DPT 707 Musculoskeletal I Lumbar Spine Patient ...

DPT 707 Summer 2017

1

Dr. Leal PT, DPT, OCS, FAAOMPT

DPT 707 Musculoskeletal I Lumbar Spine Patient “Conversation” and Physical Examination Primer

I. Structures capable of producing symptoms

Lumbar spine symptoms can come from a variety of structures that are located both in the

anterior and dorsal compartments of the spine. Any structure that is innervated by the nervous

system has the capacity of being a potential source of symptoms. This can include but is not

limited to the zygapophyseal joints, the intervertebral discs, ligaments, muscles and fasciae of

the lumbar spine (Twomey and Taylor 2000). The innervation of these somatic structures is

based upon their orientation in the anterior or posterior column of the spine. Below is a list of

structures and their innervation sources based on innervation. This can serve as a good guide

for your hypothesis of “potential structures” that you would need to investigate.

Column Structure Innervation

Anterior Vertebral bodies Located deep into the cancellous bone and vertebral end plates: Anterior and Posterior Plexi *

Anterior Intervertebral discs Outer 1/3 of the annulus, proprioceptive role but can also be nociceptive: sinuvertebral nerve *

Anterior Anterior longitudinal ligament Anterior Plexus: Lumbar sympathetic trunk *

Anterior Posterior longitudinal ligament Posterior Plexus: Lumbar sinuvertebral nerves (lumbar ventral rami) *

Posterior Neural arches of the lumbar vertebra / joints / ligaments

Posterior Rami of the Spinal Nerves

Posterior Iliocostalis lumborum muscle Lateral Branch of the L1-L3 Dorsal Rami

Posterior Longissimus thoracis muscle Intermediate Branches of the L1-L4 Dorsal Rami

Posterior Multifidus / Interspinous muscles Medial Branch of the L1-L3 Dorsal Rami

Posterior Thoracolumbar fascia Lateral Branch of the L1-L3 Dorsal Rami

*= Sympathetic nervous system

Legend:

VB = vertebral body, P = periosteum, IVD =

intervertebral disc, PM = psoas major, QL = quadratus

lumborum, IL = iliocostallis lumborum, LT = longissimus

thoracis, M = multifidus, ALTLF = anterior layer of the

thoracolumbar fascia, PLTLF = posterior layer of the

thoracolumbar fascia, ESA = erector spinae aponeurosis,

DS = dural sac, ZJ = zygapophyseal joint, PLL = posterior

longitudinal ligament, ALL = anterior longitudinal

ligament, VR = ventral ramus, DR = dorsal ramus, M=

medial branch, I = intermediate branch, L = lateral

branch, SVN = sinuvertebral nerve, GRC = grey ramus

communications, ST = sympathetic trunk

From: Twomey and Taylor (2000) Physical Therapy of the

Low Back; Innervation and Pain Patterns of the Lumbar

Spine

DPT 707 Summer 2017

2


II. Somatic referred pain

Defined as “pain perceived in regions innervated by nerves other than those that innervate the

actual source of pain” (Towmey and Taylor pg . 98). It is important to note in some cases that

the referral area may be remote to the site of injury but it can also be adjacent to it as well. In

clinical terms it is pain perceived as occurring in a region of the body topographically distinct

from the region in which the actual course of pain is located (IASP; Part 1-c). Any of the

following structures of the lumbar spine can be a source of somatic referred pain:

Dura: dull / aching / deep: felt over the buttocks

Muscles: dull / aching / deep: felt over the buttocks / inguinal region / thigh / at times the leg

Ligaments: Interspinous only: aching / deep: buttock and lower limb

Facet joint (z joints): aching / deep: see PDF posted in week 2 for details (Facet Joint Pain

Patterns) Fukui et al 1997. In general higher lumbar facets will refer pain to the iliac crest

region, buttock, and groin and lower lumbar segments will tend to be felt in the buttock and

lower limb.

Intervertebral discs: minimal studies in general may refer to the buttock and or lower limb but

evidence is weak. Only effective if outer 1/3 of the disc is injured (only component innervated).

Somatic referred pain is the result of “convergence” as previously mentioned in lecture (Kendal

2013 pgs. 534-536). The afferent fibers from the vertebral column synapse in the spinal cord

with second-order neurons. These second-order neurons also receive afferent information from

other nerves. In cases where there is no additional localizing information going to the brain, it

perceives the afferent signal from the second order neuron as both the vertebral source and

other convergent fibers. This is how lumbar spine facet “pain”, say for example a problem at

the L5S1 facet, can be referred to the lateral thigh or buttock. In either of these cases the

lateral thigh and or buttock region are not supplied by the posterior rami of the lumbar spine

yet via convergence the brain interprets it as such.

