Lumbar/PGP Practical mostly from Website and Pictures Flashcards

Question

Lumbar Tx: Mechanical Traction Practice/Describe/Think it through (mostly just parameters we learned last year)

Answer 1

Mechanical traction is usually performed after a trial of manual traction **_Clinical Guidelines for Lumbar Traction_** **Lumbar Spine - HNP:** * Weight: 30-40% body weight, no more than 50% * Position: Supine hooklying * ON:OFF time: 60:20 * Duration: Begin with 3-5 minutes progress to 15 minutes * PT/PTA need to remain by patient for one full cycle **Lumbar Spine – Joint Dysfunction DDD:** * Weight: 30-40% body weight, no more than 50% * Position: Supine hooklying * ON:OFF time: 30:10 (intermittent) * Duration: Begin with 10-12 minutes progress to 20 minutes * PT/PTA need to remain by patient for one full cycle **_Steps to Setting up Traction_** 1. Apply stabilization harness: * Place thoracic harness below ribs * Place pelvic harness at ASIS 2. Tighten: * Harness * Thoracic straps * Weight rope 3. Turn on unit and set: * Duration * ON/OFF time * Choose: Progressive Intermittent option 4. After 1^st full cycle unlock table to prevent friction * Remain by patient for one full cycle

Answer 2

● Extensor endurance ○ Prone with the lower body fixed at the ankles, knees, and hips; upper body extended over the edge of the table. Table surface is 25 cm (9.8 inches) above floor. UE held across the chest with the hands resting on the opposite shoulders as the upper body is lifted off the floor to horizontal. Subjects maintain the horizontal position as long as possible. The endurance time is recorded in sec from the point at which the subject assumes the horizontal position until the upper body drops from horizontal.

Answer 3

● Flex, abduct, and ER the hip so that the lateral ankle rests on the opposite thigh just above the knee. While stabilizing the opposite side of the pelvis at the ASIS, the knee of the involved side is lowered toward the table until end range is reached. If no symptoms, OP is added. Inclinometer is 2.5 cm distal to the patient’s flexed knee. A + test is reproduction of the patient’s symptoms or limitation of motion.

Answer 4

* Palpation (can put pillow under hips/abs to help with feeling and/or if they do not tolerate prone well) * Spinous Processes (PAVIM hand grip) * Facet joints (~1 inch lateral to SP)/transverse processes (use thumbs, make sure you are palpating the side you are standing on) * L5 vs S1: * L5 is usually less prominent than L4 * Can look for drop off of sacrum by palpating startinglateral to S2 and moving fingers cephalically until you feel drop-off. * PSIS/SIJ * Posterior Dorsal SI ligament Test (use 0-3 scale) * Sacrum (use same hand grip as PAVIM) * Soft Tissue (make sure you are palpating perpendicular to the way the muscle runs so you can feel if it is ropey, etc). In general keep hands relatively flat, but also must tilt whole hand so the fingers dig in a bit to really feel the muscle fibers. * Glut max * Glut med/min * Piriformis * sciatic nerve is also there (halfway between ischial tubs and greater troch) * Rotators * Sciatic nerve on posterior thigh * Palm flat on posterior thigh just below gluteal fold. Apply pressure and tilt hand down a bit (so fingers are digging in a little) and push hand medial and lateral while assessing for s/s. * Greater trochanter * Isch tube * Palm flat on posterior thigh just below gluteal fold. Then slide hand on thigh in cephalic direction (towards fold) and will bump up and feel the Isch tub (much less invasive than how we palpated them before) * Lumbar Soft tissue * Multifidi and parapsinals * Palpate perpendicular to fibers between the spinous process and transverse processes (will be palpating more than one level at a time) * Erector spinae * Quadratus Lumborum

Answer 5

AB with Cat and camel exercise in quadruped: A range of motion exercise focusing on flexion and extension of the spine. Teaching abdominal bracing: The patient is asked to contract the muscles to make them stiff. The abdominal wall is not drawn in or pushed out. Bracing is used to encourage co-contraction of the abdominal wall and paraspinals at low levels (i.e., 10-15% of maximum voluntary isometric contraction) in supine and then used in functional activities such as getting in and out of car and on off the toilet.

Answer 6

■ This test compares apparent leg lengths with the patient prone when both knees are extended to when both knees are flexed to 90° by visually examining the left and right soles of the heel with shoes on. When the patient prone with both knees fully extended, a finding of a shorter leg compared to the opposite side suggests but does not confirm a posteriorly rotated innominate. While both heels of the patient's shoes are held, the patient's knees are passively flexed to 90°. An observable minimum difference estimated visually at 2.54 cm between the prone knee flexed and prone knee extended position is a positive test. Theoretically, an observed difference indicates a posteriorly rotated innominate.

Answer 7

Trunk Muscles Imbalance suggested if * Flex:Ext endurance \> 1.0. (Values \<1.0 are desirable with 0.84 normal for healthy young males) * Right-side-bridge:Left-side-bridge endurance \>0.05 * Either side-bride:extension endurance \> 0.75

Answer 8

* Non-Thrust Manipulation: Prone, Lumbar Central Posterior-to-Anterior (CPA) Mobilization. Central PA mobilization is similar to central PA PAIVM assessment. In Clelandthe central PA was directed at L4 & L5 using a low-velocity high amplitude oscillation at 2 Hz, a total of 60 sec for 2 sets. The therapist selects the level or chooses the L4/L5 segment because previous research suggests procedures directed toward the lower lumbar region are more effective. The position can be varied in flexion over a pillow, extension (prone on elbows), or lateral flexion.

