A Nine Procedure Spinal Examination

Transcription

1 A Nine Procedure Spinal Examination Practical Assessment of the Chiropractic Patient K. Jeffrey Miller, DC, FACO, MBA Chiropractic Orthopaedist

2 Nine Procedures 1. Drift & Maximal Foraminal Compression Tests 2. Brachial Plexus Stretch Test 3. Seated Kemp s Test 4. Modified Slump Test 5. Sphinx & Prone Knee Flexion Tests 6. Yeoman s & Femoral Stretch Tests 7. Hibb s & Patrick FABER Tests 8. Fluid Motion Test 9. Rotation/Side Posture Screening & FAIR/Piriformis Tests

3 Disclaimer The following examination procedures are the author s best recommendations for the profession based on his education and experience. The procedures do not establish a standard of care for the profession 4/3/ K Jeffrey Miller DC, MBA

4 Disclaimer The following procedures ARE NOT the encouragement of short cuts or skipping important procedures. THEY ARE designed to make the examiner efficient by gathering more information in a shorter period of time to improve diagnosis, plans of care, treatment and ultimately prognosis 4/3/ K Jeffrey Miller DC, MBA

5 Non-Technique Specific The following procedures are independent of examination procedures utilized by individual chiropractic adjusting techniques 4/3/ K Jeffrey Miller DC, MBA

6 Non-Technique Specific The doctor can combine any of the exam procedures and concepts described here with his or her choice of technique(s) and the technique's analytical procedures 4/3/ K Jeffrey Miller DC, MBA

7 Important Concepts Observation; Many clinical findings related and unrelated to the test being performed can be observed during performance of that test 4/3/ K Jeffrey Miller DC, MBA

8 Important Concepts Everything Moves; In a midline test for example If you flex the cervical spine The bones, ligaments, disks muscles, the cord, blood vessels, the trachea, the esophagus etc., all move 4/3/ K Jeffrey Miller DC, MBA

9 Important Concepts Everything Moves; In a bilateral test If a structure on one side is compressed the same structure on the opposite side is often stretched 4/3/ K Jeffrey Miller DC, MBA

10 Important Concepts Replication; many tests have the same mechanism of performance but have different pathological meanings 4/3/ K Jeffrey Miller DC, MBA

11 Important Concepts Combinations; orthopedic and neurological tests can be combined to improve efficiency and differential diagnosis 4/3/ K Jeffrey Miller DC, MBA

12 Important Concepts There are four methods for combining tests 1. Testing by Indirect Method 2. Same Mechanism/Different Pathology 3. Different Mechanism/Same Pathology 4. Sequential Testing 4/3/ K Jeffrey Miller DC, MBA

13 Testing by Indirect Method Examples Pulse and Respiration Rates Orthopedic Tests and Range of Motion 4/3/ K Jeffrey Miller DC, MBA

14 Same Mechanism/Different Pathology Examples Soto-Hall and Lindner s C6 Motor Function and Cozen s Test 4/3/ K Jeffrey Miller DC, MBA

15 Different Mechanism/Same Pathology Examples SLR and Lindner s Brudzinski s and Kernig s 4/3/ K Jeffrey Miller DC, MBA

16 Sequential Testing Examples SLR and Bragard s Cervical Compression and Cervical Distraction 4/3/ K Jeffrey Miller DC, MBA

17 Important Concepts Patient Position; Orthopedic and neurological tests have traditional patient positions but most can be performed in more than one position. Tests depicted in photos may vary slightly from the recommended examination procedures for demonstration purposes Why? 4/3/ K Jeffrey Miller DC, MBA

18 Important Concepts Space Considerations: There are instances where a test may replace another when examination room space is limited 4/3/ K Jeffrey Miller DC, MBA

19 Combination Drift and Maximum Foraminal Compression Test PROCEDURE ONE

20 Drift and Maximum Foraminal Compression Drift is a test for upper motor neuron lesions Maximal Foraminal Compression Test is for radicular problems emanating from the cervical spine

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22 Drift Basic Life Support (BLS) American Heart Association Cincinnati pre-hospital stroke Scale (one positive) Facial droop Arm drift Abnormal speech Acceptance/Reliability

23 Drift F.A.S.T. Face Arms Speech Time

24 Drift Names Drift Pronator Drift Spontaneous Drift Barre s Test (some confusion here because there is a Barre s test for the cervical spine) Jean Alexandre Barre first described the sign

25 Drift Positive Indications: One hand rolling from supination to pronation is a positive Typical sign is the hand rolling from supination to pronation with the arm dropping toward the floor The arm drifts laterally (outward) in cerebellar lesions These lesions are unilateral The arm drifts upward in Parietal lesion These lesions are contralateral

