objective examination: lumbar spine

Question 1

list the order of the objective examination for the lumbar spine

Answer 1

observation
AROM
repeated movements
PROM/passive accessory motion testing (joint play)
muscle performance testing
neurological testing
special tests
palpation

Question 2

what are some observations to watch for in the exam?

Answer 2

gait pattern
posture in standing
sitting posture (rate it)

Question 3

how do we name a shift or acute defromity?

Answer 3

by the relationship of the shoulders to the pelvis

Question 4

what do we do with AROM?

Answer 4

expose the area when possible, look for midline movement or deviations that can occur. derrangements may deviate away from painful side. ANRs may deviate to the side of the ANR.

Question 5

what is the normal AAOS value for flexion?

Answer 5

60º

Question 6

what is the normal AAOS value for extension?

Answer 6

25º

Question 7

what is the normal AAOS value for side-bending?

Answer 7

25º

Question 8

what is the normal AAOS value for rotation?

Answer 8

45º

Question 9

what repeated movements can we do for the lumbar spine?

Answer 9

repeated flexion in standing (RFIS)
repeated extension in standing (REIS)
repeated flexion in lying (RFIL)
repeated extension in lying (REIL)
side gliding in standing

Question 10

what is derangement syndrome?

Answer 10

a classification defined by the presence of directional preference with RAPID change in symptoms associated with the obstruction of a particular joint

Question 11

what is dysfunction syndrome?

Answer 11

classification associated with symptoms from typical mechanical deformation of structurally impaired soft tissue

Question 12

what is postural syndrome?

Answer 12

a classification associated with no pathophyisiological abnormalities but an abnormal stress to the tissue

Question 13

what is the other group for mechanical diagnosis and therapy classifications?

Answer 13

do not display the anticipated responses or characteristics of the aforementioned syndromes; subgroups within the classification help narrow down the treatment

Question 14

what are some responses to movement during?

Answer 14

decrease, abolished, increase, produced, no effect, centralizing, peripheralizing

Question 15

what are some responses to movement after?

Answer 15

better, no better, worse, no worse, no effect, centralized, peripheralized

Question 16

what is the progression of forces?

Answer 16

self generated joint AROM
self generated joint AROM and overpressure
clinician overpressure
clinician mobilization
clinician manipulation

Question 17

what is PROM for lumabr?

Answer 17

performed in sidelying. looking to reproduce patient’s symptoms. looking to assess the motion between motion segments

Question 18

what is the end feel for PROM flexion?

Answer 18

firm

Question 19

what is the end feel for PROM extension?

Answer 19

firm or hard

Question 20

what is the end feel for PROM sidebending/rotation?

Answer 20

firm or hard due to the approximation of the aygoapophyseal joints

Question 21

what are we looking for with passive accessory motion testing (joint play)?

Answer 21

performed in prone
looking to reproduce the patients concordant sign
looking to assess motion at a specific segment
note end feel- should be firm

Question 22

what muscle performance testing do we do?

Answer 22

MMT
resisted isometrics and muscle endurance testing (core endurance tests of McGill - front plank test)
hicks CPR on stabilization (treatment based classification scheme)

Question 23

what MMTs do we perform for lumabr?

Answer 23

trunk flexion, trunk extension, trunk rotation

Question 24

what is the point of hicks CPR on stabilization?

Answer 24

identifies more likely to benefit from a stabilization approach

Question 25

what are the variable of hicks CPR on stbailization?

Answer 25

younger than 40 y/o greater general flexibility (SLR ROM >90) "instability catch" or aberrant movements during flexion/extension ROM positive findings on the prone instability test

Question 26

what does 3 out of the 4 variables of hicks CPR increase the likelihood of succes with a lumbar stabilization program to?

Answer 26

33% to 67%

Question 27

what are other important predictors of a successful outcome include for hicks CPR?

Answer 27

hx of episodic LBP: increased frequency of episodes higher scores on the FABQ higher pain rating scores hypermobility detected during PAIVM testing

Question 28

what are neurological exam testing we can do in the presence of symptoms below the knee, vague pattern/behavior or red flags?

Answer 28

myotomes, dermatomes, MSRs/DTRs, CNS impairments: clonus, babinski, hoffman, LLNT (SLR, slump, prone knee bend)

Question 29

recap dermatome testing

Answer 29

L1 upper thigh L2 middle thigh L3 lower thigh, knee joint region L4 medial (and post-med) shin, medial malleolus L5 lateral (and post-lat) shin, top of foot, great toe S1 lateral border of foot, heel, middle of posterior calf S2 popliteal fossa, posterior thigh

Question 30

recap myotomal testing

Answer 30

L1-L2 hip flexion L3 knee extension L4 ankle DF L5 great toe extension S1 ankle PF S2 knee flexion S3-S4 toe flexion

Question 31

recap DTR/MSR

Answer 31

L3/4 patellar tendon S1 achilles tendon

Question 32

what does the SLR and slump test do?

