Lumbar spine physical examination in physiotherapy.pptx

Introduction
The presentation titled "Lumbar Spine Physical Assessment" by Avani Akbari outlines a comprehensive approach to examining the lumbar spine. This assessment is crucial for identifying the underlying issues related to back pain and spinal dysfunction.

Anatomy and Applied Anatomy
Facet Joints: The lumbar spine consists of facet joints that bear 20-25% of the load. The superior facets are medially and backward concave, while the inferior facets are laterally and forward convex. These joints control the direction of movement and have a close pack position in extension, which increases the load on the facet joints. Common issues include lumbarization and sacralization.
Intervertebral Discs: These discs function as shock absorbers and facilitate load distribution. They are composed of the annulus fibrosus and the nucleus pulposus, which decreases in water content with age. The discs are avascular, receiving blood supply via diffusion from the cartilage endplate. Disc herniation, protrusion, prolapse, extrusion, and sequestration are conditions that affect the discs, potentially leading to cauda equina syndrome due to spinal cord pressure.
Patient History
Pain Assessment: Includes the type, course, aggravating and relieving factors, posture/movement effects, diurnal variation, and specific red flags like a history of cancer or sudden weight loss.
Stiffness and Weakness: Stiffness in movement, paresthesia, and weakness in the lower limb during activities like walking or climbing stairs are assessed.
Sleeping Position and Micturition: Sleeping positions affecting the spine, and issues like myelopathy and cauda equina syndrome are considered.
Daily Activities: Altered psychosocial behavior and the impact on work and leisure activities are evaluated.
Physical Examination
Observation: Posture is observed from anterior, posterior, and lateral perspectives to check for alignment and any abnormalities.
Active Movements: Assess range of motion (ROM) in different movements without any trick movements. Pain in prolonged flexion, extension, side flexion, and rotation are noted.
Passive Movements: These are more challenging due to body weight and are performed if active movements are pain-free. The end feel of lumbar movements is checked.
Resisted Isometric Movements: These movements are tested in a sitting position, with dynamic and isometric tests for abdominal and extensor muscles, internal/external abdominal obliques, and back rotators/multifidus.
Myotomes: Specific muscle groups corresponding to nerve roots are tested for strength, and resisted isometric pressure is applied.
Functional Assessment
Special Tests:
SLUMP Test: Checks for neurodynamic issues with high sensitivity.
Straight Leg Raising Test: Indicates disc herniation based on pain location.
Passive Lumbar Extension Test: Assesses lumbar instability.
90-90 SLR Test, Ober Test, Rectus Femoris Test, Thomas Test: Evaluate various muscle tightness and nerve involvement.
Reflexes and Dermatome

1. LUMBAR SPIN E PHYSICAL ASSESSMENT Avani Akbari (PT) MPT 2 nd year

2. Physical Examination Active movements Passive movements Resisted isometric movements Myotomes Functional assessment Special tests Reflexes and dermatomes Joint play movements Applied anatomy Patient History Observation Spinal posture OUTLINE

3. Anatomy 10 facet joint facet joint – 20-25% load superior facets – medially and backward, concave Inferior facets – laterally and forward, convex Facet joint control - direction of movement Facet joint close pack position – extension Extension – facet jt load ↑se lumbarization – mobile S1 Sacralization – non mobile L5

4. Anatomy Intervertebral disc – shock absorber & load distribution, allow movement between bones, provide space for nerve through intervertebral foramen, aging – degeneration Annulus fibrosus – 3 zones Nucleus pulposus – 85- 90% water, ↓es with age Iliolumbar ligament – stabilize L5 and prevent forward displacement Ligaments of lumbar spine

5. Applied anatomy Disc – avascular, periphery receives blood supply, other by diffusion from cartilage end plate Nerve supply- posterior-sinuvertebral nerve, lateral-anterior & grey rami communicants Pain-sensitive structure – anterior & posterior longitudinal ligament, vertebra, nerve root and facet cartilage Disc herniation – nucleus pulposus, because direct vertical pressure Protrusion – posterior disc bulge, no damage to annulus Prolapse – still few fibers of annulus intact Extrusion – annulus tear, disc material in epidural space Sequestrated – fragments of disc, out of annulus Pressure on spinal cord – cauda equina syndrome

6. Applied anatomy Different Posture- ↑es pressure on disc Nerve root – intervertebral foramen, named depending on vertebra Ex, L4 between L4-L5 L4- rarely compress L5 – more common for compression L5-S1 – most common site for pathology, because, bear most of weight, L5 is movable and S1 stable, angle between L5-S1 more, more amount or movement