26 Positive Indications: Drift Movements are slow and may take a few seconds to initiate Tapping the hand or arm may help initiate movement Both arms drifting is not significant

27 Lower Extremity Drift Starting and Normal This is a side note Confirmatory Test to Upper Extremity Drift (UMN) The eyes

28 Lower Extremity Drift Abnormal This is a side note Are the eyes closed? Does it matter?

29 Maximum Foraminal Compression Max Cervical Upper Extremity Radicular Symptoms

30 Head Rotation The lesions identifiable by Drift are present regardless of head position This allows the test to be performed with the head rotated and allows the test to be combined with other tests

31 Drift and Maximum Foraminal Compression UMN vs. LMN Upper Motor Spastic Muscle Weakness Hyper-reflexia Pathological Reflexes Present Superficial Reflexes Diminished/Absent Centralization Lower Motor Flaccid Muscle Weakness Hypo-reflexia No Pathological Reflexes Present Superficial Reflexes are Present Localization

32 Adson s and Halstead s While the examiner will not be palpating the radial pulse during the examination recommended, the patient may report TOS extremity symptoms with this head position S/S on side of head rotation=adson s S/S on the side opposite of head rotation=halstead s

33 Replication of Hautant s Test Vertebral Artery Test Doctor Should Position Patient s Head Eyes Must be Closed Held Seconds Each Side Drift Objective Validity by Common Use

34 An Additional Test Replicated During Drift Test George s Functional Maneuver

35 Vertebral Artery Worth Mentioning Another side note Underberg s Test Hautant s combined with marching in place It tests for the same pathology While we like combinations, stability is a question here Underberg s Test without head rotation is a Fukuda test The test is for balance and the positive indicator is the patient rotating has he marches

36 Vertebral Artery Worth Mentioning Interesting Clinical Information Drop Attacks Anxiety Two curious experiences The fighter pilot Amarosis Fugax DDx - Migraines

37

38 Comparison

39 Brachial Plexus Tension Test PROCEDURE TWO

40 Brachial Plexus Tension Test Brachial Plexus/Nerve Root Test Upper Extremity Equivalent of SLR Built in Confirmatory Test Nerve vs. Muscle

41 Tests Replicated or Observed During Brachial Plexus Testing Shoulder Depressor Test Don t Whip the Head to the Side!!

42 Shoulder Depressor Brachial Plexus Test Nerve vs. Muscle Head Stabilization and Shoulder Motion (Depression)

43 Kemp s Test PROCEDURE THREE

44 Kemp s Test Seated Facet Syndrome/Lumbar Disc Pathology Seated Over Standing? Medial vs. Lateral Disc

45 Tests Replicated or Observed During Kemp s Test Antalgia Sign Scheplemann s

46 Antalgia Sign Correlate with medial vs. lateral disc Can be seen standing or seated In some cases lying down Also Known As Vanzetti s Sign

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48 Scheplemann s Test Pain possible on either or both sides Intercostal Neuralgia of Rib Cage Strain/Sprain Other rib pathologies

49 Modified Slump Test PROCEDURE FOUR

50 Test-How Many Squares?

51

52

53 The Modified Slump Test Tests for Neuromeningeal Tract Tension The Most Complicated Yet Most Productive Test

54 Tests Replicated or Observed During the Modified Slump Test Soto-Hall Lindner s L Hermitte s Brudzinski s Seated Adams Compression Fracture Bechterew s SLR / Lasegue's CSLR Tripod Hamstring Tension Kernig s Bragard s Fajersztajn s Homan s Dejerine s Valsalva s Fortin s Finger Sign

55 Papers on the Slump Test Maitland, GD. The slump test: examination and treatment. The Australian Journal of Physiotherapy Miller, KJ. The slump test: application and interpretations. Chiropractic Technique. November 1999 K. Jeffrey Miller, DC, DABCO

56 Breaking It Down The Slump Test The Original Description Five Steps The Slump, Cervical Flexion, Leg Extension, Foot Dorsiflexion, Cervical Extension Miller s Modifications Three Steps Simultaneous Leg Extension. Simultaneous Bilateral Foot Dorsiflexion, Cough K. Jeffrey Miller, DC, DABCO

57 The Neuromeningeal Tract Note the tension and direction of pull on the cord and Sciatic nerve K. Jeffrey Miller, DC, DABCO

