General tests
1. Gross motion testing
2. Standing Flexion Test
3. Seated Flexion Test
Babinski test to check for an upper motor neuron lesion damage to the brain or spinal cord, possibly as a result of trauma or a growing tumour.
Orthopaedic tests to reproduce lower back in particular, leg pain:
1. The straight leg raise test
2. The well leg raise test
3. The slump test
4. The Kernig test
Orthopaedic tests to trigger lower back or leg pain by increasing intrathecal pressure (inside the spinal cord) and extrathecal pressure (outside the spinal cord). The spinal cord is surrounded by cerebrospinal fluid. When a patient performs leg lifts, they engage their psoas and abdominal muscles, which increases pressure on the cerebrospinal fluid. This can replicate pain symptoms. Similarly, when a patient performs a Valsalva manoeuvre (bearing down as if constipated), it also increases the pressure on the cerebrospinal fluid, potentially reproducing the pain.
1. The Milgram test
2. The valsalva manoeuvre
Orthopaedic Tests
Gross motion test
Physical Exam of the Spine: Flexion, Extension, Side-Bending, and Rotation
1. Patient in briefs stands and actively performs spine movements (flexion, extension, sidebending, rotation) to assess general lumbar motion.
2. For the flexion test, the therapist stands beside the patient, hand on sacrum and shoulders, and guides them to bend forward, monitoring for smooth lumbar motion of about 60°, pain-free.
3. For extension, the therapist supports the patient's knee and back, and gently leans them backwards, checking for a pain-free lumbar curve and about 35° movement.
4. Side-bending is checked by stabilizing the patient's pelvis, guiding one hand down towards the knee, and observing for a smooth 20° lumbar movement on each side.
5. For rotation, the therapist kneels, stabilizes the pelvis, and turns the patient's torso, checking for about 5° lumbar rotation each way (remainder of rotation is thoracic).
Standing Flexion Test
Standing Flexion Test:
This test checks for restrictions between the ilium and sacrum.
1. Patient stands. Therapist finds the iliac crests, then moves to the PSIS (below the two dimples).
2. Therapist applies gentle pressure on the PSIS and asks the patient to bend forward. Observe how the ilium moves on the sacrum.
3. Both PSIS should move evenly. If one moves first, it might indicate a problem on that side, like a lumbar facet lock, tight muscles, or a restriction at the sacroiliac joint causing the ilium to pull the sacrum upwards - a potential iliosacral dysfunction.
4. Confirm iliosacral dysfunction with another test, the seated flexion test.
Manipulations
Back II from pages 25-41
The Back Examination
**1. Ideal Posture (Using Plumb-Line):**
- Align ear, deltoid muscle, hip joint, knee, and lateral malleolus in a straight line.
**2. Standing Observation:**
**a. Posterior View:**
- **Skin:** Check for rashes, growths, cysts, moles, scars, and lipomas (refer abnormalities to GP).
- **Head Alignment:** Check for side bending or rotation.
- **Ear Levels:** Ensure they are even.
- **Neck and Cervical Spine:** Look for straightness, side bending, or scoliosis.
- **Muscle Tone:** Compare right and left for symmetry.
- **Shoulder and Scapula Levels:** Check alignment; note scapula positioning (T3 to T7-T8).
- **Thoracic and Lumbar Spine:** Observe for straightness or scoliosis.
- **Iliac Crest Heights:** Ensure they are level.
- **Pelvic Lurch:** Check for due to Gluteus medius muscle weakness.
- **Legs:** Observe for bow legs or knock knees.
- **Calf Muscle Tone/Atrophy:** Note the quality and any atrophy.
- **Heels:** Check for valgus, indicating medial talus slip, possibly from dropped arches.
**b. Side View (Using Plumb-Line):**
- **Head Position:** Check if central, protracted, or retracted.
- **Shoulder Position:** Observe for protraction or retraction.
- **Abdomen:** Look for ptosis, indicating weak abdominal muscles.
- **Spinal Curvature:** Note normal or excessive lordosis (cervical spine), kyphosis (thoracic spine), and lordosis (lumbar spine).
**3. Anterior View:**
- **Head and Trachea:** Ensure central alignment.
