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1
Lumbar Spine

L3 dermatome

distal anterior medial thigh

2

Local muscles of the trunk control what?

 Inter-segmental motion
(Multifidus, intertransversari, interspinalis, transversus abdominus, internal
oblique, deep Erector spinae)

3

50-75% slippage=

Grade 3

4

name of muscle

quadratus lumburum

5

in the lumbar spine, passive range of motion examination is done by

two parts:

  1. Osteokinematic PROM: good reliability
  2. Arthrokinematic (segmental) motion tests: poor reliability:
    • PAIVM (Passive accessory intervertebral motion: joint glides to determine end-feel (hyper, hypo, normal) and pain/no-pain
    • PIVM (Passive intervertebral motion): move the spine osteokinematically and
      palpate motion of a single segment 

6

what is the main function of the interspinales and intertransversarii muscles

  • Primary function may be as motion indicators
  • Small muscles with small moment arms and loaded with proprioceptors 

7

The multifidus attaches to the spinous processes and, therefore, has an excellent moment arm for _________ . It also has a compressive element and contributes to sacral nutation.
 

spinal extension

8

Right Rotation of the lumbar spine is associated with posterior rotation of the right ilium. The right ASIS will move ________ as L5 rotates right relative to the sacrum.
In this position the right SI joint is _______ .

  1. superiorly
  2. “gapping.”

9
what it is for?

name of test?

Gaenslens test

  • SI pain provocation test

10

>95% of lumbar disc herniations occur at

 L4-5 or L5-S1 

11

Right Rotation of the lumbar spine is associated with posterior rotation of the right ilium. The right ASIS will move superiorly as L5 rotates right relative to the sacrum. In this position the right SI joint is “gapping.” Given the ___________ ligaments this makes sense. As the ilium moves posterior it “drags” the ipsilateral transverse process with it. Or conversely, as L5 rotates right it provides “slack” in the iliolumbar ligament “allowing” posterior rotation of the ilium.
 

iliolumbar

12

SPONDYLOLYSIS

Fx of pars inter-articularis
 

13

what are the 5 predictors that has been validated to thrust the spine?

  • No symptoms distal to the knee
  • Recent onset < 16 days
  • FABQW < 19
  • Hypomobility of at least 1 segment
  • At least 35 degrees one hip IR

14
💡during AROM

Reproduction of symptoms when the pelvis was stabilized implicates a dysfunction originating primarily from the _____ .
 

spine

15

The psoas and DES provide opposite tensions to the spine, thereby ________ it, similar to “guy wires” for a tent pole. 

stabilizing

16

zygapophyseal joints.

facet joint

17

"main goal of the examination of the lumbar spine is....

reproduction of pain."

(Dr. )

18
👉🏻what is the cut off time for pt with LBP?

name of test

Sorensen Test (Sn: 92%, -LR 0.08; Sp: 94%, +LR 15.4)

  • Patient presentation: younger age < 40 years, hypermobility in SLR, aberrant movements during, lumbar flexion and extension, Positive prone instability test.
  • normal 2-3 minutes
  • Cut off for patients with LBP is > 28-29 sec (Arab et al, 2009) 

19

"a predictor for who may develop LBP" (Dr. M)

Sorensen test

20

Slump Test (Sn: 84%, -LR 0.19; Sp: 83%

  • lumbar radiculapathy 
  • Patient slumps as far as possible producing full trunk flexion; examiner adds firm overpressure
  • +ve test is reproduction of patient’s symptoms 

21

Nutation (meaning to nod) is defined as the relative _______ of the base (top) of the sacrum relative to the ilium. 

anterior tilt

22

name of manipulation

LUMBOPELVIC THRUST MANIPULATION 

23

______% of patients with LBP will have non-specific mechanical LBP

85%

24
💡can develop into which pathology?

Clinical significance of the ligamentum flavum

  • It is located inside the spinal canal
  • With age, the ligament flavum will degenerate and may hypertrophied (becoming fibrotic) → spinal stenosis 

25

when you directly impart forces to a single segment creating joint glides and determine the end-feel and amount of motion of a single segment (hypo, hyper, normal). You will also determine the
presence or absence of pain at each segment you push on.