Answer 32

examines the mechanical and physiological properties of nervous tissue and related structures looking for reproduction of patients symptoms or impaired mobility 3 criteria for considering test positive (reproduce comparable signs, asymmetrical findings, sensitizing movement changes in patients symptoms)

Question 33

how is the straight leg test performed?

Answer 33

pt lying supine on the table with head in and neck in and neck in neutral support the leg at the heel and raise the leg to the point of symptom reproduction sensitizing maneuvers = test is reproduction of concordant symptom, sensitization, and asymmetry

Question 34

what is SLR interpretation?

Answer 34

Neurologic pain which is reproduced in the leg and low back between 30-70 degrees of hip flexion is suggestive of lumbar disc herniation at the L4-S1 nerve roots. Pain at less than 30 degrees of hip flexion might indicate acute spondyloithesis, gluteal abscess, disc protrusion or extrusion, tumor of the buttock, acute dural inflammation, a malingering patient, or the sign of the buttock. Pain at greater than 70 degrees of hip flexion might indicate tightness of the hamstrings, gluteus maximus, or hip capsule, or pathology of the hip or sacroiliac joints. Positive Cross Straight Leg Raise – indicative of nerve root compression secondary to disc protrusion or extrusion.

Question 35

what are common nerve bias and sensitizing maneuvers?

Answer 35

Sciatic n. - (supine) hip flexion/adduction, knee extension, ankle dorsiflexion Tibial n. - (supine) hip flexion, knee extension, ankle dorsiflexion/eversion Sural n. - (supine) hip flexion, knee extension, ankle dorsiflexion/inversion Fibular n. - (supine) hip flexion, knee extension, ankle plantarflexion/inversion

Question 36

how is the slump test performed?

Answer 36

Pt sits straight with the arms behind the back, legs together, back of knees against the edge of the table Ask the patient to slump as much as possible (keep the sacrum vertical) Maintain full spinal flexion with overpressure, ask the patient to look down Ask the patient to extend their knee Add dorsiflexion of the patient’s ankle Lastly, neck flexion is released to see if symptoms abate

Question 37

what is a positive slump test?

Answer 37

Reproduction of concordant symptoms Sensitization movement changes symptoms asymmetrical findings (knee extension less on the involved side)

Question 38

how is the prone knee bend test performed?

Answer 38

Pt lies prone on the table, arms at the side or above shoulder level (picture) Examiner places one hand on pelvis, with the other hand he/she flexes the pt’s knee. Bend the knee until reproduction of symptoms Sensitizing movements include hip extension- Femoral n.

Question 39

what are some special tests for the lumbar spine?

Answer 39

Special Tests for Stabilization Exercises ◦ Prone Instability Test ◦ Posterior Pelvic Pain Provocation (P4) Test ◦ Active Straight-Leg Raise Test ◦ Trendelenburg Test Quadrant Test Sign of the Buttock

Question 40

how is the prone instability test performed?

Answer 40

Pt lies with their torso on the table, legs off the edge, feet resting on the floor Examiner performs a central PA pressure over the spine, looking to elicit pain Maintaining contact with the painful segment, the examiner asks the pt to lift their feet of the floor With the patient’s feet in the air the examiner performs a central PA pressure again + test = significant reduction of painful symptoms

Question 41

how is the posterior pelvic pain provocation (P4) test performed?

Answer 41

The patient is supine. The therapist passively flexes the patient’s hip to 90 degrees and applies a posteriorly directed force through the longitudinal axis of the femur. The test is positive if the patient reports a deep pain in the gluteal area during the test.

Question 42

how is the active straight- leg raise test performed?

Answer 42

The patient is supine with straight legs and feet 20 cm apart. The patient is instructed to lift the legs one after the other approximately 20 cm above the table without bending the knee. The patient is asked to score the difficulty of the task on a 6-point scale (0, no difficulty at all; 1, minimally difficult; 2, somewhat difficult; 3, fairly difficult; 4, very difficult; 5, unable to do). Any score greater than 0 is a positive test.

Question 43

how is the trendelenburg test performed?

Answer 43

The therapist is behind the standing patient. The patient is asked to stand on one foot while flexing the opposite knee and hip to 90 degrees. The test is positive if the hip descends on the flexed side.

Question 44

how is the quadrant test performed?

Answer 44

Patient stands with feet shoulder width apart The examiner asks the patient to lean back, rotate, and side-bend to one side (“reach for the back of your knee”) Image: Ext, L SB, L Rot The movement is repeated on the opposite side + test is identified by reproduction of the pt’s concordant sign