Kin191 A.Ch.10. Lumbar. Thoracic. Evaluation
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Kin191 A.Ch.10. Lumbar. Thoracic. Evaluation

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Kin191 A.Ch.10. Lumbar. Thoracic. Evaluation Kin191 A.Ch.10. Lumbar. Thoracic. Evaluation Presentation Transcript

  • KIN 191A Advanced Assessment of Lower Extremity Injuries THE THORACIC AND LUMBAR SPINE EVALUATION
  • INTRODUCTION
    • HISTORY
    • INSPECTION
    • PALPATION
    • ROM TESTS
    • STRESS/STREE TESTS
    • NEUROGIC TEST
    • VASCULAR TEST
  • HISTORY
    • Location of pain
    • Onset of pain
    • Mechanism of injury
    • Consistency of pain
    • Prior history
    • Aggravating/alleviating factors
    • Activity changes
  • Location of Pain
    • Often difficult to isolate specific location of pain with low back injuries/conditions
    • Radiating pain indicative of nerve root irritation
      • Must have perspective on myotome/dermatome patterns for evaluation
      • Regarding peripheral nerves, must have perspective on nerve root level origin
  • Onset of Pain
    • Acute, traumatic onset of symptoms, while possible, is not a typical presentation of low back pain symptoms
    • May be able to isolate one incident with onset of symptoms, but typically that incident is representative of accumulative stresses over time which reach their “breaking” point
  • Mechanism of Injury
    • Direct trauma may indicate spinal fracture/s and/or internal organ injury
    • Hyperextension activities (gymnastics, FB lineman, etc.) predispose to pars interarticularis injuries
    • Multiple compression and shear forces depending upon activities engaged in
    • Often difficult to isolate specific MOI
  • Consistency of Pain
    • Constant pain
      • If unable to affect pain with position change, associated with inflammation from injury (acute or chronic) – swelling from facet sprain or pars interarticularis fracture
    • Intermittent pain
      • If symptoms impacted (alleviated or aggravated) with spine position, associated with mechanical injury – compression/stretching of nerve root
  • Prior History
    • Must question regarding previous history of low back injury/pain
    • Structural or degenerative changes may predispose to symptoms
    • Scar tissue may irritate tissues causing symptoms
  • Aggravating/Alleviating Factors
    • What makes it better? …worse?
    • Posture/s
      • Prolonged sitting, etc. with activities
    • Activities
      • May have postural component with performance of activities
  • Activity Changes
    • As with many lower extremity injuries/conditions, must be mindful of changes in
      • Intensity of workouts
      • Duration of workouts
      • Training surface
      • Footwear
      • Sleeping arrangements
  • INSPECTION
    • Posture/Curvatures
      • Standing, sitting, with activities (e.g. – lifting)
      • Lateral shift away from pain/nerve root impingement
      • Frontal curvature – scoliosis (see slide 14)
      • Sagittal curvature – excessive/absent lordosis
    • Muscular appearance
      • Evaluate for spasm/atrophy – often readily visible
    • Gait
    • Skin markings
      • Café-au-lait spots (neurofibramatosis), Faun’s beard (spina bifida)
      • Neurofibromatosis
        • Increased cell growth of neutral tissues; normally a benign condition; pain possible secondary to pressure on the local nerves
      • Spina bifida occulta
        • Incomplete closure of the spinal vertebrae
  • Postures/Curvatures
  • Scoliosis
    • Forward flexion test
      • Posterior view of the spinal column while the patient flexes the spine; note the presence of hump over the spine, suggesting scoliosis
      • If functional, “hump” disappears
      • If structural, “hump” present
  • PALPATION (Thoracic Spine)
    • 1. Spinous processes
    • 2. Supraspinous ligament
    • 3. Costovertebral junction
    • 4. Trapezius
    • 5. Paravertebral muscles
    • 6. Scapular muscles
  • PALPATION (Lumbar Spine)
    • 1. Spinous processes
    • 2. Step-off deformity
    • 3. Paravertebral muscles
  • PALPATION (Sacrum & Pelvis)
    • 1. Median sacral crest
    • 2. Iliac crest
    • 3. PSIS
    • 4. Gluteals
    • 5. Ischial tuberocity
    • 6. Greater trochanter
    • 7. Pubic symphysis
  • RANGE OF MOTION TESTS
  • AROM
    • Flexion
      • Measure with distance from finger tips to floor
      • Affected by hamstring/calf/paraspinal tightness
    • Extension
    • Lateral flexion/bending
      • Measure finger tips to floor or at level on LE
    • Rotation
      • Best done in sitting to stabilize pelvis/LE
      • Should be bilaterally equal
  • PROM
    • Flexion
      • Bring knees to chest in supine position
    • Extension
      • Prone position and “press-up” with pelvis on table
    • Lateral flexion/bending
      • Often referred to as side gliding – often eliminated
    • Rotation
      • Knees/hips flexed and rotate pelvis with shoulders on table
  • RROM
    • Flexion
      • Stabilize pelvis, resistance to sternum with “crunch”
    • Extension
      • Stabilize low back, resistance near scapula to “reverse crunch”
    • Lateral flexion/bending – typically not assessed
    • Rotation
      • Stabilize opposite ASIS, resistance to opposite shoulder for “curl crunch”
  • SPECIAL TESTS
    • Ligamentous testing
      • Spring test for facet mobility/irritation
    • Tests for nerve root impingement
      • Valsalva maneuver
      • Milgram test
      • Kernig test
      • Straight leg raise and well straight leg raise tests
      • Quadrant test
      • Slump test
    • Test for malingering
      • Hoover test
  • Spring Test
  • Increased Intrathecal Pressure
    • Increased pressure may compress intervertebral disc forcing nucleus pulposus out causing nerve root irritation/impingement – radiating pain
    • Valsalva Maneuver
      • Seated, simulated bowel movement – hold breath
    • Milgram Test
      • Supine, SLR to a few inches and hold
  • Valsalva Test
  • Milgram Test
  • Kernig’s Test /Brudzinski’s Test
    • Evaluative for nerve root impingement from disc bulge or herniation
    • Supine, perform unilateral SLR with knee extended until pain occurs
    • Flex knee at pain and symptoms should subside
    • Brudzinski’s test – modification with cervical flexion to further stretch neural elements
  • Kernig ’ s test / Brudzinski ’ s test
  • SLR and Well SLR Tests
    • Evaluative for nerve root impingement, typically discogenic in nature
    • SLR test
      • Supine, flex hip (SLR) on affected side to pain with knee extended, back off a little, DF ankle, if symptoms reoccur, + test
    • Well SLR test
      • SLR of opposite (uninvolved) leg, test + if pain felt on opposite side
  • Straight Leg Raise test
  • Well Straight Leg Raise test
  • Quadrant Test
    • Often performed, not often named as such
    • Standing, patient extends then laterally bends and rotates to affected side
    • If radiating pain, indicative of nerve root irritation or impingement
    • If local pain with no radiating symptoms, indicative of facet irritation/sprain
  • Quadrant Test
  • Slump Test
    • Evaluative for nerve root, dural sheath or spinal cord irritation/inflammation
    • Seated, cervical flexion and thoracic “slump” followed by knee extension and ankle dorsiflexion
    • Pain and/or radiating symptoms are + test – due to neural element lengthening/stretch
  • Slump Test
  • Hoover Test
    • Evaluative for malingering patient
    • Supine, clinician holding both heels, patient instructed to perform active SLR on involved side
    • Pressure should be noted in opposite heel by clinician – attempt to stabilize for movement
    • Absence of pressure or inability to do SLR is + for malingering
  • Hoover Test