Answer 9

From Book: 10 Meter walk test is an easy, reliable test to measure walking speed. A straight, level 20 m path is used beginning with 5 m for acceleration, 10 m for timed walking at a comfortable pace, and ending with 5 m for deceleration. the average of 2 trials is scored. The amount of change needed for a **small but meaningful improvement is 0.04 to 0.06 m/s** and for a **substantial change 0.08 to 0.14 m/s.** Gait speed of less than 1 m/s identifies well functioning older person at high risk of adverse health outcomes within 1 year. Gait speed is a standards measure that has the potential to predict functional decline and future health status. Because self-selected walking speed is slower in pts with CLBP, walking speed should be assessed when appropriate to provide data relevant to the pt's future functional ability and safety. While variations exist related to age and gender, **the normal range for walking speed is 1.2 to 1.4 m/s**

Answer 10

● ND mobilization procedures are passive or active movements centered on regaining the neural tissue’s ability to move & withstand normal daily stresses. Non-provocative gliding techniques are thought to result in a larger longitudinal excursion with a minimal increase in strain and to produce sliding movement between neural structures and adjacent non-neural tissue. These techniques are performed in an on and off or oscillatory manner and not performed as stretching techniques.

Answer 11

○ Slump Sliding Technique: Step 1: Knee extension/knee flexion.Step 2: cervical & thoracic flexion and return to neutral.Repeat in an on/off manner.Pain free.Tensile loading techniques, as performed in the Cleland et al738 slump stretching study (Figure 4-121), are more aggressive since tension is taken up from both ends of the nervous system at the same time. ND mobilization is not indicated in patients with neurological signs of impaired conduction such as weakness, impaired sensation, and diminished DTRs. ○ With minimal improvement, impairments associated with NPNS were first addressed through seated slump in knee extension adding ankle dorsiflexion as a HEP & progressing to adding cervical flexion. At the 4th session prone PAIVM and sidelying PPIVM (Figure 4-128) in combination with SLR neurodynamic mobilization were initiated with full resolution of symptoms by the 6th session.

Answer 12

■ MMT Abduction: While stabilizing the pelvis in side lying or supine with the hip at end range active abduction, the clinician provides a force directed into adduction. The patient is asked to resist this force.

Answer 13

■ Monitor the inferior slope of the PSIS bilaterally. Patient is asked to bend forward. The clinician maintains palpation with the inferior slope of the PSIS/ilium bilaterally and monitors movement of the PSISs and ilia during forward bending. The normal response is symmetrical anterior tilt of both ilium over the femoral heads without deviation from the sagittal plane. The side that moves further cranially is suggested as the dysfunctional side with an observable minimal difference between sides estimated at 2.54 cm or at least 1 inch.

Answer 14

▪ Repeated Flexion in Standing (RFIS). Repeat 10-15 repetitions, continually ask the patient about any change in symptoms, location, or intensity during movement or at end range and note any change in quantity of movement. Picture: we asked the person to slide hands on legs to help them feel more stable (not out in the air like in picture)

Answer 15

■ MMT Adduction: ■ Adduction: With the hip at end range active adduction, stabilize the pelvis and provide a force into abduction. The patient resists. Observe for poor trunk control. If the hip flexes during abduction, the TFL is overactive; may be substituting for a weak gluteus medius, poor trunk control, or stiff adductors. ● In the past, we performed this in side-lying with the leg we are testing down. We stood behind the pt, held the top leg up, asked the pt to use the bottom leg to meet the top leg, let it drop a bit and then applied pressure and asked pt to resist us pushing their bottom leg down.

Answer 16

■ Gaenslen’s test: With one hip flexed toward the patient’s chest & the other extended over the edge of the table, apply overpressure to both sides at the same time. Perform on both sides to create a posterior SIJ rotational load of the flexed hip and an SIJ anterior rotational load of the extended hip. Repeate on both sides (each side is considered 1 test for the 6-test cluster to rule out SIJ problem). The pain would just be reproduced on the same side whether you tested with right leg up or down)

Answer 17

* Book (chapter 3) * Lumbopelvic sitting is preferable (anterior pelvic rotation, lumbar lordosis, and thoracic relaxation). Simply telling a pt to “sit up straight” does not facilitate an optimal position of the spine. * First the pt’s unsupported sitting posture is observed with the feet flat on the floor and hips in 80 degrees flexion. The clinician manually assists anterior rotation of the pelvis 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; and (d) head -on-neck posture adjusted with gentle occipital lift away from cervical extension. The clinician manually repositions the scapulae as needed. The patient is asked to actively maintain this position. The effect of postural correction on the pt’s symptoms is assessed to determine relevance. Symptoms may increase, decrease, or remain the same or pts may have difficulty assuming the desired position, perhaps due to impaired spinal mobility. Note: not all deviations from what is considered normal or ideal should be considered pathological, and some faulty postures should not always be corrected. (example pts with LSS)

Answer 18

■ Performed by the therapist with oscillatory techniques between the ilium and sacrum (Figure 4-154) The knee is flexed and brought to the axilla with one hand placed under the ischial tuberosity and the other on the top of the patient's knee. The pelvis is rotated posteriorly by pushing down on the shaft of the femur and lifting up firmly with the thenar eminence hand on the ischial tuberosity.

Answer 19

○ Beginner Level 1: Performed against the wall with the elbows flexed feet close together. Alternate position with elbows straight. With the spine braced the patient pivots on the balls of the feet from the left side-bridge position to the front plank position and then to the right plank position in a slow controlled manner with no motion in any plan occurring in the spine and normal breathing. ○ Beginner Level 2 side bridge: In right sidelying with knees flexed and hips in neutral, the left hand grasps the right shoulder. The right hip and right elbow support the side-flexed trunk. The start position for hip and knee angles varies, but the end position does not. With the spine braced, the trunk is straightened until the body is supported on the elbow and knee in line with the hips and shoulders. ○ Intermediate level Side-bridge: Performed the same as beginner except now the lower extremities are extended. The upper leg is slightly in front of the lower leg. The trunk is straightened until the body is supported on the elbow and feet and in line with the hips and shoulder. Video shows plank progression from side to prone to sid

Answer 20

○ Side lying, lower leg flexed, stabilize the pelvis & passively place the hip in abduction and extension. Knee flexed to 90° or extended. Keep the hip in line with the trunk, lower the thigh into adduction. A + test is if the hip does not adduct past the horizontal or when symptoms or complaints of tightness are reproduced. Modified Ober’s test allows significantly more hip adduction than the original Ober’s test; the two procedures should not be used interchangeably

Answer 21

■ Teaching abdominal bracing: The patient is asked to contract the muscles to make them stiff. The abdominal wall is not drawn in or pushed out. Bracing is used to encourage co-contraction of the abdominal wall and paraspinals at low levels (i.e., 10-15% of maximum voluntary isometric contraction) in supine and then used in functional activities such as getting in and out of car and on off the toilet.

