1. All of the scanning exams. a. Why do we do scanning exams? a. What is the purpose of each and every test in all of the scans?

i. Screen for serious pathology ii. Asses status of neurological system iii. Identify areas that need further biomechanical examination

1. AROM is the most important test. Testing Neuro-Muscular Skeletal against gravity

2. Asses for: a. Serious pathology (Cardinal plane no combined

motion) i. Orthopedic pathologies

1. Fractures 2. Major muscle injuries 3. Acute joint injuries.

b. Once has been identify PIVM are performed. c. Less serious pathologies or chronic (combined

motions, or special test performed)

AROM

Response if +

Flexion Site and behavior: 1. does the motion brings leg pain 2. Is the existing pain remains the same? 3. a normal spine at the end of lumbar flexion the lower three segments should appear to be fixed lordosis.

Lum

bar scan

Acute posterior lateral protrusion disc History Observation Response to ROM testing

1. Felt something o back 2. Immediate pain and then not

much 3. Next day

Worse back pain Appearance of leg pain Hurts to sit, bend,

4. Lateral shift away from painful side

5. Flattened lumbar lordosis

Flexion: Limited with Increased leg pain Contralateral deviation ↑ dural stretch

Extensio

n

Sudden ↑LBP If leg pain= bad Inflammation sensitive to pressure

SideB Ipsi = ↑LBP Contra= ↑leg pain

Rot Hard to sit Unpredictable

Lum

bar scan

Acute posteriomedial disc protrusion

History Observation Response to ROM testing

Similar to posterior Ipsilateral shift

Flattened lordosis

Flexion Limited Reproduction Ipsi leg pain Ipsi deviation

Extension Limited ↑ LBP

SB Ipsi= limited reproduces leg pain Contra= limited and may produce LBP and leg pain.

Rotation Inconsistet results.

Lum

bar scan

Acute Central disc Protrusion History Observation Response to ROM testing

Bilateral leg pain

Numbness/ paraesthesia’s

Flexion or rotation

Flatten lordosis

No shift

Flexion Severely limited Reproduction LBP quickly Reproduction of leg pain quick

Extension Very limited Reproduces Severe LBP If ↑ leg pain = poor prognosis

SB Usually no pain May be limited to muscle spasm ** Differential diagnosis **

Rotation May not be able to test in sitting Incosistent results.

Lum

bar scan

Instability History Observation Response to ROM testing

Previous Hx of trauma Long hx of LBP Double jointed (congenital) C/O giving out minimal activity May have Chiro. success. Pain ↑ with Extension Hurts supine with legs straight May complaint of leg pain may be somatic

No shift ↑ Lordosis or not Non consistent findings.

Flexion WNL ROM Not painful Gowers Sing

Extension Acute:

Inability to do it SubAcute:

Can do it ↓ROM

Often ↑ LBP (ante shearing mechanism of incompetent)

Causes SDB -Typically unrestricted -Clinically important ( rules out extension loss) biomechanics of lumbar facet motion. -May reproduce pain wit Con-SB

Contribution iliolumbar ligament

L5S1 Sbing coupled with piriformis

Trauma Connective tissue disorders Heredity Eher’s Dannos

Rotation -Sitting will tighten up TFL -Facets and neural arches resist -Typically not painful except in severe degeneration.

Lu

mb

ar scan

Z joint Arthritis History Observation Response to ROM testing (if degenerative)

Flexion Not much restricted depending on the level of injury

Extension The most painful Restricted

Possible causes Sbing Ipsilateral restriction and pain.

-Pain is not Isolated. -Capsular pattern; EX/Rot/Sding affected side. Radicular= if Nerve root injured

Rotation Ipsilateral restriction and pain.

Lum

bar scan

Lateral Stenosis History Observation Response to ROM testing

-Older patients -LBP/leg pain ↑ activity -Activity in stooped position -Hurts lie in supine -Resemble instability found in younger population.

