Lower Back Assessment PDF

Lower Back Assessment *What follows is key observations, anatomy palpation, ranges of motion, & special orthopaedic tests* Bony Palpation Iliac Crest PSIS Spinous Process of L1-L4 TVP’s Sacrum Coccyx Soft Tissue Palpation Paraspinal Muscles Quadratus Lomborum Lumbar Fascia Gluteal Muscles (Glut Med,...

Lower Back Assessment *What follows is key observations, anatomy palpation, ranges of motion, & special orthopaedic tests* Bony Palpation Iliac Crest PSIS Spinous Process of L1-L4 TVP’s Sacrum Coccyx Soft Tissue Palpation Paraspinal Muscles Quadratus Lomborum Lumbar Fascia Gluteal Muscles (Glut Med, Min, Max, Piriformis) Ranges of Motion of the lower back Active ROM (AROM) - Patient copies movement of practitioner or is told to move in particular direction Movements should be done in an order such that expected painful ones are done last and no residual pain is carried over from the previous movement. If very acute, some movements may be left out to avoid exacerbation of symptoms. ACTIVE ROM: Flexion = 40 - 60 degrees Patient Seated or standing Arms crossed if sitting and patient leans forward If standing, try to touch toes Extension = 0 - 15 degrees Patient seated and Extends back Lateral Flexion = 15 - 20 degrees Patient seated with arms crossed and Laterally bends Rotation = 3 - 18 degrees Patient seated with arms crossed and Rotates Passive ROM Patient seated with arms crossed Examiner applies an over pressure to the end of each active ROM to assess end feel Resisted ROM Patients is seated with arms crossed Examiner resists all of the lumbar AROM Assess for weakness Special Orthopaedic Tests Lower Limb Tension Tests 1 & 2 1. Sciatic Nerve - LLTT 1. Perform the Straight Leg Raising Test (Test is below) 2. Postive = Radicular Symptoms 2. Femoral Nerve - LLTT 1. Patient lying prone 2. Examiner stands on the same side as assessment 3. Grasps the patient's ankle and passively flexes the knee bringing the ankle to the patient's buttocks 4. Positive = radicular symptoms in the anterior thigh along the femoral nerve distribution If the examiner is unable to flex the patient's knee past 90° because of a pathological condition in the hip, the test may be performed by passive extension of the hip while the knee is flexed as much as possible. Unilateral neurological pain in the lumbar area, buttock, or posterior thigh may indicate an L2 or L3 nerve root lesion Other Special Tests Straight Leg Raising Test or Lasegue’s Patient lying supine, hip is medially rotated and adducted Lift involved leg upward by supporting the foot around the calcaneus (keep knee straight) Positive = Pain at 10-30 degrees Indicates = Tight Hamstrings (Ask where pain is_ Positive = Pain at 35-70 degrees Indicates = IVD pressure on sciatic nerve (usually a lateral herniation) Positive = Pain at 70 degrees or more (Ask where pain is) Indicates = SI joint pain Well Leg Raising Test (WLR Test) Patient in supine while doctor raises the uninvolved leg Positive = back and sciatic pain on the opposite side Indicates = Further presumptive evidence of a space occupying lesion such as a herniated disc (usually a medial herniation Bragard’s Test (Sign) Patient lying supine or sitting Doctor lifts leg off table like in SLR Test to the level of pain Examiner then lowers the leg just below the level of pain and adds dorsiflexion of the ankle stretching the sciatic nerve Positive = pain radiating below knee Indicates = disc herniation, neural impingement Valsalva Test Patient is seated, takes a deep breath and blows out with closed mouth (like straining at stool) Positive = Pain in back or down the legs Indicates = A space occupying lesion causing an increase in intrathecal pressure Kemp’s Test Place patient in standing position Instruct the patient to slowly extend, sideband, and rotate the thorax and lumbar spine to the affected side. The idea is to have the patient run their fingertips of the hand on the affected side down the posterolateral aspect of the affected leg as far as they can go. This movement helps to compress the intervertebral foramen, the nerve root and the facet joints on that side Positive: Radiating pain or other neurological signs in the affected leg (nerve involvement) or localized pain (Facet involvement) **The picture is a bit misleading. Patient is in proper position but the examiner is applying pressure to the right shoulder. This is technically called the Quadrant Test. Without applying pressure, it is the Kemp Test.*** Bechterewis Test The patient sits with a flexed neck. The patient is asked to extend one knee at a time. If no symptoms result, the patient is asked to extend both legs simultaneously. Positive = Symptoms in the back or leg Indicates = Sciatic Nerve Involvement Belt Test (Supported Forward Bend Test) The patient is in a standing position. The examiner stands behind the patient and asks the patient to bend or flex forward until the lumbosacral pain is felt. The patient then returns to the upright position. The examiner again asks the patient to bend forward. The examiner, this time, supports the patient’s sacrum with his or her thigh and guides the movement by grasping both the ilium (pelvis immobilized). Positive: Pain Disappears Indicated: Sacroiliac Syndrome Gillet’s Test/Marching Test While the patient stands, the squatting examiner palpates the PSIS’ with one thumb and the other thumb parallel with the first thumb on the sacrum. The patient is then asked to stand on one leg while pulling the opposite knee up toward the chest. This causes the innominate bone on the same side to rotate posteriorly and the sacrum to rotate to the same side. The tcst is repeated with the other leg palpating the other PSIS. Positive = If the sacroiliac joint on the side on which the knee is flexed moves minimally or up, Indicates = the joint is said to be Hypo-mobile, Normally, the tested PSIS moves down or inferiorly Single Leg Lumbar Hyperextension Test Patient stands in the straddle position with one lower limb extended behind the other The patient stands on one leg and extends the spine while balancing on the leg Patient then leans back as far as possible while examiner prevents patient from falling over Test is repeated with lower limb position reversed Positive = pain in the back and is associated with a pars interarricularis stress. Indicates = Spondylolysis and spondylolisthesis Piriformis Test Side lying with the involved side up Flex upper hip (testing side) 60-90 degrees Flex knee 90 degrees Stabilize the hip with doctor's free hand Downward pressure with doctor's other hand Positive = Pain in the piriformis area or recreation of symptoms Indicates = Tight Piriformis or piriformis syndrome Brudzinski-Kernig Test The patient is supine with hands cupped behind the head The patient then flexes the head onto the chest The patient then raises the extended leg ACTIVELY by flexing the hip until pain is felt When pain is felt, the patient flexes the knee and to make pain disappear Positive = If pain is felt and goes away with knee flexion Indicates = Meningeal irritation, dural irritation, or dural Involvement Hoover Test The patient is supine The examiner places one hand under each calcaneus The patient is then asked to lift one leg off the table, keeping the knees straight Positive: If patient does not lift the leg or the examiner does not feel pressure under the opposite heel Indicated: Malingering Milgram’s Test Patient lies supine and actively lifts both legs at the same time, off the table about 2-4 inches Holding this position for 30 seconds. Positive = If patient can’t hold for 30 seconds or symptoms are reproduced Indicates = Lumbosacral pathology