www.fisiokinesiterapia.biz

Laboratory Manual Evidence‐based Examination & Selected Interventions for Patients with Lumbo‐Pelvic Spine & Hip Disorders

www.evidenceinmotion.com

1

10/26/2009

Evidence‐based Examination and Selected Interventions for Patients with Lumbo‐Pelvic Spine & Hip Disorders

LABORATORY SESSION

Weekend Ground Rules

• Lab intensive focus

• Flow will be examination, intervention, exercise instruction, & supplemental Home Exercise Program (HEP) – Test – treat – retest - instruct

• Discussions encouraged (open forum – don’t be shy!)

• Keep discussions evidence–based whenever possible

• Provide quality feedback to partners

– SOFT THERAPEUTIC HANDS!!!

• Skill Check: Faculty assessment & self assessment

2

10/26/2009

EXAMINATION PROCEDURES (DAY 1)

Neuoromotor sensory Screening Examination AROM with overpressure (standing/sitting); Standing Quadrant Stork (SI Fixation) & Standing Flexion Test Seated Flexion test Thoracic Screening‐ Sitting Hip Screening‐ Sitting SLR test FABER (Patrick) test; FADDIR‐Hip Scour; PA Spring (Spring Test) – Central and Unilateral Prone Instability Test (PIT) Segmental Examination‐transverse process through arc of motion (Sitting Flexed, Prone, Prone on Elbows) Observation of Curves

Sensory Screen

☼ L1: Inguinal area ☼ L2: Anterior mid-thigh ☼ L3: Medial knee ☼ L4: Medial malleolus ☼ L5: Distal medial dorsum of foot ☼ S1: Lateral border of foot ☼ S2: Medial / posterior calcaneus

3

10/26/2009

Motor Function

•L2-3 Hip flexors

•L3-4 Knee extensors

•L4 Ankle dorsiflexors

•L5 Hallux extension

•L5-S1 Ankle plantar flexors

•S1-S2 Ankle evertors

•Positive finding- significant weakness or diminished resistance relative to opposite side

Reflex- MSR/DTR

• Quadriceps (femoral nerve, L2-4): Tap center quadriceps tendon with reflex hammer. Observe for leg movement or quadriceps muscle twitch

• Gastroc-Soleus (posterior tibial nerve, L5-S1): Tap Achilles tendon superior to calcaneal insertion with reflex hammer. Observe for foot movement

• MSRs may be facilitated by having patient grasp fingers and pull apart with maximum isometric effort (Jendrasik maneuver).

• Positive Finding: Diminished amplitude of movement compared to the opposite side

• Babinski (UMN)

4

10/26/2009

Vascular Screen

Abdominal Aorta Femoral Artery

Dorsalis Pedis Posterior Tibial

Functional Quick Tests

• Patient demonstrates activity that causes symptoms or therapist identifies functional activity that is problematic

• Frequent ‘functional quick tests for the LPH – Step-Up, Step-Down, Squat, gait, bending/lifting – Sit-to-stand,gait, don/doff socks, crossing legs, etc – Work required activity

• Assess quality, ROM, pain (0-10), symptom location

• Use for: – Re-assessment after interventions (‘test/retest’) – Differential diagnosis of primary pain generator

5

10/26/2009

Postural Examination

Bony Landmarks

Posterior: – Gluteal Folds - crease – PSIS – skin dimple – Iliac Crests (IC) - elevate soft-

tissue, apply inward pressure, lower hands until top of IC contacted

Anterior – Iliac Crests – ASIS

6

10/26/2009

Lumbar AROM (w or w/o overpressure)

• Flexion • Extension • Side bending • Quadrant – sustained

• Identify a Comparable Sign ** – Remember to re-test after treatment!

Goniometry: Placement at T12

• Place bubble inclinometer at T12 level – Sagittal plane for flx/ext – Frontal plane for SB

• Zero out the inclinometer prior to AROM initiation

• When re-measuring, be sure to place at same level again

7

10/26/2009

Goniometry: Flexion & Extension

Flexion • Patient assumes standardized foot

position, goniometer placed • Patient fully flexes trunk without

bending knees. • Therapist records measurement at

end-range to nearest degree Extension • From starting position, patient fully

extends trunk without bending knees (therapist may support)

• Therapist records measurement at end-range to nearest degree

Goniometry: Side bending

Side bending • Patient assumes standardized

foot position, goniometer placed

• Patient instructed to slide hand down thigh and fully side- bends trunk without bending knees.