-May attempt to hold back in flexed position -If severe, could develop contralateral shift

Flexion Usually loss ROM

Relieves pain

May Gower sing/depends etiology.

Extension May/may not reproduce pain time dependent

Sbing Ipsi Sbind if sustain ↑ leg pain

Rotation Since is performed in sitting pain free.

Lum

bar

Scan

Central Stenosis

Most compelling findings is the presence of cauda equine or cord S&S

Patter of AROM will reflect primary causative agent.

Possible bilateral loss sensory, motor, reflex.

Lumbar stress test

Test Rationale Response/ and results

Compression overload Test

Damage to vertebral body, end-plate or disc will create and inflammatory reaction. The resultant paint will be aggravated by any intra-vertebral or intra discal pressure. (Not done with NO trauma patients, or three months chronic pain)

Reproduction of the reported pain constitutes a positive test and indicates damage to the vertebral body, end-plate disc. *If test is negative then we can start flexion exercises.

Torsion Test Torsion is resisted by annular fibers of the disc and therefore, also by their attachment to the end-plate. Torsion is also resisted by Z-joints and therefore also the neural arches between them. Test is designed for acute pathologies. Fractured neural arch, unlike the compression test this test may be used to assess even very chronic pathologies due to mechanical pain.

Reproduction of pain with 1 phase (Lower Thoracic and opposite innominate) then segmental testing.

1. Unilateral positive: a. Possibility of a fracture through

Z-joint (compression) b. Or Traumatic arthritis c. In chronic dysfunction a positive

result = Segmental instability 2. Bilateral positive: pain in both

directions indicates the possibility of : a. Acute disc-end plate lesion b. Or a fracture neural arch

P/A shearing Test

1) First a rapid PA 2) Then a slow PA

a) Reproduction of pain + soft end feel indicates possibility of segmental PA instability.

Reproduction of patient’s pain with initial, rapid PA thrust indicates:

1. Possibility of an acute segmental dysfunction

2. Or irritable segmental dysfunction A slow PA will reproduce more pain.

Lum

bar Scan

nin

g

Iliolumbar ligament History /Patophysiology function / History Response to ROM Testing

Attaches to L5 Sacrum Several parts

Tip of anterior inferior aspect of L5 TP

Runs laterally and splits in two bands

o Lower band: across and anterior SI Jt ligament to reach posterior marging of iliac fossa.

o Upper band: QL attach, passes iliac crest, anterior to SI joint is continous with TFL

Stabilizer of lumbrosacral junction; prevents shearing of L5 on S1 Hx: 1. Can become involved with a problem affecting L5/S1 2. L2 innervation can produce concurrent

somatic anterior thigh pain and groin pain.

Flexion

Extension Taught

Rotation

SBing Becomes taught with contralateral Sbing

Response/ Test

Nerve root Peripheral Spinal cord Cauda Equina

SS S ee enn n

ss s oo orr r yy y

Pain Constant intense Intermittent milder Constant Intense Constant intense

Segmental Multi-segmental

Segmental

Muti-segmental Match 1 peripheral N.

Multi-segmental Multi-segmental

PPaarreesstthheessiiaa

AArreeaa

Big Segmental

Small Multi-segmental Match 1-peripheral N.

Huge Multi-segmental

Huge Multi-segmental

NNuummbbnneessss Small. (overlap) Have to look at the distal portion of the root problem. (dermatome)

Big Distal distribution of the peripheral area.

Huge Multi-segmental

Huge Multi-segemental

MMoottoorr Key muscles affected Muscles distal to

injury site that are innervated by the peripheral nerve

Spasticity More than 3 beats when testing SCI

Flaccid, fatiguing weakness, Multi-segmental MM

oott oo

rr

RReefflleexx Hyporeflexia Areflexic

Hyporeflexive Areflexic

Spastic or Clonus Hypereflexia

Hypo-Areflexic

OOtthheerr Bowell and

bladder retention Bowel and bladder incontinence

PPaarraaeesstthheessiiaa

AREA Possible cause

Total lower quadrant Might indicate central stenosis

Quadrilateral parathesia Specially aggravated by neck flexion indicates cervical cord compression

Contra-lateral head and limb paraesthesia Cerebral stroke

Diffuse, No-segmental, Non-cerebral, Non-mechanically-irritated paraesthesia

Multiple Sclerosis.