Answer 22

■ Supine lumbopelvic regional thrust manipulation (also used in lumbar tx). Preliminary CPR has been developed to identify postpartum women with LBP or PGP who are likely to respond to a supine lumbopelvic thrust manipulation technique followed by 10 repetitions of a hand-heel rock ROM exercise in quadruped.

Answer 23

■ Supine: In supine the patient grasps the knee with both arms, holds firmly, and pushes hard against the arms for 5-10 seconds. In supine the patient uses a belt to hold the knee and pushes hard against the belt for 5-10 seconds. The patient contracts the abdominal muscles while pushing with the knee to encourage posterior rotation of the pelvis and when lowering the leg. The exercises are repeated alternately on each side at least 3 times. If pain is severe, the patient performs the exercises every few hours throughout the day for 4 to 5 days, then 3-4 times daily for a week, and then as needed. ■ Sitting: Performed in sitting. The patient contracts the abdominal muscles while pushing with the knee to encourage posterior rotation of the pelvis and when lowering the leg. The exercises are repeated alternately on each side at least 3 times. If pain is severe, the patient performs the exercises every few hours throughout the day for 4 to 5 days, then 3-4 times daily for a week, and then as needed. ■ Standing: Performed in standing using a stable surface.The patient contracts the abdominal muscles while pushing with the knee to encourage posterior rotation of the pelvis and when lowering the leg. The exercises are repeated alternately on each side at least 3 times. If pain is severe, the patient performs the exercises every few hours throughout the day for 4 to 5 days, then 3-4 times daily for a week, and then as needed. Picture: note external rotation in the supine example (good)

Answer 24

■ Central posterior-to-anterior movement is also assessed directly on the sacrum to the coccyx. (same positions as nutation and counternutation)

Answer 25

■ Distraction: apply a posteriorly directed force through both ASISs purported to distract the anterior aspect of the SIJ.

Answer 26

● Inferior glide: In supine with the hip passively held at 90° flexion the clinician grasps the proximal thigh as close to the hip joint as possible and applies an inferiorly directed force. Picture: PT is on ipsilateral side. Put leg over shoulder (unlike picture) to avoid stressing knee.

Answer 27

● Long-axis distraction: In supine the clinician grasps the patient’s ankle passively moving the hip into 20-30° of hip flexion and 30° of abduction. A longitudinal distraction force is applied. Perform in an oscillatory manner to assess onset of symptoms, stiffness through range, end feel and to assess a pain and stiffness relationship. Picture: grab proximal to malleoli (not like in picture)

Answer 28

● To differentiate between neuro and vascular claudication ● Self-selected pace ≤ 10 min (stop when symptoms dictate); rest 10 mins and measure how long to recovery; 15° incline ≤ 10 mins (stop when symptoms dictate); how long to recovery ● (+) for neuro = earlier onset and prolonged recovery time with level walking

Answer 29

From Book: Some differences are noted between RFIS and RFIL. In severe cases, RFIS may be more difficult, possibly due to the effects of gravity. SEgmental lumbar motion during RFIS occurs from proximal to distal, whereas in RFIL, the motion occurs from distal to proximal, possibly causing increased tension of lower lumbar segments more quickly than RFIS. RFIS where knees are extended places more tension on the lumbosacral nerve roots than RFIL where the knees are flexed. Symptoms aggravated by RFIS may be caused by stress to both non-neural structures or neural neurodynamics, but symptoms aggravated by RFIL are most likely caused only by non neural structures because the neural structures are on slack. Basically pt is in supine hooklying and brings knees towards chest (assisted by pts hands when in reach) and puts feet back on mat 10-15 times while therapist assess for change in symptoms.

Answer 30

■ Hip posterior glide at various ranges ● Posterior glide: In supine with variations in hip flexion and adduction ranges, the clinician applies a posteriorly directed force in line with the long axis of the femur. Picture: example of one position

Answer 31

Persons under 60 years of age should be able to maintain all of these conditions for up to to 30 seconds: * EO * EC * EO foam * EC foam To increase the challenge, a tandem and then single leg stance are tested on a firm surface with EO and EC. Persons under 45 should be able to complete these tests.

Answer 32

* hip inferior glide or medial glide sidelying * In sidelying with the lower leg in 45° of hip flexion, an inferior or medial glide is performed through the greater trochanter while supporting the leg in abduction.

Answer 33

■ The piriformis muscle length test also assesses the other hip external rotators, but it is commonly known as the piriformis muscle length test. The piriformis is primarily an ER of the hip and assists with abduction and extension. When the gluteal muscles are weak or inhibited, the piriformis may overwork to assist hip extension and abduction resulting in a short muscle. With the hip above 60° of flexion, the piriformis acts a hip internal rotator. The diagnostic utility is unknown. ■ Piriformis Test Above 90 degrees: in supine flex the hip to 90 and add ER. While maintaining Flex and ER, adduct the hip toward the opposite shoulder. ■ Piriformis Test Less than 90 Degrees: In supine place the foot of the tested LE just lateral to the untested knee if the pelvis remains in neutral. If the pelvis elevates from the table, place the foot of the tested LE just medial to the untested knee. While manually stabilizing the pelvis on the tested side, passively move the hip into ADD and IR by moving the knee toward midline. A + test is side-to-side asymmetry. Relevance is based on clinical experience. A normal test response is unknown.

