LS Anatomy, Exam, Subgrouping Flashcards
(89 cards)
1
Q
Some LBP stats….
A
50-75% exp @ one pt in life
40% LBP in any one year
15-20% current LBP
LBP is presenting reason for 50% pts seeking care in OP PT
2
Q
LBP choice of Tx
A
reflects skill of professional rather than needs of pt
3
Q
GO BACK TO ANATOMY REVIEW
A
SLIDES 4-26
4
Q
LS exam sequence…
A
Always take thorough Hx
Always have pt complete SRO
5
Q
When it comes to LBP
DO LESS in….
A
LESS in pts w/ high irritability/acute injury
*avoid irritating pt OR worsening pathology
6
Q
When it comes to LBP…
DO MORE OR ALL in…
A
MORE OR ALL in..
Less irritable/subacute/chronic pts
7
Q
when it comes to LBP
Do “Enough”
A
to make sound tx decisions and classify pt into subgroup
8
Q
LB pain
As pts are improving….
A
DO:
high lvl functional testing– sport, work
9
Q
GOAL of LBP Exam:
A
Be able to “classify” pt into subgroup
10
Q
LBP Exam Sequence
A
see pics
11
Q
LBP Exam:
General questions
A
- onset/MOI?
- onset/when? since onset are sx’s same, better, worse?
- Where is your pain? Pain or radation of sx’s down leg? where?
- Peripheralization vs. centralization
- numbness, tingling leg, foot, toes? where?
- weakness? clumsiness in legs?
- past episodes or similar probs in past?
- 0-10 pain rating–now? worst? avg over past week?
12
Q
LBP Exam
Gen Questions cont’d…
A
- constant or intermittent? on and off?
- makes it better?
- makes it worse?
- pain @ night? –discs hydrate (swell) @ night
- B&B problems? Saddle or pelvic floor parasthesia or numbness?—-RED FLAGS!! –Cauda Equina Syndrome
- Is pain worse w/ cough or sneeze?
- what acts are difficult? problems w/ functionally?
13
Q
LBP Exam:
Gen Questions cont’d…
A
- better or worse w/ sitting? standing? walking?
- working now? what do you need to get back to?
- prior exercises/fitness/PLOA
- Any tx so far?
- any meds?
- any dx studies? imaging?
- What are your goals??? *****
14
Q
Fear Avoidance Behavior Questionnaire
FABQ
covers psychosocial aspects
A
- Score range Phys Act: 0-24
- Score range Work: 0-42
- Best Possible Score: NO FEAR:0
- Worst Possible Score: HIGH amts
- Phys Act: 24
- Work: 42
Best==Low score
Worst==High score
15
Q
LS Observation/Inspection
A
- Posture
- sitting
- standing
- ant
- post
- lateral
- Antalgic gait? AD? Footwear?
- scoliosis or lateral shift?
- Observed leg length
- LOOK @:
- medial malleoli
- popliteal creases
- glute folds
- greater trochs
- PSIS
- ASIS
- illiac crests
- LOOK @:
16
Q
LQS
DTRS
A
L3, 4==patellar tendon
S1,2==achilles
17
Q
LQS
Abnormal reflexes
A
Babinski==UMN
Clonus==UMN
18
Q
LQS
Myotomes
A
- L1,2,3– hip flexion
- L3,4– knee extension
- L4,5– ankle DF (heel-walking)
- L5–hallux EXT (EHL)
- L5,S1– knee flex
- S1, S2– PF (walk on MET heads)
19
Q
LQS
Dermatomes
B/L light touch; pt eyes CLOSED
“tell me where you feel it”
“is it the same on left vs right”
“how is it different”
A
- L1–prox medial thigh (groin)
- L2–prox ant thigh
- L3–dist anteromedial thigh + knee
- L4–anteromedial leg and med border foot
- L5–D1/D2 webspace, anterolateral leg, dorsal foot
- S1– lateral dorsal foot, post thigh + calf (more lateral)
- L5 and S1–plantar surface of foot
- S2– post thigh + calf (more medial)
20
Q
NOTE: Dermatomes
A
Dermatomes overlap
This is why radiculopathies typ may cause PARTIAL numbness or parasthesias, but unlikely to result in complete anasthesia
21
Q
Peripheral Joint Screening:
Look for sx repro/aggravtion and/or limtd or abnormal motion
What does this entail?
