Thoracic and Lumbar Spine Examination

Herniated Nucleus Pulposus (HNP)

-90% involve the L5 or S1 nerve roots from the L4-L5 or L5 disc -With a posterolateral herniation, LR disc encroaches on S1 nerve root

Lumbar Segmental Mobility: PAIVM

-Assessing accessory mobility of lumbar spine -Grade: normal, hypomobile, hypermobile -If painful, note when pain occurs relative to R1 and R2

Lumbar Segmental Mobility: PPIVM

-Assessing for intersegmental mobility (palpating space between the SPs) for physiological movements -Grading: normal, hypomobile, hypermobile (name the segment)

Lumbar Quadrant Test

-Assessing maximum closing of unilateral lumbar facet joints -Combining motions of extension, ipsilateral sidebend, and/or ipsilateral rotation -If concerned with moderate irritability, then have patient perform actively first -If patient experiences reproduction of their symptoms plus referred leg pain then need to further assess if facet referral or facet/nerve referral

Lumbar Facet Referral

-Conflicting evidence if lumbar facers refer to below the knee of not

Differential Diagnosis: Low Back Pain

-Facet syndrome -Annular tear (disc) -Ligament sprain -Muscle strain -Vertebral fracture -Sacroiliac (SI) Sprain -Hip Referral --Joint --Muscle -Visceral Referral --Gastrointestinal --Gentiourinary -Spinal tumor or infection

Intervertebral Discs (IVD): Functions

-Helps the spine absorb and transmit shock --able to provide resistance to compression, shear, and tensile forces -Maintains flexibility --provides a "spacer effect" as the IVDs account for 25% of total height of lumbar spine --increased height = improved lumbar mobility and space for spinal nerve roots -Helps stabilize the spine under higher loads --distributes load evenly on the vertebral bodies

Low Back Pain with Related Lower Extremity Pain

-International Classification of Disease (ICD) diagnosis of flatback syndrome or lumbago due to displacement of intervertebral disc -Non-neurogenic discal referred pain (but often associated with radiating leg pain secondary to lumbar radiculopathy) Body Chart: low back pain commonly associated with referred buttock, thigh, or leg pain -sometimes low neck pain only (discogenic band) -possibly leg pain worse than low back pain -may not have low back pain (*emphasizes why we always clear the lumbar spine) AGGs: usually worsens with flexion-based activities and sitting/driving (symptoms can peripheralize) EASEs: Symptoms can be centralized and diminished with positioning, manual procedures, and/or repeated movements -Usually LE symptoms improve with extension-based movements (symptoms can centralize)

Lumbar Spine Pain Referral - Combined States

-Local somatic and somatic-referred pain may occur in addition to nerve root symptoms and signs -For example, with intervertebral disc herniation, the outer rings of the annulus are damaged and tension is placed on posterior longitudinal ligament and dural sleeve concomitant with nerve root compression

Hypermobility/Instability/Ligamentous Weakness Signs and Symptoms

-May be hypermobile if not guarding on motion tests, particularly forward bending -AROM signs of instability --Catching sensation --Painful arc --Thigh climbing (Gower's sign) --Reversal of lumbopelvic rhythm: extend lumbar then hip from FB to stand --Hesitancy to move --Sudden shake

Chronic Radiating Leg Pain: Lumbar Central Stenosis

-Narrowing of the spinal canal so spinal cord may be affected (myelopathy) -Causes: --Osteophyte formation --Face hypertrophy --Disc herniation --Ligamentum flavum encroachment --Degenerative disc disease --Spondylolisthesis --Congenital, developmental

Janda's Lower Crossed Syndrome

-Patients with LBP had less glute max strength and shorter lumbar extensor muscle length compared to group without LBP -Correlation between hip extension ROM (Modified Thomas test) and prone hip extension AROM coordination (excessive lumbar compensation) with patients with chronic LBP