Passive accessory intervertebral motion

PAIVM

26

Contraction of the erector spinae muscles will cause sacral _______
 

nutation

27

L2-L4 reflex

patellar

28

Patients with acute symptoms should be informed that...

recovery is likely in a short-period of time, but recurrence is likely and this does not mean a failure of treatment

29

contraindicated exercises in a patients with spondylosis 
 

extension ex in the early phase

30

  • age > 50 
  • with Degenerative narrowing of the spinal canal or intervertebral foramen
  • with  Neurogenic claudication (bilateral leg pain) with walking

Spinal Stenosis

31

S2 dermatome

heel

32

Anterior displacement of spine above pars inter-articularis fracture 

SPONDYLOLISTHESIS
 

33

  • Urinary retention (Sn: 0.90, Sp: 0.95)
  • Motor deficits at multiple levels
  • Fecal incontinence 
  •  Saddle anesthesia
  • Sensory deficits in the buttocks, posterior superior thigh, and perianal region
     

CAUDA EQUINA

medical emergency

History question: Do you feel numbness between your legs when you wipe after using the toilet?

34

name each disc pathology in the picture

35

L2/L3 myotome

hip flexion

36
Specificity and Sensitivity

lumbar radiculopathy special tests

  • Crossed Straight Leg Raise (Sn: 25%, -LR 0.79; Sp: 95%): rule in
  • Straight Leg Raise (Sn: 97%, -LR 0.05; Sp: 57%): rule out
  • Slump Test (Sn: 84%, -LR 0.19; Sp: 83%)
  • Femoral Nerve Tension Test (Sn 84%)

37
what it is for?

name of test?

Thigh Thrust Test

  • SI pain provocation test

38

Provocations in ____ or more tests plus tenderness in Fortin’s area is fairly conclusive of SI joint origin to the pain.
 

three

39

Neurogenic claudication, also known as pseudoclaudication, is 

  • bilateral leg pain
  • claudication, from the Latin for limp, because the patient feels a painful cramping or weakness in the legs.
  • NC should therefore be distinguished from vascular claudication, which is when the claudication stems from a circulatory problem, not a neural problem.

40

TBC: mobilization group treatment 

  • Mobilization and manipulation of the lumbopelvic region
  • Active ROM exercises
     

41

L2 dermatome

anterior mid thigh

42

THORACOLUMBAR FASCIA is located directly under the skin, and is very important for

lumbar stability 

43

  • DF weakness
  • Great toe extension weakness
  • Ankle reflex S1 (Sn 0.83)
  • Sensory deficit
  • Clinical tests:
    • SLR (Sn0.91)
    • X-SLR (Sp 0.88)

Sciatica

44
grade?

<25% slippage =

Grade 1

45

primary stabilizers ligaments of the SI joint

  • Anterior SI ligaments
  • Posterior SI ligaments 

46

L4 dermatome

medial melleolus

47
📖 Donald Neuman textbook

The downward force of gravity resulting from body weight passes through the lumbar vertebrae, usually just anterior to an imaginary line connecting the midpoints of the two sacroiliac joints. At the same time, the femoral heads produce an upward directed compression force (GRFV) through the acetabula. Each of these two forces acts with a separate moment arm to create a _______ torque about the sacroiliac joints

nutation 

48
💡During AROM examination

Reproduction of symptoms when the lumbo-pelvic region rotates as a unit implicates a ______ dysfunction.

 hip

49

 intermittent low back pain with increasing frequency, excessive ROM, catching, weakness, increased joint mobility, “fidgeter”, returns from FB by holding onto thighs: 

all suggest hypermobility and necessity of Stabilization exercises

50
TBC

  • Symptoms distal to the buttock
  • Symptoms peripheralize with lumbar flexion
  • Symptoms centralize with extension
     

Specific Exercise Extension group

51

TBC: stabilization group treatment

  • Strengthening of the large global muscles
  • Motor control training of the deep local muscles 

52
Movement Analysis II

Clinically ______ exercises temporarily reduce pressure on a lumbar nerve root impinged by obstructed foramen 

flexion

But flexion also increases compresses forces anterior disc which push nucleus posterior
 

53

what is the main difference between facet joint syndrome and spinal stenosis

  • In both the pain is worse with extension and improves with flexion
  • However, in facet joint syndrome pain is very localized, whereas in spinal stenosis the pain radiates down the the leg

54

  • Morning stiffness and repeated episodes of waking night pain
  • Onset of pain before 40
  • Pain persisted over 3 mo
  • Slow gradual onset
  • Improvement with exercise

Ankylosing Spondylitis 

55

treatment of spinal stenosis

  • Flexion exercises
  • Mobilization of the hips
  • Body weight support treadmill
  • Manual therapy

