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Lumbar Screening Exam
Musculo Lumbar Screening Exam
178
Anatomy
Graduate
04/23/2012

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Term
what are the 3 basic components of a lumbar screen
Definition
subjective exam, objective exam, treatment ideas
Term
what does a subjective exam entail
Definition
history, special questions, health-related quality of life instruments
Term
what does an objective exam entail
Definition
lumbar screen, biomechanical testing
Term
what to get from history
Definition
have patient paint the picture for you. Get complete information on ADLs
Term
how can you get the patient to paint the picture for you
Definition
get the who what when where why of the chief complaint
Term
what can info about ADLs tell you
Definition
what factors may have predisposed this patient to the problem or might delay recovery
Term
what to ask about pain in lumbar subjective exam
Definition
aggs/eases, 24-hour pain cycle, pain diagram/where is pain, pain description,
Term
what can pain info from subjective exam help you to form
Definition
working diagnosis
Term
what special topics should be asked about in subjective lumbar exam
Definition
bilateral cord symptoms, sleep positoin, pain with cough or sneeze
Term
what special questions to ask about bilateral cord symptoms
Definition
bilateral numbness/weakness? Drop attacks? Bladder/bowel function?
Term
if a patient has drop attacks preceded by pain, is it neural or muscular
Definition
muscular
Term
what does pain with cough or sneeze tell you
Definition
increased pressure on low back/intra-abdominal pressure combined with herniated disc causes pain in back/shoots down leg = nerve compression = herniated disc
Term
why is it good to have a health related quality of life instrument
Definition
asks the kinds of questions you want to know answers to
Term
what are the 3 purposes of the lumbar screen
Definition
1. identify the exact location of the patient's source of complaint; 2. eliminate confusing information; 3. rule out non-PT pathology such as visceral origin, neoplasm, fracture
Term
what parts of the lumbar objective exam are done in standing
Definition
observation, trunk AROM, repeated flexion/extension, L4/S1 myotomes
Term
what to observe in regular standing and as the patient enters the room
Definition
willingness to move, compensatory movements, gait
Term
is a visual inspection of posture reliable/valid
Definition
no
Term
what are better options for measuring postue
Definition
flexicurve ruler, pneumap
Term
what AROM movements are done in standing
Definition
flexion, extension, sidebend
Term
what can AROM show you
Definition
signs of lumbar instability
Term
what are signs of lumbar instability in AROM
Definition
painful arc in flexion, painful arc in return from flexion, instability catch, gower sign, reversal of lumbopelvic rhythm
Term
what is the lumbar painful arc
Definition
when you flex forward at the hip and come back up, there's an area of movement that hurts and then goes away
Term
does a painful arc in flexion implicate something in particular
Definition
no
Term
what will you see if someone has a painful arc on return from flexion
Definition
positive gowers
Term
what is positive gowers
Definition
walking up thighs to return to standing from flexion
Term
what is reversal of lumbopelvic rhythm
Definition
when coming back up from flexion, putting spine in lordosis to guard/lock out low back pain and pull up from hips. Not allowing vertebrae to stack one on top of another
Term
all combined, what does positive gowers, instability catch, painful arc, and reversal of lumbopelvic rhythm suggest
Definition
aberrant movements during lumbar flexion
Term
what are motion patterns seen in patients with chronic LBP
Definition
asymmetry in lateral flexion, abnormal extension:flexion ratio
Term
what causes asymmetry in lateral flexion in patients with chronic LBP
Definition
possibly due to abnormal coupling pattern of lateral flexion and ispilateral rotation as opposed to normal lumbar coupling of lateral flexion with contralateral rotation
Term
normally, how much extension can you get compared to flexion in lumbar spine
Definition
extension is 40% of flexion
Term
if someone is very flexible in extension and limited in flexion, what is that called
Definition
abnormal extension:flexion ratio
Term
what is a good and easy way to measure trunk sidebend AROM
Definition
fingertip to floor
Term
if someone's pain starts to peripheralize, what should you do?