A
- quick gait assess.
- hip, knee, ankle, foot, toes
- quick observation/inspection
- hip, thigh, knee, lower leg, ankle, foot, toes
- HIP
- deep squat
- FABER —static, let sit
- KNEE
- deep squat
- ROM
- ANKLE/FOOT
- deep squat
- active sup/pro (open chain)
22
Q
AROM: Single Rep Motions
Flex
EXT
LF
Rot
A
% of Normal
If NO PAIN @ rest: “let me know if this brings on or provokes pain”
If PAIN @ rest: “let me know if this mvmt worsens, relieves, or has no effect on you pain”
*if worsens or relieves, ask about centralization/peripheralization*
23
Q
Single rep AROM testing sequence:
A
Standing FLEX
Standing EXT
LF R/L
Rotation (stabilize pelvis w/ hands)
NOTE:
- pts willingness to move/face/non-verbals
- pain? where? referral/radiation?
- if pain–painful arc or @ end range?
- “instability jog—sudden mvmt shift
24
Q
AROM: Repeated Motions
aka Directional Preference
Why???
A
- baseline sx’s before beginning
- 10-15 reps to tolerable end ROM
- see if same, better, worse from baseline
- Centralization or peripheralization?
- if NO–> move to next movement on list
25
AROM: **Repeated Motions**
## Footnote
**Order of Testing**
* Repeated FLEX in standing (RFIS)
* Repeated EXT in standing (REIS)
* Repeated FLEX in lying (RFIL)
* Repeated EXT in lying (REIL)
26
What should you remember in terms of **Repeated Motions Outside Sagittal Plane**
the Shift is named in terms of **Shoulder Direction**
**which way are the shoulders leaning?**
27
Repeated Motions Outside of Sagittal Plane
\***may be dealing w/ relevant lateral component to derangment**
**ex. disc (NP) protrudes more laterally**
**Do Rep'd motions outside of sagittal plane**
**ORDER OF TESTING:**
* Repeated EXT w/ **hips offset contralateral** to sx's
* Repeated EXT w/ **hips offset ipsilateral** to sx's
* Flexion Rotation
28
RROM
## Footnote
**isometric tests in _neutral sitting:_**
Strong and painfree?
Strong and painful?
Weak and painful?
Weak and painless?
\***Defined on another card**
29
Strong and Painless
No lesion or neuro deficit involved in mm or tendon
30
Strong and Painful
Minor lesion of the tested muscle or tendon
31
Weak and Painless
Disorder of the NS, NMSK junction, complete rupture of the mm or tendon, disuse atrophy
32
Weak and Painful
Serious, painful pathology such as fx or neoplasm
OTHERS: acute inflammatory process that inhibits mm contraction, exercise induced mm damage, partial rupture of mm or tendon
33
Special Tests:
**SLR**
see pics
34
+ Brudzinski's
Cervical flexion INC pain
35
+Brogards
DF foot INC pain
36
Special Tests:
## Footnote
**Sign of the Buttock Test**
see pics
37
Special Tests:
**Slump Test**
**\*indicates nerve root involvement\***
**\*biases pons, cord, meninges, sciatic tract**
see pics
38
Special Tests: **Prone Knee Bending Test**
## Footnote
**\*biases femoral tracts, mid and upper lumbar roots, meninges, cord**
see pics
39
Special Tests:
## Footnote
**Quadrant Test**
see pics
40
Manual Traction Tests
**Positions**
Prone---flat
Supine---knees bent, hips in slight flexion
41
2 Special Tests for **Instability**
## Footnote
**Standard Tests:**
1. Prone Instability Test (legs off table one)
