Lumbopelvic Spine Exam - Lecture 1

Question 1

KNOW: Herniated discs / stenosis can both cause radiculopathy

Question 2

Why might a tight iliopsoas cause back pain?

Answer 2

Because it originates on those lumbar discs

Question 3

KNOW: Low back can refer down into the hip

Question 4

Triple A can refer to the lower back and is a pulsatile force

Just to the left of the umbilicus
* IF I can feel a pulse more than 3 fingers out its greatly distended out
* Or if you can see it pulsing

Question 5

1 organ visceral referal pattern for LBP

Answer 5

Kidney

(urinary track can also refer in the groin area)

Question 6

KNOW: Cauda equina syndrome / Vascular claudication / limb threatning ischemia are all capiable of causing LBP (and are red flags)

Question 7

All red flags for LBP

Question 8

KNOW

Question 9

KNOW: Fracture S/S (Low back)
* Midline tenderness at level of fracture
* Bruising
* LE neurological deficits (new or significantly worsened = red flag)
* Evidence of increased thoracic kyphosis (sets them up for a wedge fracture)
* Loss of function or mobility
* Most common at T11, T12, and L1

Question 10

Organ refferal

Question 11

KNOW: kidney refferal would be a good differential diagnosis for greater trochanteric pain syndrome

Question 12

KNOW: If they have low back pain w/ LE symptoms think cauda equina but then quickly try and rule it out

Question 13

How do we rule cauda equina in? (5)

Answer 13

Bowel and bladder disturbances (starting or stopping flow or fecal incontinence)

Saddle paresthesia (groin / medial thighs)

Sexual disturbances (inability to maintain and erection or inability to ejactulate)

Sensory motor deficits in the feet (bilatearl foot numbness)

Weak DF, toe extension, ankle PF weakness (gait disturbances)
* Note - the dysfunction is further down so they will have greater hip flexion to adjust for these weakened muscles that are lower down
* actively hip flex and throw leg out

Refer out if positive (this is a red flag)

check dermatomes and myotomes for these pts

Question 14

Claduication is what?

Answer 14

Compressive event in vessle (narrowing or occulusion of vessels)

If its higher up then were going to have symptoms down the chain (cutting off the garden hose)

Question 15

Vascular Claudication symptoms: (4)

Answer 15

Relieved w/ resting (never present when resting)

**Starts when exercising **

Aching or burning in leg muscles (not getting enough BF)

Sitting position does not change symptoms
* does not matter what positon they’re in when they’re exercising - its just moving for a certain amount of time brings on those symptoms

Normally its a set amount of time with movement that brings on symptoms

Question 16

Is stenosis more about activity level or position of the spine?

Answer 16

Position of the spine

Question 17

What makes spinal stenosis worse flexion or extension?

Answer 17

Extension - closes down on the spinal n

Question 18

What makes disc issues worse flexion or extension?

Answer 18

Flexion

Question 19

Two-Stage Treadmil test
* Level treadmil for 10 minutes
* Then incline treadmil 15 degrees for 10 minutes - this causes the lumbar spine to become more flexed
* If they have lumbar stenosis it should subside because they are in a flexed position (neurogenic claudication - something is occluding the n)
* If the symptoms don’t change were thinking its more vasculogenic (vasculogenic cluadication) in nature

Question 20

If the pt is doing a two stage treadmil test and the treadmil is raised 15 degrees and symptoms go away what am I thinking they have and why? (test question)

Answer 20

Lumbar stenosis (neurogenic claudication)

Because extension makes it worse and we put them in a flexed position which took away their symptoms

Question 21

If pt is doing a two stage treadmil test and the treadmil is inclined 15 degrees and the pts symptoms remain constant. What am I thinking it is? Why? (Test question)

Answer 21

Vasculogenic cluadication

Because if it was neurogenic cluadication that incline should’ve reduced symptoms (taken the perssure off the nerves) however relieve pressure meaning its more vasculogenic claudication in nature

Question 22

What is acute limb threatening ischemia?

Answer 22

Some kind of ischemia that blocks the vessels quickly and causes blood not to flow down them

Question 23

Is acute limb threatening ischemia rare?

Answer 23

Yes

Question 24

Does Acute Limb threatening ischemia come on quickly or slow

Answer 24

Very quickly

Question 25

Whats the best way to check for acute limb threatening ischemia?