- **Clavicle:** Check for central positioning.
- **Chest:** Observe for deformities (pigeon chest, barrel-shaped chest).
- **Umbilicus:** Confirm central position.
- **ASIS Heights and Hip Levels:** Ensure they are even.
- **Knees:** Check alignment.
- **Foot Arches:** Look for dropped longitudinal arches (flat feet).
Physical Examination of the Spine
**Patient Position:** Standing, dressed down to briefs.
**A) Gross Motion Testing of Lumbar Spine:**
1. **Patient's Active Movements:**
The patient performs flexion, extension, side bending, and rotation to assess the gross motion of the lumbar spine.
2. **Therapist's Assessment:**
- Conduct a standing/seated flexion test.
**B) Detailed Spinal Movements Assessment:**
1. **Flexion:**
- Stand beside the patient.
- Place one hand on the sacrum and the other hand across the top of the shoulders.
- Instruct the patient to bend forward as far as comfortable, as if to touch their toes.
- Monitor the spine for smooth, free-flowing movements.
- Check for approximately 60° of movement in the lumbar spine without pain and 12° of movement in each lumbar vertebra.
- **Important:** Ask the patient to report any pain during the movement.
2. **Extension:**
- Place your knee behind the patient's knee.
- With hands still, on the sacrum and shoulders, lean the patient backwards into extension.
- Observe for a smooth lumbar curve and about 35° of movement without pain.
3. **Side Bending:**
- Stand behind the patient.
- Stabilize the pelvis with one hand on the left iliac crest and the other on the right shoulder.
- Instruct the patient to slide their right hand down towards their knee.
- Check for smooth side-bending movement and about 20° of lumbar movement. Repeat on the opposite side.
4. **Rotation:**
- Kneel on one knee.
- Stabilize the pelvis with hands anteriorly (right side) and posteriorly (left side).
- Ask the patient to rotate their body to the left, observing for about 5° of lumbar rotation.
- The rest of the rotation comes from the thoracic spine.
- Switch hand positions and repeat for right rotation.
Standing Flexion Test:
1. **Patient Position:** Standing.
2. **Locating PSIS:**
- Therapist locates the iliac crest bilaterally with both hands and moves onto the PSIS (below the two dimples, obvious in some people).
3. **Testing Movement:**
- Apply firm but gentle pressure with thumbs on the PSIS.
- Ask the patient to bend forward comfortably.
- Observe the movement of the PSIS on both sides as the ilium moves forward on the sacrum.
4. **Observation:**
- Both PSIS may move evenly on the sacrum, or one may move earlier than the other.
- The side where the PSIS moves earliest may indicate dysfunction.
- Possible causes: facet locking in the lumbar spine on the same side, hypertonic muscles, or a restriction of the ilium on the sacrum at the sacroiliac joint.
- This may suggest the ilium is pulling the sacrum upwards, indicating an iliosacral dysfunction on that side.
5. **Confirming Dysfunction:**
- To confirm if it's a true iliosacral dysfunction, perform a seated flexion test.
Seated Flexion Test:
1. **Patient Position:** Sitting with feet flat on the ground.
2. **Setting Up:**
- Therapist kneels on one knee.
- Locate the top of the iliac crest bilaterally and move thumbs distally onto the sulcus of the sacrum (notable as two dimples in some people).
3. **Patient Movement:**
- Patient interlocks fingers behind the neck.
- Instruct the patient to bend forward, tightening the spine downwards.
4. **Observation:**
- As the patient bends forward, observe the thumbs.
- Thumbs may move evenly, or one may move higher than the other.
- The side where the thumb moves higher indicates a dysfunction, termed sacroiliac dysfunction.
**Simplification of Test Outcomes:**
- If both the standing and seated flexion tests are positive on the same side, it indicates sacroiliac dysfunction.
- If only the seated flexion test is positive, it suggests a sacroiliac dysfunction.
- If only the standing flexion test is positive, it points to an iliosacral dysfunction.
Further Orthopaedic Tests Referenced from Hoppenfeld Pages 256-260:
1. **Babinski Test:**
- Purpose: Checks for upper motor neuron lesions, indicating potential damage to the brain or spinal cord from trauma or tumour.