Structure affected Manifestation of behavior.

Arterial Occlusion Felt over a large area

Unilateral

Multi-segmental

Intense pricking brought with movement

Nerve Root Compression Felt over a large area

Will be identifiable

Dermatomal distribution (will be more painful tingling sensation, longer periods of time.

Constant tingling needles with dermatome distribution without necessarily becoming numb= Pressure on a NERVE ROOT

Peripheral Nerve Root Compression Felt over a small area

Will be identifiable (segemental)

Peripheral distribution

Low intensity tingling (rapidly proceeded by numbness)

Non painful (unless neuritis is involved) short lived (minutes to hours) rapid progresses to numbness

Bilateral, constant tingling in the “glove and sock” distribution, with or without numbness == Peripheral neuropathy

Dietary insufficiency Over massive areas o Both arms and legs. o Even trunk.

RSD or Nerve Root Traction Non segmental o Segmental o Or multisegmental

Sliding Tension Protective

Gen

eral D

escriptio

n

Distal tension makes pain decreased Full ROM

Distal tension makes pain increased full ROM at joints ROM limitations exist only by pain, may have full PROM

Distal tension makes Pain increased ROM at joints limited muscle tension.

Symp

tom

s

1. c/o aches and pain at site along course of nerve 2. Sx distance related with time tethering 3. If not inflamed sx intermittent 4. Sx reproduction when move through it’s full ROM

1. Aches and pain 2. Possible paresthesia 3. Impairment of sensation 4. May be intermittent 5. only occur when nerve is tensioned or has a sustain posture that tension the nerve

1. Altered muscle dysfunction occurs in a pattern that protects a specific neural structure.

Histo

ry

1. Hx possible interface dysfunction 2. repetitive motion with terminal ROM 3. Use it, it gets worse, 4. Rest improves

1. Stretching out brings the patient symptoms.

Ph

ysical fin

din

gs

1. Confusing 2. Additional tension component may relief pain ON = ON = Reduce pain ON = OFF = may ↑ Sx

1. AROM & PROM loss ROM when nerve under tension Proximal ON= distal OFF = ↑ Sx Proximal ON= Distal ON = Sx worse Proximal OFF= Distal ON = ↑Sx.

1. Will ↑muscular resistance to motion 2. Need test Nuero 3. Muscular resistance ON= ON may ↑ Sx.

Neruodynamic Testing of the lumbar Scan

SSLL

RR

Test: 1. Taking up the slack 0-35° 2. Assessing ability of neural tissue to glide 30°-60° 3. The remaining motion is tensioning: nerves, and articular and

myofascial elements. If suspect hx of inflammatory process is best to start with SLR rather than Slump T. Response:

1. If sx are produced within the expected ROM the key is to reproduce and decreased symptoms with Foot/Ankle (distal component) and Head/ Neck(proximal component)

2. Test done over the other leg. If Symptoms are reproduced on contralateral leg and reproduces LBP and/or Ipsilateral leg symptoms == BAD PROGNOSIS == sure large disc injury.

3. If both are negative then repeat with both legs at the same time == Sign of central disc lesion.

4. If negative to this but positive to Slump test == disc lesion sensitive to WB compression.

5. Sitting position: WB causes disc to protrude enough to cause symptoms.

6. Supine position body weight relieved the protrusion is no longer enough to produce sx.

Slump If pt c/o sounds like radicular pn but SLR didn’t reproduce sx perform the Slump T.