Answer 25

Check for a pulse - if they don't have one rule this in

Question 26

**6 P's that come on w/ Acute Limb threatening ischemia** Not out practical just kind of know what these are for test

Answer 26

1) Pain at rest - not consisten w/ vasculogenic claudication 2) Pallor (paleness) 3) Pulseless 4) Parasthesia 5) Paralysis 6) Perishing cold - because they no longer have BF to that limb and won't have the warmth fromt hat blood KNOW: Will have an acute immediate onset - will proably be in an atheltic sport not out pt (because they won't have time to make it to u in OP) Red flag call 911

Question 27

Whats a good way to differeintaite acute limb threatening ischemia from vascular claudication?

Answer 27

w/ limb threatening ischemia they will have pain at rest and but they will have no pain at rest w/ vascular cluadication

Question 28

What would you do for someone w/ vascular claudication

Answer 28

Not a 911 call We would put them on a walking program where they walk to the onset of symptoms then rest then walk again once symptoms leave NOTE: This is something blocking the vessel - so the increased BF though the vessel needed won't be able to make it when doing CV activity Do this EX every single day without missing Malls are the best place because of the bistanders around just incase something goes wrong

Question 29

KNOW: When measuring lumbar spine to clear it we do AROM w/ OP * Just like in the C-Spine we OP halfway through AROM and an axial load

Question 29

KNOW: Oswestry Disability Index (ODI) is best for LBP * Higher # = more distability * out of 50 * 50% = 25 questions answered | Scoring system (very subjective)

Question 30

Do we over press PT's w/ pain?

Answer 30

No!!

Question 31

Dermatone testing: (in neuro screen) * NEVER DONE OVER CLOTHING * Testing side to side back and forth * have pt close eyes * say when they feel * always start on uninvolved side and touch then ping pong back and forth * not just touch but doing small little arcs in the dermatome pattern * Great quick screener

Question 32

KNOW: for myotomes we have them do the action first then we load it EX: To check L3 we would have them kick leg all the way out * Then you load it for a period of time (not just one quick second) * We are checking fatiguability - not just strength - nerves have stored potential energy (stored ACl) * My goal is to see if it fatigues by slowly loading * **A compressed n is like a compressed garden hose - theres still going to be some water is the more distal end when its compressed - we have to get that water out then check it (thats the stored ACl that were getting out first then seeing if it fatigues)**

Question 33

How many relfexes do we check when doing reflexes for myotome testing?

Answer 33

6 reflexes - looking for it to diminish (getting rid of that stored potential)

Question 34

KNOW: When doing reflexes make sure you're supporting them so they're fully relaxed (the muscle cant be contracting) KNOW: For clonus were doing a quick extension then holding it in that position and seeing if we get MORE THAN 3 twitches (will happen very quickly)

Question 35

KNOW: Inverted supinator sign is taken 1-2 finger widths proximal from the radial styloid process

Question 36

KNOW: Very common ataxic gait pattern for LE is kicking leg out (because they dont get full extension)

Question 37

Facet refferal patterns for LE

Question 38

LE dermatomes

Question 39

KNOW: Radicular pain is often sharp and shooting following a dermatomal pattern (doesnt have all the stuff that radiculopathy has) * Radiculopathy = follows that dermatomal pattern but also has numbness / tingling reflex issues / deep tendin reflex issues / myotome issues / dermatome issues Reffered pain = dull aching cant pinpoint

Question 40

What is repeated motion testing?

Answer 40

repeating the same motion over and over (~10 times) * Won't do w/ high irritability pts * Were trying to figure out what centrializes / peripheralizes the pain * Goal is to get pt back to midline before doing this (make sure the latearl shift has been fixed)

Question 41

What is a latearl shift?

Answer 41

pt shifting laterally AWAY from pain

Question 42

KNOW: Whenever there is radicular or reffered pain we need to centralize that pain * Not pts might report worse back pain after that LE is centeralized - this is good * educate pts that this is a good thing

Question 43

3 ways to do flexion

Question 44

2 ways to do extension

Question 45

KNOW: w/ repeated motion tests we want to start by getting that pain centralized * so if flexion makes it better were doing flexion over and over * However, life isnt lived all the time in flexion. So once we have those symptoms centralized (several weeks in) were going to start working into those extension movements as well

Question 46

What is a flexion directional preference?

