) leg into extension to stress L inotimate
241
Thrust Test
1) Supine with hip flexed
2) PT has one hand under scrum with thumb on PSIS
3) PT does posterior force to stress the ilium to stress the SI joint
Positive: pain or excursion compared to the other side
242
Spring Test
1) Prone
2) hand on sacrum for pure posterior to anterior force
Positive: excursion and pain
243
Faber Test/Patric Test
1) pt supine
2) PT passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity
3) examiner slowly abducts the involved lower extremity towards the table
Positive test: Involved LE does not abduct below level of uninvolved side
SI pathology, iliopsoas tightness
244
Diff dx
Lateral Thigh
Lateral cutanous nerve of the thigh
--numb with tight jeans, tight belt compressing the nerve
peripheral vs dermatome:
-dermatomal nerve spirals
245
Diff Dx
Medial Thigh
Obterator nerve
Dermatome: different levels that innevrate the medial thigh
246
Diff Dx Lateral Calf
Peripheral:
proximal: common peroneal nerve
Distal: superficial peroneal nerve
Between the toes: Deep peroneal nerve
L5: down between toes but use other distribution parts to help
247
Diff Dx
Posterior Calf
Sural nerve
S1/S2 lateral foot border and go up calf
248
LE diff dx
| Peripheral nerve vs. dermatome
* Lateral thigh = lateral cutaneous nerve of thigh/ multiple dermatomes
* Prox- medial thigh = obturator vs. multiple dermatomes
* lateral calf
* proximal = common peroneal nerve
* distal = superficial peroneal nerve
* deep peroneal nerve btwn toes (L5)
* Sural nerve – posterior-lateral calf- more distinct boundaries vs. S1-S2
