Stanbridge - T4 - TMT - W2 - Thoracolumbar Spine and Sensory Testing

Objectives of Trunk Testing Study Notes

• Review the spine's anatomy, mainly the thoracic and lumbar regions.
• Learn techniques for measuring the active range of motion in the thoracic and lumbar spine.
• Learn different methods to evaluate the strength of the muscles in the thoracic and lumbar areas.
• Discuss why range of motion and strength are crucial during everyday tasks, mainly for the thoracic and lumbar spine.

Ligaments of the Spine

• The anterior longitudinal ligament runs along the anterior surface of the spine and prevents hyperextension.
• The posterior longitudinal ligament runs along the vertebral bodies inside the vertebral foramen and prevents excessive flexion.
• The supraspinal ligament runs from C7 to the sacrum along the posterior spinous processes.
• The interspinal ligaments run between successive spinous processes.
• The ligamentum nuchae is a cervical ligament that replaces the supraspinal and interspinal ligaments and attaches to the laminae anteriorly.

Thoraco-Lumbar Flexion with Tape Measure

• Landmarks for the flexion test are the spinous processes of T1 and S2; the landmark must be located by touch and confirmed.
• The patient stands, bends forward, and the initial and final readings are measured.
• The therapist stands behind the patient, holds the measuring tape, and stabilizes the pelvis to prevent anterior tilt.
• The tape measure is positioned at T1 and S2, and the difference between the start and end is recorded.
• Normal thoraco-lumbar flexion, measured with a tape measure, equates to a 4-inch (10.16 cm) difference between start and end measurements, as per Norkin and White, 2016.
• The AAOS uses T1-S1, but there is little motion between S1 and S2, S1 is more difficult as a landmark.
• In performing the procedure, the tape measure is aligned between the spinous processes of T1 and S2, allowing it to lengthen with the patient's movement. The difference between measurements assesses the degree of thoracolumbar flexion.
• Pelvis is stabilized to prevent anterior pelvic tilt.

Thoraco-Lumbar Flexion with Double Inclinometers

• Inclinometers are positioned over the spinous processes of T1 and S2 with the patient standing.
• Both inclinometers are zeroed
• At the end of the motion, the values on the two inclinometers are read and the difference between the values are recorded to show the amount of flexion from thoracolumbar region
• Normal ROM with this method is 80 degrees per the AAOS.

Thoraco-Lumbar Extension with Tape Measure

• There are no AAOS norms for this method
• Landmarks: spinous processes of T1 and S2, located through palpation
• Patients stand with feet shoulder-width apart and knees extended.
• The therapist stands behind the patient and holds the measuring tape at two landmarks to stabilize pelvis and avoid posterior tilt.
• Measure initial and final reading, and calculate the difference
• To perform the procedure, place the patient in a standing position with a tape measure aligned between the spinous processes of T1 and S2.
• The tape measure may shorten with movement.
• The distance between the two spinous processes is recorded at the start and end of the movement, and the difference indicates the amount of thoracolumbar extension.
• Double inclinometers can also be used for measurement; position one inclinometer over the SP of T1 and the other over the sacrum at S2.
• Both inclinometers are then zeroed, and at the end of the motion, the readings are compared to determine the amount of extension.
• Normal range of motion is 25 degrees per the AAOS.

Thoraco-Lumbar Lateral Flexion with Goniometer (Side Bend)

• The normal value per AAOS is 0-35 degrees.
• Relevant bony landmarks are T1 and S2 spinous processes; landmarks located via touch
• The patient is in a standing position.
• The therapist must stand behind the patient to stabilize the pelvis to prevent lateral tilt
• When administering the goniometer, position it as follows.
  • The fulcrum is on the spinous process of S2.
  • The stationary arm is perpendicular to the ground.
  • The movable arm is on the T1 spinous process.