Repeated or Sustained Movements

-Perform repeated or sustained movements if patient reports as aggravating factor Sustained Movement: If patient starts to get radiating leg symptoms with sustaining of closing movements, then central and/or lateral foraminal narrowing may be playing a role Repeated Movements: Centralization vs Peripheralization associated with IVD lesion Centralization: "The progressive and stable reduction of the most distal pain towards the spinal midline in response to standardized repeated end-range movements or sustained loading testing procedures:" -More common in patients with acute low back pain

Physical Impairments (LBP with Radiating Pain)

-Posture: possible hinge point (unilaterally or bilaterally) --Couple possibly get relief of resting symptoms with traction -Function/AROM: can be related to excessive closing or opening -Limited nerve mobility -Possibly hypomobile painful segment or hypermobile painful segment with adjacent hypomobility (relative stiffness within the lumbar spine) -Muscle strength and/or endurance deficits of trunk, abdominal, and hip muscles (not helping maintaining foraminal space) -Hip Mobility --Limited hip extension during terminal stance can contribute to excessive extension of lumbar spine --Limited hip flexion during forward bend can increase lumbar spine flexion and thus neural tension

Medical Management: 1st Point of Contact

-Presents with red flags of serious medical pathology (cancer, fracture, spinal infection, cauda equina, etc) -Present with serious comorbidities that typical do not response to standard rehab alone (RA, cervical myelopathy, central sensitization, etc)

Red Flags: Cancer/Malignancy

-Previous history of cancer (+LR 7.25) -Unexplained/unintentional weight loss (+LR 1.87, -LR 0.96) --More than 5-10% of weight in 6 months (+) 2/2 = +LR 10.25 Poor Likelihood Radio: -Pain awakens from sleep -Age over 50 years old

Red Flags: Spinal Fractures

-Prolonged use of corticosteroids (+LR = 48.5) -Significant trauma (+LR = 10) -Age greater than 70 years old (+LR = 11) -Female 1 out of 4 positive: +LR 1.8 (not good indication) 2 out of 4 positive: +LR 15.5 3 our of 4 positive: +LR 218.3 (pretty good indication)

How can you differentiate between low back pain related to IVD irritation and lumbar extensor muscle irritation?

-Prone trunk exercises wouldn't irritate IVD but maybe can irritate muscle

Describe how limited hip flexion PROM may increased compressive forces on lumbar IVD with prolonged sitting?

-Puts you into flexion of lumbar spine so it can cause posterior-lateral bulging of IVD

Lumbar Stenosis Signs and Symptoms

-Radiating pain into one or both legs; may have paresthesia -Aggravating factors: standing up, ambulation (extension based positions and movements) -Easing factors: sitting (flexion-based), walking with shopping cart or walker -Neurologic signs may be present --Sensory, motor, DTR, neural tension tests, quadrant and wide-based gait AROM -Forward Bending: reduced symptoms due to decompressing nerve root -Backward Bending: painful and limited due to compressing nerve root Differentiated from vascular claudication: bicycle test -Pain stays the same for flexion and extension

Differential Diagnosis: Leg Pain

-Radiculopathy (Nerve root) --Disc herniation --Instability --Spondylolisthesis --Stenosis -Piriformis syndrome -Intermittent claudication -Facet syndrome (may or may not go all the way down to foot) -Ligament sprain -Muscle strain -Annular tear (disc) -Sacroiliac sprain

Red Flags: Cauda Equina Syndrome

-Recent loss of bladder control (urine retention) : +LR 2.31 -Recent loss of bowel control (excluding diarrhea): +LR 2.78 -Sexual dysfunction -Usually, bilateral lower extremity symptoms -Saddle region anesthesias -Neuro screen changes (hyporeflexia, myotomal weakness, dermatomal changes) -Gait instability **Symptoms mimic cervical myelopathy