For the clinician a way to differentiate somatic referred pain from radicular or neurogenic pain

is that it is nociceptive in nature. The pain is typically reproduced by stimulation of nerve

endings of afferent fibers that innervate the vertebral / spinal segment of concern. Often

time’s patients describe this pain as “deep”, “achy” and or “boring” (Dutton pg. 1296).

III. Radicular pain and Peripheral Nerve Trunk pain

Radicular pain is usually produced by spinal nerve root irritation and is typically reported by the

patient as “sharp”, “lancinating”, “electric” or “shooting”. The distribution is often in a

willrobles

Highlight

willrobles

Highlight

DPT 707 Summer 2017

3


dermatomal pattern, linear in fashion shooting in a downward direction towards the distal part

of the limb. Often radicular pain results from mechanical deformation of the nerve itself or via

nerve root compression at the intervertebral foramen. There may be associated complaints of

“numbness” and or “tingling” that is cutaneous in nature unlike somatic referred pain which

does not have a cutaneous distribution. Myotomal weakness in the corresponding primary

spinal nerve root (s) as well as diminished reflexes for the appropriate level may also be

present.

IV: The Neurological Examination

After completing the patient interview for an individual with lower back and or lower extremity

complaints the need for performing a lower quarter neurological examination is determined by

considering the following FACTORS:

1.) Area of symptoms: a standard lower extremity neurological examination needs to be

performed on any lumbar spine patient or lower quarter patient with suspected lumbar spine

involvement with symptoms that meet any of the following criteria:

a. radiating into the groin or distal to the groin anteriorly

b. radiating distal to the gluteal fold posteriorly

c. complaints of weakness and or paresthesia

d. bilateral LE symptoms require a central nervous system exam (CNS / UMN) in addition to a

standard segmental (LMN) screen

e. in the LE present without corresponding symptoms in the lumbar spine BUT exhibit behavior

that indicated that they may be related to lumbar spine aggravating and easing factors

2.) History of the disorder:

a. severe local lumbar spine pain /symptoms of RECENT onset (patient may develop referred

symptoms over the next few days and the clinician would have needed to establish a baseline)

b. previous history of referred symptoms (to detect any pre-existing neuro deficits which never

resolved from previous episodes of symptoms; again for baseline purposes)

3.) Special questions:

a. patient interview revealed positive answers to questions related to cauda equina

involvement and or sensory disturbance in the saddle area

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

DPT 707 Summer 2017

4


b. potential CNS involvement (bilateral glove / sock distribution of numbness / tingling / gait

abnormalities, spasticity requires CNS screening for: hyper-reflexia, Babinski sign, clouns,

muscle tone, and bilateral glove sock distribution

5.) Physical Examination Considerations: a lower quarter neurological examination is required

for all patients in which you want to perform any neurodynamic testing of which includes

slump, straight leg raise, or if mobilization of the nervous system will be an eventual treatment

approach you may take .

Standard PNS or LMN screening should include:

1. Sensory testing

2. Deep tendon reflexes

3. Strength testing (myotomes)

Standard CNS or UMN screening should include:

1. Babinski sign testing

2. Clonus testing

3. DTR’s (hyper-reflexia)

4. Sensation testing for bilateral glove / stocking presentation

5. Assessment of muscle tone via passive movement of the extremities

Neurodynamic Assessment (will review in week 4):

1. Passive neck flexion in supine

2. Straight leg raise

3. Slump testing

Neurodynamic tests are movements which place or presume to place a load onto the nervous

system (Butler 2002). These are often tests used to determine where a peripheral nerve may

have static or dynamic issues either based on the nerve itself or the tissue container it is located

in (i.e. fascia, muscle etc). Because this can often be a mobility issue and not necessarily a

conduction issue there may or may not be true neurological changes.

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

DPT 707 Summer 2017

5


Peripheral Neurogenic Pathology:

Peripheral nerve trunk: Pathology at the peripheral nerve trunk creates a pattern of altered

sensation corresponding with the cutaneous distribution of that peripheral nerve distal to the

site of the pathology.

Spinal nerve root: Pathology at the spinal nerve creates a pattern of altered sensation in a

dermatomal distribution.

Pathology affecting the peripheral nerve trunk (PNS

lesion) includes one or more of the following

neurological signs:

1. Altered sensation in a cutaneous field pattern distal

to the site of pathology

2. Absent / decreased strength in muscles supplied by

the peripheral nerve trunk distal to the site of the

lesion

3. May include absent or decreased DTR’s if the

peripheral nerve trunk innervates the muscle tested

by the DTR (e.g pathology affecting the femoral nerve

may cause absent/ decreased patellar DTR because

the femoral nerve innervates the quads).