Answer 34

■ ROM/OP Extension (prone): With the knee extended or flexed, the patient raises the leg off the table, OP may be applied if the lumbar spine, pelvis, and hip are controlled. The clinician stabilizes the pelvis at the PSIS or ischial tuberosity, grasps the distal thigh with the knee extended or flexed and passively moves the hip into extension, OP is added as indicated. Can use a pillow if needed (if pt has reduced hip extension or lumbar extension is agg)

Answer 35

○ Central PA PAIVM. In prone with arms at the side place hypothenar eminence just distal to the pisiform over SP. Place the other hand on top. Keep elbows straight and sternum directly over the SP. Progress in an oscillatory manner to assess symptom response & quality of movement through range and at end range. Do not push on the spine; lean forward to translate the weight of the trunk to the spine.

Answer 36

* Watch out for Supine Hypotension Syndrome (SHS) with pregnancy.Fetus may press on inferior vena cava. If pt has symptoms, roll them to left side and they should feel better pretty quickly. This is something with a high possibility of happening, so make sure you respond if the pt shows s/s or complains of feeling weird. Also do not overly worry if the pt shows s/s because it is probably SHS that you can easily reverse (but do it immediately). The pt is most likely not experiencing something worse.

Answer 37

○ Non-Thrust Manipulation: Prone, Lumbar Unilateral Posterior-to-Anterior Mobilization. Technique performance is the same as for assessment. Treatment of the painful and dysfunctional level is more effective in pain reduction than a randomly selected level. In asymptomatic subjects no difference was found between amplitudes or grades of mobilization as measured by pressure pain thresholds. Variations or progressions include positioning the patient in flexion, extension or lateral flexion.

Answer 38

Lumbar lateral flexion in sidelying away from the painful side Can add rotation

Answer 39

* Resisted Abduction test (we talked about in lab but I didn’t find it in the book) * Pt supine, hips in 30 degrees abduction * PT tries to adduct hips and asks pt to resist * Anterior hip pain suggests hip problem * Posterior pain suggests SIJ problem

Answer 40

○ Unilateral Posterior-to-Anterior PAIVM (Figure 4-85b). In the same position as described for central PA PAIVM the clinician uses both thumbs to produce the passive accessory movement. The thumbs are placed in the area of the zygapophyseal joints, 2-3 cm lateral to the SP, beginning on the uninvolved side making a side-to-side comparison.

Answer 41

■ SIJ Traction with knee extended: The ankle is grasped at about 45° of passive SLR providing a strong pull on the leg in the long axis for about 5 sec. During distraction the patient tightens the abdominal muscles to facilitate posterior pelvic rotation. Traction is done on each leg one at a time for 4-5 reps. Reassess frequently. ■ This technique is used to traction the leg if unable to traction through the ankle. For the right side place the left forearm under the right knee and the left hand over the front of the left knee. Stabilize the right ankle with the right hand holding the knee in flexion. The clinician tractions the leg through the left forearm using the left hand to lever the traction which lifts the buttock on that side. Reassess frequently. Picture: be sure to pull above the malleoli

Answer 42

Extension: Resting symptoms: quality, quantity, symptom response. With your knees straight, hands on your hips, bend backwards Inclinometer at the T12 spinous process provides a measure in degrees of total flexion, extension. The amount measured combines motion available at the lumbopelvic and hip regions.

Answer 43

○ Trunk supported feet on floor. Perform a central PA PAIVM on the symptomatic segment. Patient lifts the legs \< 6 inches Central PA PAIVM is repeated. Patient note change in symptoms. Test: + if the symptoms on first part of the test disappear on the second part of the test. Pain present with the initial central PA PAIVM, but not present with lifting the legs (activating spinal extensors) suggests that stabilizing the symptomatic segment. Picture: part 2

Answer 44

○ Subjects sit on the table with the upper body against a support with angled at 55°. Both the knees & hips are flexed to 90° with arms folded across the chest, hands placed on the opposite shoulder; feet stabilized manually or under straps. Subjects maintain the body position while the wedge is pulled back to begin the test. The test ends when the upper body falls below 55°.

Answer 45

■ Thigh thrust: Hip flexed to 90 ° and knee comfortably flexed, apply a downward vertical force through the femur. Stabilize the sacrum with one hand & encircle the flexed knee. The force provides a posterior SIJ shearing force on that side. Picture: PT is standing on contralateral side. Don't forget to put a towel or hand under sacrum!!

Answer 46

To assess for hip OA475 or determine hip joint irritability. +LR 2.4 and -LR 0.51 for OA. Flex and adduct the hip until resistance to movement is noted. Maintaining the flexion, the hip is gently moved into abduction bringing the hip through 2 full arcs of motion. If the patient has no pain, repeat the test while applying long-axis compression through the femur. Use good communication so as not to exacerbate symptoms. Patient rates pain on a 1-10 NRS. A + test is provocation

Answer 47

● Anterior glide: In prone with the hip extended to neutral or near end range the clinician applies an anteriorly directed force over the posterior aspect of the greater trochanter or over the proximal femur just distal to the ischial tuberosity. The knee may be flexed or extended.

Answer 48

▪ Lateral Flexion, OP: stabilize the pelvis on the side opposite the lateral flexion and applies OP through the opposite shoulder into lateral flexion.

Answer 49

* Patient supine; test uninvolved side first; 1 hand under ankle; 1 above knee. Passively lift into hip flexion; keep hip in neutral & knee extension until symptoms are produced or significant resistance is reached. Note onset of resistance, hip flexion angle, and symptoms. Use an inclinometer zeroed on proximal tibial crest to measure hip flexion angle. Avg ROM of the L and R sides \> 91° is a key factor in a CPR to consider if a patient will benefit from a lumbopelvic stabilization program.413 Distinguish between familiar symptoms and symptoms due to HS tightness - which is not a positive test. (sensitizign manuver ankle DF or PF). * Contralateral performed the same way, except s/s are reporduced in leg that stays on table * Can use ipsilateral to rule in HNP; contralateral to rule out HNP. Picture: do not use a head pillow (ulness you use it each time you reassess)

Answer 50

Assess passive physiological flexion, extension and segmental motion of L5- S1 through T10-12 and determine if movement at an appropriate spinal segment reproduces the patient’s symptoms and whether the segmental motion is normal, hypomobile, or hypermobile for purposes of diagnostic classification and guiding intervention. Diagnostic utility is discussed in chapter 3. ■ Flexion: Patient in sidelying in neutral lumbar spine with knees flexed. Face the patient supporting the uppermost leg or both legs at the ankle with the knees resting on the clinician’s thigh. Use the middle or index finger of the other hand to palpate the L5-S1 interspace. A neutral position for each segment is the starting position. Slowly bring the hips into flexion to recruit motion at each segment. Assess the amount of opening at the interspinous space.