Prone Knee Bending

1. Test nerve roots from L1-L4. a. Note commonality of L4 in both SLR and Slump test and PKB

test

Passive Neck Flexion

Consider a very sensitive test if reproduces pain in the LB or in the legs o CLASSIC MENINGITIS

SIJ RISK GROUP 1. Ankylosis Spondylitis == usually starts c/o pain in the SIJ. (late teens)

2. Hypermobility Syndrome == a. Ehler’s Danloss Syndrome b. Marfan’s syndrome c. Generalized hypermoblity (womens)

3. Pregnancy

4. Specific trauma

5. Chronic loss of hip motion

6. Chronic LBP problem

Key Muscles Associated with Assessing Nerve Root Function

Upper limbs nerve root key muscle alternative

C4 diaphragm levator scapulae

C5 supraspinatus infraspinatus

C6 biceps extensors of wrist

C7 triceps flexors of wrist

C8 extensor pollicis longus opponens pollicis

T1 medial two palmar interossei

Lower limbs nerve root key muscle alternative

L2 psoas major

L3 quadriceps hip adductors

L4 tibialis anterior may affect quadricps

L5 extensor hallucis longus hip abduction

L5 & S1 peroneals EDL

S1 hamstrings, gastrocnemius FHL, FDL

S2 gluteus maximus hamstrings, FDL, FHL

Dermatomes

Although it is well accepted that there is not one absolutely correct dermatome chart, for testing

purposes, we need to all be thinking the same thing. So for testing purposes, please use this

dermatome chart.

Cervical

C1-2: Scalp. Central portion of anterior and posterior neck side of head, upper half of ear, cheek and

upper lip.

C3: Entire neck. Lower mandible, chin, and lower half of the ear.

C4: Top of shoulder, front of chest including pectoral region, and lower half of neck.

C5: Shoulder, front of the arm, and forearm to base of thumb.

C6: Lateral arm and forearm, thumb, and index finger.

C7: Back of the arm and forearm, INDEX, LONG, and RING finger; primary supply of tip of middle finger

C8: Inner, medial forearm, inner half of the hand, LONG, RING, and LITTLE fingers.

T1: Inner side of forearm as far as the wrist

T2: A ‘Y’ shaped area stretching from the inner conovle of the humerus at the elbow, up to the arm and

dividing into two areas reaching to the sternum anteriorly and the vertebral border of the scapula

posteriorly.

T3: Area on front of chest and patch in axilla.

T4

T5 >Around trunk to level of nipple. T6 T7-9: Around trunk to lower costal margin T9 T10 >Around trunk to lower costal margin T11 T12: Probably to groin and area between iliac crest and greater trochanter. L1: Lower abdomen and groin: skin at L2-4, and upper and outer aspect of buttock.

L2: Lower lumbar and upper buttock: medial thigh.

L3: Upper buttock: anterior and slightly medial aspect of thigh , knee and leg to medial malleolus.

L4: Outer thigh and leg crossing to the medial border of the ankle and foot including the BIG TOE.

L5: Outer aspect of the leg, the top of the foot, the FIRST, SECOND, and THIRD TOES, inner half of the SOLE of the foot.

S1: The lower half of the posterior aspect of the leg and ankle, the outer half of the SOLE of the foot and the LAST TWO TOES.

S2. Back of the thigh and leg, back of the heel and the planter aspect of the heel. Some books show S2 as not going to the heel saying that S1 does the entire heel.

S3: Area around the anus, strip following the inguinal ligament, and inner thigh to the knee.

S4: Saddle area, anus, perineum, scrotum, and penis. Vagina and labium, and inner most thigh.