Pathology affecting a spinal nerve root includes one

or more of the following neurological signs:

1. Altered sensation in a dermatomal pattern

2. Absent / decreased strength in a myotomal pattern

3. May include absent or decreased DTR’s

*may present as “Radicular Pain”

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

DPT 707 Summer 2017

6


Myotomes (Lower Extremity):

L1, L2, L3

Iliopsoas (L2)*

Iliacus

Quadratus lumborum

Gracilis

Rectus femoris (L3) (VL/VM/VI)*

Sartorius

L4, L5, S1

Quadriceps

Anterior tibialis (L4)

Extensor Hallicus Longus (L5)

Hamstrings (L5, S1)

Gastroc (S1)*

Glut Med/Max (L5,S1)

Extensor digitorum

Posterior tibialis

Peroneals (L5,S1)

Flexor digitorum (L5,S1)

Dermatomes:

From Moore; Clinically Oriented Anatomy 7th ed. 2014 (WCU Library)

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

willrobles

Highlight

DPT 707 Summer 2017

7


V. Beginning the Physical Examination

According to Cook (2012) there are 5 key criteria the therapist should have established prior to

initiating the objective examination. They are the following:

1. A list (or no findings) that represent potential red flags to items that require further

testing to “rule out” a condition.

2. Post subjective set of competing HYPOTHESES to allow the clinician to isolate certain

components of the physical examination for more specific findings.

3. The nature of the problem driven by the severity, irritability and stage of the condition.

4. The patient’s expectations and prediction of the outcome (through goals).

5. The concordant or asterisk sign and a hypothesis of what physical activities may be

associated with it. The concordant sign will drive the examination and subsequent

treatment.

Cutaneous distribution:

From Moore; Clinically Oriented Anatomy 7th ed. 2014 (WCU Library)

willrobles

Highlight

DPT 707 Summer 2017

8


VI. Lumbar Spine Physical Examination

A typical examination structure includes the following:

1. Observation (including posture and gait)

2. Structural differentiation tests

3. Active physiological movements

4. Passive physiological movements

5. Passive accessory movements

6. Special clinical tests

A pattern of patient positing during the examination tends to follow a STAND → SIT → SUPINE

→ PRONE. These positions may vary in order based on the patient’s tissue irritability, severity of

the condition as well as the need to provide highly sensitive tests first to rule out sinister

pathologies. A neurological examination may be needed based on the key criteria described

earlier in this chapter. The neurological examination may be integrated throughout the

examination or done as a separate entity when deemed appropriate.

Observation:

Posture

2 key points need to be understood about posture in general. 1.) The observation of posture

involves the careful identification of potential contributors to the patient’s impairments, and 2.)

the presence of a postural fault or body asymmetry does not dictate a pathology or

impairment. Keeping those points in mind postural dysfunction can be the cause of painful

conditions especially those which involve microtrauma to myofascial, periarticular, articular and

or neural tissues (overuse). The other factor is that postural dysfunction can be caused by

painful conditions in which the patient adopts postural positions that inhibit optimal conditions

for tissue healing (adaptive). When one assesses posture the following ideas and or thoughts

should be concerned as it applies towards your clinical reasoning process:

Muscle length impairments

Muscle strength and or endurance impairments

Relationship / interaction of muscle length / strength

Movement patterns / muscle firing sequences

Joint mobility impairments

Symptom avoidance posturing (could be an insight into a maladaptive issue)

Structural anatomic impairment

Development features (changes in posture throughout the lifespan)

Neurological examination: LMN / UMN and or

Neurodynamic testing as needed (can be

integrated in exam or added when appropriate)

willrobles

Highlight

DPT 707 Summer 2017

9


Postural Grid

Good posture Part Postural Faults Muscle Impairments Intervention

Head is held erect in a position of good balance

Head

Arms hang relaxed at the sides with the palms of the hands facing toward the body. Elbows are slightly bent, so forearms hang slightly forward. Shoulders are level and neutral in the frontal plane. Scapulae lie flat against the rib cage ~ 4 inches apart

Arms & Shoulders

A good position of the chest is one in which it is slightly up and slightly forward (while the back remains in good alignment)

Chest

In older children and adults the abdomen should be flat

Abdomen

The front of the pelvis and the thighs are in a straight line. The buttocks are not prominent in back but slope slightly downward. The neck and lumbar spine should be in lordosis and the thorax and sacrum in kyphosis

Spine and pelvis (side view)

Ideally the body weight is distributed evenly on both feet and the hips are level

Hips, pelvis and spine (back view)

Legs are straight up and down, patella face straight forward, the knees are straight in the sagittal plane

Knees and legs

In standing the longitudinal arch has the shape of a half dome. The feet toe out slightly

Feet

Toes should be straight. They should extend forward in line with the foot and not be squeezed together or overlap.