2. **Straight Leg Raise Test:**
- Purpose: Stretches the sciatic nerve longitudinally on the ipsilateral side, used to reproduce lower back and leg pain.
3. **Well Leg Raise Test:**
- Purpose: Stretches the sciatic nerve transversely through the exit foramina, targeting lower back and leg pain.
4. **Slump Test:**
- Procedure: Tighten the spine downwards by interlocking fingers behind the neck, bending forward, and lifting the leg to stretch the sciatic nerve upwards.
5. **Kernig Test:**
- Purpose: Stretches the spinal cord downwards to reproduce leg pain via irritation of the meninges (dura mater, arachnoid mater, and pia mater). Pain in the lower back or leg is a positive sign.
- Note: Positive Kernig test, especially alongside SLR or slump test, warrants referral for further investigation.
6. **Milgram Test:**
- Procedure: Patient lifts both legs off the couch slightly, increasing intrathecal pressure inside the spinal cord and extrathecal pressure outside it.
7. **Valsalva Manoeuvre:**
- Procedure: Patient bears down as if constipated, increasing pressure on cerebrospinal fluid, affecting the spinal cord.
8. **Hoover Test:**
- Purpose: Checks for malingering (pretending or faking), often used in cases where there's a pending court case.
These tests are critical in diagnosing various spinal conditions, and positive results in some tests necessitate further medical investigation.
Mobilization
Mobilizing the Lumbar Spine (Side Shifting):
Patient's position: Prone
1. **Positioning:**
The therapist stands to the side of the patient.
2. **Hand Placement:**
- Place both hands flat across the lumbar spine.
- Position both thumbs on the ipsilateral side of the spinous processes at the L1 level.
3. **Mobilization Technique:**
- Gently rock the spine by pushing with your thumbs.
- Work down the spinous processes from L1 to L5.
- Assess for areas of restriction.
4. **Repeat on Opposite Side:**
- Perform the same procedure on the other side of the spine.
**Example Observation:**
- It's common to find varying restrictions at different levels like L1 being more restricted on one side and L4 to L5 on the opposite. Junction areas of the spine are more prone to facet locking. However, restrictions can occur at any level.
Mobilizing Lumbar Spine in Flexion (Side-Lying Position):
1. **Patient Positioning:**
- Patient lies on their side.
2. **Preparation:**
- Passively flex the patient's knees and hips to 85 - 90°.
3. **Positioning for Mobilization:**
- Place one hand under the knees and the other around the pelvis closest to the couch.
- Slide the patient towards you until the knees overhang the edge of the couch.
4. **Therapist's Stance:**
- Adopt a squat position and support the patient's knees with your abdomen.
5. **Locating Spinal Processes:**
- Locate the iliac crest with one hand.
- Slide posteriorly onto the spinous process of L5.
6. **Mobilization Technique:**
- Place the other hand on top of the first.
- Use your fingertips to locate the interspinous groove between L5 and L4.
- Slightly flex the patient's hips with your abdomen to feel the spinous process of L5 opening on L4 in flexion.
7. **Progressing Up the Spine:**
- Move fingers upwards to locate the interspinous groove between L4-L3.
- Continue the same procedure up to the L1 opening on T12.
- Check for restrictions in flexion where one spinous process is not opening on the one above it.
**Note:**
- For L5, minimal hip flexion is required.
- As you progress up the spine, more hip flexion is needed to facilitate mobilization.
Mobilizing the Lumbar Spine in Extension (Side-Lying Position):
1. **Patient Positioning:**
- Patient lies on their side.
2. **Preparation:**
- Passively flex the patient's knees and hips to 85 - 90°.
3. **Positioning for Mobilization:**
- Place one hand under the knees and the other around the pelvis closest to the couch.
- Slide the patient towards you until the knees overhang the edge of the couch.
4. **Therapist's Stance:**
- Go into a squat position and support the patient's knees with your abdomen.
5. **Locating Spinal Processes:**
- Locate the iliac crest with one hand and slide posteriorly onto the spinous process of L5.
- Locate the interspinous groove between L5 and L4.
6. **Mobilization Technique:**
- Place one hand on top of the other.