Thoracolumbar Rotation with a Goniometer

• Normal range of motion is 0-45 degrees based on the AAOS standards.
• The patient must be seated in a backless chair during administering the goniometer.
• The therapist stands behind the patient and stabilizes the pelvis to prevent rotation.
• The goniometer should be positioned as follows during the test:
  • Fulcrum: center of the cranium (superior view).
  • Stationary arm: parallel to the iliac crest tubercles (palpate).
  • Movable arm: lined with two acromial processes (palpate).

Thoraco-Lumbar Lateral Flexion with Tape Measure

• There are no AAOS norms for this method
• The patient positions with back to wall, feet shoulder width apart, with arms relaxed at their sides.
• Mark where the tip of the 3rd finger touches thigh while in starting position
• The patient then side bends/laterally flexes
• Re-mark where 3rd finger is (in end position) and measure the difference.

Functional Application of Trunk Movement

• Hsieh and Pringle research included 48 participants with a mean age of 26.5 years.
• Sit to stand and stand to sit required 56-66% of lumbar flexion range.
• Putting on socks required 90% of lumbar flexion range.
• Picking up an object from the floor required 95% of lumbar flexion range.

Strength Testing of the Trunk

• Strength testing on the trunk includes tests for the abdominals, lateral trunk, and back extensors.

Muscles of the Trunk

• These can be reviewed: Rectus Abdominis, External Oblique, Internal Oblique, Transversus Abdominis, Erector Spinae group, Transversospinalis group, Interspinalis, Intertransversarii and Quadratus Lumborum

Upper Abdominal Muscle Test

• The patient is supine with legs extended, using a small roll under the knees if posterior pelvic tilt cannot be completed.
• The patient performs a trunk curl slowly, completing spine flexion then moves into hip flexion with strong resistance to abdominal muscles.
• Resistance: feet may be held down during hip flexion, only if the trunk maintains curl and stays in posterior pelvic tilt after completing the spine flexion phase
• Technique:
  • The patient's pelvis tilts posteriorly during the trunk curl to flatten the lower back during the test.
  • After this phase, the pelvis tilts to move over the thigh in hip flexion, but remains in posterior tilt in relation to the trunk
• Test ends if anterior pelvic tilt occurs, as it can cause strain on abdominal muscles and lumbar spine.
• For normal grade abdominal strength, patients slowly curl up while keeping their hands behind their head.
• Good grade: continue into a sitting position, while flexing the spine with arms folded across the chest
• Fair + grade can complete the same test, while extending arms, but not holding full lumbar flexion when entering hip flexion.

Upper Abdominal Muscle Test: Weaker Anterior Trunk Muscles

• Fair grade can perform the test while supine with knees flexed over roll, and are able to approximate pelvis and keep torso stable.
• Poor grade cannot main posterior tilt while raising head
• Trace grade shows a contraction can be palpated, but no movement is observed.

Lower Abdominal Muscle Test

• Targets the rectus abdominis and external oblique (lateral fibers)
• The patient lies supine on a firm surface with forearms folded across the chest.
• The examiner assists to raise both legs of patient to 90 degrees, depending on the patients hamstring range
• The patient posterior pelvic tilts to flatten the lower back, and then both legs are slowly lowered towards the ground.
• The resistance comes from body weight and muscle force
• The examiner should stand by to catch patient if the LEs start to arch, or they come out of posterior pelvic tilt.
• The patient is weak if the head starts to raise, their shoulder's start to come out of the posterior pelvic tilt

Lower Abdominals Grading

• The range of lower extremity movement from the ground determines the grade.
• The test ends when the lumbar spine starts to move into extension, or the pelvis moves out of posterior pelvic tilt.
• The examiner can have a hand at just below ASIS to feel when this occurs.
• The hand should be ready to support LEs if this occurs.
• Strength is graded on the ability to lower the legs from 90 degrees while keeping the back flat.

