Lumbar Assessment Flashcards
(22 cards)
Red Flags
- Age of onset <20 or >55 years
- Violent trauma, e.g. fall from height, RTA
- Constant, progressive, non-mechanical pain
- Thoracic pain
- PMH – Carcinoma
- Systemic steroids
- Drug abuse, HIV
- Systemically unwell
- Unexplained weight loss
- Persisting severe restriction to lumbar flexion
- Widespread neurology
- Structural deformity
- TB
If there are suspicious clinical features, and if pain has not settled in 6/52’s further investigations should be considered.
Cauda Equina symptoms
Definite red flags:
- Bilateral radiculopathy (loss/diminished strength, feeling of touch or reflexes)
- Progressive neurological deficits in the legs
- Widespread (>one nerve root) or progressive weakness in the legs and/or gait disturbance.
Possible red/white flags:
- Unspecified urinary disturbance (any new change in bladder function but with preserved control)
- Loss of anal sphincter tone/faecal incontinence
- Saddle anaesthesia about the anus, perineum or genitals
- Erectile dysfunction or changes in sexual function
Definite white flags:
- Urinary retention or incontinence
- Faecal incontinence
- Perineal anaesthesia
Infection symptoms
- General feeling unwell
- High temperature (fever)
- IVDU (intravenous drug use)
- Recent surgery / open wounds
Cancer signs
- Previous Hx of cancer in themselves or family
- Unexplained weight loss
- Non- mechanical, constant pain
- Night sweats
- Generally feeling unwell
Fracture signs
- Major trauma (motor vehicle accident, fall from height)
- Minor trauma or strenuous lifting in an older or osteoporotic patient
- Constant pain, worse on weight bearing
- Swelling/ bruising
- Steroid use
- Osteoporosis/ osteopenia
Inflammatory Disorders (Ankylosing spondylitis etc.) signs
- Gradual onset
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement/tendionpathies/aches
- Iritis, skin irritation (psoriasis), colitis, urethral discharge
- Family history
Myelopathy (Central cord compression in cervical (most common), thoracic or lumbar (rare) spine) signs
- Neck, arm, leg or lower back pain
- Tingling, numbness or weakness
- Difficulty with fine motor skills, such as writing or buttoning a shirt
- Increased reflexes in extremities or the development of abnormal reflexes
- Difficulty walking (ataxic gait)
- Loss of urinary or bowel control
- Issues with balance and coordination
SQs
- Bladder and bowel dysfunction- bladder retention and bowel incontinence are signs of Cauda equina
- Sacral numbness - Sign of Cauda equina
- Gait disturbances/ataxia, knees or ankles giving way - sign of severe motor weakness
Observation
- Gait:
- Excessive weight bearing through one leg
- Antalgic gait,
- Positive Trendelenberg,
- Posture during gait
- Postural alignment noting any asymmetry – scoliosis/kyphosis/flattened thoracic region
- CoG
- Adaptive postures- Pain avoidance, guarding/bracing
- Muscle tone/bulk
Neurological testing
If pain referred below the crease of the buttocks then neurological testing is indicated
-
Myotomes (look for weakness not pain)
- L2: Hip flexion
- L3: Knee extension
- L4: Dorsiflexion
- L5: Great toe extension
- S1: Eversion, contract buttock, knee flexion
- S2: Knee flexion, toe standing
-
Reflexes
- Knee Jerk (L3-4, Femoral Nerve)
- Ankle Jerk (S1-2, Tibial Nerve)
- Dermatomes
Neurodynamics:
- Slump test: sciatic nerve and above
- Patient in sitting-ask patient to slump chin to chest and sump thoracic spine forward. Physio will apply a gentle force through the patients thoracic spine and neck. Patient is asked to extend their knee to point of discomfort is posterior leg. Release pressure on thoracic spine and ask patient to extend neck. Relief from discomfort in posterior of leg indicates a positive sign of neural tension on sciatic nerve.
