1. All of the scanning exams. a. Why do we do scanning exams? a. What is the purpose of each and every test in all of the scans? i. Screen for serious pathology ii. Asses status of neurological system iii. Identify areas that need further biomechanical examination 1. AROM is the most important test. Testing Neuro-Muscular Skeletal against gravity 2. Asses for: a. Serious pathology (Cardinal plane no combined motion) i. Orthopedic pathologies 1. Fractures 2. Major muscle injuries 3. Acute joint injuries. b. Once has been identify PIVM are performed. c. Less serious pathologies or chronic (combined motions, or special test performed) AROM Response if + Flexion Site and behavior: 1. does the motion brings leg pain 2. Is the existing pain remains the same? 3. a normal spine at the end of lumbar flexion the lower three segments should appear to be fixed lordosis. Lumbar scan Acute posterior lateral protrusion disc History Observation Response to ROM testing 1. Felt something o back 2. Immediate pain and then not much 3. Next day Worse back pain Appearance of leg pain Hurts to sit, bend, 4. Lateral shift away from painful side 5. Flattened lumbar lordosis Flexion: Limited with Increased leg pain Contralateral deviation ↑ dural stretch Extension Sudden ↑LBP If leg pain= bad Inflammation sensitive to pressure SideB Ipsi = ↑LBP Contra= ↑leg pain Rot Hard to sit Unpredictable
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1. All of the scanning exams. a. Why do we do scanning exams? a. What is the purpose of each and every test in all of the scans?
i. Screen for serious pathology ii. Asses status of neurological system iii. Identify areas that need further biomechanical examination
1. AROM is the most important test. Testing Neuro-Muscular Skeletal against gravity
2. Asses for: a. Serious pathology (Cardinal plane no combined
motion) i. Orthopedic pathologies
1. Fractures 2. Major muscle injuries 3. Acute joint injuries.
b. Once has been identify PIVM are performed. c. Less serious pathologies or chronic (combined
motions, or special test performed)
AROM
Response if +
Flexion Site and behavior: 1. does the motion brings leg pain 2. Is the existing pain remains the same? 3. a normal spine at the end of lumbar flexion the lower three segments should appear to be fixed lordosis.
Lum
bar scan
Acute posterior lateral protrusion disc History Observation Response to ROM testing
1. Felt something o back 2. Immediate pain and then not
much 3. Next day
Worse back pain Appearance of leg pain Hurts to sit, bend,
4. Lateral shift away from painful side
5. Flattened lumbar lordosis
Flexion: Limited with Increased leg pain Contralateral deviation ↑ dural stretch
Extensio
n
Sudden ↑LBP If leg pain= bad Inflammation sensitive to pressure
SideB Ipsi = ↑LBP Contra= ↑leg pain
Rot Hard to sit Unpredictable
Lum
bar scan
Acute posteriomedial disc protrusion
History Observation Response to ROM testing
Similar to posterior Ipsilateral shift
Flattened lordosis
Flexion Limited Reproduction Ipsi leg pain Ipsi deviation
Extension Limited ↑ LBP
SB Ipsi= limited reproduces leg pain Contra= limited and may produce LBP and leg pain.
Rotation Inconsistet results.
Lum
bar scan
Acute Central disc Protrusion History Observation Response to ROM testing
Bilateral leg pain
Numbness/ paraesthesia’s
Flexion or rotation
Flatten lordosis
No shift
Flexion Severely limited Reproduction LBP quickly Reproduction of leg pain quick
Extension Very limited Reproduces Severe LBP If ↑ leg pain = poor prognosis
SB Usually no pain May be limited to muscle spasm ** Differential diagnosis **
Rotation May not be able to test in sitting Incosistent results.
Lum
bar scan
Instability History Observation Response to ROM testing
Previous Hx of trauma Long hx of LBP Double jointed (congenital) C/O giving out minimal activity May have Chiro. success. Pain ↑ with Extension Hurts supine with legs straight May complaint of leg pain may be somatic
No shift ↑ Lordosis or not Non consistent findings.
Flexion WNL ROM Not painful Gowers Sing
Extension Acute:
Inability to do it SubAcute:
Can do it ↓ROM
Often ↑ LBP (ante shearing mechanism of incompetent)
Causes SDB -Typically unrestricted -Clinically important ( rules out extension loss) biomechanics of lumbar facet motion. -May reproduce pain wit Con-SB
Rotation -Sitting will tighten up TFL -Facets and neural arches resist -Typically not painful except in severe degeneration.
Lu
mb
ar scan
Z joint Arthritis History Observation Response to ROM testing (if degenerative)
Flexion Not much restricted depending on the level of injury
Extension The most painful Restricted
Possible causes Sbing Ipsilateral restriction and pain.
-Pain is not Isolated. -Capsular pattern; EX/Rot/Sding affected side. Radicular= if Nerve root injured
Rotation Ipsilateral restriction and pain.
Lum
bar scan
Lateral Stenosis History Observation Response to ROM testing
-Older patients -LBP/leg pain ↑ activity -Activity in stooped position -Hurts lie in supine -Resemble instability found in younger population.