7. C ommo n conditions Spondylosis – injury, degeneration, or trauma to facet joint and disc Spondylolysis – defect In pars interarticularis Spondylolisthesis – forward displaced vertebra Retrolisthesis- backward displacement

8. PATIENT HISTORY Age: disc problem (15-40 yr), AS (18-45 yr), spondylosis (>45 yr) & malignancy (>50 yr) Occupation: strenuous activity, truck drivers and warehouse workers, etc.. Gender: women > men, menstruation, osteoporosis, AS common in men Mechanism of injury: trauma, lifting heavy weight, prolonged standing, stress In low back - men > women (men are taller) Duration: acute (3-4 week), subacute (12 week) or chronic (>3 months) Site of pain: specific joint or general? unilateral pain without radiating- mechanical low back pain (strain, sprain, injury to facet or sacroiliac joint), muscle pain-movement ↓es and pain ↑es with repeated movement, disc involvement- pain in standing ↑es and ↓es with walking. Radiating pain: centralization or peripheralization? Peripheralization- corelate with dermatome, pain radiating below knee (disc pathology), Minor disc injury- pain over back or buttock, L4-anterolateral leg pain, L5- posterior foot, SI pain- back and buttock, referred pain from abdominal organ

9. PATIENT HISTORY Type of pain: deep, Superficial, Shooting, Burning, Aching Course of pain: pain improving, worsening, or same? We can know Condition inflammatory or healing Aggravating factor: pain ↑es by coughing, sneezing, deep breathing or laughing? Suggest neurological issue (pressure on spinal cord), getting into car, long sitting in bed Relieving factor: should be identified and incorporated in treatment Posture/Movement: sitting, lifting, twisting, bending, ( ↑es intradiscal pressure), standing (relaxed standing is cause), walking (extension is cause), prone lying (extension is cause), supine (infection, swelling or tumour), stiffness after rest (AS), mechanical pain (↑es with activity,↓es with rest), prolong forward posture (disc pathology), anterior pelvic tilt Diurnal variation: pain worse in the morning or evening? Pain with day progression? Worse night pain? Degenerative condition- pain more in morning then gradually ↓es

10. PATIENT HISTORY Stiffness in movement: iliopsoas- tightness, abdominals- atrophy, lumbar spasm- difficulty to sit Paresthesia: occur when pressure off nerve root, numbness- with pressure, sensation in perianal area - micturition problems Weakness: In lower limb while walking or stair climbing? Cause: injury to muscle, nerve, reflex inhibition Sleeping position: mattress? Best position- side lying with legs bend, prone- stress on posterior elements, supine- spine flat ↓es pressure Micturition: m yelopathy, cauda equina syndrome, tabes dorsalis, tumor, multiple sclerosis, disc protrusion, spinal stenosis, problems like- retention, loss of awareness to void Red flag: history of cancer, sudden weight loss, immunosuppressive disorder, infection, fever, or bilateral leg weakness Medication: long term steroids-osteoporosis, pain medication before assessment- not give accurate pain reading Daily activities: altered psychosocial behavior, FABQ-scale used, trouble with work, leisure activities, washing, dressing ?

11. Spinal posture OBSERVATION

12. Anteriorly: head on shoulder, nose in line with manubrium, sternum, xiphisternum and umbilicus, shoulder and clavicle, waist angle, ASIS, patella, head of fibula, medial and lateral malleoli should be in line, medial longitudinal arches should be evident & arms in equal distance from trunk Posteriorly: level of shoulder, spine and angle of scapula, lateral curve, waist angle, gluteal, knee level & heels Laterally: Neutral pelvis (ASIS lower than PSIS), earlobe in line with acromion and iliac crest, any curve is ↑es or ↓es? (lordosis) SPINAL POSTURE

13. EXAMINATION

14. Active movements Patient standing, check ROM without trick movement, painful movement done last If pain in prolonged flexion Posture- maintain 10-20 sec Extension- check in standing or sphinx position - 10-20 sec hold Side flexion in standing, measure from fingertip to floor Rotation - in standing or sitting History- pain in combined and repeated movement, that should be assessed Tape measurement- 7-8 cm (flexion), Forward flexion (40° to 60°), Extension (20° to 35°), Side flexion (15° to 20°), Rotation (3° to 18°) Standing flexion- at end pain, supine flexion (knee to chest) - at starting pain, correlate (L5-S1 pathology)