Definition
stop
Term
what is centralization
Definition
pain comes more medial/proximal to low back
Term
what is peripheralization
Definition
pain spreads more distal/lateral away from low back
Term
what parts of the lumbar objective exam are done in sitting
Definition
observation, active/passive/resisted trunk rotation, dermatomes, myotomes, reflexes, IR/ER
Term
what is the S1 myotome
Definition
walk on toes
Term
what is the L2 myotome
Definition
hip flexors
Term
what is the L5 myotome
Definition
extend big toe/evert foot
Term
what is the L3 myotome
Definition
extend leg at knee
Term
what is the L4 myotome
Definition
walk on heels
Term
what does slump test tell you
Definition
dural mobility of L4-S3
Term
what is a positive slump test
Definition
patient has pain in butt or low back in test position and pain changes with movement of head or feet
Term
what reflexes are tested in lumbar objective screening exam
Definition
patellar tendon L3, achilles tendon S1, babinski, clonus
Term
what parts of the lumbar objective exam are done in supine
Definition
SLR, modified SLR, SIJ provocation tests, ASIS palpation
Term
what is the purpose of SLR
Definition
test mechanical movement of sciatic nerve and test its sensitivity to mechanical stress/compression
Term
in SLR, what is the range of pain to be considered attributable to sciatic nerve tension
Definition
35-70 deg
Term
what happens to sciatic nerve in 35-70 deg SLR
Definition
sciatic roots tense over IV disc
Term
if you have pain in SLR past 70 deg, what is the likely cause
Definition
joint pain
Term
what is the difference between regular SLR and modified/Lasegue's SLR
Definition
in modified, pt's leg is adducted and internally rotated
Term
when do you stop raising leg in modified SLR
Definition
when patient complains of pain or tightness in back or back of leg
Term
what to do after reaching point of pain in modified SLR
Definition
slowly lower leg until pt feels no pain/tightness. Next, passively dorsiflex foot and/or pt flexes neck.
Term
what is a positive Lasegues/modified SLR
Definition
reproduction of sciatic pain with dorsiflexion or neck flexion
Term
how many SIJ provocation tests are there
Definition
5
Term
which of the 5 SIJ provocation tests are done in supine
Definition
gapping, torsion/gaenslens, posterior shear
Term
which of the 5 SIJ provocation tests are done in sidelying
Definition
compression
Term
which of the 5 SIJ provocation tests are done in prone
Definition
sacral thrust
Term
in gapping, which side is closest to PT, affected or unaffected side
Definition
affected side
Term
what part of the SIJ is compressed in gapping
Definition
posterior
Term
what part of the SIJ is is stressedin compression testing
Definition
anterior
Term
in the torsion/gaenslen's test, is the affected or unaffected side close to the PT
Definition
affected side
Term
in the torsion/gaenslen's test is the affected or unaffected side lowered
Definition
affected side
Term
in the posterior shear test, is the affected side or unaffecte side next to the PT
Definition
affected side
Term
in posterior shear test, does the force pushed through the knee of the affected or unaffected side
Definition
affected side
Term
in compression, is the affected side up or the unaffected side
Definition
affected side
Term
in compression test, to what angle are the hips flexed
Definition
45
Term
in compression test, to what angle are the knees flexed
Definition
90
Term
how many of the 5 SIJ compression tests must be positive in order to say that this is really an SIJ problem
Definition
3
Term
in the compression test, is the anterior SIJ compressed or stressed
Definition
compressed
Term
in the compression test, is the posterior SIJ compressed or stressed
Definition
stressed
Term
is the compression test a test of the anterior or posterior SIJ and why
Definition
posterior: it stresses the posterior SIJ
Term
what is the sacral thrust
Definition
an anterior shearing force of the sacrum on the ilia
Term
at what part of the sacrum is the sacral thrust
Definition
palm of the hand at S2. find PSIS, come to center, push down
Term
what is a sacral base thrust
Definition