-May attempt to hold back in flexed position -If severe, could develop contralateral shift
Flexion Usually loss ROM
Relieves pain
May Gower sing/depends etiology.
Extension May/may not reproduce pain time dependent
Sbing Ipsi Sbind if sustain ↑ leg pain
Rotation Since is performed in sitting pain free.
Lum
bar
Scan
Central Stenosis
Most compelling findings is the presence of cauda equine or cord S&S
Patter of AROM will reflect primary causative agent.
Possible bilateral loss sensory, motor, reflex.
Lumbar stress test
Test Rationale Response/ and results
Compression overload Test
Damage to vertebral body, end-plate or disc will create and inflammatory reaction. The resultant paint will be aggravated by any intra-vertebral or intra discal pressure. (Not done with NO trauma patients, or three months chronic pain)
Reproduction of the reported pain constitutes a positive test and indicates damage to the vertebral body, end-plate disc. *If test is negative then we can start flexion exercises.
Torsion Test Torsion is resisted by annular fibers of the disc and therefore, also by their attachment to the end-plate. Torsion is also resisted by Z-joints and therefore also the neural arches between them. Test is designed for acute pathologies. Fractured neural arch, unlike the compression test this test may be used to assess even very chronic pathologies due to mechanical pain.
Reproduction of pain with 1 phase (Lower Thoracic and opposite innominate) then segmental testing.
1. Unilateral positive: a. Possibility of a fracture through
Z-joint (compression) b. Or Traumatic arthritis c. In chronic dysfunction a positive
result = Segmental instability 2. Bilateral positive: pain in both
directions indicates the possibility of : a. Acute disc-end plate lesion b. Or a fracture neural arch
P/A shearing Test
1) First a rapid PA 2) Then a slow PA
a) Reproduction of pain + soft end feel indicates possibility of segmental PA instability.
Reproduction of patient’s pain with initial, rapid PA thrust indicates:
1. Possibility of an acute segmental dysfunction
2. Or irritable segmental dysfunction A slow PA will reproduce more pain.
Lum
bar Scan
nin
g
Iliolumbar ligament History /Patophysiology function / History Response to ROM Testing
Attaches to L5 Sacrum Several parts
Tip of anterior inferior aspect of L5 TP
Runs laterally and splits in two bands
o Lower band: across and anterior SI Jt ligament to reach posterior marging of iliac fossa.
o Upper band: QL attach, passes iliac crest, anterior to SI joint is continous with TFL
Stabilizer of lumbrosacral junction; prevents shearing of L5 on S1 Hx: 1. Can become involved with a problem affecting L5/S1 2. L2 innervation can produce concurrent
Dermatomal distribution (will be more painful tingling sensation, longer periods of time.
Constant tingling needles with dermatome distribution without necessarily becoming numb= Pressure on a NERVE ROOT
Peripheral Nerve Root Compression Felt over a small area
Will be identifiable (segemental)
Peripheral distribution
Low intensity tingling (rapidly proceeded by numbness)
Non painful (unless neuritis is involved) short lived (minutes to hours) rapid progresses to numbness
Bilateral, constant tingling in the “glove and sock” distribution, with or without numbness == Peripheral neuropathy
Dietary insufficiency Over massive areas o Both arms and legs. o Even trunk.
RSD or Nerve Root Traction Non segmental o Segmental o Or multisegmental
Sliding Tension Protective
Gen
eral D
escriptio
n
Distal tension makes pain decreased Full ROM
Distal tension makes pain increased full ROM at joints ROM limitations exist only by pain, may have full PROM
Distal tension makes Pain increased ROM at joints limited muscle tension.
Symp
tom
s
1. c/o aches and pain at site along course of nerve 2. Sx distance related with time tethering 3. If not inflamed sx intermittent 4. Sx reproduction when move through it’s full ROM
1. Aches and pain 2. Possible paresthesia 3. Impairment of sensation 4. May be intermittent 5. only occur when nerve is tensioned or has a sustain posture that tension the nerve
1. Altered muscle dysfunction occurs in a pattern that protects a specific neural structure.
Histo
ry
1. Hx possible interface dysfunction 2. repetitive motion with terminal ROM 3. Use it, it gets worse, 4. Rest improves
1. Stretching out brings the patient symptoms.
Ph
ysical fin
din
gs
1. Confusing 2. Additional tension component may relief pain ON = ON = Reduce pain ON = OFF = may ↑ Sx
1. AROM & PROM loss ROM when nerve under tension Proximal ON= distal OFF = ↑ Sx Proximal ON= Distal ON = Sx worse Proximal OFF= Distal ON = ↑Sx.
1. Will ↑muscular resistance to motion 2. Need test Nuero 3. Muscular resistance ON= ON may ↑ Sx.
Neruodynamic Testing of the lumbar Scan
SSLL
RR
Test: 1. Taking up the slack 0-35° 2. Assessing ability of neural tissue to glide 30°-60° 3. The remaining motion is tensioning: nerves, and articular and
myofascial elements. If suspect hx of inflammatory process is best to start with SLR rather than Slump T. Response:
1. If sx are produced within the expected ROM the key is to reproduce and decreased symptoms with Foot/Ankle (distal component) and Head/ Neck(proximal component)
2. Test done over the other leg. If Symptoms are reproduced on contralateral leg and reproduces LBP and/or Ipsilateral leg symptoms == BAD PROGNOSIS == sure large disc injury.