• Therapist records measurement at end-range to nearest degree

• Repeat on opposite side

8

10/26/2009

AROM Flexion With Overpressure

• Standardize patient positioning • Ask the patient to fully flex the

lumbar spine while keeping the knees straight

• Apply overpressure by adducting your arms

• Add neck flexion to differentiate adverse neural dynamics from other sources of pain or decreased ROM

• Note end-feel, range, pain and resistance

AROM Extension With Overpressure

• Standardize patient positioning

• Ask the patient to fully extent his lumbar spine

• Apply overpressure as indicated

• Note end-feel, range, pain and resistance

9

10/26/2009

Lumbar Quadrant

• Standardize patient positioning

• Stabilize the pelvis

• Guide the patient into Left

• Rotation, LSB and Extension

• Sustain for 5 seconds if needed

• Note end-feel, range, pain and resistance

Range of Motion Assessment

• Aberrant Motion Assessment – 1. Painful Arc in Flexion – 2. Painful Arc on Return

from Flexion – 3. Gower’s Sign – 4. Instability Catch – 5. Reversal of

Lumbopelvic Rhythm

10

10/26/2009

Stork / Gillet Test

Standing Flexion & Stork Test

Standing Flexion Test • Patient assumes standardized foot position • The therapist palpates the inferior aspects of

the PSIS with thumbs or index fingers and judges symmetry of PSISs

• The patient fully flexes and the therapist judges PSIS symmetry in the fully flexed position

• Positive finding - More cephalward motion of one PSIS relative to the other PSIS

• The patient places both feet together • The therapist palpates the inferior aspect of the PSIS of tested side with one

thumb and mid-point of sacrum (~S2) with other thumb •The patient flexes his hip and the therapist judges if inferior and lateral movement of the tested PSIS occurs relative to the sacrum. •Positive finding- No inferior movement of thumb on PSIS

Spine vs. Hip Differentiation

• The therapist can localize movement to hip by ensuring trunk and pelvis move as a unit.

• Repeat rotation again, but this time the therapist localizes movement to the lumbo-pelvic region by stabilizing the pelvis.

Positive findings:

1) Reproduction of symptoms when the lumbo-pelvic region rotates as a unit implicates a hip dysfunction 2) Reproduction of symptoms when the pelvis was stabilized implicates a dysfunction originating primarily from the spine

11

10/26/2009

Landmarks & Sitting Flexion Test

• Iliac Crests • PSIS • Sacral inferior lateral angles (ILA) • Transverse Processes (T12-L5)- Palpate ~1

cm lateral to spinous process • Paraspinal muscles

Sitting Flexion Test • Palpate inferior aspect of PSIS with

thumbs or index fingers, judge symmetry of PSISs

• The patient fully flexes, therapist judges PSIS symmetry in fully flexed position

• Positive finding- More cephalward motion of one PSIS relative to the other PSIS

Thoracic Screening

• The therapist stabilizes the pelvis and hips by supporting the patients knees as shown

• Passively rotate the patient’s trunk in both directions

• Apply overpressure at end range.

Positive Finding: Reproduction of pain or familiar symptoms. If positive, a detailed exam of the thoracic spine and rib cage should be considered.

12

10/26/2009

Hip Screening

Therapist stabilizes the iliac crest opposite the tested lower extremity (LE)

FABER (flexion, abduction, & external

rotation) • Rest ankle of tested LE on opposite

knee. Apply downward pressure over knee of tested LE, apply overpressure when endpoint reached

F/Add (flexion, adduction) • Rest knee/posterior thigh of tested LE on

opposite knee. Apply adduction force over lateral knee of tested LE, apply overpressure when endpoint reached

Hip Internal & External Rotation

• The patient sits with his hands under his thighs so that his arms stabilize the thighs laterally

•The therapist sights between knees and passively internally rotates (IR) the hips bilaterally

