Examination, evaluation & Assessment of Spine Musculoskeletal Physical Therapy Lecture For D.P.T students

1. Examination, evaluation & Assessment of spine
Dr. Abid Ullah PT
Lecturer FIMS
Abbottabad
Email:
dr.abidullahpt@yahoo.com

2. OBJECTIVES
 Review the clinical anatomy and physical exam of the
spine
 Formulate a pathoanatomic diagnosis in the clinical
setting
 Discuss common clinical conditions that can be
elicited from the physical exam

3. INTRODUCTION:
 Vertebral column consists of a number of separate irregular bones
called VERTEBRAE
 Forms the central axisof the body
 Functions:
Provides protects for spinal cord.
Supports and transmits body weight.
Provides attachment toaxial muscles.
Provides movement of the trunk
Stability of the trunk and the extremities

5.  Vertebrae arenamedaccording to region in which they lie.
 There are33 vertebrae butonly 31 spinal nervesand 23 intervertebral
disks.
Vertebrae Number Spinal Nerve Number
Cervical 7 Cervical 8
Thoracic 12 Thoracic 12
Lumbar 5 Lumbar 5
Sacral 5 Sacral 5
Coccygeal 4 Coccygeal 1
 In adults, 5 sacral vertebrae fuse together to form ‘sacrum’ 4 coccygeal vertebrae
fuse togetherto form ‘coccyx’.

6. ANATOMY OF LUMBAR SPINE

7.  A smallest functional unit in a spine.
 One mobile segment=two adjacent vertebrae, the
intervening intervertebral disk and all the soft tissue
around.

8. The mobile segment
A smallest functional unit in a
spine.
One mobile segment=two
adjacent vertebrae, the
intervening intervertebral disk
and all the soft tissue around.

9. A typical vertebra
Consist of two major parts
 anterior -vertebral body
 posterior -neural arch
 which provide the gliding mechanism for
movement

10. Intervertebral Foramina
 The intervertebral foramina are b/w each vertebral
segment in the posterior pillar
 their anterior boundary is the intervertebral disk
 the posterior boundary is the facet joint
 the superior and inferior boundaries are the pedicles of the
superior and inferior vertebrae of the spinal segment.
 The size of the intervertebral foramina is affected by spinal
motion,

11. Structure and Function of Intervertebral Disks
 consisting of the annulus fibrosusand nucleus
pulposus
 Annulus fibrosus.
 The outer portion of the disk is made up of dense layers of
collagen fibers and fibrocartilage.
 helps restrain the various spinal motions as a complex
ligament.
 The annulus fibrosus is supported by the anterior and
posterior longitudinal ligaments .

12.  Nucleus pulposus.
 The central portion of the disk
 located centrally in the disk except in the lumbar spine, where
it is situated closer to the posterior border than the anterior
border of the annulus.
 With flexion the anterior portion of the disk is compressed,
and the posterior is distracted.

13. PATHOLOGY OF THE INTERVERTEBRAL DISK
 Herniation:
 any change in the shape of the annulus that causes it to bulge beyond
its normal perimeter
 Protrusion:
 nuclear material is contained by the outer layers of the annulus and
supporting ligamentous structures
 Prolapsed:
 frank rupture of the nuclear material into the vertebral canal.
 Extrusion:
 Extension of nuclear material beyond th confines of the posterior
longitudinal ligament or above and below the disk space, as detected
on magnetic resonance imagine (MRI), but still in contact with the disk
 Free sequestration:
 the extruded nucleus has separated from the disk and moved away
from the prolapsed area

14. LUMBAR DISC PROLAPSE
 It is condition in which there is out pouching of the
disc Nucleus pulposus along with few annular fibres
and end plate cartilage through the tears in annulus
fibrosus into the extradural space.
 the most common diagnosis of sciatica.
 98% of intervertebral disk prolapse cases involve L4-
L5 or L5-S1 lumbar disk space

15.  AGE: 20 – 45 years
 SEX: Males affected than females by about 3:2
 MOST COMMON LEVEL: L5-S1 ( 46.9%), L4-L5 o
(40.4%), and 2.1 % at the upper three disks were
present.
 MOST COMMON TYPE: Posterior or Posterolateral
protrusions are most common

16. CAUSES
 Repetitive movements:
 Forwards bending, twisting, haveay lifting
 Traumatic injury to lumbar discs
 commonly occurs when lifting while bent at the waist, rather than
lifting with the legs while the back is straight.
 Living a sedentary lifestyle
 Obesity
 Spinal degeneration can be quickened as a result of the burden of
supporting excess body fat.
 Practicing poor posture
 Improper spinal alignment while sitting, standing, or lying down
strains the back and neck.

17. symptoms
 aggravated with activities that increase the intradiskal
pressure, such as
 sitting, forward bending, coughing, or when attempting to
stand after being in a flexed position
 Forward bending is limited
 Numbness, paraesthesia
 Radiating pain in a dermatomal pattern
 decreased straight leg raising,
 The sciatic nerve is the most commonly affected nerve
 The femoral nerve can also be affected and cause the
patient to experience a numbness
 Pain back,buttocks, thigh, may radiate into the foot and/or toe.