move superior on sacrum to push at S1
Term
is there an increase in hip internal or external rotation with a posteriorly rotated innominate
Definition
increase in external rotation
Term
has research shown an increase in internal rotation with an anteriorly rotated innominate
Definition
no, but you'd think there would be
Term
when someone has LE pain of insidious onset, what should you screen first
Definition
low back, SI, hip
Term
if symptoms include limp, groin pain, and limited IR, what is the likely cause
Definition
hip
Term
if someone has positive femoral nerve tension, what is the likely source of the problem
Definition
spine OR spine and hip
Term
where does hip arthritis often hurt
Definition
low back/back of butt and/or anterior hip/groin pain
Term
if someone has limited hip IR and a positive femoral nerve tension, what is the likely source of the problem
Definition
spine and hip
Term
is there high reliability/validity in ASIS palpation in supine
Definition
no
Term
what to look for in ASIS palpation to find anterior/posterior rotation in the sagittal plane
Definition
compare heights of L/R ASIS to umbilicus
Term
what to look for in ASIS palpation to find inflare/outflare in the horizontal plane
Definition
orientation of L/R ASIS compared to umbilicus
Term
what parts of the lumbar objective screening exam are performed in prone
Definition
SIJ sacral thrust, prone knee bend, palpation of paravertebral muscles, torsion test of lumbar spine, P-A central mobilization/provocation
Term
what does the prone knee bend test?
Definition
quads flexibility, femoral nerve tension
Term
how to make prone knee bend a femoral nerve tension test
Definition
have pt flex head and look under table. If pain changes when they lift their head back up, femoral nerve is implicated.
Term
what is a positive prone knee bend test for femoral nere tension
Definition
unilateral pain in lumbar area
Term
describe torsion test of lumbar spine
Definition
patient prone. Hand on lumbar spine to stabilize. Lift up at opposite ASIS to put torsion in lumbar spine.
Term
PA at any lumbar spine level moves how many vertebrae
Definition
5
Term
what segments are flexed when you do PA at L5
Definition
none
Term
what segments are extended when you do PA at L5
Definition
L5, L4, L3, L2, L1
Term
what segments are flexed when you do PA at L4
Definition
none
Term
what segments are extended when you do PA at L4
Definition
L5, L4, L3, L2, L1
Term
what segments are flexed when you do PA at L3
Definition
none
Term
what segments are extended when you do PA at L5
Definition
L5, L4, L3, L2, L1
Term
what segments are flexed when you do PA at L2
Definition
L5, L4
Term
what segments are extended when you do PA at L2
Definition
L3, L2, L1
Term
what segments are flexed when you do PA at L1
Definition
L5, L4
Term
what segments are extended when you do PA at L1
Definition
L3, L2, L1
Term
when you push at L3-L5, what happens
Definition
you get all extension in lumbar spine
Term
when you push at L1-2, what happens
Definition
you get flexion at L45 and extension at L123
Term
if I want to flex someone at L45 but they're in a lot of pain with active flexion, what can I do
Definition
do PA at L12
Term
what are 4 types of detailed biomechanical tests for the lumbar spine
Definition
combined motion tests, PPIVMs, PAIVMs, prone instability tests
Term
what are detailed biomechanical tests in standing for combined motion testing
Definition
movement in pattern of capital H to look for pain or limited motion
Term
what movements are performed in standing detailed biomechanical tests for combined motion testing
Definition
L SB and flex; L SB and ext; R SB and flex; R SB and ext
Term
when does combined motion testing indicate hypomobility
Definition
when the full quadrant position cannot be reached
Term
when does combined motion testing indicate instability
Definition
when the full range of motions can be reached in one route but not another
Term
what movements are done with PPIVMs in lumbar spine
Definition
flexion, extension, sidebend
Term
how to do flexion PPIVMS
Definition
patient sidelying facing PT. PT blocks/holds lumbar spinous process with cephalic hand. PT flexes hips by holding ankles with caudal hand