Toes

You may have to prioritize what is important AND relevant as non-ideal posture does not

always result in significant or relevant dysfunction

DPT 707 Summer 2017

10


From Kendall (4th ed. 1993) Be familiar with what muscles groups would be ELONGATED and

WEAK as well as those that are SHORT and STRONG

Gait and Functional Screening (*)

Gait:

Functional * screen: looking for REPRODUCTION of the patient’s asterisk sign or movement

which provokes “their pain”.

Functional quick neurological screen: (not to be used in substitution of a thorough and

complete neurological exam but can be quickly performed after watching the patient walk).

1. Single leg sit to stand (L3/L4)

2. Heel walk (L4/L5)

3. Toe walk (L5/S1)

DPT 707 Summer 2017

11


Active physiological movement:

The main objective is to identify the asterisk or concordant sign. Positive findings may be used

as treatment. Overpressures are used to rule out joints. The concept of “centralization” may be

observed during your motion assessment of the spine. This is when the patient reports pain

arising from the spine and felt laterally from the midline that is reduced and transferred to a

more central or near midline position when certain movements are performed. If this occurs

during the first visit there is evidence to support that your patient may overall have a successful

outcome. When looking at physiological movement (flexion, extension, side bending and

rotation) it is recommended that the student follow the sequence below:

1. Have the patient stand in a standardized position (feet about 4-6 inches apart use your

foot to set the measurement).

2. Have the patient ACTIVELY move to the first point of pain (hold) and assess the response

(0-10 scale) if pain occurs prior to end range.

3. Have the patient then move past the point of pain (as long as they are comfortable and

able to do so) to their limit (hold) and assess the response (0-10 scale).

4. The patient then repeats the movement to determine if pain or range has changed while

the therapist again assesses their response.

If there is NO PAIN an OVERPRESSURE is applied. The use of overpressure is designed to “rule

out” potential movements and directions which may not be contributing to the patient’s

presentation. Overpressure is also performed as an attempt to reproduce the patient’s

concordant and or asterisk sign.

List of movements and position: (in order)

1. Flexion (standing) 5. Rotation RIGHT (seated) Repeated Flexion = SP 94 RR + OP (as indicated) Flexion + OP (as indicated) 6. Rotation LEFT (seated) 2. Extension (standing) LR + OP (as indicated) Repeated Extension = SP 94 Extension + OP (as indicated) 7. Quadrant RIGHT (EXT+SBR+RR) (standing) 3. Lateral flexion RIGHT (standing) Repeated Lateral flexion RIGHT = SP 94 8. Quadrant LEFT(EXT+SBL+LR) (standing) Lateral flexion RIGHT + OP (as indicated) 4. Lateral flexion LEFT (standing) 9. Extension Rotation Test RIGHT (seated) = SN 100 Repeated Lateral flexion LEFT = SP 94 10. Extension Rotation Test LEFT (seated) = SN 100 Lateral flexion LEFT + OP (as indicated)

willrobles

Highlight

DPT 707 Summer 2017

12


ACTIVE PHYSIOLOGICAL FLEXION

1. The patient is positioned in a neutral standing position and baseline symptoms are

assessed.

2. The patient is instructed to flex forward to his or her first point of pain and the pain is

questioned if it is their concordant sign.

3. The patient is then instructed to push past the initial point of pain and symptoms are

again questioned.

4. The patient is then asked to perform repeated movements past and or near the end

range of motion.

5. While performing the movement the patient is instructed to report whether his or her

symptoms are worsening, improving or staying the same (and or centralizing or

peripheralizing or neither). It is also imperative that you monitor to see if ROM has

changed as well.

6. If repeated flexion to end range was pain free, gently take up the slack on the last

repetition and apply firm pressure to engage the end feel.

7. Perform small oscillations at end range to rule out this motion.

8. If pain was present during flexion the overpressure is unnecessary.

If the repeated or sustained movements and overpressure are pain free the movement can be

identified as nonprovocative.

Notes: .

DPT 707 Summer 2017

13


ACTIVE PHYSIOLOGICAL EXTENSION


assessed.

2. The hands of the patient are placed on each side of his or her hips and baseline pain and

radicular/referred symptoms are reported.

3. The patient is instructed to bend backwards to his or her first point of pain and the pain

is queried to determine if it is their concordant or asterisk sign.

4. The patient is then instructed to progress past the first point of pain; symptoms again

are assessed.

5. The patient is then instructed to perform repeated movements past and/or near the

end range of motion.