18.  Symptoms can affect the lower
back,buttocks, thigh, anal/genital region (via
the Perineal nerve), and may radiate into the foot
and/or toe.
 The sciatic nerve is the most commonly affected
nerve, causing symptoms of sciatica.
 The femoral nerve can also be affected and cause
the patient to experience a numbness, tingling
feeling throughout one or both legs and even feet
or even a burning feeling in the hips and legs.

19. Stenosis
 Spinal stenosis is a narrowing of the spaces within
spine, which can put pressure on the nerves that travel
through the spine
 foraminal spinal stenosis nerve root canal, or
foramen (lateral stenosis)
 central canal stenosis. refers to a narrowing of the
spinal canal

20. causes
 caused by soft tissue structures such as
 a disk protrusion,
 Aging: degenerative changes to the spine, osteoporosis
 Arthritis: Osteoarthritis, R.A,osteophyte formation
 Congenital: Spinal canal is too small at birth
 Instability of the spine: spondylolisthesis
 Trauma
 Tumors: joint swelling or by bony narrowing
 With progression, neurological symptoms develop

21. symptoms
 Standing discomfort
 lower limb numbness, weakness, diffuse or radicular
leg pain associated with paresthesi (bilaterally),
 weakness and/or heaviness in buttocks radiating into
lower extremities with walking or prolonged standing.
 Symptoms occur with extension of spine
 Relieved with spine flexion
 Relived by lying in supine

22. Spondylolysis
 Spondylolysis is a crack or stress fracture develops through
the pars interarticularis, which is a small, thin portion of
the vertebra that connects the upper and lower facet joints
 Spondylolysis is a crack or stress fracture in one of the
vertebrae, the small bones that make up the spinal column.
 Common site : fifth & fourth vertebra of the lumbar
(lower) spine
 most often occurs in children and adolescents who
participate in sports that involve repeated stress on the
lower back, such as gymnastics, football, and weight lifting.

23. Spondylolisthesis
 In some cases, the stress fracture weakens the bone so
much that it is unable to maintain its proper position
in the spine—and the vertebra starts to shift or slip out
of place. This condition is called spondylolisthesis
 If left untreated, spondylolysis can weaken the
vertebra so much that it is unable to maintain its
proper position in the spine. This condition is called
spondylolisthesis.

24. History
 Children: spondly0sthesis, TB
 Adolescent:

25. INSPECTION
 Lordosis
 Scoliosis
 Swelling
 Gate: Antalgic gate, heel walking L5, Toe walking S1
 Deviation
 Muscle atrophy

26. - Muscle spasm
- Color changes
- Abnormal hair
- Postural changes

27.  Bone – Joint:
 Spinous processe
 Interspinous spaces
 Facet joints
 İliac crests
 Coccyx

28. • SOFT TISSUES
• Swelling
• Ligaments
• Umblicus (L3-4)

29. Flexion ( 40-60 degree)
Extension ( 20 -35 deg)
Lateral Flexion ( 15 -20 deg)
Rotations (3-18 deg)
Repetitive motion
Combine movements

30. Neurologic examination
 Slump test
 (1) Identifies dysfunction of neurologic structures supplying the lower
limb.
 (2) Patient sitting on edge of table with knees flexed. Patient slump sits
while maintaining neutral position of head and neck. The
 following progression is then followed.
 (a) Passively flex patient's bead and neck. If no reproduction of
symptoms move on to next step.
 (b) Passively extend one of patient's knees. If no reproduction of
symptoms move on to next step.
 (c) Passively dorsiflex ankle of limb with extended knee.
 (d) Repeat flow with opposite leg.
 (3) Positive finding is reproduction of pathologic neurologic
symptoms.

31. Slump Test & its Modification
Slump Test (ST1) Slump Test
(ST2)
Side Lying Slump
Test (ST3)
Long Sitting
Slump Test (ST4)
Cervical spine Flexion Flexion Flexion Flexion, rotation
Thoracic &
lumbar spine
Flexion (slump) Flexion
(slump)
Flexion (slump) Flexion (slump)
Hip Flexion (90+) Flexion (90+),
abduction
Flexion (20+) Flexion (90+)
Knee Extension Extension Flexion Extension
Ankle Dorsiflexion Dorsiflexion Planter Flexion Dorsiflexion
Foot ---- ---- ---- ----
Toes ---- ---- ---- ----
Nerve Spinal cord, cervical
& lumbar nerve
roots, sciatic nerve
Obturator
nerve
Femoral nerve Spinal cord, cervical
& lumbar nerve
roots, sciatic nerve

32. Lasegue's (straight leg raising) test.
 Identifies dysfunction of neurologic structures that
supply lower limb.
 Patient supine with legs resting on table.
 Passively flex hip of one leg with knee extended until
patient complains of shooting pain into lower limb.
Slowly lower limb until pain subsides then passively
dorsiflex foot.
 Positive finding is reproduction of pathologic
neurologic symptoms when foot is dorsiflexed.