Red Flag: Spinal Pain

-Relatively uncommon: 80% of 1172 patients had reported at least 1 red flag finding, but only 1% had a serious pathology with the majority of being a spinal fracture --High false positive rate with only 1 finding Absence of red flags does not necessarily rule out serious/sinister pathology, so clinical reasoning is needed as red flag screenings are only one component --64% of patients with malignancy had no associated red flags --Poor negative likelihood ratios for red flags for spinal fractures, so cannot rule out with negative findings

Spontaneous Healing of Disc Injuries

-Sequestered Disc: 96% -Extruded Disc: 70% -Protruded Disc: 41% -Bulging Disc: 13% Education: -Most healing occurred within 1st year starting around 2-3 months -The more the severe the MRI findings, the more healing occurred

Physical Impairments of Lumbar Stenosis

-Similar impairments to lateral canal stenosis -However, efficacy of applying the same interventions to address those impairments has been low -Possibly a bigger role for factor that affect systemic inflammation (cardiovascular exercise, sleep quality, stress levels, and nutrition)

Spondylolisthesis Signs and Symtpoms

-Step deformity in standing, if unstable the step-off disappears in prone lying -May show signs had symptoms of instability -Moller et al, studied 111 patients with spondylolisthesis --62% had sciatics -->80% had sleep disturbances, back stiffness and increased pain with walking and sitting

Clinical Prediction Rule to Identify Patients Who Would Benefit from Stabilization Exercises

1. Age < 40 years old 2. Aberrant motion present 3. Average SLR > 91 deg 4. + Prone instability test 3 out of 4 presence: + LR 4 increasing probability of success from 33% to 67% Group with aberrant motion and + prone instability test, lumbar stabilization exercise had significant effect on disability compared to: -group without those findings -group with those findings that receives manual therapy instead

Trunk Muscle Performance Tests

1. Double leg lowering test (trunk flexors): cutoff at 50-60 degrees (anterior pelvic tilt/loses contact of low back on surface) 2. Plank: 84.17 seconds in healthy adults 3. Prone Trunk Extension (30 degree extension): cutoff 31 seconds 4. Bridge (Glute Max) Holds: --With LBP: 76.7 seconds -- Without LBP: 172.9 seconds

Low Back Pain with Radiating Pain

1. ICD diagnosis of lumbago with sciatica, lumbar radiculopathy (neuritis or radiculitis) 2. Associated with radiating pain in the lower extremity -Usually unilateral (leg pain = hallmark sign) 3. Lower extremity paresthesias, numbness, and weakness may be reported 4. MRI or CT recommended for patients with severe or progressive neurologic deficits

LBP with Mobility Deficits

1. ICD diagnosis of lumbosacral segmental/somatic dysfunction, facet dysfunction 2. Body Chart: Low back, buttock, or thigh pain (most likely no symptoms past the knee) -Symptoms usually unilateral 3. Hallmark Signs -Restricted lumbar ROM --Closing issue (occasionally opening issues can occur but less common) ---May see asymmetrical closing or opening during ARROM --Pain and/or restricted RROM with extension, unilateral SB/rotation AROM -Restricted segmental mobility (PAs) -Positive Quadrant Test 4. No imaging indicated for acute symptoms lasting 1 month or less in absence of red flag signs

Low Back with Movement Coordination Deficits

1. ICD diagnosis with spinal instabilities 2. Acute exacerbation of recurring low back pain and associated (referred) lower extremity pain 3. Symptoms may be produced at any range of the motion with midrange being the most common that can worsen at end range 4. Lumbar segmental hypermobiltiy may be present (PA pressures) 5. Lumbar muscle involvement: pain with stretch, contraction, and palpation (less common for symptoms to refer past buttocks region) 6. Need to rule out SIJ involvement

General Physical Impairments of LBP with Movement Coordination Deficits

1. Regional interdependence: mobility deficits of thoracic spine and pelvis/hips may be present 2. Diminished trunk or pelvic-region muscle strength and endurance of local and adjacent muscle groups 3. Movement coordination impairments during functional activities leading to excessive segmental stress or musculature overload