6. While performing the movement, the patient is instructed to report whether his or her

symptoms are worsening, improving, or staying the same, and or

centralizing/peripheralizing, or neither. It is also imperative that you monitor to see if

ROM has changed as well.

7. If end range extension was pain free, gently take up the slack on the last repetition and

apply firm pressure to engage the end feel.


9. If pain was present during extension the overpressure is unnecessary.


identified as nonprovocative. Also if these movements do not demonstrate centralization it

may be helpful to assess the movements in prone.

Notes:

DPT 707 Summer 2017

14


ACTIVE LATERAL FLEXION (SIDE BENDING)


assessed.

2. The hands of the patient are placed on each side of his or her hips and baseline pain and

radicular/referred symptoms are reported.

3. The patient is instructed to bend to his or her RIGHT / LEFT side to the first point of pain

and the pain is queried to determine if it is their concordant or asterisk sign.

4. The patient is then instructed to progress past the first point of pain; symptoms again

are assessed.

5. The patient is then instructed to perform repeated movements past and/or near the

end range of motion.

6. While performing the movement, the patient is instructed to report whether his or her

symptoms are worsening, improving, or staying the same, and or

centralizing/peripheralizing, or neither. It is also imperative that you monitor to see if

ROM has changed as well.

7. If end range lateral flexion was pain free, gently take up the slack on the last repetition

and apply firm pressure to engage the end feel. (PT standing to the side being

overpressed)


9. If pain was present during lateral flexion the overpressure is unnecessary.


identified as nonprovocative.

Notes:

DPT 707 Summer 2017

15


ACTIVE ROTATION in SITTING

1. To test rotation the patient is instructed to sit and cross tightly their arms on the chest

wall while sitting on the treatment table.

2. The clinician uses his or her knees to block the knees of the patient to reduce

compensation at the pelvis.

3. A baseline assessment in regards to pain is queried.

4. The patient is instructed to rotate as far as possible to the right side and pain is again

questioned specifically if it is their concordant or asterisk sign.

5. If pain free gently take up the slack and apply firm pressure to engage the end feel.

6. If end range rotation was pain free, gently take up the slack on the last repetition and

apply firm pressure to engage the end feel.


8. If pain occurred any time during the movement the overpressure is unnecessary.

9. Repeat on opposite side.

Notes:

DPT 707 Summer 2017

16


ACTIVE QUADRANT


assessed.

2. The patient is then instructed to extend, rotate (right) and side bend (right) while the

symptoms are assessed.

3. This is then repeated for the left side

This can be a highly sensitive type technique but does not have the capacity to define the

specific origin of pain. A negative finding during the combined tests may be more useful than

a positive finding. It is useful to follow this active motion up with the seated rotation test

explained below.

Notes:

DPT 707 Summer 2017

17


Structural differentiation tests:

EXTENSION ROTATION TEST (Seated)

SN = 100

1. The patient is positioned in sitting position and the knees

are blocked as best possible. (may be modified according

to table height)

2. The patient is passively pushed into full extension.

3. The patient is then taken into full rotation on both LEFT

and RIGHT sides; while maintain full extension.

4. A positive finding is pain at end range extension and

rotation.

Notes:

Neurodynamic Assessment:

Sequencing of tests in order of least to most aggressive on the nervous system:

1. Passive neck flexion

2. Straight leg raise

3. Slump test

**PASSIVE NECK FLEXION (Supine) ** = A LMN neurological examination needed prior to performing

SN = Not reported

1. Passive neck flexion can be performed in two ways. Upper cervical flexion places the

load on the cervical and cranial meninges and if this is combined with lower cervical

flexion, a considerable load is placed right through the entire neuromusculature system.

2. This technique can frequently reproduce back pain suggesting nervous system

involvement. This is the preferred test to perform prior to SLR and SLUMP because it is

the least aggressive load on the nervous system and functions as a quick screen of their

current nervous system state.

DPT 707 Summer 2017

18


**STRAIGHT LEG RAISE (Supine) ** = A LMN neurological examination needed prior to performing

SN = 97

1. Have the patient assume a supine position close to your side

of the plinth with both legs extended. This closeness allows for

improved patient handling during the technique. If you decide

to use a pillow under the head make sure you use it every time

to standardized your test position.

2. Stand facing your patient and place one hand under the ankle

avoiding pressure on the peripheral nerves where they are

superficial and place the other hand above the patella.

3. Keeping the knee extended flex the hip in a perpendicular

plane.

4. The patient’s trunk and hips should remain neutral avoiding any

internal or external rotation of the hips.

4. The leg is taken short of, to, or into sensory and or motor

responses depending on prior reasoned hypothesis of

pathobiological processes involved.

5. Be aware of symptom responses before, during and after the

technique.