- Keep the hips flexed at 90° using your abdomen.
- Push the pelvis posteriorly while pulling anteriorly with your hands on the spine.
- Check for the spinous process of L5 closing on L4 in extension.
7. **Progressing Up the Spine:**
- Move the pads of your fingers up the spine.
- Locate the interspinous groove between L4 - L3 and repeat the same procedure up to L1 - T12.
- Continuously check for any restriction in extension.
**Note:**
- Maintain pelvic flexion at 90° throughout the technique.
- No further flexion is involved in this mobilization method.
Mobilizing Lumbar Spine in Side Bending (Patient Prone):
1. **Patient Positioning:**
- Patient lies prone (face down).
2. **Initial Setup:**
- Flex the patient's knee.
- Place one hand under the thigh and rest the patient's foot against your shoulder.
- Tighten the quadriceps muscles by passively flexing the knee using the shoulder.
3. **Locating Spinal Processes:**
- With your other hand, locate the top of the iliac crest.
- Turn your hand sideways so that your thumb is on the junction of L4 to L5.
4. **Mobilization Technique:**
- Place your thumb against the spinous process (sp) of L5 on the ipsilateral side, with the remaining fingers on the contralateral side.
- Slightly abduct the thigh to feel for movement at the sp of L5 in side bending towards the same side.
5. **Progressing Up the Spine:**
- Work your way up each vertebrae until you reach L1.
- Note that the further up the spine you go, the more abduction is required.
6. **Repeat on Opposite Side:**
- Perform the same procedure from the opposite side.
- Continuously check for areas of restriction.
This technique involves methodical progression from L5 up to L1, with careful attention to the degree of thigh abduction and movement observed at each vertebral level.
Conditions
**Prolapsed Intervertebral Disc (PID) and Herniation: Overview and Grades**
**Anatomy and Common Sites:**
- Intervertebral discs are prone to issues primarily in the lower cervical and lower lumbar regions due to high mobility and strain.
- Least common in the thoracic spine, where the ribcage provides support and limits movement.
**Mechanism of Prolapse:**
- Initial rupture of the Annulus Fibrosus causes acute pain and muscle spasms.
- Protrusion of the nucleus pulposus through the rupture, potentially entering the spinal canal.
- Prolapses typically occur laterally due to the protection of the posterior longitudinal ligament at the disc's central posterior part.
- Lateral prolapses may impinge on a nerve root, causing pain, sensory impairment, and muscle weakness in the affected area.
- Central prolapses are rarer but can have different clinical patterns.
**Causes:**
- Disc degeneration with age.
- Traumatic injury.
- Chronic poor posture or usage.
- Occupational hazards (e.g., prolonged bending/lifting).
**Grades of Herniation:**
1. **Grade 1 and 2 Herniation:**
- Less severe, might not require medication.
- Good response to non-invasive treatments.
2. **Grade 3 Herniation:**
- More severe, may need medications.
- Possible consideration for epidural injections.
3. **Grade 4 Herniation:**
- Severe, often requires surgical intervention.
- Typically managed in an A&E department.
- Surgery is considered for cases unresponsive to other treatments.
**Treatment Responses:**
- **No Meds, Good Response:** Non-surgical management effective (e.g., physical therapy, lifestyle changes).
- **Needs Meds, Different Response Levels:** Varying degrees of medication required, from oral pain relievers to epidural injections.
- **A&E Dept, Needs Operation:** Critical cases requiring immediate surgical intervention.
*Lumbar Disc Lesion:**
- Represents a common site for disc issues due to the high stress and mobility of the lumbar region.
In managing disc herniations, the treatment approach is often tailored to the severity of the herniation, the symptoms presented, and the individual's overall health status.
**Intervertebral Disc (IVD) Overview and Pathology:**
**Structure:**
- **Nucleus Pulposus:** Soft, a hydrophilic substance in the disc's centre, varying in position across spinal regions. High water content in early life reduces with age, altering mechanical behaviour.
- **Annulus Fibrosus:** Composed of annular bands, weakest posteriorly-laterally, predisposing to Prolapsed Intervertebral Disc (PID). Fibers anchor to the vertebral bodies, interwoven with bony trabeculae.