Movement Systems Impairments: Lumbar Extension Movement Deficit

1. Static Posture: Anterior pelvic tilt/excessive lordosis in standing, supine/prone and/or sitting (shorter people that cannot get low back against chair back or touch feet on the ground) 2. Lumbar regions extends more than hips extensors extend the hips -Functional Activities: reaching overhead, carrying objects, during terminal stance of gait/running -AROM: Does not fully revere curve during forward bend, excessive extension o lumbar paraspinal initiation during return from bending, hinging during extension -Active prone hip extension: excessive/early lumbar extension -Quadruped: prefers to be in extended position 3. Excessive hinge at one lumbar segment 4. Abdominal and glute strength deficits 5. Paraspinal and hip flexor muscle stiffness/shortness

Lumbar Flexion Movement Deficit

1. Static posture: excessive lumbar flexion/flat lumbar spine/posterior pelvic tilt in sitting/standing 2. Forward Bending: -Lumbar spine flexion > 20-25 degrees -Hip flexion < 70 degrees secondary to hip joint, hamstring, or nerve stiffness 3. Functional Activity: lifting, squatting, sitting/driving 4. Movement Tests -Quadruped position and rocking back -Seated knee extension -Seated and supine active hip flexion

Diagnostic Clinical Tests

1. Symptoms reduced with neurodynamic testing (*desensitized, sensitized with movement of joint 2 body regions away from symptoms, reproduction of their symptoms, and 10-15 degree compared to the other side) -Straight leg raise test -slump test -Femoral nerve test 2. Sign of possible nerve root involvement (sensory, strength, or reflex deficits) -Not reliable for specific level 3. Reproduction of radiating leg symptoms with the following: -Lumbar AROM: may be with closing or opening movements -Lumbar PA pressures

Lumbar Rotation Movement Deficit

1. Symptoms with rotation movement of the low back often when combined with flexion or extension 2. Symptoms usually unilateral or greater on one side 3. Static Posture: trunk sidebendebd and/or rotation in standing, sitting, or sidelying (asymmetrical skin folds or paraspinal muscle bulk asymmetry) 4. Possible asymmetric muscle imbalanced of hip flexors, glutes, hamstrings 5. Movement Tests -Bend knee fall out -Prone active hip rotation -Sidelying hip abduction/external rotation -Quadruped unilateral arm lift

Intervertebral Disc Radiographic Findings

50 years or younger (3097 individuals) -Those with LBP were 2.24 times more likely to have a degenerative disc (DD) compared to asymptomatic individuals -DD possibly less relevant in older populations though 3110 asymptomatic individuals: lumbar DD incidence -20s: 37% -80s: 96% 350 asymptomatic individuals (18-22 years old) -30% had signs of a disc desiccation -13% with at least 1 disc narrowing

Straight Leg Raise Test Modifications

A. Tibial nerve bias: ankle DF and eversion (TED) B. Sural nerve: ankle DF and inversion (SID) C: common peroneal nerve: ankle PF and inversion (PIP)

Red Flags: Ankylosing Spondylitis

At least 4 of the following: -age of pain onset < 40 years old -insidious onset (no trauma) -improvement with exercise/movement -no improvement with rest -pain at night (improvement with upon rising)(later 1/3rd of sleep) -morning stiffness 4 out of 6 need to take a diagnostics Diagnostic tests: HLA-B27 blood test, imaging

Patterns of Back Pain

Back-Dominant Pain/Mechanical Cause: 1. Back/Buttocks (>90% back pain), Myotomes seldom affected, dermatomes not affected = Aggravating moment from flexion/stiff in morning; relieving moment from extension. Cause: disc involvement (minor herniation, spondylosis), sprain, strain. 2. Back/buttocks , myotomes seldom affected, dermatomes not affected = Agg from extension/rotation; Relief from flexion. Cause: facet joint involvement, strain Leg-Pain Dominant/Non Mechanical Cause: 3. Leg (usually below knee), Myotomes commonly affected (especially in chronic cases), Pain in dermatomes = Agg from flexion; Relief from extension; Causes: nerve root irritation (most likely cause - disc herniation) 4. Leg (usually below knee; may be bilateral), myotomes commonly affected (especially in chronic cases), pain in dermatomes = Agg from walking (extension); Relief from rest (sitting and/or postural change); Cause: neurogenic intermittent claudication (stenosis)