Answer 51

○ Supine Pelvic Tilt Range of Motion (ROM) Exercise. In supine with hips and knees bent, feet flat on the floor, the patient slowly flattens the low back by gently drawing in the stomach and rotating the pelvis backwards without breath holding. The ROM exercise is pain-free performed 10 x, 3-4x daily.

Answer 52

■ MMT Extension: While stabilizing the pelvis in prone with the hip at end range active extension, the clinician provides a force directed into flexion. The patient is asked to resist this force. If poor trunk control is noted and to enhance the control of prone extension, performance of the abdominal drawing-in maneuver (ADIM) is advised to limit excessive anterior pelvic tilt and minimize over activity of the superficial spinal extensors.

Answer 53

■ ROM/OP Flexion (supine): Ask the patient to bring the knee up towards the chest; if full range and no symptoms, add OP; if painful &/or limited, or the clinician passively performs hip flexion.

Answer 54

○ Supine legs straight, feet 20 cm apart. Patient raises 1 leg at a time 8 inches without bending the knee Score the effort needed to raise the leg on a 6-point scale: not difficult at all = 0, minimally difficult = 1, somewhat difficult = 2, fairly difficult = 3, very difficult = 4; unable to do = 5. Both sides are added totaling score from 0-10. A score of 1 or higher is a positive test suggesting a lack of dynamic stabilization and impaired load transfer. Observe for poor motor control strategies such as breath holding, thoracolumbar rotation, pelvic rotation to stabilize the thorax, low back, and pelvis. ASLR is then repeated with manual or belt compression through the ilia and any change in effort or pain is noted.

Answer 55

Note: none of our professors use this ○ Patient prone: Passively elevate both LE at the same time about 12 inches from the table while keeping the knees straight & gently pulling the legs. Assess response during elevation of both legs and on return. During elevating both legs the test is + with complaint of strong LBP, or a feeling as if the low back is coming off; and if the pain goes away with leg lowering. Mild numbness or prickling sensations are not a + test.

Answer 56

■ If symptoms change, neural mechanosensitivity is implicated. If symptoms do not change, somatic tissues are implicated.432, 433 For both the prone and sidelying versions of this test: an increase or reproduction of the patient’s familiar symptoms, asymmetry between uninvolved to involved sides, a positive sensitizing maneuver describe a positive test. Symptoms of pulling or pain related to tension on the rectus femoris or quadriceps, or hip or knee somatic structures are normal responses. Symptoms may also refer from the lumbar spine or hip. Prone knee bend * Prone Knee Bend For neurodynamics: Perform in prone; or sidelying the slump knee bend test. In prone with the hip in neutral and the pelvis stabilized, passively flex the knee attempting to differentiate symptoms from the lumbar spine, hip, knee, quadriceps or neural tissue mechanosensitivity. The addition of hip extension may be used as sensitizing maneuver, but still allows movement of various somatic structures.

Answer 57

○ Right Supine Lumbopelvic Regional Thrust Manipulation. Patient supine with fingers interlocked behind the head. PT opposite the side to be manipulated & passively moves the patient into lateral flexion toward the side to be manipulated.Maintain the laterally flexed position, place thrust hand on ASIS.Passively rotate the patient toward.Perform HVLA thrust to the ASIS in a posterior and inferior direction.

Answer 58

* Basic Progression (static lumbar spine) * single heel slide, opposite leg supported * single leg heel slide unsupported * single leg heel slide opposite leg unsupported with pressure biofeedback (see above) * Bent leg Fallout * Advanced progression (unstalbe surfaces, functional activities, etc) * Sit \<-\> Stand, Lifting/pushing Teach ADIM activation first. Once they can breathe normally for 10 seconds 10 times, start adding movement (with coordinated activation of superficial abdominals over the top of the ADIM)

Answer 59

■ Start position; palpate S2 spinous process with the left thumb; the right thumb is on the right PSIS and hand on ilium. In standing the patient is asked to raise the right knee toward the ceiling (i.e., flex the right hip). The clinician maintains palpation of the S2 spinous process with the left thumb; the right thumb on the right PSIS and hand on ilium & monitors movement of the right PSIS & ilium. The right ilium should move into posterior tilt relative to the sacrum. Compare left and right sides. Theoretically, the PSIS that does not move posteriorly and inferior relative to S2 is considered a positive test.

Answer 60

■ Assess passive physiological flexion, and extension segmental motion of L5- S1 through T10-12 and determine if movement at an appropriate spinal segment reproduces the patient’s symptoms and whether the segmental motion is normal, hypomobile, or hypermobile for purposes of diagnostic classification and guiding intervention. Diagnostic utility is discussed in chapter 3. ■ Extension: In sidelying in neutral lumbar spine with hips and knees flexed. Facing the patient supporting the uppermost leg or both legs at the ankle with the knees resting on the clinician’s thigh. Use the middle or index finger to palpate the L5/S1 interspace. A neutral position for each segment Is the starting position. Slowly bring the hip or hips into extension to recruit motion at each spinal motion segment. Assess the amount of closing at the interspinous space.

Answer 61

● Zero inclinometer on the upper tibial anterior border. In supine the untested LE is stabilized on table with the knee extended. The clinician holds the tested LE in 90° of hip flexion and passively extends the knee to end range of HS length. A + test is asymmetry from side-to-side. Relevance is based on clinical experience. Normative data are not available for either test position. I found another note saying zero inclinometer on table, not on pt

Answer 62

▪ Extension, OP: the clinician steps behind the patient whose arms are crossed and places one hand at the lower lumbar region while the other hand reaches across the upper body to provide OP into extension.