Plank Test (Strand, 2014)

• A study was conducted with 471 college-aged, healthy participants
• Plank position: forearms and toes supporting body in rigid body position (phalangeal extension, neutral ankle, hip and knee extension, and neutral spine) with humerus perpendicular to horizontal plane, elbow directly beneath shoulders, forearms neutral and hands in front of elbows
• Time starts once proper position has been achieved.
• Conditions for test termination were:
  • Participant has voluntary stopped due to fatigue
  • Participant was not able to maintain the proper position
  • Participant reports symptoms unassociated with fatigue in the test
  • Investigator notices ill effects from the participant during the test
• During testing the participants were given verbal cues on their position and the test is terminated after two uncorrected cues.
• Each subject only performed the test once.
• Duration:
  • All participants averaged 100 seconds +/- 63 seconds
  • Males averaged 124 seconds +/- 72 seconds
  • Females averaged 83 +/- 63 seconds
• On average durations were 49% higher in males.
• Participants with greater activity had longer hold times.

Side Plank Test (Healthy Pain Free) (St. Catherine University, 2014)

• Also known as the side support" or "side bridge test."
• Challenges the quadratus lumborum & anterolateral trunk wall muscles
• There is excellent intra-rater reliability.
• A St. Catherine study had 116 participants with an average age of 28.8 years old, and who were pain free along with other inclusion/exclusion criteria.
• The patient props body up while weight bearing only on one elbow and feet with body in a straight line
• Start timer once correct position is reached
• Stop timer once the individual can no longer hold this position
• Monitor that the body does not drop out of alignment and that the patient's pelvis is not rotating in transverse plane.
• The results of the study show
  • Right Side Plank: mean hold time 54 seconds & Left Side Plank: mean hold time 55 seconds.
• Side plank test results are dependent upon the shoulder complex. Precautions should be taken; pre-adolescents have a joint position that is not centered in the shoulder.
• Side plank variations include the top leg being anterior to the body and medial side of that foot touching the ground.

The Original Sorensen Test (Demoulin, 2004)

• Important to have a chair placed in front of the patient in case fatigue occurs
• In the starting position, have the patient perform a concentric contraction to hold the spine in a horizontal position.
• The patient’s arms should be bent across their chest.
• The patient’s hips should be fully extended.
• The ASIS placed at the edge of the table.
• 3 straps should secure the patient as follows:
  • One strap at the pelvis
  • One strap behind the knees
  • One strap at the ankles
• Visually assessed, this was originally assessed by the clinician
• The test is stopped when the patient can no longer maintain a horizontal position, becomes too fatigued to continue, or experiences pain. If the test is not challenging for 240 seconds, the test is stopped.

The Biering-Sorensen Extension Test (St. Catherine University study)

• Results from test show
  • Female subjects averaged 103.9 seconds versus 95.6 seconds for male subjects.

Sensation Testing General Guidelines

• Always adhere to what is within doctor's Rx, PT POC, your licensure, and all the precautions and contraindications of the patient.
• Always consider what stage of injury/protocol the patient is in, their integumentary/systemic/immune, and other relevant issues when treating
• Bones, skin, muscles, &joints involved in the tests should be stable and have integrity. Consider appropriate testing positions and patient tolerance.
• Monitor and listen to the patient & note any changes in patient status.

Sensory testing

• Thin or sensitive skin must be handled with caution
• Patient must be cognizant and able to follow directions
• Be sure that devices used are appropriate and the patient is as well
• Be sure to set up an appropriate environment in which position the patient is comfortable and draping is sufficient

Sensory Testing Basics

• The patient must be relaxed, educated, & understand the testing procedures
• Testing should be performed efficiently to prevent sensory fatigue
• Vision should be occluded to ensure accuracy
• Vary the stimulus, and don't follow a pattern during testing
• Compare sides of the body
• Start tests in "normal" areas, if applicable.
• Check peripheral or dermatomal distribution of sensation

Review of Dorsal Roots and Peripheral Nerves (Lippert, 2017)

• Dorsal/posterior roots (sensory: nociceptive and proprioceptive, going into spinal cord).
• Dorsal Root ganglion: lies in the intervertebral foramen.
• Ventral/Anterior roots (motor: visceromotor and skeletal muscle afferents, coming out of spinal cord)
• Spinal nerve (sensory and motor) peripheral nerves.
• Rami: Spinal nerve divides into anterior and posterior rami to the level of the transverse process.

