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


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

  1. 1. KIN 191A Advanced Assessment of Lower Extremity Injuries THE THORACIC AND LUMBAR SPINE EVALUATION
  2. 2. INTRODUCTION <ul><li>HISTORY </li></ul><ul><li>INSPECTION </li></ul><ul><li>PALPATION </li></ul><ul><li>ROM TESTS </li></ul><ul><li>STRESS/STREE TESTS </li></ul><ul><li>NEUROGIC TEST </li></ul><ul><li>VASCULAR TEST </li></ul>
  3. 3. HISTORY <ul><li>Location of pain </li></ul><ul><li>Onset of pain </li></ul><ul><li>Mechanism of injury </li></ul><ul><li>Consistency of pain </li></ul><ul><li>Prior history </li></ul><ul><li>Aggravating/alleviating factors </li></ul><ul><li>Activity changes </li></ul>
  4. 4. Location of Pain <ul><li>Often difficult to isolate specific location of pain with low back injuries/conditions </li></ul><ul><li>Radiating pain indicative of nerve root irritation </li></ul><ul><ul><li>Must have perspective on myotome/dermatome patterns for evaluation </li></ul></ul><ul><ul><li>Regarding peripheral nerves, must have perspective on nerve root level origin </li></ul></ul>
  5. 5. Onset of Pain <ul><li>Acute, traumatic onset of symptoms, while possible, is not a typical presentation of low back pain symptoms </li></ul><ul><li>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 </li></ul>
  6. 6. Mechanism of Injury <ul><li>Direct trauma may indicate spinal fracture/s and/or internal organ injury </li></ul><ul><li>Hyperextension activities (gymnastics, FB lineman, etc.) predispose to pars interarticularis injuries </li></ul><ul><li>Multiple compression and shear forces depending upon activities engaged in </li></ul><ul><li>Often difficult to isolate specific MOI </li></ul>
  7. 7. Consistency of Pain <ul><li>Constant pain </li></ul><ul><ul><li>If unable to affect pain with position change, associated with inflammation from injury (acute or chronic) – swelling from facet sprain or pars interarticularis fracture </li></ul></ul><ul><li>Intermittent pain </li></ul><ul><ul><li>If symptoms impacted (alleviated or aggravated) with spine position, associated with mechanical injury – compression/stretching of nerve root </li></ul></ul>
  8. 8. Prior History <ul><li>Must question regarding previous history of low back injury/pain </li></ul><ul><li>Structural or degenerative changes may predispose to symptoms </li></ul><ul><li>Scar tissue may irritate tissues causing symptoms </li></ul>
  9. 9. Aggravating/Alleviating Factors <ul><li>What makes it better? …worse? </li></ul><ul><li>Posture/s </li></ul><ul><ul><li>Prolonged sitting, etc. with activities </li></ul></ul><ul><li>Activities </li></ul><ul><ul><li>May have postural component with performance of activities </li></ul></ul>
  10. 10. Activity Changes <ul><li>As with many lower extremity injuries/conditions, must be mindful of changes in </li></ul><ul><ul><li>Intensity of workouts </li></ul></ul><ul><ul><li>Duration of workouts </li></ul></ul><ul><ul><li>Training surface </li></ul></ul><ul><ul><li>Footwear </li></ul></ul><ul><ul><li>Sleeping arrangements </li></ul></ul>
  11. 11. INSPECTION <ul><li>Posture/Curvatures </li></ul><ul><ul><li>Standing, sitting, with activities (e.g. – lifting) </li></ul></ul><ul><ul><li>Lateral shift away from pain/nerve root impingement </li></ul></ul><ul><ul><li>Frontal curvature – scoliosis (see slide 14) </li></ul></ul><ul><ul><li>Sagittal curvature – excessive/absent lordosis </li></ul></ul><ul><li>Muscular appearance </li></ul><ul><ul><li>Evaluate for spasm/atrophy – often readily visible </li></ul></ul>
  12. 12. <ul><li>Gait </li></ul><ul><li>Skin markings </li></ul><ul><ul><li>Café-au-lait spots (neurofibramatosis), Faun’s beard (spina bifida) </li></ul></ul><ul><ul><li>Neurofibromatosis </li></ul></ul><ul><ul><ul><li>Increased cell growth of neutral tissues; normally a benign condition; pain possible secondary to pressure on the local nerves </li></ul></ul></ul><ul><ul><li>Spina bifida occulta </li></ul></ul><ul><ul><ul><li>Incomplete closure of the spinal vertebrae </li></ul></ul></ul>
  13. 13. Postures/Curvatures
  14. 14. Scoliosis <ul><li>Forward flexion test </li></ul><ul><ul><li>Posterior view of the spinal column while the patient flexes the spine; note the presence of hump over the spine, suggesting scoliosis </li></ul></ul><ul><ul><li>If functional, “hump” disappears </li></ul></ul><ul><ul><li>If structural, “hump” present </li></ul></ul>
  15. 15. PALPATION (Thoracic Spine) <ul><li>1. Spinous processes </li></ul><ul><li>2. Supraspinous ligament </li></ul><ul><li>3. Costovertebral junction </li></ul><ul><li>4. Trapezius </li></ul><ul><li>5. Paravertebral muscles </li></ul><ul><li>6. Scapular muscles </li></ul>
  16. 16. PALPATION (Lumbar Spine) <ul><li>1. Spinous processes </li></ul><ul><li>2. Step-off deformity </li></ul><ul><li>3. Paravertebral muscles </li></ul>
  17. 17. PALPATION (Sacrum & Pelvis) <ul><li>1. Median sacral crest </li></ul><ul><li>2. Iliac crest </li></ul><ul><li>3. PSIS </li></ul><ul><li>4. Gluteals </li></ul><ul><li>5. Ischial tuberocity </li></ul><ul><li>6. Greater trochanter </li></ul><ul><li>7. Pubic symphysis </li></ul>
  19. 19. AROM <ul><li>Flexion </li></ul><ul><ul><li>Measure with distance from finger tips to floor </li></ul></ul><ul><ul><li>Affected by hamstring/calf/paraspinal tightness </li></ul></ul><ul><li>Extension </li></ul><ul><li>Lateral flexion/bending </li></ul><ul><ul><li>Measure finger tips to floor or at level on LE </li></ul></ul><ul><li>Rotation </li></ul><ul><ul><li>Best done in sitting to stabilize pelvis/LE </li></ul></ul><ul><ul><li>Should be bilaterally equal </li></ul></ul>
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  21. 21.