2. Passive Lumbar Instability Test (PASSIVELY check instability)
42
Special Tests for Instability
## Footnote
**Prone Instability Test**
see pics
43
Special Tests for Instability
**_Passive_** **Lumbar Instability Test**
see pics
44
**Specialized Group of Instability Tests**
**Post-partum women w/ pelvic girdle pain**
**5 tests**
1. P4 Test (Posterior Pelvic Pain Provocation
2. +Active SLR (ASLR) test
3. Provocation of Long Dorsal SI Ligament
1. pain must last longer than 5s AFTER palpation
4. Provocation of pubic symphysis w/ palpation
1. pain must last longer than 5s AFTER palp
5. Modified Trendelenburg test
1. standing on 1 leg, if they lean hips TOWARD pain side === + test
\***Criteria to define this sub-group==positive composite of tests**
45
Specialized Group
## Footnote
**Post-partum women w/ pelvic girdle pain**
**P4 Test**
see pics
46
**Specialized Group**
**Post-partum women w/ pelvic girdle pain**
**ASLR Test**
**\*have them just lift leg and try to get to your hands**
see pics
47
**Specialized Group**
**Post-partum women w/ pelvic girdle pain**
**Provocation of Long Dorsal SI Ligament**
**Provocation of Pubic Symphysis w/ Palpation**
see pics
BOTH BELOW
\*NOTE: just remember pain sx's must last longer than 5s AFTER palpation
48
**Specialized Group**
**Post-partum women w/ pelvic girdle pain**
**Modified Trendelenburg Test**
see pics
49
Special Tests for the **SIJ:**
## Footnote
**which is the most USEFUL type of test?**
**PROVOCATION TESTS**
**\*Highest _reliability_** **and _validity_**
50
Of all studied, 4 tests contributed to making the dx of SIJ pain and dysfunction
What are they?
1. SI Distraction
2. Thigh Thrust
3. SI Compression
4. Sacral Thrust
## Footnote
**\*NOTE: Robinson et al. found that _reliability of PAIN PROVOCATION_ was GOOD while _reliability of palpation tests_ was POOR**
51
SIJ dysfunction Tests
## Footnote
**SI Distraction**
see pics
52
SIJ Dysfunction Tests
## Footnote
**Thigh Thrust**
**\*hand under buttcheek (middle of sacrum) one**
see pics
53
SIJ Dysfunction Tests
## Footnote
**SI Compression**
see pics
54
SIJ Dysfunction Tests
## Footnote
**Sacral Thrust**
see pics
55
HOOVER TEST
tests for suspicion of...
malingering
56
Hoover Test
## Footnote
**For malingering**
**The one where you hold under calcaneus and when they lift one leg up, the other foot should push DOWN on your hand!!**
see pics
57
Accessory Motion Testing
2 of them:
* **PIVM (Passive Intervertebral Motion)**
* **Flexion in sidelying**
* bring their knees off table
* **PAIVM (Passive Accessory Intervertebral Motion)**
* **P-A central vertebral pressure**
* ****push directly on SP
* **PA U/L vertebral pressure**
* ****pressing on R/L TP
\*Pushing on R. TP induces what motion--\> **L. ROTATION!!**
58
FUNCTIONAL TESTS
Basic ADLs
Work-related
Sports-Performance
59
LB Exam
## Footnote
**Important landmarks/structures to PALPATE**
* L1-S2 (use landmarks!!)
* L1-- after 12th rib
* L5--iliac crests
* S1-- PSIS
* Iliac crests
* PSIS
* ASIS
* Erector Spinae--I Love Soup
* Iliocostalis--most lateral
* Longissimus
* Spinalis--most medial
60
AFTER basic LS exam:
What is BEST to do?