UPPER QUADRANT

SENSORY INNERVATION

AREA SEGMENTAL PERIPHERAL

Ear and over jaw C2 Greater auricular

Lateral neck C3 Transverse cutaneous

Upper traps to skin over upper chest C4 Supra-clavicular

Lateral arm C5 Upper-Axillary Lower- Radial

Posterior Arm C5 Radial

Posterior-lateral hand Over 1st interosseous

C6 Radial

Posterior forearm C7 Radial

Lateral forearm C6 Musculo-Cutaneous

Antero-lateral hand including 3 ½ digits and finger tips C6 Median

Lateral palm and palmar surface of middle 3 ½ digits C7 Median

Anterior and posterior lateral hand including med 2 digits C8 Ulnar

Medial arm T1 Medial cutaneous of arm

Medial forearm C8 Medial cutaneous of f-arm

Axilla (arm pit) T2 Costo-brachial (APR T2)

Upper Quadrant MOTOR

Anterior C/V flexors C1+2 APR

Diaphragm C3+4 Phrenic

Levator Scap C3+4 Dorsal Scapular

Supraspinatus and Infraspinatus C5 Suprascapular

Deltoid C5 Axillary

Biceps (long head) Brachialis, Coraco-brachialis C6 Musculocutaneous

Supinator C6 Radial

Brachioradialis C6 Radial

Wriste extensors C6 Radial

Triceps (long head) C7 Radial

Extensor pollicis longus and Abductor pollicis longus C8 Radial

Flexor Carpi Ulnaris C8 Ulnar

3rd and 4th interrossei T1 Ulnar

LOWER QUADRANT SENSORY INNVERVATION AREA SEGMENTAL PERIPHERAL

Upper medial thigh L2 Obturator

Lower medial thigh and medial knee L3 Medial femoral cutaneous (femoral)

Anterior thigh L3 Intermediate femoral cut (Femoral)

Lateral thigh L4 predom Lateral cutaneous (plexus)

Posterior thigh S2 Posterior cutaneous (plexus)

Medial knee and calf L3 Saphanous ( Femoral )

Medial side of foot up to but not including hallux L4 Saphenous (Femoral)

Anterior and lateral calf L4+5 Superficial Peroneal (Common P.)

Hallux L4 Superfical Peroneal (Common P. )

Dorsum of foot and Middle 3 toes L5 Superfical Peroneal (Common P.)

Web space between halluz and 2nd toe L4 (?L5) Deep Peroneal (Common P.)

Posterior lateral calf S1 Sural (Tibial)

Lateral foot and 5th toe S1 Sural (Tibial)

Medial sole over 1st MTP joint L4 Medial plantar calcaneal (Tibial)

Medial sole excluding 1st MTP joint L5 Medial plantar calcaneal (Tibial)

Lateral sole S1 Lateral Plantar Calcaneal

Heel S2 Tibial.

LOWER QUADRANT

MOTOR INNVERVATION

AREA SEGMENTAL PERIPHERAL

Psoas L2 APR L2,L3+L4

Iliacus L2 Femoral

Quadriceps L3 Femoral

Adductors L3 Obturator

Tibialis Anterior L4 Deep Peroneal (Common P.)

Extensor Hallucis L5 Deep Peroneal (Common P.)

Evertors L5+S1 Superficial Peroneal (Common P.

Ankle Plantarflexors S1 Tibial

Hamstrings S1+S2 Sciatic

Hip abductors L5 Superior Gluteal

Gluteus Maximus S2 Inferior Gluteal

Resistan

ce Testing

Mid range testing Best indicator of muscle stain

Shortened Position Muscle will contract mechanically in disadvantage firing from 60-80%

Best indicator for Neural Conductivity.

Lengthened position Best indicator of Connective tissue in the fascia of the muscle, contractile lesion.

1 degree more than likely pain will be given by the fascia

2 degree: just put those muscle fibers in this position will give patients pain.

3 Degree: Complete rupture.

Strong 4-5/5

Painful Moderate/ Severe grade II, muscle tendon

Fracture Pain ↑ compression

Multiple planes of joint pain

Pain ↑ vibration

Total splinting of motion

Weak 3+↓/5

Painless Grade II mm tear

Fatiguing weak Motor palsy