Term
how to test PAIVM
Definition
patient prone. P-A force on lumbar spinous processes with PT's hypothenar eminence
Term
how to judge PAIVMs
Definition
mobility of each segment is normal, hypermobile, hypomobile. Note presence or absence of pain
Term
if instability is suspected based on detailed biomechanical testing, what is the gold standard for diagnosis
Definition
flexion and extension radiographs
Term
what is the possible history that results in instability
Definition
recurrent LBP, short term relief from manipulation, history of trauma, reduced symptoms with bracing, ligamentous laxity
Term
what are the 9 points of the beighton ligamentous laxity screening
Definition
hyperextension of elbow greater than 10 deg, hyperextension of 5th finger past 90 deg, passive abduction of thumb to contact forearm; hyperextension of knees greater than 10 deg; able to flex trunk and place hands on floor
Term
what is the patient's initial position in the prone instability test
Definition
prone with torso on table, feet on the floor (bending over onto table)
Term
what does the PT do in prone instability test
Definition
PAIVM
Term
if PAIVM is painful in prone instability test, what is the next step
Definition
pt raises legs into air
Term
what is the purpose of pt raising legs into air in prone instability test
Definition
muscles contract, stabilizing LB
Term
what does PT do after pt raises legs into air in prone instability test
Definition
perform PAIVM again
Term
what is a positive prone instability test
Definition
pain with initial PAIVM, relief with 2nd PAIVM
Term
what are treatments for lumbar hypomobility
Definition
joint mobilizations/PAIVMs, stretching, assess for hypermobility above and below
Term
what are treatments for lumbar hypermobility
Definition
check for hypomobility above/below and mobilize there; core stabilization training; segmental muscle re-education
Term
how to do segmental muscle re-education
Definition
manual resisted seated trunk rotation: eccentric and concentric
Term
what are treatment ideas for non-acute sciatica
Definition
McKenzie exercises, gentle nerve flossing that stays just short of the pain as in SLR; mechanical traction
Term
when is static traction helpful
Definition
disc pathology
Term
how much body weight to use in static traction
Definition
start at 50% body weight and increase as needed to get centralization
Term
how much body weight is the minimum needed to begin a traction force
Definition
at least 1/4 body weight
Term
when to use prone traction
Definition
disc herniation
Term
when to use supine traction
Definition
joint hypomobility and DDD
Term
when palpating the psoas, what can you do to be sure that you are really on the posas
Definition
ask your patient to flex their hip very slightly. If you are on the psoas, yo uwill feel the contraction
Term
what do you do once you have found the pubic tubercles with the heel of your hand
Definition
turn hand and relocate thetubercles. Palpate medially and laterally. Note the distabce between pubic tubercles and whether there is any asymmetry
Term
what is the patient position for palpating inguinal ligament
Definition
patient supine, knee slightly flexed and supported
Term
how to know you're in the femoral triangle
Definition
feel pulse of femoral artery
Term
how to feel for motion at the SIJ
Definition
press medial to PSIS at SIJ an dpassively IR/ER ipsilateral hip You should feel a small amount of motion at the SIJ
Term
patient position for palpating sacral base
Definition
patient prone
Term
how to palpate/find sacral base
Definition
palpate the space between the 2 PSIS's. this is the base of the sacrum
Term
where to palpate for sacral sulcus
Definition
directly medial to PSIS
Term
how to palpate/find piriformis
Definition
locate PSIS, coccyx, greater trochanter. These points make a T. palpate along the bottom of the T to feel the piriformis, moving from sacrum to greater trochanter
Term
how to palpate/find sacrotuberous ligament
Definition
patient prone. Find ischial tuerosity with the base of yoru palm. Replace palm with thumb pads and palapate diagonally toward the sacrum, strumming the ligament along the way. Note pain/tenderness