Anatomy of Lumbar Spine

Composed of 2 layers -Annulus Fibrosus: Outer layer compromised 15-25 concentric layers of fibrocartilage (type 1 cartilage) --superficial layers innervated --very outermost fibers have blood supply in adults -Nucleus Pulposus: inner layer of well hydrated proteoglycan gel

Spondylolisthesis

Definition: Anterior displacement of vertebral body following fracture or elongation of the pars interarticularis -Different grades (1-4) based on % of anterior displacement Types: -Pars/Isthmic: Pars defects develop from a stress fracture of the congenitally weak pars interarticularis (Kim, 1993) --Common with athletes that perform repetitive hyperextension (gymnastics) -Degenerative (most common): degeneration of lumbar IVD leads to facet hyper-mobility -Congenital (Dysplastic) -Traumatic -Pathologic

Lumbar Spine Pain Referral: Somatic Pain, Discogenic Referred Pain

Disc Provocation -Low back (LB) and hip pain: 9/9 -LB, hip and thigh: 5/11 -LB, hip. thigh, and below knee: 3/5

Red Flags (Not Absolute Truths)

Do not proceed with physical exam/treatment and send for immediate medical care (emergency room/urgent care) -Spinal fracture -Spinal infection -Acute, rapidly progressing cauda equina syndrome Do not proceed with physical exam/treatment and send with immediate follow up with physician -Cancer/malignancy Can proceed with physical exam/treatment with follow up with physician -Ankylosing Spondylitis --No manipulations of spine

Treatment Based Classification

Does the patient: 1. Centralize with 2 or more movements in the same direction (I.e., flexion or extension) OR 2. Centralize with a movement in 1 direction and peripheralize with an opposite movement? Yes = Radiating leg pain and/or related LE pain (possible nerve/disc involvement) = Specific Exercise Classification NO? (continue down) Does the patient: 1. Have a recent onset of symptoms (<16d) AND 2. No symptoms distal to the knee? Yes = Usually associated with lumbar mobility deficits (facet syndrome) = Manipulation Classification NO? (continue down) Does the patient have at least 3 of the following: 1. Average SLR ROM >91 2. Positive prone instability test 3. Positive aberrant movements 4. Age <40 years old Yes = Muscle power coordination deficits (lumbar sprain/strain) = Stabilization Classification NO?? -Which subgroup does the patient best fit?

Facet Syndrome Etiology and Causes

Etiology -Lifting -Bending or twisting -Prolonged flexed posture -Excessive extension Causes -Resolved hemarthrosis, synovitis, or capsular sprain -Immobilizing by bracing or guarding -Lack of congruence in opposing joint surfaces -Entrapment of synovial material or a synovial meniscoid

Stabilization Classification

Factors Favoring -Hypermobility with spring testing -Aberrant motions present -Increasing episode frequency -Younger age (< 40 years) -3 or more prior episodes -Greater SLR (<91 deg bilateral ROM) Factors Against -Discrepancy in SLR ROM (>10 deg) -Low FABQ scores (FABQPA score <9)

Mobilization/Manipulation Classification

Factors Favoring -More recent onset (<16 days) -LBP only (no distal symptoms) -Low FABQ scores (FABW score <19) Factors Against -Symptoms below the knee -Increasing episode frequency -Peripheralization with motion testing -No pain with spring testing

Specific Exercise Classification

Factors Favoring -Preference for one posture -Centralization with motion testing -Peripheralization in direction opposite centralization Factors Against -LBP only (no distal symptoms) -Status quo with all movements

