MSK week 3 summary.pdf

3.1 Lumbar and pelvis examination OBJ: Approach Key components Red and Yellow Flags Listen to your patient Understand Norms IF and THEN Algorithms Rule in and Rule out Limit exam to respect severity and irritability Outcomes Measures Waddell’s signs Fear Avoidance Beliefs Questionnaire FABQ Tampa Ba...

3.1 Lumbar and pelvis examination OBJ: Approach Key components Red and Yellow Flags Listen to your patient Understand Norms IF and THEN Algorithms Rule in and Rule out Limit exam to respect severity and irritability Outcomes Measures Waddell’s signs Fear Avoidance Beliefs Questionnaire FABQ Tampa Bay Scale of Kinesiophobia Acute low back pain screening questionnaire Oswestry COMPONENTS Observations and inspection function ROM MMT Palpation Joint Mobility Special Tests Neuro Assess YELLOW FLAGS (psychosocial) Belief that pain is actually harmful Red Flags Back Pain sickness behaviors (extended rest) Immunosupression Fear and avoiding activity trauma low mood isolation recent onset of bowel or bladder dys problems at work recent fever or chills unsociable hours unexplained weight loss overprotective family or lack of suppor t Malignancy RED FLAGS Serious Spinal Pathology Pain at rest age. Younger than 20 and older than 55 Physical Exam constant progressive non mechanical pain Neuro deficit in LE malaise Saddle anesthesia corticosteroid use Anal Sphinctor weakness history of osteoporosis Fever Posture observe posture when patient isnt expecting it explain posture in work environments, home, sleep, activities Movement How lumbar spine and pelvis move together Function Squat gives ton of information Symmetry? How pelvis moves? Flexibility? Make task meaningful Limit Exam SINS dictates exam. Extent,intensity/difficulty 3.2 Lumbar Spine Examination Lumbar spine examination 1. natural observation - pt doesn’t know (waiting room etc) 2. formal observation - pt knows (asking them to perform sit to stand, may even need assistance) - pt may adjust how they do it bc performing Components of Examination 1. Observation/Inspection - upright posture/different activities/sitting/working/hobbies - LOOK AT DIF ANGLES 2. Fxn 3. ROM 4. MMT 5. Palpation 6. Joint Mobility 7. Special Tests 8. Neurological Assessment Posture • view from multiple angles: ant/post/lat - willingness to WB - LE positioning • identify normal lordotic curve • check for symmetry!!! • observe skin - creases - faces of discomfort • identify muscle development changes Determining List vs. Scoliosis List = protective/habitual - protective: muscle spasm, pull, herniated disc, irritated n root - habitual: discomfort, studying in bed with pillow leaning on one arm, lean when driving • list can be altered in standing but can change symptoms Scoliosis = developed over time • unless kid: see scap winging/position of SP • observed w/ flexion • leg discrepancy • diagnosed w/ observation but confirmed w/ x-ray structural scoliosis: see w/ rot fxnal scoliosis: changes when lay down (dont have) but stand up present List and Herniated Disc (HNP) deviated from pelvis A: is pt trying to get away from something? R side bend • getting away from herniation above n. root • more space = comfy L side bend • pain bc compression of n. root where herniation is B: herniation medial to n. root R lat shift • pain down LE / radiation from irritated n. root L lat shift • clear area no symptoms Correcting a List 1. use your body to shift trunk and stab hip 2. determine rxn When do • irritability is low In photo • direct force to left to take away R shift ROM 1. do exam in same order, put some thought into it 2. watch for deviations 3. get a baseline, move, inquire, return, inquire - “how are you now” 4. proved over pressure if appropriate 5. assess in all planes (lumbar) ex: fwd flexion: lordotic curve? extension: hinging? movement at level? when pain occurs/relieved side bend • see how far can reach to knee crease (see creases on back too) • see segmental mob of spine rot • assess sitting/standing over pressure • stressing structures/tissues quadrant • ext, rot, and side bend • closes foraminal space & closes facets = compromising what are we looking for? • willingness to move • symmetry • creases • muscle spasms/response • compensations - lifting for - rotation - bending the knees MMT • include full LE assessment seated • move to LE/trunk test while laying down • minimize moving up and down L2 - hip flexion L3 - knee ext L4 - DF L5 - great toe ext S1- hip ext S1/S2 - knee flexion Neurological Exam • get baseline • relate to symptoms • record differences side to side • do exhaustive DTRs (3x) Summary • structure exam to current presentation of severity/irritability • follow regime to limit pt from changing positions • capture info via observation/dialogue w/ pt throughout exam • ROM will provide info that can direct special tests/mobility testing 3.3 Lumbar Examination PT. 2 Muscle Length Testing - If able, assess length of hip flexors - Can use Thomas test, legs off table while performing SKTC on 1 side - Important if possible due to attachment to lumbar spine - Iliopsoas could contribute to lumbar dysfunction Palpation - Top of iliac crest, level of L4-L5 interspace - Important when mobilizing, & figuring out segmental movement Joint Mobility: PIVMS & PAIVMS - PIVMS (Passive Intervertebral Movements) - A: Flexion - Take both knees up to chest, while palpating interspaces w/ fingers - B: Extension - Take legs backwards, testing if interspaces are closing - C: Side Flexion - Can take both legs up/or just top one, feeling the side that’s closing at each segmental segment - PAIVMS (Passive Accessory Intervertebral