Answer 46

They like flexion (going into that motion allivates peripheral symptoms and centralizes them)

Question 47

KNOW: lateral shift is shifting away from pain, however, in an acute phase they might shift towards pain

Question 48

This is a lateral shift correction for lumbar spine (want to maintain about 50% of this from visit to visit - in the acute phase they are going to keep wanting to shift away from pain)

Question 49

**How many degrees of lumbar flexion do you need to get from sit to stand? (test)**

Answer 49

35

Question 50

**How much lumbar flexion do you need to put on socks? (test)**

Answer 50

55 deg

Question 51

**Picking up an object form the floor requires how much lumbar flexion (test)**

Answer 51

60 deg

Question 52

**Average lumbar flexion**

Answer 52

40-60 deg

Question 53

**Average lumbar extension**

Answer 53

20-35

Question 54

**Average lateral flexion (lumbar spine)**

Answer 54

15-20

Question 55

**Average lumbar rotation**

Answer 55

3-18deg

Question 56

What are aberrant movements?

Answer 56

Movements that shift out of line w/ pain (think s curve - shifts out then back in) * Can be seen on squatting and many other movements * Think shifting around and back

Question 57

KNOW: Aberrant movements are often because of lumbar functional instability (shifting out then shifting back in - like theres a catch)

Question 58

What is a Gowers sign?

Answer 58

Having to push up on thighs to get back up

Question 59

KNOW: Hip pts can have painful arc w/ flexion - somewhere in their flexion causes pain

Question 60

KNOW: During lumbar AROM we are looking for reversal of lumbopelvic rhythm - which is over using hips or knees t Yoib retyrb frin a firward bent position, pt suddenly bends their knees to extend the hips, shifting pelvis anteriorly as they return to standing position

Question 61

KNOW: To do a lumbar CPA you put pisiform over SP and press down w/ other hand - mobilizing w/ body

Question 62

**KNOW: for lumbar UPA * Go 1 thumb lateral = facet plane * TP = 2 thumb widths over and just slightly superior to hit the same lvl TP** then use other hand to push down - or you can just use your pisiform to push down KNOW: Lots of muscles here so might not really feel it well - will be uncomfertable for pt | Not using thumbs in this one

Question 63

KNOW: Resisted procacation tests dont test for strength - they test for pain w/ contraction

Question 64

What is the max closing down position of the lumbar spine? What kind of pain are we looking to bring on? called extension quadrent test

Answer 64

Extension Lateral flexion Ipsialtearl rotation Brings on facet joint realted pain This test being positive doesnt tell us much - its a negative test that tells us a lot * If negative im thinking its not a stenosis issue / facet closing issue / not radiculopathy Its not going to be comfertable but were making sure it doesnt reproduce the pain that they came into the clinic w/

Question 65

4 tests to look for lumbar instability * Prone Lumbar Extension Test * Trendelenburg Test * Active SLR * Prone Instability Test These 4 tests are all under the umbrella for LBP w/ movement coordination inpairments - makes me think some type of muscular weakness / instability

Question 66

How to do Prone Lumbar Extension Test

Answer 66

Therapist Lifts both legs of pt passively about 2 feet off the table They need to maintain that pure extension While maintaing that extended position pull the legs out (distracting LE) Positive = pain in the lumbar region that is relived when the legs are lowered back to the table Dont fully understand positive but done in lab

Question 67

How to do Active SLR

Answer 67

Therapist asks pt to slowly raise a straight leg off the treatment table 8 inches, pause then slowly lower the leg to the ttable and repeate on the other side If pt admits to difficulty in raising the leg OR symptoms are proboked w/ the active straight leg raise, the ASLR is repeated w/ the therapist providing compression to the anterior pelvis (lateral to medial on IC) Or posterior pelvis (at the level of the PSIS) *** If symptoms are relieved or the ease of leg raising is improved w/ anterior or posterior pelvic compression, the test result is positive** So if compression helps them do it more easily im thinking it could be releated to functional/clinical instability * Im compressing asis / psis into sacrum | Shows PT pushing anterior and posterior

Question 68

Prone instability Test | He said it sucks

Answer 68

PA pressure applied to each targeted lumbar vertebrae If provocation of pain is reporte, the patient lifts the feet off the floor and the pressure is reapplied at symptomatic level Positive = pain is present in the first position but not reportuced to the same severity when pressure is reapplied to the symptomatic vertebra w/ the second position checking for instability

Question 69

LBP **w/ radiating pain tests** * SLR * Crossed SLR * Slump Test * Lateral Shift Correction (lumbar side glide) * Ely's Test (femoral n tension test)