Lumbar Spine Pain Pattern

Low back pain may occur as: -an isolated symptom of an underlying structure: facet joints, annulus, lumbar extensors, posterior spinal ligament (SS, IS, PLL) -in association with referred pain to the buttocks and lower limbs, or sometimes in the groin or abdominal wall

Treatment Based Clafficiation

Medical Management (Red) -"Red flags" -Medical comorbidities precluding rehabilitation -Leg pain with progressive neurologic deficits Rehab Management (Yellow) -Medium-to-high psychosocial risk status -Low psychosocial risk status with predominantly leg pain -Minor or controlled medical comorbidities Self-Care Management (Green) -Low psychosocial risk status -Predominantly axial low back pain' -Minor or controlled medical comorbidities

Red Flags: Spinal Infection

Meningitis, infection after surgery, etc -Recent infection (+LR 9.31) -Fever, chills, or sweating (+LR 1.71, -LR 0.95) (+)2/2: +LR 13.15 -Pain awakens from sleep (presence/absence does not significantly change probability of spinal infection) -Persistent sweating at night -IV drug abuse

McGill: Trunk Endurance Tests in Young, Heathy Individuals

Modified Sorenson Test: -Men 146 +/- 51 sec -Women 189 +/- 60 sec Trunk Flexor Test: -Men 144 +/- 76 sec -Women 149 +/- 99 sec Side Bridge/Plank: -Men 94-97 +/- 34-35 sec -Women 72-77 +/- 31-35 sec

Lumbar Radiculopathy

Nerve-root related pain due to irritation in lateral foramina (usually compressive in nature) -Usually, nerve root is irritated secondary to surrounding tissues: 1. Degenerative spine conditions: degeneration of IVD 2. Disc bulge or herniation 3. Facet hypertrophy or hypermobility 4. Ligamentous hypertrophy 5. Spondylolisthesis (anterior slippage of vertebrae) 6. Red Flags: malignant/benign growth, infection

Straight Leg Raise Test

Neural Tension Test -Sciatic Nerve (L4-S2) --Straight leg raise (SLR) test (Magee, pg 599) ---sensitivity for herniated nucleus pulposus (HNP): 72-97% ---Well's SLR Test: illicit radiating leg symptoms in opposite leg due to increased sciatic nerve tension secondary to disc herniation **In isolating, the test is insufficient to make a diagnosis and shows high sensitivity with heterogenous specificity

Lumbar Disc Nomenclature Version 2.0

North American Spine Society/American Society of Neuroradiology/American Society of Spine Radiology -Bulging Disc: Not considered a herniated disc, but has the presence of disc tissue extending beyond the edges of the ring apophyses throughout the circumference of the disc. -Herniated Disc: either a protrusion or extrusion --Protruded Disc: Present "if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space" --Extruded Disc: Present "if any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space" -A Sequestered Disc: If disc material is beyond the disc space and no longer connected to the remaining disc (a type of extruded disc)

Slump Test

Patient is sitting on edge of table with knee flexed. Patient slumps sits while maintaining neutral postion of head and neck. Follow this progression after: 1.- Passively flex patient's head and neck. If no reproduction of symptoms, move on to next step. 2.- Passively extend one of patient's knees. If no reproduction of symptoms, move on to the next step 3.- Passively dorsiflex ankle of limb with extended knee 4.- Repeat steps 1-3 with opposite leg (+) TEST: reproduction of pathological neurological symptoms

Low Back Pain with Related Lower Extremity Pain

Postural Findings: Lateral trunk shift, reduced lumbar lordosis -Possibly centralization or peripheralization of symptoms with correction of lateral shift Common Impairments Include: -Limited lumbar extension mobility (AROM, segmental mobility) --Restricted forward bending with possible peripheralization with repeated bending --Centralization with repeated backward bending -Thoracic (excessive flexion) and hip (limited flexion) mobility deficits -Reduced trunk and pelvic-region muscle strength and endurance (usually posterior chain) -Movement coordination deficits (usually excessive lumbar flexion) during functional activities Can also have signs and symptoms associated with radiating leg pain category (neuro exam changes, + neurodynamics, etc)