33. Cont…
 The neck flexion movement called Hyndman’s sign,
Brudzinski’s sign, lidner’s sign and the soto-Hall test
 The ankle dorsiflexion movement has also called the
Bragard’s test
 Pain that increased with neck flexion, ankle dorsiflexion or
both indecates stretching of the dura matter of the spinal cord
or lession within the spinal cord ( disc herniation,
tumor,meningitis)
 Pain that does not increased with neck flexion may indicate
tight hamstring, lumboscaral, sacroillic joint

34. Cont…
 Sicard’s test involves straight leg raising & the
extension of big toe instead of dorsiflexion. It is
identical to bragard test with one exception : the
greater toe is dorsiflexed instead of the foot
 Turyn’s test involve only extension of big toe .
Dorsiflexion of the greater toe with the knee extended
& the hip positioned neutrally. – to cause
radicular/sciatic pain if an extradural lesion is present

35. Cont…
 With unilateral straight leg raising, the nerve root,
primarily the L5, S1 & S2n nerve roots( sciatic nerve)
are normally completely stretched at 70 deg
 Pain after 70 deg is probably joint pain from lumbar
area ( facet joint, sacroiliac joint)

36. Straight Leg Raise Test & its Modifications
SLR
(Basic)
SLR 2 SLR 3 SLR 4 SLR 5
Hip Flexion &
Adduction
Flexion Flexion Flexion &
Medial
Rotation
Flexion
Knee Extension Extension Extension Extension Extension
Ankle Dorsi-
flexion
Dorsi-
flexion
Dorsi-
flexion
Planter
flexion
Dorsiflexio
n
Foot ---- Eversion Inversion Inversion ----
Toes ---- Extension ---- ---- ----
Nerves Sciatic &
Tibial
Nerve
Tibial
Nerve
Sural Nerve Common
Peroneal
Nerve
Nerve Root
( Disc
Prolapse)

37. Femoral nerve traction test
 Identifies compression of femoral nerve anywhere
along its course. (L2-L4)
 Patient lies on non-painful side with trunk in neutral,
head flexed slightly, and lower limb's hip and knee
flexed. Passively extend hip while knee of painful limb
is in extension. If no reproduction of symptoms flex
knee of painful leg.
 Positive finding is neurologic pain in anterior thigh.

38. Valsava maneuver.
 Identifies a space occupying lesion.
 Patient sitting. Instruct patient to take a deep breath
and hold while they "bare down" as if having a bowel
movement.
 Positive finding is increased low back pain or
neurologic symptoms into lower extremity.

39. Babinski test
 Identifies upper motor neuron lesion.
 Patient supine or sitting. Glide bottom end of a
standard reflex hammer along plantar surface of
patient's foot.
 Positive finding is extension of big toe and (abduction)
of other toes.

40. Quadrant test or Kemp’s test
 Identifies compression of neural structures at the
intervertebral foramen and facet dysfunction.
 Patient standing.
 (a) Intervertebral foramen: cue patient into side bending
left, rotation left, and extension to maximally close
intervertebral foramen on Lhe left. Repeat to other side.
 Facet dysfunction: cue patient into side bending left,
rotation right, and exten+sian to maximally compress facet
joint on left. Repeat to other side.
 Positive finding is pain and/or paresthesia i.n the
dermatomal pattern for the involved nerve root or localized
pain if facet dysfunction.

41. Stork standing test
 Identifies spondylolisthesis.
 Patient standing on one leg. Cue patient into trunk
extension. Repeat with opposite leg on ground.
 Positive finding is pain in low back with ipsilateral leg
on ground

42. McKenzie's side glide test
 Differentiates between scoliotic curvature versus
neurologic dysfunction causing abnormal curvature
(lateral shift) of trunk.
 Test is performed if "lateral shift" of trunk is noted.
Patient standing. Stand on side of patient that upper
trunk is shifted towards. Place your shoulders into
patient's upper trunk and wrap your arms around
patient's pelvis. Stabitize upper trunk and pull pelvis
to bring pelvis and trunk into proper aligrunent.
 Positive test is reproduction of neurologic symptoms
as alignment of trunk is corrected.

43. Table for assessment of spine
Muscle
Strain
Herniatio
n Nucleus
Pulposus
Osteoart
hritis
Spinal
Stenosis
Spondylo
thesis
Scoliosis
Age 20-40 30-50 >50 >60 20 30
Pain
pattern
location
Back
unilateral
Back, leg
unilateral
Back
unilateral
Leg
bilateral
Back Back
Onset Acute Acute Insidious Insidious Insidious Insidious
Standing
Sitting
Bending
S.L.R - + - + (Stress) - -
Plane
X-ray
- - + + + +