Based on exam findings, classify pt into a tx group--\> match tx to **subgroup** **characteristics/predictors**
61
Sub-Groups of pts w/ LBP
## Footnote
**What was the _Traditional Medical Model?_**
* Indiv's based on pathoanatomical dx and source of sxs
* **relevant pathology ID'd in LESS THAN 10% of cases**
* **\*matched tx to clusters of s/s**
62
Sub-Groups of pts w/ LBP
## Footnote
**NOW**
**Guide to PT Practice (2001) recommend...**
* Classify pts based on **S/S...._NOT_ presumed pathoanatomical causes**
* Sub-group pts to **ultimately direct _tx decisions_**
63
Who proposed a **classification structure for pts w/ LBP**
Delitto et. al 1995
\***research supports this process as resulting in _better outcomes_ in PT tx**
64
These are the **original tx-based classifications** as proposed by **Delitto**
**\*NOTE: intended for pts w/ _acute_ or _subacute_ exacerbation of LBP**
**What are the _4_ classifications???**
1. Specific Exercise **AKA Directional Preference**
1. **Flex**
2. **EXT**
3. **Lateral shift patterns**
2. Stabilization
3. Manipulation
4. Traction
65
Evidence-Based Exam/Intervention Strategies for Pts w/ LBP
revised by Alrwaily 2016
**3 big topics w/ subtopics**
1. **Symptom Modification**
1. ****directional preference
2. manipulation/mobilization
3. traction
4. active rest
2. **Mvmt Control**
1. ****sensorimotor
2. stabilization and flexibility ex's
3. **Functional Optimization**
1. ****work/sport specific
2. strength, conditioning, aerobic and gen. fitness ex's
66
4 Subgroups of Tx-Based Classification
## Footnote
**WE LEARNED:**
1. Manipulation
2. Specific Exercise **AKA Directional Preference/Rep'd Motions**
3. Instability
4. SI-Provocative
67
1. **Specific Exercise (Directional Preference) Sub-group**
## Footnote
**\*popularized by Robin McKenzie 1989**
**Explain...**
* Pts classified based on response to **repeated mvmts**
* Focuses on **centralization/peripheralization**
**See Pics**
68
Traditional **hallmark findings** for **specific exercise classification**
**AKA directional preference**
**4:**
1. **Dec** or **abolish** pain/parasthesia
2. Centralization
3. **Centralization MAY cause symptoms proximal to intensify**
4. **INCd ROM**
69
**Directional Preference**
**DEFINED**
**(**Kilpkowski, 2002)
* Mvmt in **one direction** IMPROVES pain and ROM
* Mvmt in the **opposite direction** will cause s/s to WORSEN
70
Directional Preference and pts exhibiting centralization
2 things to remember about pts w/ **directional preference**
* 1. Pts **exhibiting centralization** will also demonstrate a **directional preference**
**_BUT..._**
* 2. Pts w/ a **directional preference DO NOT ALL** demonstrate **centralization**
71
\*Strong correlation exists b/w **centralization and disc pathology** seen via positive discography
See Study:
* Laslett et al. 2005: **Centralization as predictive of _disc pathology_**
* **__Sn:** True Positive (SnNOUT)= 37%-40%
* **this means observation of centralization picks up disc pathology \<50% of time----LOTS of pts w/ disc patho. that do NOT centralize**
* **SP:** True Negative (SpPIN)=94%-100%
* **this means pts that DO centralize most likely HAS disc pathology**
**\*Donaldson et al. --\>** Centralization was _more accurate than MRI_ in detecting symptomatic discs when using discography as **reference standard**
72
TREAT THE PATIENT, NOT THE IMAGES!!!!!!!
!!!!!!!!!!
73
**FLEXION SPECIFIC** Exercise Classification
Key things to remember
* MOST COMMON in **older pts**
* **\*anterior derangement is the _exception!_**
* Correlates w/ medical dx of **Spinal Stenosis**
**Whitman et. al 2006**
* Subjects \>50yo w/ directional preference for FLEX
* Group A did better:
* mob/manip of spine and/or LE
* ex's to address impairs of strenght and/or flexibility
* BW-supported TM walking
* WHY?