6. A positive test is concordant reproduction of symptoms, positive sensitization (in this

case the use of passive neck flexion or passive ankle dorsiflexion to change either distal

or proximal symptoms), or overall gross asymmetry findings.

Notes:

DPT 707 Summer 2017

19


**SLUMP TEST (Seated) ** = A LMN neurological examination needed prior to performing

SN = 84

1. Starting position

The patient is sitting up straight and sitting with their

hips and thighs supported on the plinth with their knees

creases at the edge of the plinth. Ask your patient to put

their knees together and then relax their legs. Ask them

to link their hands together behind their back which will

keep the patient’s arms out of the way. Sit next to the

patient with your hands ready to guide the movement.

Assess symptoms.

2. Spinal slump

As your patient to then “sag in the middle of their spine”

while still looking forward and keeping their sacrum

perpendicular to the table. A small tactile cue of pushing on the stomach gently in the

posterior direction can help facilitate this if necessary. You won’t to avoid any pelvic

rotation as best as possible. Another great verbal cue is “keep tall while letting your

spine sag”. At this point there is no need for direct overpressure on the spine. Assess

symptoms.

3. Neck flexion

With the spine in this slumped position ask the patient to bend their head down or bring

their “chin to chest”. Watch their movement and imagine how much more the nervous

system is being loaded at this time. Tucking her chin in could also add more load to the

NS if needed.

4. Knee extension

Now have the patient extend their knee (usually non-affected leg first if the patient is

presenting with leg pain). Have them relax so that the ankle stays in a relative plantar

flexed position and not active dorsiflexed at this time. Take note of the patient’s

symptoms with this movement especially paying attention to if the non-affected leg

movement causes the opposite side symptoms to occur or worsen.

DPT 707 Summer 2017

20


5. Release neck flexion

Have the patient then release neck flexion to “look up a little” using your hand to help

guide her neck and be aware of any change in symptoms. If a small amount of neck

flexion alters the patient’s lumbar spine or leg symptoms clearly the nervous system

could be “sensitive” at this time. You can refine the test by having her slowly extend her

neck back and at the same time check when symptoms change.

6. Extend knee

With the above position held ask the patient if they can straighten their knee any

further, this will often be the case. Check to see if it brings on symptoms again.

Additional modifications:

Ankle dorsiflexion = ankle and foot movements can easily be included in the

examination. A command such as “toes up towards your face” for dorsiflexion or “toes

to the floor” for plantar flexion is helpful directions for the patient in regards to

completing those movements. Ankle movements may be useful if the individual can full

extend their knee in regards to loading the nervous system as well as a movement for a

more proximal related issue.

Bilateral knee extension = after the patient has completed the routine slump it may be

worth asking the patient to extend both of their knees which will allow the therapists to

compare left versus right. It is important to remember that this as well is a progression

from the standard slump in regards to loading the nervous system a bit more

aggressively.

Notes:

DPT 707 Summer 2017

21


Passive Accessory Intervertebral Motion (PAIVM):

PALPATION (PRONE): (Always start with this)

1. Have the patient positioned in supine and skin exposed for an overall scan of the

tissue and palpation assessment. Head needs to be supported in a neutral position.

2. Use the palmar aspects of your hands to sweep up and down the lumbar spine area

feeling for muscle bulk / atrophy as well as temperature, sweat, and overall coloration

or any discoloration of the tissue. This is a good introductory for you to have with your

patient in regards to touch. Be sensitive to cold hands and the position of the patient

(prone unable to view what is going on). Assess symptoms as needed.

3. Palpate the following: QL (left and right), ES (left and right), and the supraspinous as

well as iliolumbar ligaments. Note any differences left versus right and assess for

symptoms.

4. Palpate the iliac crests and then find the spinous process of L4.

Notes:

PASSIVE ACCESSORY INTERVERTEBRAL MOTION (PAIVM): Central PA

1. The patient is placed in prone with their hands down at

their sides and their head in a neutral position. Palpate

the iliac crests to then move across the midline part of

the body to find the spinous process of L4. Once at L4

count upwards to L1; this will be your starting point.

2. Once at L1 place the pisiform of one hand on the spinous

process of L1.Then take your other hand and intertwine it as

shown in the picture to the right. Your elbows should be

straight and your head / trunk should be directly over your

arms and over the L1 segment. You should be able to “look

straight down” at the L1 segment with your head over the

opposite side of the patient’s trunk. Assess for symptoms.

3. Once in this position the clinician applies ~ 4kg of force (blanching of your fingernail

if pushing down on the plinth) while at the same time assessing for symptoms and

or a response to the applied pressure. The pressure should be light first followed by

progressive intensities.