Patterns of Sensation

• Dermatome: sensory area of skin supplied by a single spinal nerve and its dorsal root ganglion.
• Cutaneous sensory area: sensory area of skin supplied by a peripheral nerve.
• Areas overlap, especially in trunk dermatomes

Sensory Testing Basic Information

Testing should be completed within and along one dermatome When testing in a peripheral nerve distribution, it should be completed within that one distribution area at a time

Categories of Sensation

Superficial:

• light touch , Sharp/dull Deep:
• proprioception, kinesthesia, vibration, pressure, deep pain Cortical (combined):
• Exteroceptive +Proprioceptive + Cortical sensory association areas
• Bilateral simultaneous stimulation, stereognosis, two-point discrimination, barognosis, localization of touch, graphesthesia
• Start with superficial, then deep, then cortical
• Must have other sensation intact to perform cortical

Light Touch Sensation Testing

• Test using cotton ball, sensory brush, or index finger.
• Use a light stroke/touch without indenting the skin.
• Ensure each dermatome is tested thoroughly by staying within one dermatome.

Light Touch Sensation Testing Procedure

• Orient the tool/device that will be utilized on the patient and explain the test, then obtain consent.
• Perform the test on an unrelated area to ensure patient understands the directions and what the sensation should feel like
• Start on the unaffected side in the appropriate dermatome- palpate spinal level:
  • With eyes open--Move proximal to distal along same dermatome.
  • Ask if they feel it, yes or no with a head nod
  • Then test the dermatome while eyes are closed, moving proximal to distal.
  • If there are any irregularities, note the area along the dermatome where the light touch sensation is not felt by the patient.
• Next, begin test on affected side in the appropriate dermatome – palpate spinal level:
  • Same procedure, tested with eyes close

Temperature Testing

• Often can get overlooked, but it's important to test patients in this category.
• Always ask patient to distinguish between warm and cool
• Temperature testing includes a starting explanation and consent, and by first testing on an unrelated area to ensure patient can discriminate between hot and cold.
• Next, move to the unaffected side/ limb first with the eyes open, then eyes closed, then moving to the affected side with eyes closed.
• Start at the proximal dermatome (after palpation to determine spinal level) and move distally.
• Utilize any of the following procedures: water on washcloth, tuning forks, or test tubes.

Superficial Pain Testing (Sharp/Dull)

• Test using an disposable device.
• Use an unrelated area to establish a sensory baseline: then test unaffected and affected areas with baseline.
• Alternate randomly between sharp and dull.
• Finally, ask the patient to report hypoaesthesia (feels blunter) or hyperaesthesia (feels sharper) and compare side to side

Semmes Weinstein Monofilaments

• Used for objective data collection for protective sensation with patients of various sensory impairments
• The monofilament should be applied to the skin and tested area where it is then pressed to bend the wire.

Grading of Sensation

• A score for the grading system is as follows:
  • Score of 0 is Absent: patient cannot correctly determine question for sensation test
  • Score of 1 is Altered or Impaired: patient's response to sensation test is increased or decreased
  • Score of 2 is Intact or Normal: patient is able to correctly respond to all aspects of test.
  • NT or Not Tested: cannot compare with testing, patient is unable to tolerate, or testing is not appropriate

Therapeutic Measurement and Testing of the Trunk

• Documentation includes goniometry, manual muscle testing (MMT), and sensory testing, with associated guidelines.
• Sensory testing documentation includes the type of test performed.
• It should include the area where the test was performed and the patient's response, the presence of hypoesthesia, hyperesthesia, dysesthesia, or a normal response.
• Grading scores documentation: Intact, poor, fair, good per subjective
• The grading scores assigned are defined as follows: 0 if absent, 1 if impaired, 2 if intact, and NT if not tested.