Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
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