• Passively external rotation (ER) of each hip is performed individually

•Apply overpressure at end-range for both IR & ER

•Positive Findings: Judgments regarding pain and/or limited motion are made. Examine further if positive

13

10/26/2009

Straight Leg Raise

• With the patient supine and close to the edge of the plinth, passively flex the hip while maintaining the knee in full extension

Hip Quadrant/Scour (FADDIR)

• Hip flex/add/IR with overpressure

• Note end-feel, range, pain and resistance sure

14

10/26/2009

Hip FABER

• Stabilize opposite pelvis first

Five-Factor

Prediction Rule

• Duration of symptoms < 16 days

• FABQ work subscale 18 or less

• Symptoms not distal to the knee

• At least one hip internal rotation PROM > 350

• Hypomobility at one or more lumbar levels with spring testing

Flynn, et al. Spine 2002 Childs et al. Annals Int Med 2004

15

10/26/2009

Prone Lumbar Central/Unilateral PA

• Segmentally palpate lumbar spine • Note end-feel, range, pain and resistance

– Rate as hypomobile, hypermobile, or normal • Comparable sign **

Hip Internal ROM

Internal rotation • Abduct the left lower extremity ~ 300

• Flex the right knee to 900 with the tibia perpendicular to the horizontal plane

• Place the goniometer inferior to the lateral malleolus and zero • Internally rotate hip until the opposite (left) pelvis/buttock begins to

rise • Record measurement

16

10/26/2009

Prone Instability Test

• P-A spring test for pain provocation

• Identify painful segments

• Repeat P-A with pt’s hips extended

• Positive finding – previously painful segments become pain-free

Segmental Exam Flexion-Neutral-Extension

• Identify painful segments • Sense quality of tissue, asymmetry, and “blink” response

Flexion Neutral Extension

17

10/26/2009

MANUAL THERAPY PROCEDURES

Lumbo-Pelvic (SI Regional) Supine Manipulation

Lumbar Sidelying Rotational Manipulation

Lumbar Sidelying Rotational Manipulation-Flexion Bias (towel roll)

Lumbar Sidelying Rotational Manipulation-Extension Bias

Long Axis SI Regional & Hip Traction Manipulation

Thoraco Lumbar Rotational Manipulation

Sacro-Iliac Region Manipulation: Supine

Treat the Right Side

• Translate the pelvis towards you and maximally side-bend the patient’s lower extremities and trunk to the right

• Without losing the right sidebending lift & rotate the trunk so the patient rests on their left shoulder

• Contact the patient’s right ASIS with your left hand • Grasp the top shoulder and scapula with your right hand and rotate the trunk to the

left while maintaining the right side-bending • Once the right ASIS starts to elevate, perform a smooth thrust in an anterior to posterior

direction • Reassess symptoms and impairments

18

10/26/2009

’

’

Sacro-Iliac Region Manipulation: Supine with Alternate Operator

Arm Position

Treat the Right Side

• Same set up as previous technique

• Instead of shoulder/scapular grip, thread your cephalid forearm through the patient s arms. Rest your fingertips on the patient’s sternum or the table.

Gap Left L4-L5

Segmental Neutral “Gapping” Manipulation

• Flex the top leg until you first begin to

palpate motion at L4-L5 interspace; place the patient’s foot in the popliteal fossa as shown

• Grasp the patient’s right arm and shoulder and induce right sidebending & left rotation until you begin to palpate motion at the L4-L5 interspace

• Place your left thumb on the left side of the L4 SP & position the patient s arms around your left arm

• While maintaining your setup log roll the patient towards you

• While monitoring the right side of the L5 SP, use your right arm to induce a high velocity, low amplitude (HVLA) thrust in anterior direction

19

10/26/2009

Alternative S/L Neutral Lumbar Manipulation –

Gibbons & Tehan

Close Right L4-5

Extension (Closing) Manipulation

• Grasp the trunk and translate towards

you until you localize the extension to the L4-L5 motion segment

• Rotate the patient’s body to the right until you begin to palpate motion at the L4-L5 motion segment

• Place your right thumb or finger on the right side of the L4 SP & position the patient’s arms around your right arm as demonstrated

• Log roll the patient towards you • With your left arm induce a high

velocity, low amplitude thrust in anterior and cephalic direction

20

10/26/2009

Long-Axis Distraction Manipulation

(Hip & SI Region Modification)