56
cut off time for pt with LBP?

name of test

Supine Isometric Chest Raise Test (Sn: 96%, - LR 0.24; Sp: 72%. +LR 4.0)

  • Cut off for patients with LBP is > 34 sec for males and > 24 seconds for females (Arab et al, 2009)
     

57

90% of patients with herniations function normally in
 

6 months

58

 Note facet orientation, orientation return back to frontal plane from sagittal plane facets of lumbar spine. This prevents _______ slippage of the lumbar segment 

anterior

59
TBC

  • Signs and symptoms of nerve root compression
  • No movements centralize symptoms

Traction group

60

What are the predictors for the development or prognosis of LBP?

Not identified yet

Patients with lower than average initial pain, shorter duration of symptoms, and fewer previous episodes recovered quicker (not validated)
 

61

Seronegative arthritis characterized by inflammation and, eventually, ankylosis
 

Ankylosing Spondylitis 

62

pain location in spondylolysis

Lumbosacral pain
 

63

Nutation at the sacroiliac joints increases the compression and shear forces between joint surfaces, thereby increasing articular _______

 stability

(close-packed position of SIJ)

64

spinal stenosis responds best to?

disc herniation responds best to?

  1. flexion
  2. extension 

65

  • 50% of patients with LBP return to work in 2 weeks, while 83% returned in 3 months 
  • 28% of patients with LBP still had symptoms at ________

12 months

66

Lumbar spine predominantly favors flexion and extension and some constant degree of lateral flexion, especially at the L5-S1 facet joint. This is important for lower segmental lumbar side bending, which is necessary for _______.

gait

67
MA II

The facet surfaces of the L5-S1 apophyseal joints are usually oriented in a more _____ plane than those of other lumbar regions

frontal

68
TBC

  • No symptoms distal to the knee
  • Recent onset < 16 days
  • FABQW < 19
  • Hypomobility of at least 1 segment
  • At least 35 degrees in one hip

Mobilization group

(only clinical prediction rule that has been validated)

69

Right Rotation of the lumbar spine is associated with _______ _________ of the right ilium.

posterior rotation

70

which muscles insert in the thoracolumbar fascia?

  • Latissimus and glut maximus 
  • Diagonal relationships between gluteus maximus and latissimus dorsi
    • Can be used for excercise prescription
  • Has attachments across entire lumbar spine and SI joints.
  • Increased muscle activity = increased stabilization

71

Reduced AROM, either symmetric or asymmetry, with limitation of pain in one direction, short history of complaints, absence of neuro signs, perhaps related to overuse or mild trauma, with decreased motion in one segment seen in AROM and in PAIVMs all suggest:

Mobilization

72

  • Younger age  < 40 years
  • SLR > 90 degrees (hypermobility)
  • Aberrant movements during lumbar flexion and extension
  • Positive prone instability test

Stabilization group

73
cut off time for pt with LBP?

name of test

Prone Isometric Chest Raise Test (Sn: 80%, -LR 0.08; Sp: 80%, +LR 15.3)
 

  • Patient presentation: younger age < 40 years, hypermobility in SLR, aberrant movements during, lumbar flexion and extension, positive prone instability test
  • Cut off for patients with LBP is > 31-33 seconds (Arab et al, 2009)
     

74

"Extensor Hallucis Longus weakness is pretty specific for ____ nerve root radiculopathy." (Dr. M)

L5

75

S1 myotome

ankle plantar flexion

76

in left lumbar rotation, which SI joint is "gapping"?

left SIJ

77

During the neutral gapping thrust manipulation, the therapist’s superior hand is on the  ____________ pushing toward the table. The therapist’s inferior hand is on the _____________ pulling upwards to the ceiling.

  1. superior segment’s spinous process
  2. inferior segment’s spinous process 

78

Global muscles of the trunk

  • Rectus abdominus
  • Psoas (Dr. M)
  • external oblique
  • superficial erector spinae
     

79

Intervention for reduced force closure:
 

  • SI belt
  • Postural alignment
  • Local muscle co-contraction—stabilization exercises (as per lumbar)
     

80

Intervention for excessive force closure:

  • Education regarding need for relaxation
  • Relaxation exercises
  • Stop excessive exercising/stabilizing exercises
  • Easy aerobic exercise, yoga…
     

81

L5 myotome

great toe extension

(specific for L5 nerve root radiculopathy) 

82

Degenerative narrowing of the spinal canal or intervertebral foramen
 

Spinal Stenosis

83

 to determine motion at a joint segment, you move the spine osteokinematically and
palpate motion of a single segment (hypo, hyper, normal). That is, as you move the spine with one hand, you are feeling the joint motion with the other.