- **Cartilage End Plate:** Present on vertebral body surfaces, 1 mm thick, ossifies and calcifies with age, becoming brittle.
**Pathology:**
- Lumbo-sacral region is the most frequent prolapse site, followed by L4-L5 and L5-S1.
- Nucleus pulposus protrudes through the annulus fibrosus, usually postero-laterally.
- Large protrusions may herniate through the posterior ligament, impinging nerve roots and causing sciatic pain.
**Signs and Symptoms:**
- Age range typically 18-50 years.
- Severe lower back pain, possibly radiating to the leg.
- Pain worsens with flexion, coughing, sneezing, and defecation.
- Spinal deviations like sciatic scoliosis or loss of lordosis.
- Tenderness, muscle spasm, tingling, numbness in the affected area.
- Pain severity and location vary.
**Tests:**
- Decreased flexion, side bending to the affected side, Straight Leg Raise (SLR).
- Pain on pressing relevant spinal level.
**Diagnosis:**
- Myelogram, CAT scan.
**Medical Treatment:**
- Rest, corset, painkillers, hospitalization with traction (1-4 weeks).
**Physical Treatment:**
- Rest, massage, traction, mobilizations.
**Definition of Disc Injury:**
- Nucleus pulposus compromises the annulus fibrosus, causing back pain, spasms, and possible radicular symptoms.
**Injuries - Sciatica (Nerve Root Compression):**
- Manifests as linear pain along the back of the leg.
- Causes: Disc lesions, inflammation, adhesions, space-occupying lesions.
- Treatment: Massage, faradic stimulation, ultrasound, mobilization.
**Nerve Root Irritation:**
- Intermittent pain, relief by certain positions/activities.
- Can present as lower back pain, gluteal pain, sciatic nerve irritation, or myofascial pull pain.
- Treatment: Massage, faradic stimulation, manipulation, muscle energy techniques, ultrasound, exercises.
The approach to treating disc-related pathologies and sciatica involves a combination of medical and physical therapies, tailored to the specific type and severity of the condition.
**Spondylosis and Spondylolysis: Overview and Management**
**Spondylosis:**
- **Description:** Degeneration of the joint space between the disc and vertebral bodies, accompanied by osteophytes (bone spur) growth on the vertebral borders.
- **Implications:** The osteophytes can eventually impinge on nerves, leading to pain or neurological symptoms.
- **Treatment:** Surgery may be necessary to remove osteophyte growth if it causes significant impingement or discomfort.
**Spondylolysis:**
- **Definition:** A fracture or break in the pars interarticularis (part of the neural arch) of the L5 vertebra.
- **Consequence:** Leads to loss of bony continuity between superior and inferior articular processes, often replaced by fibrous tissue. This condition can progress to spondylolisthesis (forward slipping of a vertebra).
- **Causes:**
- Congenital factors.
- Trauma.
- Stress fracture (most common cause).
**Clinical Features:**
- **Prevalence:** Common in athletes involved in sports like weightlifting, rowing, and fast bowling.
**Symptoms:**
- Lower back pain (LBP) or unilateral pain.
- Pain may radiate to the buttocks.
- Rarely causes referred neurological pain.
- Some cases may be asymptomatic.
*Treatment:**
- **Non-surgical:**
- Use of a corset or back brace to provide support and limit movement, allowing healing.
**Surgical:**
- Spinal fusion may be considered to close the defect, particularly in cases where there's significant pain, instability, or progression to spondylolisthesis.
In managing these conditions, the treatment approach is determined by the severity of symptoms, the degree of anatomical changes, and the patient's overall health and activity level. Regular monitoring and imaging studies may be required to assess the progression of the condition and the effectiveness of the treatment.
Spondylolisthesis Overview:
**Definition:**
- Spondylolisthesis is characterized by the forward (or occasionally backwards) slippage of one vertebra over another.
**Causes:**
- Spondylolysis (fracture in the pars interarticularis).
- Osteoarthritis (OA) affecting the posterior facet joints.
- Congenital malformation of the articular process.
**Signs and Symptoms:**
- Symptoms can vary significantly.