Question 70

How to do a SLR * W/ radiating pain test

Answer 70

Hip is slowly flexed as the knee is maintained in full extension Positive = reproduction of LE pain at <30 deg of hip flexion has been strongly correlated w/ herniated disc - because at that point I havent put any tension on the hamstring msuculature * anything passed 70 degrees were def involving the hamstrings Patient asked to respond to the movement, and the degree of hip flexion that is attained when their symptoms are reported. Now to play with proximal/distal sites * Further sensitization can be applied by adding hip adduction Or ankle dorsiflexion before raising the leg (tighten sciatic n) * Further sensitization can be added by passive neck flexion to increase dural tension (stretching the dura of the SC further sensitizing it) * If moving the hd hurts the back of the leg im thinking thats def not connected to the HS so its proably nervey at that point (same thing w/ DF of foot???) Used to rule out (negative = rule it out) TESTS SCIATIC N

Question 71

Crossed Straight LEg Raise ("well" SRL test) * w/ raidation pain How to perform

Answer 71

Same as the SLR just above except If the SLR of the contralateral leg causes symptoms on the involved leg, a symptomatic **herniated disc** is suspected Crossed just means other leg (how to remember) TESTS SCIATIC N

Question 72

Slump Test * w/ radiating pain * How to do

Answer 72

Assesses for neuropathic related symptoms Positive test = LE symptoms reproduced and knee extension is limited in the slump sit position AND symptoms are alleviated and knee ROM is improved with a return to the neck neutral position TESTS SCIATIC n

Question 73

**For a pt w/ increased irritability would I do the slump test or the SLR test? (test question)**

Answer 73

SLR doesnt bring on symptoms nearly as badly - slump test is much more aggresive

Question 74

Femoral n tension test (Ely) * W/ radiating pain * How to do

Answer 74

Therapist passively flexes the patient's test knee to 90 degrees flexion (whilst in prone) and then lifts the hip into full extension * Positive = provocation of anterior thigh pain w/ the stretch position (compairable sign) * obvisouly stertching femoral n * can further it by extending the neck or plantar flexing the foot TESTS FEMORAL N

Question 75

Sacrioiliac Joint Related - special tests * Supine to sit test * Gillet Marching Test * FABER * SI Provocation Test Item Cluster

Question 76

Supine to sit test * sacroiliac joint related pain * How to do

Answer 76

You check in a sitting position to see where their legs are at then have them lay down and see if they rotated

Question 77

Supine to sit test * sacroiliac joint related pain * How to do

Answer 77

We would look at medial malleolus (because its part of an imovable position) and see if it they are level * we then lift their legs up to the sky and set them back down and see if they're level * Anterior hip rotation would make the ipsialteral side longer * Would strengthen hip extensors - if its pulled forward I would want to strngthen the muscles that would pull it backwards (note - its rotating in the sagital plane so an anterior rotation is what causes that lordosis)

Question 78

Gillet Marching Test * sacroiliac joint related pain * How to do

Answer 78

if it does not move the thought is that its not moving w/ SIJ (during marching)

Question 79

What population has more SIJ movement? (2)

Answer 79

1) pregnancy (relaxin) 2) hypermobility - marfan / downsyndrome / elhers danlos

Question 80

laslets cluster: what are they * Used to rule in SIJ Provocation * Must have ruled out pts that have pain that centralizes (lumbar radiculopathy) before using these

Answer 80

1) Distraction Provocation (ASIS gap) 2) ASIS Compression Provocation 3) Thigh Thrust Provocation - basically dorsal glide for hip 4) Gaenslen's Provocation 5) Sacral Thrust Provocation Need 3/5

Question 81

Distraction Provication ASIS Gap * SIJ Provocation Tests

Answer 81

Essentailly distracting ASIS Do it for 10 seconds After 10 seconds if they don't have pain quickly pulse (thrust) Reproduces SIJ pain (can radiate down back of leg but were thinking its posterior thigh / butt)

Question 82

ASIS Compression Provoation * SIJ Provocation Tests

Answer 82

Essentially compressing ASIS Slowly load 10 seconds (stop if theres pain) Pulse

Question 83

Thight Thrust Provocation (Ostgaards test) * SIJ Provocation Tests

Answer 83

can do it w/ adduction / abduction

Question 84

Gaenslen's Provocation * SIJ Provocation Tests

Answer 84

pt is off the edge of the table forcefully flexing flexed hip and forcefully extending extended hip Looking to see if pain is reproduced

Question 85

Sacral Thrust Provocation * SIJ Provocation Tests

Answer 85

Question 86

Physical Performance Tests Isometric abdominal test

Answer 86

Question 87

Physical Performance Test * Biering-Sorenson Fatigue Test (lumbar extension endurance test)

Answer 87

pain free should be around 77 seconds LBP pain around 36-39 seconds

Question 88

Physical Performance Test * Side Plank

Answer 88

Question 89

KNOW: He said don't study these physical performance tests that much