Movements) - What you induce as a force on vertebral level - D: Central PA’s - Central Posterior/Anterior mobilization - Thumbs on spinous process to push post -> ant - E: Unilateral PA’s - Thumbs moved to the side, on transverse process or facets - F:Transverse Vertebral Pressure - On side of spinous process, imparting rotational movement of lumbar spine small, big, big, small Joint Mobilization/Manipulation - Can perform Grades 1-4 on available motion - Outside of physiological range, doing manipulation (Grade 5) - Grades 1-2 - Address more of pain modulation - Grade 1 is small amplitude, Grade 2 is large amplitude - Not into resistance - Grade 3-4 - Grade 3 is large amplitude, Grade 4 is small amplitude - Going into resistance -resistance manipulation - beyond physiological range Grades - Grade 1 - Small amplitude of movement at beginning of range - Grade 2 - Large amplitude of movement at beginning of range - Grade 3 - Large amplitude of movement into resistance near end available range - Grade 4 - Small amplitude of movement performed into resistance near end available range - Grade 5 (HVLA) - High Velocity, low amplitude beyond available range (manipulation) grade 1&2: thumb grade 3&4: hypothenar group # & - Handhold used for grades 3-4 & central PA’s -Using pisiform to press through spinous process, going into resistance/end range wa Use a Sequence - Best advice, have a method - Doing 1-2 first, don’t impart anything that would influence - Can be either starting at L1 or other way around other parts of back - Actual Sequence - Grades 3-4 going into resistances if they can tolerate it - Central PA’s - Assess irritability - (Grades 1-2) - Unilateral PA’s (Unaffected) - (Grades 1-2) - Unilateral PA’s (Affected) - (Grades 1-2) - Return to Start - Central PA’s - (Grades 3-4) - Unilateral PA’s (Unaffected) - (Grades 3-4) - Unilateral PA’s (Affected) - (Grades 3-4) - Compare - Go back on the comments the patient made throughout - Look at what you think are contributing factors & compare with others - Allows you to see what to focus on first, as well as what to go back on in later sessions Special Tests & Neurodynamic Tests - Be selective of the tests you perform - Special tests should not be used in isolation - Consider ‘if & then’ for constructing special tests - Stiff, would go to joint mobility - Feels loose, would go instability tests - Use special tests to rule in or rule out structures - Risk of nerve latency pain w/ neurodynamic tests - Save it for LAST or NOT AT ALL 3.4 pelvic examination dr denney going in order of how she would do her tests while w a pt observation: posture • look for neutral pelvis & normal lordotic curve • inquire if they wear shoe lifts or orthotics posture is key when looking at pelvis • always do in standing • can appreciate inclination bc of lordosis • post aspect: looking at symmetry of PSIS clear the lumbar spine!! even if there is no indication and they dont think the low back is involved in case of stiffness/abnormalities • • perform ROM of lumbar spine & quadrant • may reproduce symptoms so we need to ask where they are experiencing symptoms • quadrant would be include (as mentioned before idk why she put it twice LOL) fxn go based off activities that they have described you ex: step up sit to stand rolling over supine to sit *look what i wrote on her back* palpation • observation/inspection • fxn • ROM • MMT • palpation: comes early -check to see if iliac crest is symmetrical • jnt mobility • special tests • neurological assessment using PSIS would help us see symmetry active mvmnts: baseline, forward flex & ext not much motion • keep hands on PSIS as pt flexes or ext to feel it move flex: ilium moves ant ext: post motion there shouldnt be much motion single leg lift special test: gillette test • ask pt to lift 1 knee up to chest while you palpate PSIS • expect PSIS to move inf on same side that leg is moving into hip flex (or post rot of ilium) • do on both sides leg length symmetry pt in supine • gentle tug of both legs or have pt bridge then lower • tell them NOT to reposition legs after tug • place thumbs on med malleoli and compare to see if look what i wrote on pts legs symmetrical if unequal, consider placing pt in hooklying to • determine if there is a femur (or tibia) length difference (we are looking at knee caps to see if one is higher than the other) leg length: measure • use tape measure • ASIS to med malleoli • compare side to side • document in centimeters jnt mobility: supine 1. post translation of ilium on sacrum (post push in ASIS) 2. asses mobility 3. compare side to side 4. be gentle will feel springy sensation when you push but should be normal (just have to get used to it) • you will KNOW when one doesnt move *could be performed in prone* • supine better bc its easier to push than pull jnt mobility: sidelying testing mobility of pelvic rot • • assess symptom response and overall mobility test both sides or area of concern “driving a bus” bus driver has a big wheel and their elbows are out to side and its a rotational type mvmnt look what i wrote on back post rot of hemipelvis ant translation of hemipelvis jnt mobility: prone • sacral apex pressure test2 i couldn't tell if • spring test • check for symptom response and mobility ~ these were the same test or not PTs hands on apex of sacrum then gently pushing down (counternutation motion for sacrum) summary • palp w mvmnt is crucial w assessment of pelvis • consider relationship of reported symptoms w assessment • communication is critical w assessments • conduct examination in an order that does not require pt to continuously change position