3. If both are negative then repeat with both legs at the same time == Sign of central disc lesion.
4. If negative to this but positive to Slump test == disc lesion sensitive to WB compression.
5. Sitting position: WB causes disc to protrude enough to cause symptoms.
6. Supine position body weight relieved the protrusion is no longer enough to produce sx.
Slump If pt c/o sounds like radicular pn but SLR didn’t reproduce sx perform the Slump T.
Prone Knee Bending
1. Test nerve roots from L1-L4. a. Note commonality of L4 in both SLR and Slump test and PKB
test
Passive Neck Flexion
Consider a very sensitive test if reproduces pain in the LB or in the legs o CLASSIC MENINGITIS
SIJ RISK GROUP 1. Ankylosis Spondylitis == usually starts c/o pain in the SIJ. (late teens)
2. Hypermobility Syndrome == a. Ehler’s Danloss Syndrome b. Marfan’s syndrome c. Generalized hypermoblity (womens)
3. Pregnancy
4. Specific trauma
5. Chronic loss of hip motion
6. Chronic LBP problem
Key Muscles Associated with Assessing Nerve Root Function
Upper limbs nerve root key muscle alternative
C4 diaphragm levator scapulae
C5 supraspinatus infraspinatus
C6 biceps extensors of wrist
C7 triceps flexors of wrist
C8 extensor pollicis longus opponens pollicis
T1 medial two palmar interossei
Lower limbs nerve root key muscle alternative
L2 psoas major
L3 quadriceps hip adductors
L4 tibialis anterior may affect quadricps
L5 extensor hallucis longus hip abduction
L5 & S1 peroneals EDL
S1 hamstrings, gastrocnemius FHL, FDL
S2 gluteus maximus hamstrings, FDL, FHL
Dermatomes
Although it is well accepted that there is not one absolutely correct dermatome chart, for testing
purposes, we need to all be thinking the same thing. So for testing purposes, please use this
dermatome chart.
Cervical
C1-2: Scalp. Central portion of anterior and posterior neck side of head, upper half of ear, cheek and
upper lip.
C3: Entire neck. Lower mandible, chin, and lower half of the ear.
C4: Top of shoulder, front of chest including pectoral region, and lower half of neck.
C5: Shoulder, front of the arm, and forearm to base of thumb.
C6: Lateral arm and forearm, thumb, and index finger.
C7: Back of the arm and forearm, INDEX, LONG, and RING finger; primary supply of tip of middle finger
C8: Inner, medial forearm, inner half of the hand, LONG, RING, and LITTLE fingers.
T1: Inner side of forearm as far as the wrist
T2: A ‘Y’ shaped area stretching from the inner conovle of the humerus at the elbow, up to the arm and
dividing into two areas reaching to the sternum anteriorly and the vertebral border of the scapula
posteriorly.
T3: Area on front of chest and patch in axilla.
T4
T5 >Around trunk to level of nipple. T6 T7-9: Around trunk to lower costal margin T9 T10 >Around trunk to lower costal margin T11 T12: Probably to groin and area between iliac crest and greater trochanter. L1: Lower abdomen and groin: skin at L2-4, and upper and outer aspect of buttock.
L2: Lower lumbar and upper buttock: medial thigh.
L3: Upper buttock: anterior and slightly medial aspect of thigh , knee and leg to medial malleolus.
L4: Outer thigh and leg crossing to the medial border of the ankle and foot including the BIG TOE.
L5: Outer aspect of the leg, the top of the foot, the FIRST, SECOND, and THIRD TOES, inner half of the SOLE of the foot.
S1: The lower half of the posterior aspect of the leg and ankle, the outer half of the SOLE of the foot and the LAST TWO TOES.
S2. Back of the thigh and leg, back of the heel and the planter aspect of the heel. Some books show S2 as not going to the heel saying that S1 does the entire heel.
S3: Area around the anus, strip following the inguinal ligament, and inner thigh to the knee.
S4: Saddle area, anus, perineum, scrotum, and penis. Vagina and labium, and inner most thigh.
UPPER QUADRANT
SENSORY INNERVATION
AREA SEGMENTAL PERIPHERAL
Ear and over jaw C2 Greater auricular
Lateral neck C3 Transverse cutaneous
Upper traps to skin over upper chest C4 Supra-clavicular
Lateral arm C5 Upper-Axillary Lower- Radial
Posterior Arm C5 Radial
Posterior-lateral hand Over 1st interosseous
C6 Radial
Posterior forearm C7 Radial
Lateral forearm C6 Musculo-Cutaneous
Antero-lateral hand including 3 ½ digits and finger tips C6 Median
Lateral palm and palmar surface of middle 3 ½ digits C7 Median
Anterior and posterior lateral hand including med 2 digits C8 Ulnar