DPT 707 Summer 2017

22


4. The clinician continues from distal to proximal on the patient’s spine again assessing

for symptoms (specifically the patient’s asterisk sign if possible) as he or she assess

each segment.

5. The clinician attempts at each segment to make a decision regarding if the movement

is: NORMAL, HYPOMOBILE, or HYPERMOBILE often times in relationship to each of the

other segments.

6. The clinical is encouraged to assess tissue movement through various GRADES OF

MOVEMENT as established by Maitland (see below):

GRADES OF MOVEMENT REVIEW:

A system of graded movements (I, II, III, IV, V) is used to describe where this motion takes

place within the continuum of the overall total motion of the joint.

Grade I: small amplitude movement performed at the beginning of range.

Grade II: large amplitude movement performed within a “resistance-free” part of range.

Grade III: large amplitude movement performed “into resistance” or up to the limit of range.

Grade IV: small amplitude movement performed well into resistance.

Grade V: To be discussed in Ortho (DPT 707)

Concept of R1/R2 (Maitland): Resistance to movement may manifest as a loss of the friction-

free feeling through range of stiffness, increasing as the movement is carried further into range.

The term R1 is used to represent the onset of resistance and R2 to represent the quality of

resistance which acts to limit range of motion.

Start of Range End of Range

II

I

III

IV

Joint Range of Motion R1 R2

DPT 707 Summer 2017

23


PASSIVE ACCESSORY INTERVERTEBRAL MOTION (PAIVM): Unilateral PA

1. The is similar to the central PA as mentioned above but you are

now applying pressure and assessing left and right sides

independently. This unilateral pressure is directed towards the

right facet, lamina and transverse process (one motion) of each

lumbar vertebra and then the other side is assessed in a similar

fashion.

2. Find L1 as you did previously. Once at L1 place a thumb pad to

thumb nail contact. The clinician then applies a gentle force

perpendicular to the targeted transverse process of the lumbar

spine (right or left).

3. Once in this position the clinician applies ~ 4kg of force (blanching of your fingernail

if pushing down on the plinth) while at the same time assessing for symptoms and

or a response to the applied pressure.

4. The clinician continues from distal to proximal on the patient’s spine again assessing

for symptoms (specifically the patient’s asterisk sign if possible) as he or she assess

each segment.

5. The clinician attempts at each segment to make a decision regarding if the movement

is: NORMAL, HYPOMOBILE, or HYPERMOBILE often times in relationship to each of the

other segments.

6. The clinical is encouraged to assess tissue movement through various GRADES OF

MOVEMENT as established by Maitland (see section above for details).

Notes:

Summary for PAIVM’s:

It may yield useful information in the detection of lumbar pathology

It is useful in isolating the dysfunctional segment (pain)

May be reliable when assessing pain but not as reliable when reporting or assessing

“Stiffness only”

IIs beneficial when pain provocation is the purpose of the segmental examination

Necessary “last part” when clearing the lumbar spine

DPT 707 Summer 2017

24


Passive Physiological Intervertebral Motion (PPIVM):

PASSIVE PHYSIOLOGICAL INTERVERTEBRAL MOTION (PPIVM):

Piano Grip: the basic position of the clinician’s palpating hands

takes on a “piano grip” with each finger in between the various

lumbar spine vertebrae (INTERSPINOUS SPACE) which will feel like a

small gap between adjacent spinous processes. This is used to

assess quality and quantity of movement at various spinal levels.

Patient positioning: for the PPIVM testing the patient is on their

side close to you with the hips bent to ~ 45 degrees and the knees

to ~ 60 degrees. The table height should be at clinician’s mid-thigh

level (needs to be lower than your ASIS).

Motions tested: there are 4 motions that are tested: flexion,

extension, side bending or lateral flexion and rotation. The details are listed below.

Flexion and Extension:

1. The clinician places the knees of the patient against his or her

anterior – superior iliac spine and or hip region to further stabilize the

patient’s lower extremities. This also allows the clinician to be able to

passively move the patient into flexion and extension using their trunk

to support the extremities. The clinician may have to slightly lift up

the legs to prevent drag on the table from the LE’s or use a towel or

sheet on the table to help reduce friction on the plinth.

2. During these movements of flexion and extension the clinician

palpates the interspinous spaces of the patient’s lower back for an

assessment of quality and quantity of movement at various spinous

levels.

Side Bending (Lateral Flexion):

1. Same start position as noted above

2. The clinician grabs both ankles of the patient to allow a lift as one

lever arm; if the patient is large the clinician can substitute by using

their one hip / leg.

FLEXION

EXTENSION

SIDEBEND

DPT 707 Summer 2017

25


3. The clinician gently lifts the legs feeling for separation and movement between the spinous

processes expecting movement from the distal to proximal direction. A general assessment of

quality and quantity of movement at various spinous levels is made as one progressive up the

spine.