Answer 63

■ MMT External Rotation: In sitting with the hip at end range active ER, the clinician stabilizes the lateral knee and applies a force directed into internal rotation. The patient is asked to resist this force.

Answer 64

TrA palpation and ADIM * In supine hooklying & neutral spine posture, gently palpate 2 cm medial & inferior to the ASIS. At the end exhalation, the patient performs a slow, gentle TrA contraction (i.e, 15% of max) by drawing the navel in toward the spine & up toward the chest -AKA the abdominal drawing-in maneuver (ADIM). If the muscle contracts properly, an increase in deep tension is palpated. Hold the contraction for 10 sec. Cues for women: gently lift your pelvic floor; men: imagine gently lifting the testicles. Note: abdominal bulging an abnormal response during the ADIM TrA activation with biofeedback pressure unit * Supine: In hooklying the cuff is placed under the lumbar spine and inflated to 40 mm Hg. The procedure for TrA activation is the same as for palpation. A successful contraction is an increase of 0-5 mm Hg and the ability to maintain the change in pressure. A firm or hard surface is recommended to minimize measurement error. The addition of a series of leg loading activities such as unilateral heel slides may be used as a progression. * Prone: The cuff is placed under the abdomen with the navel in the center and the distal edge of pad in line with the ASIS on both sides. Inflate the cuff to 70 mm Hg and allow the reading to stabilize. The dial moves with normal respiration. TrA activation is the same as for palpation. A successful contraction lowers the reading by 6-10 mm Hg. A change of \< 2 mm Hg, no change, or an increase suggests the person is unable to correctly contract the TrA. May also be used to monitor trunk stabilization with arm movement.

Answer 65

○ Right Sidelying Lumbar Spine Thrust Manipulation or Mobilization Targeting L4/L5 Segment. Patient side-lying, painful side up. Flex top hip until motion is felt at the L4-L5 interspinous space & place the patient’s foot in the popliteal fossa. Maintain position, grasp the lower shoulder/arm to introduce SB & rotation until motion is felt at L4-L5. Maintain the setup, position the patient’s arms around the clinician’s arm & log roll toward. Apply HVLA thrust manipulation to the pelvis in an anterior direction using the right arm. May be used as a rotational mobilization.

Answer 66

○ Anterior Tilt of the ilium ■ Passive physiological motion tests: Anterior and posterior tilt of the ilium commonly performed in sidelying; while supporting the uppermost knee in the clinicians abdomen or resting on top of the other leg table supported on a pillow, the SIJ is taken through full range of motion into anterior tilt and posterior tilt by gently grasping the ilium in both hands. Reliability and diagnostic accuracy are unknown. Can be done from behind the pt too (easier that way) but I forgot the exact hand placements.

Answer 67

Repeated Extension in Lying (REIL) : A patient who peripheralizes with REIS may be able to centralize with REIL. REIL produces a greater mechanical effect than REIS. In prone with hands under the shoulders the patient raises the upper half of the body by gradually straightening the arms. The pelvis & thigh remain relaxed & allow the abdomen to sag. Initially, the response to 10-15 repetitions is observed.

Answer 68

○ Internal/External Rotation ■ ROM/OP Internal/External Rotation (sitting, supine, prone): In sitting with the hip in 90°of Flex and 0° abduction or adduction, ask the patient to bring the foot up and out/in, OP is applied as indicated. In supine, ask the patient to turn the foot out toward the side or the clinician passively performs IR/ER with OP. In prone, IR and ER can be assessed with the hip in neutral Flex, ABD, and ADD. ■ In prone, the hip on the side to be tested is in line with the body with the knee flexed to 90°. Inclinometer is zeroed on the distal fibula. IR measured at the point when the pelvis first begins to move.Interrater reliability (ICC 0.95- 0.97). At least one hip with \> 35° of IR measured in prone is a key factor in a validated, CPR that identifies patients with LBP who may benefit from manipulation

Answer 69

○ Sacral Thrust: In prone apply a posterior to anterior force to the center of the sacrum purported to produce an anterior shearing force of the sacrum on both ilia. A + test occurs when the patient’s familiar symptoms are reproduced or increased, but the test does not indicate a specific pathology or help direct treatment.

Answer 70

■ Hip posterior glide at 90 degrees flexion ● Posterior glide: In supine with the hip passively flexed to 90 °, the clinician applies a posteriorly directed force in line with the long axis of the femur.

Answer 71

○ Area of pain and other structures PRN ○ Begin at the iliac crests and move anteriorly to the ASIS looking for symmetry. By flexing and abducting the hip, attachments of the rectus femoris and tensor fascia lata to the ASIS become easily palpable. With the thumbs on the ASIS the fingers will reach to the lateral aspect of the thigh for palpation of the greater trochanter and gluteus medius. From the ASIS to the pubic tubercle on each side, palpate the inguinal ligament and pubic symphysis. The superior border of the femoral triangle is the inguinal ligament. Below the inguinal ligament is medial border of the adductor longus and lateral border of the sartorius. Within the femoral triangle, from lateral to medial, are the femoral nerve, femoral artery with a palpable pulse, femoral vein, and lymph nodes. Includes any area of the patient’s symptoms: Areas or structures might include the iliac crest, ASIS, pubic symphysis, anterior hip or groin, and abdomen. For the abdominal area general inspection, observation of breathing patterns, palpation, percussion, & auscultation procedures may be needed.