Passive intervertebral motion

PIVM

84
TBC

  • Visible frontal plane deviation of the shoulders relative to the pelvis
  • Directional preference for lateral translational movements

Specific Exercise group, lateral shift

85

L1 dermatome

inguinal region

86

is there lateral flexion in the lumbar spine?

yes, especially at the L5-S1 facet joint becasue they oriented in a more frontal plane

87

WHICH MUSCLES LOCAL VERSUS GLOBAL FOR STABILITY?
 

combination of both (Dr. M)

88

 Stabilization Special Tests:
(Endurance and stabilizations exercises)

(Younger age < 40 years, hypermobility in SLR, Aberrant movements during, lumbar flexion and extension, Positive prone instability test)

  • Sorensen Test (Sn: 92%, -LR 0.08; Sp: 94%, +LR 15.4)
  • Prone Isometric Chest Raise Test (Sn: 80%, -LR 0.08; Sp: 80%, +LR 15.3)
  • Supine Isometric Chest Raise Test (Sn: 96%, - LR 0.24; Sp: 72%. +LR 4.0)
     

89
💡 muscles

To correct anterior innominate, use activation of

hamstrings/glutes to pull innominate posterior

90

L3/L4 myotome

knee extension

91

We categorize the “pelvic disorder” and start treatment. Using the model suggested by O’Sullivan there are specific and non-specific categories. Specific means _________ pain disorders such as fractures and infections. These require medical management rather than PT. Remaining are those with dominant psycho-social factors and those with mechanical factors.
 

inflammatory

92
Mark Dutton

Because the multifidus is segmental in origin and innervation, any impairment of this muscle can produce palpable changes in the muscle, thus directing the clinician to

the segment that is dysfunctional

93
TBC

  • Older age > 50
  • Directional preference for flexion

Specific Exercise flexion group

94

name of tests

Femoral Nerve Tension Test (Sn 84% Porcher et al, 1994)
Disc problems L2 to L4
lumbar radiculopathy

  1. One hand on PSIS
  2. Bend knee until the onset of symptoms
  3. Back the leg out of the position
  4. The examiner can use PF, DF, or head symptoms to sensitize the findings
  5. Further sensitization can be elicited by hip extension 

95

Radiculopathy signs which respond to motion by improving or centralizing suggests:

Specific Exercise

96

L5 dermatome

lateral leg

97
What it is for?

name of test

Gillet Test (poor reliability)

SI dysfunction

In those with pelvic pain in which SI joint dysfunction is suspected, the PSIS may move superiorly instead, or not move at all.

98

S1 dermatome

lateral foot

99

At left toe off and right heel strike, the left ilium is anteriorly rotating while the right
ilium is posteriorly rotating. The lumbar spine is rotated _____ slightly

right

100

S1 reflex

achilles

101

The function of the ligament flavum is to resist separation of the lamina during

flexion, but there is also appreciable strain in the ligament with side bending.

102

 High levels of pain, which cannot be diminished by position or motion, allowing little assessment, suggests:

Traction (although this category should rarely be used and there is less evidence that traction works)
 

103

Counternutation occurs by _______ sacral-on-iliac rotation,_______ iliac-on-sacral rotation, or both motions performed simultaneously.

  1. posterior
  2. anterior

104

  • Inhibition of local muscles
  • Sway back
  • Often hormonal—related to pregnancy
  • +ASLR test
  • Compression RELIEVES PAIN
     

Diagnosis of reduced force closure
 

105

spondylolysis population 

  • Gymnast 
  • Dancers
  • Weightlifters 

106
Donald Neuman text-book

The sacroiliac joints perform two functions:

  1. a stress relief mechanism within the pelvic ring: this stress relief is especially important during walking and running and, in women, during childbirth
  2. a stable means for load transfer between the axial skeleton and lower limbs

107

which muscle is located closest to the spinous process in the lumbar spine?

multifidus 

108

L4 myotome

dorsiflexion

109

Spondylolysis can progress to

spondylolisthesis
 

110
what makes it positive?

name of tests

Prone Instability Test (Sn: 61%, -LR 0.69; Sp: 57%, +LR 1.41 Fritz et al, 2005)

  1. A PA spring test is given over the back and symptoms are assessed 
  2. Pt lift their legs
  3. +ve test is reduction of symptoms

111

 close- packed or more stable position of the sacrum.

nutation

112

Global muscle of the trunk control what?