Thoraco-Lumbar Junction: Rotational Manipulation

Left Rotation T12/L1

• With the patient seated and straddling the plinth, rest the patient’s arms on a pillow over your left shoulder

• Reach underneath the patient’s opposite axilla and grasp the lateral scapula

• Use your right pisiform to contact the right transverse process of T12

• Induce left spinal rotation with your left arm and body

• Engage the restrictive barrier • Apply a low velocity, high

amplitude thrust into left rotation

21

10/26/2009

FLEXIBILITY Muscle Balance Testing & Stretching

(DAY 1)

Piriformis (Above 90 degrees)

Piriformis (Below 90 degrees)

Piriformis above 90 degrees in supine

• Externally rotate and flex the hip

• Add to the stretch by adducting the hip toward the opposite shoulder.

• Once the restrictive barrier is engaged, use a sustained stretch or muscle energy technique.

22

10/26/2009

Piriformis below 90 degrees in supine

• Position the lower extremity with the hip in a position of flexion, adduction, internal rotation with the patient’s foot stabilized on the lateral side of the opposite lower extremity if possible

• Manually stabilize the ipsilateral innominate with one hand and use the other hand to impart more adduction / internal rotation

• Progress the technique by adding more adduction / internal rotation

• Once the restrictive barrier is engaged, use a sustained stretch or muscle energy technique.

THERAPEUTIC EXERCISE

Pelvic Rock (6-12)

TrA & Multifidus Basic Retraining in Supine & Quadruped

Side Support (Plank) Exercise

Lumbar Extension Principle Progression

23

10/26/2009

Opening in Supine: Pelvic Rock

• Posteriorly tilt the pelvis to flex the spine

• Reassess symptoms and painful or restricted activities or movements after performing the self mobilization

Note:

• The therapist may use verbal or tactile cues to train the patient to mobilize the appropriate region

• Placing a small pillow or towel roll under the distal buttock may be used to bias the pelvis / spine into more flexion

Closing in Supine: Pelvic Rock

• Anteriorly tilt the pelvis in an on and off manner to mobilize the spine into extension

• Reassess symptoms and painful or restricted activities or movements after performing the self mobilization

Note:

• Adding left sidebending &/or left rotation may facilitate more closing on the left (and vice versa for the right)

24

10/26/2009

Lower Abdominal Contraction Assessment:

Quadruped

• In quadruped, have the patient assume a neutral spine position and assess his ability to contract the lower abdominal muscles

• A proper contraction is a flattening or drawing in of the lower abdomen

• Good control and endurance is achieved when the patient is able to perform ten 10 second contractions

• Potential verbal cues may include: – “Draw your lower abdomen inward

away from your pants” – “Pull your lower abdomen toward

your spine” – “Draw your abdomen flat below your

belly button” • Discourage substitution patterns • Retraining may also be performed in this

position

Lower Abdominal Contraction

Assessment: Hook-Lying

• In hook-lying, have the patient assume a neutral spine position and assess his ability to contract the lower abdominal muscles

• A proper contraction is a flattening or drawing in of the lower abdomen

• Good control and endurance is achieved when the patient is able to perform ten 10 second contractions

• Potential verbal cues may include: – “Draw your lower abdomen inward

away from your pants” – “Pull your lower abdomen toward

your spine” – “Draw your abdomen flat below

your belly button” • Discourage substitution patterns • Note: Retraining may also be performed

in this position

25

10/26/2009

Stabilization Treatment

Quadratus Lumborum

Oblique Abdominals

Side Support with Knees Flexed

Side Support with Knees Extended

Side Support with Knees Flexed

Side Support with Knees Extended

Hanging Leg Lifts

Closing in Prone

• While relaxing the back, buttock, and lower extremities, the patient should use the arms to induce an extension or “closing” mobilization

• Adjust the hand position as needed to focus the intervention to a specific region of the spine (a more cranial placement will typically produce extension higher in the spine while a more cephalad placement will typically produce extension lower in the spine)

• Bias the mobilization to one side by sidebending the trunk in that direction

26

10/26/2009

ROUND ROBIN PRACTICE