Answer 72

■ Patient sits at end of table & lies down while bringing both knees to chest. The patient maintains one side in hip flexion keeping the lumbar spine & sacrum flat. The clinician passively lowers the tested limb over the end of the table towards the floor. The thigh should touch the table. Observe to see if the hip is in neutral or flexed in the sagittal plane and whether neutral or abducted in the frontal plane. The lower leg should be in neutral rotation with the knee flexed. Compare both sides and observe asymmetry. To differentiate between the 1- & 2-joint hip flexors when the thigh does not touch the table, extend the knee to place the 2-joint hip flexors on slack. If hip extension increases, the 2-joint hip flexors are implicated. If there is no change in hip extension, the 1-joint hip flexors are implicated. Abduction or ER of the thigh suggests TFL tightness. If the thigh is abducted, bring the thigh to neutral. If hip flexion increases, the TFL-ITB is short. If knee flexion is \< 80°, a short rectus femoris is suggested.

Answer 73

○ REIL with clinician overpressure: Use a cross-arm technique to place one hypothenar eminence of each hand over the transverse process of the same segment. Lean forward to produce a gentle, symmetrical pressure as the patient performs REIL. The clinician allows the motion to occur. If the pressure produces more pain, direction-specific) or mobility deficit classification may be present. If the pressure decreases symptoms or creates centralization, a direction-specific exercise classification is likely.

Answer 74

Hamstring length

Answer 75

MYOTOMES: * L1/2- Resisted hip flexion in sitting * L3/4- Resisted knee extension in sitting * L4- Resisted ankle dorsiflexion * L5- Resisted hallux extension * S1- Ankle plantarflexion * S2- Resisted knee flexion DERMATOMES: * L1/2- groin * L3- anterior and medial thigh * L4- medial lower leg * L5- lateral lower leg * S1- posterior lower leg and lateral foot * S2- posterior knee DEEP TENDON REFLEXES: * L 3/4- Patellar * S1/2- Achilles * L5/S2 - Hamstrings UPPER MOTOR NEURON SCREEN: * Hoffmann’s Sign: ‘flick’ distal phalanx of middle finger; (+) if thumb flexes in response * Babinski: stroke lateral sole of foot firmly proximal to distal; (+) if great toe extends and other toes ‘splay’ * Clonus: with patient relaxed, quickly dorsiflex ankle to end range; (+) if ankle ‘beats’ repeatedly toward plantar flexion

Answer 76

■ Compare the lengths of the inferior aspects of medial malleoli. A shorter leg compared to the opposite side suggests a posteriorly rotated innominate. Theoretically, a posterior innominate rotates the acetabulum superior carrying the leg with it giving the appearance of a short leg while supine. Hold the inferior medial borders of the medial malleoli with the thumbs; the patient comes to a long-sitting position.Apparent lengthening of the short leg, an observable minimum difference between the supine & long-sitting position estimated visually at 2.54 cm is a positive test. The reverse would occur with an anteriorly rotated innominate. Don't Forget the *Webber-Barstow maneuver* before (pictured)

Answer 77

○ After ruling out the presence of centralization or peripheralization, the patient started RFIL, plus left leg neural mobilization. With the hip at 90° flexion the knee was actively extended with the ankle in neutral to symptom onset (Figure 4-122) for 6-8 reps 5-6 x/day followed by 10 reps of REIL. Exercises progressed to repeated flexion in sitting with the left knee extended and then repeated flexion in standing. After 6 sessions & a 5-month follow-up the patient was asymptomatic for 4 wks.Flexion AROM significantly improved, sensation was normal, left SLR was 80° with hamstring tightness only, but the left Achilles reflex was still diminished.

Answer 78

■ Prone Knee Bend for Quadriceps Length: Performed in prone. While preventing anterior pelvic tilt & lumbar spine extension, passively flex the patient’s knee. Measure knee flexion with an inclinometer placed over the distal tibia & zeroed to the horizontal. A + test is side-to-side asymmetry. Relevance is based on clinical experience. Normative data are not available. ICC = .91 (.80, .96)

Answer 79

Knee Bend Tests (prone and slump sidelying) * If symptoms change, neural mechanosensitivity is implicated. If symptoms do not change, somatic tissues are implicated.432, 433 For both the prone and sidelying versions of this test: an increase or reproduction of the patient’s familiar symptoms, asymmetry between uninvolved to involved sides, a positive sensitizing maneuver describe a positive test. Symptoms of pulling or pain related to tension on the rectus femoris or quadriceps, or hip or knee somatic structures are normal responses. Symptoms may also refer from the lumbar spine or hip. Slump knee bend (sidelying) * In sidelying the patient pulls one knee to the chest bringing the head & trunk into flexion. While maintaining trunk and neck flexion, stabilize the pelvis & support the upper leg in neutral with the knee flexed to 90°. Add hip extension slowly to the point of symptom reproduction. If no symptoms occur with hip extension, add knee flexion. When symptoms are reproduced, the patient extends the neck.

Answer 80

○ Supine hooklying. Squeeze glutes to raise bottom off mat. If hamstring activation is a problem, ask pt to extend knees while blocking feet during bridge.

Answer 81

○ Sacral nutation and counternutation (PA glide at S1 through S5) ■ Passive physiological motion tests: Sacral nutation (relative posterior tilt of the ilium); apply a PA force to the base of the sacrum centrally; assess mobility and pain response. Sacral counternutation (relative anterior tilt of the ilium): apply a PA force to the apex of the sacrum.

Answer 82

Lumbar lateral flexion in sidelying and lumbar traction in supine (two versions) * Lumbar lateral flexion in sidelying away from the painful side at the affected level for 60 sec at a frequency of 1 Hz to increase the size of the intervertebral foramen. Picture: hold above the malleoli so you don't traction the ankle joints too

Answer 83

○ Right Sidelying Lumbar Spine Thrust Manipulation or Mobilization Targeting L4/L5 Segment. Patient side-lying, painful side up. Flex top hip until motion is felt at the L4-L5 interspinous space & place the patient’s foot in the popliteal fossa. Maintain position, grasp the lower shoulder/arm to introduce SB & rotation until motion is felt at L4-L5. Maintain the setup, position the patient’s arms around the clinician’s arm & log roll toward. Apply HVLA thrust manipulation to the pelvis in an anterior direction using the right arm. May be used as a rotational mobilization. Same position as Manip

Answer 84

▪ Left and Right Lateral Flexion: Resting Symptoms, Quality, quantity, symptom response, Slide left/right hand down side of your right/left leg. ▪ measure the distance the finger travels with a tape measure.