4. The method is then repeated for the opposite side.

Rotation:

1. The patient has the same initial start position as the

reported in flexion / extension and side bend testing. The

clinician uses their forearm to take up the slack in the hip and

while their first and second finger loop underneath the

spinous process of L5 or the “targeted” caudal segment.

2. Using a force of his or her own forearm placed on the side

of the rib cage and by gently applying a force on L4 (or the

targeted cephalic segment) toward the treatment table with

his or her thumb, the clinician applies a distraction moment

at the L4-L5 facet.

3. The force is in a diagonal direction toward the plane of the facet.

4. Excessive movement, pain, or gapping should be noted, since ideally rotation is very minimal

in the lumbar spine.

5. The clinician should then progress cephalically and perform the same procedures for: L5S1 –

L3L4 – L2L3 – L1-L2.

6. The method is then repeated for the opposite side.

Notes:

Proving Unaffected: (Lumbar spine)

ROTATION

Summary for PPIVM:

Generally poor inter-clinician agreement

May be useful when comparing it against active physiological motions

Assessment of the asterisk sign or concordant pain should still be the objective of this

assessment

There may be some value of PPIVM’s specifically EXTENSION and ROTATION as highly specific

tests for a confirmatory diagnosis of radiographic instability

DPT 707 Summer 2017

26


Proving unaffected:

Regarding the lumbar spine the series of tests that MUST be performed and “cleared “to be

proven unaffected is listed below: (all must be symptom free)

A. Lumbar Spine

1. Active physiological movement

A. flexion + OP

B. extension + OP

C. lateral flexion + OP

D. seated rotation + OP

2. Active lumbar quadrant

3. Seated rotation test (passive technique)

4. Palpation examination including PAIVM’s (both central and unilateral for L1-L5)

*If all are noted as pain free than the lumbar spine has been “cleared” and one should focus

their examination on other potential hypothesis and or sources related to the patient’s

problem.

B. Pelvic Girdle

C. Hip Joint Complex

D. Knee Joint Complex

1. Tibiofemoral

2. Patello-femoral

E. Ankle/Rear Foot

DPT 707 Summer 2017

27


Differential Diagnosis: Concept of Selective Tissue Tension”: (Cyriax, Chrsitensen course notes 2000)

This concept was originally devised by Dr. James Cyriax and focused on identifying patterns of

responses to a number of passive and static resisted movements for each joint complex. The list

below compiles some of those thoughts and how the physical examination and results can

assist a clinician in the direction of “potential” sources of the problem. A key question you

should be asking yourself as you are interviewing and examining your patient is: DOES THIS

SOURCE APPEAR TO BE CONTRACILE or NONCONTRACILE SOURCE

“It is important to note that interpretation of tissue function is based on the response to

a SERIES OF TESTS (included + and – findings) and the clinician must consider the

CONCEPT OF COMPARABLE SIGNS to determine which findings are most relevant to the

patient’s disorder” Christensen 2000

Examination procedures and “general” information:

Active physiological movements

Contractile tissue dominant, all tissue stretched at end-range, neural tissue must

adapt to movement, bias towards contractile but need more testing

Passive physiological movements

Likely non-contractile structures > contractile, end-range positions put many

forms of tissue on stretch, neural tissue mobility may not be maximally stressed

depending upon the position of other spinal or limb components, capsular

pattern may indicate that the joint capsule is involved, passive movement that

does not fit a capsular pattern may suggest a type of internal derangement,

general bias towards inert and neural tissue

Passive accessory movements

Look at arthrokinematics of the joint, emphasis on non-contractile tissue, quality

of resistance may tell you about muscle guarding versus a firm capsular end-feel,

most informative aspect of the spinal examination in regards to recreating the

patient’s asterisk or concordant sign and deciding if findings are central or

unilateral, during a joint assessment is it the muscle guarding that reproduces

the patient’s symptoms (contractile) or the actual pressure on the joint during the

assessment (non-contractile)

Stability tests

Static resisted tests (myotomal testing)

Muscle length tests

Muscle strength tests

Reflex testing

DPT 707 Summer 2017

28


Sensation testing

Neurodynamic testing

Indicated deficiency in ability of neural tissues to adapt to movement, this may

be related to elongation of neural tissue and associated connective tissues or

problem with excursion relative to interfacing surfaces, these tests move all

types of tissue and therefore sensitizing maneuvers are necessary to incriminate

neural tissue involvement from involvement of other tissues

DPT 707 Musculoskeletal I Lumbar Spine Patient ...

Documents

Transcript of DPT 707 Musculoskeletal I Lumbar Spine Patient ...