  22. 22.
  23. 23. PROM <ul><li>Flexion </li></ul><ul><ul><li>Bring knees to chest in supine position </li></ul></ul><ul><li>Extension </li></ul><ul><ul><li>Prone position and “press-up” with pelvis on table </li></ul></ul><ul><li>Lateral flexion/bending </li></ul><ul><ul><li>Often referred to as side gliding – often eliminated </li></ul></ul><ul><li>Rotation </li></ul><ul><ul><li>Knees/hips flexed and rotate pelvis with shoulders on table </li></ul></ul>
  24. 24.
  25. 25. RROM <ul><li>Flexion </li></ul><ul><ul><li>Stabilize pelvis, resistance to sternum with “crunch” </li></ul></ul><ul><li>Extension </li></ul><ul><ul><li>Stabilize low back, resistance near scapula to “reverse crunch” </li></ul></ul><ul><li>Lateral flexion/bending – typically not assessed </li></ul><ul><li>Rotation </li></ul><ul><ul><li>Stabilize opposite ASIS, resistance to opposite shoulder for “curl crunch” </li></ul></ul>
  26. 26.
  27. 27. SPECIAL TESTS <ul><li>Ligamentous testing </li></ul><ul><ul><li>Spring test for facet mobility/irritation </li></ul></ul><ul><li>Tests for nerve root impingement </li></ul><ul><ul><li>Valsalva maneuver </li></ul></ul><ul><ul><li>Milgram test </li></ul></ul><ul><ul><li>Kernig test </li></ul></ul><ul><ul><li>Straight leg raise and well straight leg raise tests </li></ul></ul><ul><ul><li>Quadrant test </li></ul></ul><ul><ul><li>Slump test </li></ul></ul><ul><li>Test for malingering </li></ul><ul><ul><li>Hoover test </li></ul></ul>
  28. 28. Spring Test
  29. 29. Increased Intrathecal Pressure <ul><li>Increased pressure may compress intervertebral disc forcing nucleus pulposus out causing nerve root irritation/impingement – radiating pain </li></ul><ul><li>Valsalva Maneuver </li></ul><ul><ul><li>Seated, simulated bowel movement – hold breath </li></ul></ul><ul><li>Milgram Test </li></ul><ul><ul><li>Supine, SLR to a few inches and hold </li></ul></ul>
  30. 30. Valsalva Test
  31. 31. Milgram Test
  32. 32. Kernig’s Test /Brudzinski’s Test <ul><li>Evaluative for nerve root impingement from disc bulge or herniation </li></ul><ul><li>Supine, perform unilateral SLR with knee extended until pain occurs </li></ul><ul><li>Flex knee at pain and symptoms should subside </li></ul><ul><li>Brudzinski’s test – modification with cervical flexion to further stretch neural elements </li></ul>
  33. 33. Kernig ’ s test / Brudzinski ’ s test
  34. 34. SLR and Well SLR Tests <ul><li>Evaluative for nerve root impingement, typically discogenic in nature </li></ul><ul><li>SLR test </li></ul><ul><ul><li>Supine, flex hip (SLR) on affected side to pain with knee extended, back off a little, DF ankle, if symptoms reoccur, + test </li></ul></ul><ul><li>Well SLR test </li></ul><ul><ul><li>SLR of opposite (uninvolved) leg, test + if pain felt on opposite side </li></ul></ul>
  35. 35. Straight Leg Raise test
  36. 36. Well Straight Leg Raise test
  37. 37. Quadrant Test <ul><li>Often performed, not often named as such </li></ul><ul><li>Standing, patient extends then laterally bends and rotates to affected side </li></ul><ul><li>If radiating pain, indicative of nerve root irritation or impingement </li></ul><ul><li>If local pain with no radiating symptoms, indicative of facet irritation/sprain </li></ul>
  38. 38. Quadrant Test
  39. 39. Slump Test <ul><li>Evaluative for nerve root, dural sheath or spinal cord irritation/inflammation </li></ul><ul><li>Seated, cervical flexion and thoracic “slump” followed by knee extension and ankle dorsiflexion </li></ul><ul><li>Pain and/or radiating symptoms are + test – due to neural element lengthening/stretch </li></ul>
  40. 40. Slump Test
  41. 41. Hoover Test <ul><li>Evaluative for malingering patient </li></ul><ul><li>Supine, clinician holding both heels, patient instructed to perform active SLR on involved side </li></ul><ul><li>Pressure should be noted in opposite heel by clinician – attempt to stabilize for movement </li></ul><ul><li>Absence of pressure or inability to do SLR is + for malingering </li></ul>
  42. 42. Hoover Test