- Typically presents with chronic low backache, sometimes accompanied by sciatica.
- Discomfort often worsens when standing.
- Movement may or may not be restricted.
- Visible step or gap often noted at the L5/S1 region.
- Neurological disturbances are usually minimal.
- Pain generally exacerbates with activity but improves when the patient lies down.
**Treatment:**
- No intervention if asymptomatic.
- Use of a corset or brace for support.
- Surgical intervention to stabilize the affected vertebrae, especially in more severe cases.
**Diagnosis:**
- Diagnosed primarily through X-ray imaging, which can reveal the extent of vertebral slippage.
Spondylolisthesis treatment is tailored to the severity of the condition and the patient's symptoms. In mild cases, conservative management, like physical therapy and bracing, might be sufficient, while in severe cases, it might necessitate surgical intervention for stabilization.
**Effective Stretching Techniques:**
The Right Way to Stretch
- **Relaxed and Sustained:** Stretch should be relaxed and held for a period of time, focusing on the muscles being stretched.
- **Avoid Bouncing and Pain:** Bouncing or stretching to the point of pain can be harmful, causing more damage than benefit.
Benefits of Correct Stretching
- **Ease of Movement:** Regular, correct stretching makes movements easier over time.
- **Muscle Loosening:** It takes time to loosen tight muscles, but the effort pays off with improved well-being.
The Easy Stretch
- **Initial Phase:** Start with a 10-15 second easy stretch.
- **Avoid Bouncing:** Maintain a steady position without bouncing.
- **Mild Tension:** Go to the point of mild tension, not pain. Relax into the stretch.
- **Tension Release:** The tension should subside as you hold the position. If not, ease off a bit.
The Developmental Stretch
- **Progression:** After the easy stretch, move slightly further into the developmental stretch.
- **Duration:** Hold for another 10-15 seconds.
- **Control:** Increase the stretch only to a point of mild tension. If tension increases or becomes painful, you've gone too far.
Breathing During Stretching
- **Rhythmic Breathing:** Keep your breathing slow, rhythmic, and controlled.
- **Breathe with Movement:** Exhale when bending into a stretch and breathe slowly while holding it.
- **Natural Breathing:** If breathing is inhibited, ease up on the stretch to allow for natural breathing.
Counting and Stretch Reflex
- **Avoid Counting Distractions:** Initially, you might count but eventually, stretch based on how it feels.
- **Understanding Stretch Reflex:** Muscles have a protective mechanism to contract when overstretched, preventing injury.
- **Avoid Overstretching:** Pushing too far activates the stretch reflex, leading to pain and muscle damage.
Conclusion
- **Consistent and Pain-free:** Stretching should be a regular, pain-free part of your routine.
- **Prevent Stiffness and Injury:** Proper stretching prevents stiffness and avoids muscle injury, making it a key component of physical health and fitness.
**No Gain with Pain: A Guide to Effective Stretching**
**Misconception of Pain for Gain:**
- The belief that "no gain without pain" is a misconception, especially in stretching.
- Pain during stretching is not an indicator of effectiveness; it signals something wrong.
**Correct Stretching Technique:**
- Proper stretching involves the easy stretch followed by the developmental stretch.
- These stretches do not overactivate the stretch reflex and do not cause pain.
**Understanding Stretching Phases:**
1. **Easy Stretch:**
- Hold for 10-15 seconds.
- Reach a point of mild tension; relax into the stretch.
- The tension should decrease as you hold the position.
2. **Developmental Stretch:**
- Hold for 10-15 seconds, following the easy stretch.
- Extend slightly further, maintaining mild tension without pain.
- Avoid pushing too far to prevent triggering the stretch reflex.
**Stretch Diagram Explanation:**
- The straight-line diagram represents the potential stretch capacity of your muscles and connective tissue.
- The first segment (easy stretch) prepares the muscles.
- The second segment (developmental stretch) extends flexibility without causing pain.
- The drastic stretch zone is to be avoided.
**Maximizing Flexibility Safely:**
- Regular, relaxed stretching allows natural progression beyond current limits.
- Focus on gradual improvement without forcing your body into painful stretches.
- Recognizing personal limits and potential is key to effective and safe stretching.