Term
what is the grade for an absent reflex
Definition
0
Term
what is the grade for a hypoactive reflex
Definition
+
Term
what is the grade for a normal reflex
Definition
++
Term
what is the grade for a hyperactive reflex with no clonus
Definition
+++
Term
what is the grade for a hyperactive reflex with clonus
Definition
++++
Term
what to look for in standing trunk AROM in lumbar spine
Definition
scoliosis; symmetrical movement; hinging
Term
if you get 2 beats in clonus, what does that mean
Definition
normal
Term
how many clonus twitches must occur for a sign of UMN lesion
Definition
4 or more
Term
what is positive babinski
Definition
big toe, other toes extend
Term
what is the objective of slump test
Definition
assess dural mobility of L4-S3
Term
do babinski, clonus test for UMN or LMN lesions
Definition
UMN
Term
what is another term for the modified SLR
Definition
Lasegue's test
Term
what is the objective of SLR
Definition
test movement of neurological tissues and test their sensitivity to mechanical stress or compression
Term
what is kernig's test
Definition
dorsiflexing patient's foot or flexing head/neck during modified SLR
Term
what are the 3 different positives for SLR
Definition
sicatic pain in 35-70 deg, sciatic pain with dorsiflexion, sciatic pain with neck flexion
Term
what does Gaenslen's test do
Definition
check for SIJ torsion
Term
what are some reasons for decreased motion on symptomatic side in forward flexion test
Definition
tight hamstrings, decreased iliofemoral flexion, posteriorly rotated innominate
Term
what are some reasons for increased motion on symptomatic side in forward flexion test
Definition
weak hamstrings, increased iliofemoral flexion, anteriorly rotated innominate
Term
if a person can't maintain 90 deg pelvis in SLS, what does that indicate
Definition
glute med/min weakness
Term
what does the gillet test
Definition
movement of the innominate bone posteriorly on the sacrum
Term
how to assess level of ASIS
Definition
patient supine. Have them do a bridge, then PT lowers pt legs flat on table. Pt places finger in belly button for centering point. Stand next to pt so that dominant eye is next to patient. Place thumbs under eac ASIS.
Term
what does a caudad position of one malleolus in long sitting indicate
Definition
posterior rotation of the innominate
Term
what does cephalad positining of malleolus indicate in long sitting
Definition
anteriorly rotated innominate
Term
for long sitting test to be positive, what must also happen
Definition
standing flexion test must be positive on the same side
Term
what is a treatment to counternutate the sacrum
Definition
sacral apex test/thrust
Term
what to look for in palpation fo sacral sulcus
Definition
asymmetry; one side higher than the other
Term
for the following questions, say what is the problem for the test result
Definition
ok
Term
supine to sit test: in supine, the leg was longer. In sitting, the leg is shorter
Definition
anterior innominate rotation
Term
supine to sit test: in supine, the leg was shorter. In sitting, the leg is longer.
Definition
posterior innominate rotation
Term
ipsilateral ASIS an dPSIS are higher
Definition
upslip
Term
ipsilateral ASIS and PSIS are lower
Definition
downslip
Term
ipsilateral quadratus lumborum in spasm; tight hip adductors
Definition
upslip
Term
forward flexion test: involved side PSIS moves first and farther
Definition
posterior innominate rotation
Term
tight hamstrings and adductors; tight TFL and piriformus; glute med weak
Definition
posterior innominate rotation
Term
increased tension on sacrotuberuous ligament, long posterior SI ligament, and interosseous ligaments
Definition
inflare
Term
increased tension on ipsilateral anterior SIJ capsule and ligaments, deep iliolumbar ligament, and across symphysis pubis
Definition
outflare
Term
in forward flexion tests, involved side PSIS moves first and farthest superiorly
Definition
anterior innominate rotation
Term
weak abs, glutes; tight hip flexors on involved side
Definition
anterior innominate rotation
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