- Straight leg raise: sciatic nerve and branches
- With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient’s leg while the knee is straight and slightly medially rotated. Lift until discomfort in posterior leg- sensitise by ankle dorsiflexion or cervical flexion.
- SID - sural nerve INV + DF
- PIP - peroneal nerve INV + PF
- TED - tibial nerve EVE + DF
- PKB - femoral nerve
AROM and PPIVM
Movements:
- Forward flexion (facet joints opening)
- Lateral Flexion (+ contralateral pelvic rotation)
- Extension (facet joints closing)
- Rotation in sitting (limited due to facet joint orientation)
- Quadrant testing- lateral flexion with forward flexion or extension
- PPIVMS: Passive physiological movements-flexion, extension and rotation
What are we looking for?
- Quality, range (record distance from floor to fingernails), end feel, =/- overpressure
Why might we look at shoulder elevation?
- Associated T. spine ext & side flexn
- Muscle length: scalenii ant rot towards, SF away; mid SF away; post rot away, SF towards; SCM
Muscle tests
Length tests:
- lat dorsi, thomas test (hip flexors), hamstring/glutes
Strength tests:
- hip flexors, rec fem, glutes, hamstrings, upper limbs, whole kinetic chain
Motor control tests:
- squat (double leg and single), lunge, step up, one leg stand (trendelenburg), physiological movements (change tempo)
PAIVMS
- Posterior/Anterior (PA) with cephalad (angle more cephalad the more upper Lx) - helps Lx ext by opening inferior facet joint
- Unilateral
- Transverse glide
Maitland Joint Mobilization Grading Scale: R>P or P>R
Usually painful or provocative
SIN = dosage
Palpation
- Muscle tone
- Bulk
- Pain provocation
- Hyperalgesia (hypersensitivity)
Functional Assessment
- Sit to stand
- Step ups/down
- Picking something off floor
- On and off the bed
Exclusion of other joints
- SIJ- Ant gapping and Post Gapping
- Hip – Quadrant test, OP flexion
- Knee- OP flexion (less common)
- Thx?
What are the treatment options
- Advice and Education
- Targeted Exercise
- Manul Therapy techniques
- Adjuncts
What is included in advice and education
- What is the cause of the problem? Diagnosis?
- Reassurance+++ (this is a really important one as patients often come feeling anxious about what is wrong)
- Anatomy
- Pathophysiology
- Aims of physiotherapy / expectations
- Treatment options and evidence behind these
- Scans / imaging / x-ray findings
- Cognitive functional therapy
- Address yellow flags or unhelpful psychosocial beliefs, which may be negatively affecting their recovery.
- Other contributors to pain such as sleep, nutrition, stress, anxiety and depression
- Prognosis. Patients want to know is it likely to get better and how long is it going to take?
NICE:
Provide people with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. Include:
- information on the nature of low back pain and sciatica
- encouragement to continue with normal activities
What is included in targeted exercises
- Functional (sit to stand, stairs, reaching to the cupboard etc)
- Strengthening
- Lengthening
- Graded loading
- Power
- Endurance
- Balance / control
- Proprioception
- Sports specific and / or plyometrics (jumping, hopping, change of direction etc if required)
- Gait re-education and / or walking aids
- Cardiovascular
What is included in manual therapy techniques
- Joint mobilisations (for stiff joints)
- PPIVM’s, PAIVM’s (grade I-IV) or mobilisations with movement (MWM)/SNAG’s, NAG’s
- SSTM’s - accessory, physiological or combined (for soft tissues)
- Trigger point techniques, transverse frictions or massage (soft tissues)
NICE:
Consider manual therapy for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy
What is included in adjuncts
- Heat and ICE
- Shockwave?
- Taping / bracing
Treatment plan for those with persistent low back pain
NICE:
Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person’s specific needs and capabilities), for people with persistent low back pain or sciatica:
- when they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or
- when previous treatments have not been effective.