15. Active movements: Mechanical problem - one or more movements are painful, Painful arc? Limited ROM causes - pain, spasm, or stiffness active movements Sequestration- more limited ROM Degenerative condition- sudden shift of muscle (instability) Forward flexion- knee Bend, could be tight hams or nerve root impingement Side flexion affected side painful – disc lesion Side flexion away from painful side – muscular lesion or disc lesion Capsular pattern: side flexion, rotation > extension Quick test: to check lower peripheral joint Modified Trendelenburg test: to check S1 nerve root

16. Passive movements: Difficult to perform because of body weight Active movement free and pain free then only perform End feel of lumbar movement- tissue stretch

17. Resisted isometric movement Sitting position Painful movement should done last Dynamic abdominal endurance test Crook lying, 8 or 12 cm line Crunch, 25/ min speed, without trick Isometric abdominal test (5 grade)20-30, 15-20,10-15, 1-10 Dynamic extensor endurance test , Erector spinae and multifidus Prone, edge of table, straps, do same as above Isometric extensor test , 5 grade, same

18. Resisted isometric movement Internal/external abdominal obliques test: Check same side internal and opposite external oblique Isometric internal/ external abdominal obliques test: 5 grade Side bridge test: Quadratus lumborum Side lying, upper body on elbow, knee flex, lift pelvic, difficult-leg straight Isometric - 5 grade  Back rotators/ multifidus test: quadruped position, 3 variations (5 grade)

19. MYOTOMES Hip flexion L2 Knee extension L3 Foot dorsiflexion L4 Extension of big toe L5 hip extension, Ankle eversion and plantarflexion S1 Knee flexion (S1-S2) Resisted isometric pressure should be applied, Contraction held for 5 sec Check in both extremity Check ankle with knee flexion S ingle leg sit to stand test: for L3-L4

20. FUCTIONAL ASSESSMENT Daily living function got affected, like standing, walking, bending, lifting, traveling, etc Oswestry Disability Index Quebec Back Pain Disability Scale Roland-Morris Disability Questionnaire

21. FUNCTIONAL TEST Biering-Sorensen Fatigue Test Repeated Sit-to-Stand Loaded Reach Test Timed 15 Meter Walk: 7.5 m walk, turn, and come to start position

22. SPECIAL TESTS SLUMP TEST: SLUMP back, overpressure at shoulder, cervical spine flexion, other hand foot dorsiflexion, active knee extension, release cervical spine, High Sensitivity -0.91Low Specificity -0.70 Straight Leg Raising Test: passive test, hip m.rotation & adduction, hip flexion, back pain (disc herniation in center), leg pain (pressure laterally), lower the leg, dorsiflexion or neck flexion, up to 70°- sciatic nerve, >70°- facet jt/SI jt, Sensitivity - 0.67Specificity - 0.26

23. SPECIAL TESTS Passive lumbar extension test: leg lift 30 cm, pull leg, low back pain/ heaviness, pain ↓es with leg release, lumbar instability test, Sensitivity - 0.84Specificity - 0.90 90-90 SLR test : extension within last 20° of extension, Intra rater reliability -0.91

24. SPECIAL TESTS Ober Test: TFL (IT band), stay abducted, don’t fall to table, ideally knee extension, Reliability -0.90 Rectus Femoris Test: edge of table, if knee not maintained 90°, tightness Thomas Test: hip flexor, angle of contracture can be measured, Inter rater reliability - 0.88-0.97Test re test reliability - 0.63-0.99

25. Reflexes Patellar (L3–L4) Medial hamstring (L5–S1) Lateral hamstring (S1–S2) Achilles (S1–S2) Superficial abdominal reflex Posterior tibial (L4–L5)

26. Dermatomes Lateral cutaneous nerve of thigh (L2–L3) Lateral thigh Posterior cutaneous nerve of thigh (S1– S2) Posterior thigh Obturator nerve (L2–L4) Medial thigh Femoral nerve (L2–L4) Anteromedial thigh and leg Saphenous branch of femoral nerve (L2–L4) Anteromedial knee and medial leg Sciatic nerve (L4– L5, S1) Anterior and posterior leg Sole and dorsum of foot Common peroneal nerve (division of sciatic nerve) Anterior leg, dorsum of foot

27. Joint Play Movements Flexion Extension Side flexion Posteroanterior central vertebral pressure (PACVP) Posteroanterior unilateral vertebral pressure (PAUVP) Transverse vertebral pressure (TVP)

28. Orthopedic Physical Assessment, 6th Edition REFERENCE

29. THANK YOU