Answer 85

○ MMT Flexion: While stabilizing the trunk in neutral sitting and the hip at end range active flexion, the clinician applies an inferiorly directed force on the distal thigh. The patient is asked to resist this force. (this is different from what we learned last year - we learned it last year with pt supporting self with hands back on table, PT only pushing on distal femur.)

Answer 86

▪ Iliac crests ▪ ASIS ▪ PSIS ▪ Greater trochanters

Answer 87

■ MMT Internal Rotation: In sitting with the hip at end range active IR, the clinician stabilizes the medial knee and applies a force directed into external rotation. The patient is asked to resist this force.

Answer 88

■ Anterior-to-posterior (Figure 4-140) is assessed in supine; apply an AP glide through the ASIS on one side and compare to the opposite side or apply bilaterally. Assess mobility and symptom response; compare sides for asymmetry. Posterior-to-anterior movement is assessed in prone; apply a PA glide through the PSIS on one side and compare to the opposite side. Assess mobility and symptom response.

Answer 89

* Patient stands feet together shoulder-width apart , near side elbow is flexed to 90°. PT applies gentle repeated & sustained side gliding mobilization. Pulls patient's hips and pelvis horizontally with counterpressure to the trunk in a horizontal plane to produce a lateral shearing motion rather than lateral flexion. Use a rhythmic oscillation interrupted by pressure sustained for a few seconds until obstruction to motion is achieved. A solid resistance to the side gliding pressure is felt at first, but over time (variable) the resistance appears to “soften” and a greater range of motion is achieved. Extension is added if centralization occurs. * Once full correction of the lateral shift is achieved the second component of the procedure follows. Restoration of lumbar lordosis. The patient is asked to bend backwards while the manual shift correction is maintained. This is also repeated in a rhythmical fashion until as much extension is achieved as possible. Picture: pt's right elbow is bent at side.

Answer 90

Quick functional tests for the L4/L5 and L5/S1 myotomes, respectively. S1/2 may also be tested and graded in the manual muscle test position for the gastrocsoleus complex in standing. (S2 should be tested with knee flexion MMT)

Answer 91

* Multifidus palpation (prone) * Palpate at each segment next to SP with the patient relaxed. Compare side-to-side at the symptomatic, segmental level because segmental atrophy has been noted on MRI.502To preferentially activate the MTF, gently & slowly contract & swell out the muscles under the clinician’s fingers without moving the spine; palpate for deep tension in the muscle. The goal is to hold for 10 sec while breathing naturally.If able to perform correctly test 10 reps with 10 sec holds for endurance. Incorrect activation occurs if no tension is palpated, rapid superficial tension develops, superficial thoracic erector spinae are activated and palpable resulting in stiffness or arching of the spine. Cues for MTF activation are asking the patient to draw the PSISs together, gently lift the pelvic floor, or perform the ADIM. * Multifidus palpation using contralateral arm (prone) * Activate & palpate MTF in prone through a contralateral, UE lift of 5 cm (2 inches) with the shoulder abducted to 120 degrees and the elbow flexed to 90 degrees. A small hand weight is normalized to the patient’s body mass. During fine-wire EMG this process engages about 30% of the MVIC of the multifidi.

Answer 92

▪ Purpose: to test neurodynamics of neuromeningeal structures in the vertebral canal and intervertebral foramina & mobility of the PNS of the LE in subjects with spinal & lower limb pain. High interrater reliability (k=.83). Pain of non-neural origin (i.e., experimentally induced) was not exacerbated by the slump tests. Diagnostic accuracy: Sn .84 (.74-.90), Sp .83 (.73-.90), +LR 4.94, -LR .19 in patients with and without lumbar disc herniations on MRI. ▪ Care is required at each step to assess range of movement, quality of movement, and symptom response. If symptoms are produced at any step in the procedure, the clinician attempts to differentiate between neural and non-neural structures by assessing the patient’s response to the release of neck flexion. ▪ Patient: Sitting with thighs fully supported, knees together, hands behind back. Begin on uninvolved side. Explain procedure & establish resting symptoms. Assess response after each step. Ask patient to slump; do not allow neck flexion. Gently OP thoracic/lumbar spine keep sacrum vertical. Add active neck flexion, then OP. Add active left knee extension. Add active left ankle dorsiflexion. If no response at this step, add hip flexion which is generally not required. Repeat steps 5 & 6 with right leg (involved side). Repeat steps 5 & 6 with both legs PRN. When symptoms are reproduced, release neck flexion: assess response. If symptoms decrease or disappear, increase range of the limited side until symptoms are once again reproduced.

Answer 93

○ Compression: In sidelying with hips and knees flexed to about 90°, apply a downward vertical force through the upper iliac crest, purported to compress both SIJs. Can also perform standing in front of pt.

Answer 94

Make note of how the pt gets into supine (quality, etc)

Answer 95

■ Preliminary CPR has been developed to identify postpartum women with LBP or PGP who are likely to respond to a supine lumbopelvic thrust manipulation technique (Figure 4-96) followed by 10 repetitions of a hand-heel rock ROM exercise in quadruped (Figure 4-152).

Answer 96

During a functional squat such as sit-to-stand from a chair, the thoracic and pelvic spine alignment of a neutral pelvis and spinal curves should not change. Keeping the trunk over the base of support forward movement of the trunk occurs as the hips and pelvis move posteriorly. The pelvic girdle anteriorly tilts on the femoral heads; the hips, knees, & ankle flex. The knees remain centered over the foot without varus, valgus or rotational movements. Deviations from these positions suggest altered motor control strategies. For example, an increase in lumbar lordosis suggests over activation of the erector spinae. A loss of lumbar lordosis may suggest hip mobility deficits. Excessive forward trunk lean due to limited ankle dorsiflexion (Part 1). Increased range of ankle dorsiflexion results in improved forward trunk lean (Part 2).