* **Multimodal intervention protocol precludes conclusions on any indiv procedure**
* **results suggest that interventions for older pts w/ FLEX-specific class. should include _several components_ OTHER THAN just flex-oriented ex's**
74
Examination of Pts w/ **Directional Preference**
## Footnote
**Things to include...**
* Look @ Lateral Shift
* when relevant?
* **most of time its AWAY from sx's, contralateral shift, shoulders go OPP to pain**
* Hx
* standing?
* sitting?
* walking?
* Diff standing erect after sitting?
* Loss of lumbar lordosis
* Key elements of basic LS exam **critical in determining inf pt has directional preference?**
* **REPEATED MOTIONS!!!**
75
Force Progression Concepts for Pts w/ **Directional Preference**
## Footnote
**What is the progression you learned in Lab for these Ex's?**
1. Pt. generated movement
2. Pt. overpressure using EXHALE
3. Clinical overpressure
1. PT pushes on LS as pt goes into motion (follow them)
4. Manipulation/Mobilization
76
**Force Progression Concepts for Pts w/ Directional Preference**
**Basic concept of McKenzie based tx**
**2 things to remember:**
1. Starts w/ **pt generated forces,** progressing to **therapist generated as needed**
2. MAY include **changing plane of motion**
1. **FROM sagittal TO coronal (frontal)**
**ADVANTAGES**
* gives clinician a formula for eval'ing and treating spine
* encourages pt self-tx
* empowers pts to **treat their own condition**
77
Force **_Progression**_ _**Concepts_** for Pts w/ **Directional Preference**
## Footnote
**List the order of progression again**
Pt gen'd forces
Pt overpressure (use exhale)
Clinician overpressure (mob as they move)
Clinician mobilization (P-A)
Clinical manipulation
78
**Force Progression Concepts for Pts w/ Directional Preference**
**More details...**
* Pt enters @ stage **that produces _improvement_**
* ONLY progress **when NO improvement OR stasis point**
* Ultimately move toward **patient independence**
79
**Force Progression Concepts for Pts w/ Directional Preference**
**Traffic Light Analogy**
SEE PICS
80
**Force Progression Concepts for Pts w/ Directional Preference**
**Traffic Light Analogy**
**GREEN==**
Progress Force
* Sxs improving BUT **not at a stasis point**
* reduction of sx's NOT MAINTAINED after tx
81
**Force Progression Concepts for Pts w/ Directional Preference**
**Traffic Light Analogy**
**YELLOW==**
Progress force **w/ Caution**
* Sx's INCd, **but NO WORSE**
* NO change in status when performed
* **Ex. worse @ top of press-up, but better @ rest**
82
**Force Progression Concepts for Pts w/ Directional Preference**
**Traffic Light Analogy**
**RED==**
STOP Tx
* **Peripheralization of sx's**
* **Loss of ROM in other planes**********
83
Directional Preference/Specific Ex's
Ex. **For pts w/ Directional Preference of EXT**
**EXT Ex's**
see pics
YOU KNOW THIS!!!
84
EXT W/ **LATERAL COMPONENT**
EXT EX'S w/ Lateral Component
**Progressions:**
see pics
* REIL w/ hips offset
* hips going OPP DIRECTION of pain
* Roadkill
* LIFTING leg of side W/ PAIN
85
EXT type Ex's
## Footnote
**When should you incorporate _"functional activities?"_**
Once sx's are **_Stable_**
86
LS "Box" Tape Technique
For pts w/ EXT preference who need to **Avoid FLEX**
87
Flexion Directional Preference Ex's
See pics
88
\*\***Pts w/ FLEX preference and/or OLDER pts w/ _STENOSIS_**
What should you use?
**FLEISHMAN MANEUVER**
**\*IVF OPENING MOBILIZATION**
1. **NOTE:** NOT for pts w/ **Ant. Derangement**
89
This is for pts who **DO NOT centralize w/ FLEX OR EXT**
**USE:**
Flexion/Rotation Mobilization
see pics