Move entire spine
 

113

S3-S4 dermatome

genitals

114

Examination order:

  1. Review of patient reported materials
  2. Initial observation
  3. History
  4. Review of systems → refer out/continue exam/focus on specific structures
  5. Structural Inspection
  6. Screening exam 
  7. Movement analysis: demonstration of what hurts
  8. AROM
  9. PROM
  10. MMT (endurance test in the spine)
  11. Special tests
  12. Palpation for tenderness

115
💡two things

the primary function of the deep erector spinae is...
 

to prevent anterior shear of each segment and to provide vertical compressive force.

116

very important ligament in prevention of anterior displacement of L5 on Sacrum 

Iliolumbar ligament

117

Full extension reduces diameter intervertebral
foramina by ____% and vertebral canal ___% 

  1. 11%
  2. 15%
  • Individuals with nerve root impingement limit extension activities
  • Extension migrates nucleus anterior therefore individuals with posterior or posterior-lateral disc herniations may show relief with extension

118
SIJ Joint

Are either centralisation or peripheralisation phenomena observed?

if yes →
if no →

  • If yes → diagnosis of symptomatic disc lesion
  • if no →  Are three or more SIJ provocation tests positive?

119

intervertebral discs get nutrition from ________

movement

"Discs are meant to accept load." Dr. M

120
name of ligament

resists nutation or posterior innominate motion 

Sacrotuberus and Sacrospinous ligaments

121

types of spondylolisthesis

  • Isthmic (usually L5-S1)
    • children
    • High incidence in gymnasts, weight lifters
    • Tx: PT, regular X-rays, fusion, pars repair with screw, reduction of deformity
  • Degenerative (usually L4-L5)
    • Less severe than isthmic
    • Lumbar stabilization ex.
       

122

SUPERFICIAL ERECTOR SPINAE VERSUS DEEP ERECTOR SPINAE: underneath the thoracolumbar fascia is the____________, which is the attachment for the superficial ES 

superficial erector spinae aponeurosis

123

Nutation occurs by ______ sacral-on-iliac rotation, ________ iliac-on-sacral rotation, or both motions performed simultaneously.

  1. anterior
  2. posterior

124
name of test

  1. One hand palpates left PSIS
  2. the other hand palpates S2
  3. Patient flexes the hip to 90 deg

Gillet Test

 In those with pelvic pain in which SI joint dysfunction is suspected, the PSIS may move superiorly instead, or not move at all.

(Poor reliability)

125

50% of patients with Low Back Pain (LBP) return to work in _______, while 83% returned in 3 months (Henschke et al, 2008) 

2 weeks

126

  • Compression INCREASES Pain in the SI area
  • Negative ASLR
  • Posture is OVERLY conscious and held—rigid
  • Anxious, fearful, stressed
     

Diagnosis of excessive force closure
 

127

local muscles of the spine

  • Multifidus
  • intertransversari
  • interspinalis
  • transversus abdominus
  • internal oblique
  • deep Erector spinae

(they control inter-segmental motion)

128
Movement Analysis II

Full lumbar extension increases amount of load and area of contact at

 facet joints

129

The Deep Erector Spinae attach to the_________________  and, therefore, have little moment arm for spinal extension.
 

transverse processes

130
6 evidence articles

Evidence supporting theory of dysfunctional “local” muscles
 

  1. Multifidus, at the level of the LB injury, is shown to be smaller than at other levels
  2. Transversus abdominus shown to be slower to “turn on”  in those with LBP in quick response tasks 
  3. Transversus abdominus fires first before trunk extensors in lifting tasks 
  4. Transversus abdominus fires for BOTH trunk extension and trunk flexion 
  5.  Specific training of the local system has been shown to be effective in the treatment of subsets of patients with LBP.

However, more recent evidence has NOT shown that specific exercise is superior to more general exercise for low back pain patients who are not in specific subgroups
 

131

LUMBAR LIGAMENTS
 

  • Anterior longitudinal ligament
  • Posterior longitudinal ligament
  • Ligamentum flavum (yellow ligament)
    • Inside the spinal canal
  • Supraspinous ligaments