Sahrmann Abdominal Levels

Procedure 1. Having patient perform the movement 2. Have patient activate abdominals (bracing vs hollowing) -Bracing: 25% abdominal contraction needed to improve stability -Cues: --"breathe in slowly and then slowly breathe out and hold that tension" --"Blow out birthday candles" --"cough or clear your throat" --"Breathe in or push out in my fingers" 3. "Failed" Test -Pelvis rotates -Lumbar spine extends -Rib flare -Pain

Lumbar Spine Pain Referral - Radicular Pain

Radicular (Nerve Root) Pain -Characterized by pain which is lancinating or shooting in quality within a narrow band of no more than 1 1/2 inches wide -Radicular pain is commonly considered to be severe, but need not be severe -Associated with paresthesia and positive neurologic signs -May not follow a dermatomal pattern

Neural Tension Test

Sciatic Nerve (L4-S2) -Slump test --Precaution acute herniated disc Femoral Nerve (L2-L4) -Femoral slump test (sidelying)

Herniated Nucleus Pulposus (HNP) Signs and Symptoms

Signs and Symptoms -Symptoms worsen: --Morning --Prolonged sitting --Coughing and sneezing --Rising from sitting -Symptoms reduce: --Standing --Lying --Walking

Lumbar Spine Pain Referral - Somatic Pain

Somatic Pain -Pain from tissues of the lumbar spine other than the nerve root (e.g., discs, facet joints, dura mater, ligaments and muscles) -Quality: deep, dull, aching, and hard to localize --May be sharp in acute conditions --May report cramping sensation with muscle or face capsule pain -Pain is most often referred to buttock, can extend as far as foot -There is much overlap in pain patterns from these structures due to having multisegmental innervation -Considerable variability in pain referral patterns has been shown between individuals

What subjective information and objective information may help you differentiate between a lumbar spinal fracture and lumbar facet joint irritation?

Subj: Age, trauma type, corticosteroid use Obj: No real good signs

What subjective information and objective information may help you differentiate between cauda equina syndrome and lumbar radiculopathy (unilateral nerve root)?

Subj: bilateral vs unilateral, bowel + bladder function Obj: UMN/LMN signs, gait screen

Femoral Slump Test

TEST THE FEMORAL NERVE L2-L4 Test Components - Trunk flexion, knees to chest - Patient holds bottom leg - Active cervical flexion - Passive knee flexion - Passive hip extension Procedure: Patient: - The patient is positioned in side lying on a plinth, with the side to be tested uppermost. Clinician: - Standing behind the patient. - The procedure of the test involves the patient hugging both knees to their chest, with the trunk and cervical spine in flexion, and holding on to the bottom leg. - The clinician then supports and passively moves the top leg - Bring knee into flexion - Bring hip into extension noting any symptom onset and then applies an appropriate sensitising manoeuvre.

Modified Trunk Muscle Endurance Tests: Middle Aged Adults

Test - With LBP - Without LBP Trunk Flexor (Male) - 107.9 sec +- 49.6 - 182.6 sec +- 69.3 Trunk Flexor (Female) - 57.2 sec +-33.2 - 85.1 sec +-44.8 Trunk Extensor (Male) - 85.1 sec +-44.8 - 208.2 sec +- 66.2 Trunk Extensor (Female) - 70.1 sec +-51.8 - 128.4 +- 53.0

Lumbar Anatomy

To find lumbar facets and TPs 1. Push away lumbar paraspinal muscle bulk (if too bulk, may have to apply pressures from contralateral side but need to be aware of line of force) 2. Transverse Processes: 1.o-2.5 inches lateral of spinous processes 3. Lumbar Facets: 0.8-1.2 inches lateral of spinous process