58 Slump Steps 1 & 2 K. Jeffrey Miller, DC, DABCO

59 Slump Steps 3 & 4 K. Jeffrey Miller, DC, DABCO

60 Slump Step 5 K. Jeffrey Miller, DC, DABCO

61 Modified Slump K. Jeffrey Miller, DC, DABCO

62 Tests Replicated or Observed During the Modified Slump Test Soto-Hall Lindner s L Hermitte s Brudzinski s Seated Adams Compression Fracture Bechterew s SLR / Lasegue's CSLR Tripod Hamstring Tension Kernig s Bragard s Fajersztajn s Homan s Dejerine s Valsalva s Fortin s Finger Sign

63 Physical Maneuvers that Create Lower Extremity Nerve Root and/or Sciatic Nerve Tension Primary Maneuvers Lumbar Lateral Bending Hip Flexion Knee Extension Foot Dorsiflexion Secondary Maneuvers Cervical Flexion Spinal Flexion Hip Internal Rotation Hip Adduction Great Toe Extension Increased Intrathecal- Intradiscal Pressure Patient Position

64 Lumbar Lateral Bending

65 Hip Flexion-Knee Extension

66 Foot Dorsiflexion

67 Cervical Flexion

68 Spinal Flexion

69 Hip Internal Rotation-Hip Adduction

70 Hip Internal Rotation-Hip Adduction

71 Great Toe Extension

72 Increased Intrathecal-Intradiscal Pressure

73 Disc Pressure Lying on Back Standing Walking Twisting Sitting Coughing Jumping Straining Laughing 30kg/cm2 70kg/cm2 85kg/cm2 90kg/cm2 100kg/cm2 110kg/cm2 110kg/cm2 120kg/cm2 120kg/cm2

74 Testing Postures/Positions The Majority of Disc, Radicular and Sciatic Tests are Performed Lying on the Back-30kg/cm Bechterew s - Slump are Performed Seated-100kg/cm Supine vs. Seated MR Scans

75 Recumbent Vs. Seated Recumbent MRI Seated MRI

76 Disc Pressure Lying on Back (SLR) Standing (Neri s) Walking Twisting Sitting (Bechterew's) Cough (Dejerine's) Jump Strain (Valsalva s) Laugh 30kg/cm² 70kg/cm² 85kg/cm² 90kg/cm² 100kg/cm² 110kg/cm² 110kg/cm² 120kg/cm² 120kg/cm²

77 Sitting in a Bathtub Sitting in a Recliner Legs Up vs. Fully Reclined History-ADL Bowel Movements Dejerine s Triad = ADL (cough, sneeze, strain, laugh)

78 Patient Position Escalating Pressure in the Disc Neri s Bowing Standing then bending kg/cm2 in the disc SLR-Lasegue s Lying 30 kg/cm2 in the Disc Slump-Bechterew s Sitting 100 kg/cm2 in the Disc

79 Soto-Hall Very General Test Cervicothoracic Subluxation Disc Sprain Strain Fracture Rib Fracture, The Compression Test

80 Lindner s Lower Extremity Radicular Complaints Tethered Nerve Roots

81 L Hermitte s Electrical-Shock Like Sensations in One or More Extremities Spinal Cord-UMN

82 Brudzinski s Meningitis Bacterial vs. Viral What are the Odds of Seeing This?

83 Seated Adams Scoliosis Seated vs. Standing Why do both? Compare to Kemp s

84 Compression Fracture

85 Compression Fracture Be careful! A reason for allowing the patient to move into a testing positioning Localized pain and possible angular deformity with short transition

86 Bechterew s

87 SLR/Lasegue s The same or different? They both use hip flexion and knee extension The only difference is the order the two motions occur Seated Vs. Supine

88 Lasegue s

89 CSLR Good Hurts the Bad Medial vs. Lateral Disc

90

91 Medial vs. Lateral Disc The majority of disc lesions protrude lateral to the left or right and then lie either medial or lateral to the nerve root. Medial and lateral refer to the relationship of the disc lesion to the nerve root. Lateral disc protrusions that are lateral to the nerve root are the most common presentation

92 Best Tests for Medial vs. Lateral Antalgia Sign SLR / Braggard s CSLR / Fajersztajn s Kemp s Slump

93 Adjusting Side Posture Lateral Disc Protrusion = Adjust with the side of leg pain up Medial Disc Protrusion = Adjust with the side of leg pain down This works with the antalgic posturing of the patient and the biomechanics of the pathology

94 Handedness Ambidextrous Shoulder Height-levelness Dominant side lower Grip Strength Dominant side stronger by 10% Impairment Rating Non-dominant often rated lower Side Posture Adjusting Farfan s Torsion Test Side of handedness up MillerCopyright

95 The Disc Alternating Layers of Fibers Twisting/Sports; Right Handed vs. Left Handed Individuals MillerCopyright

96 MillerCopyright

97 Farfan s Torsion Test His Idea is Good His Test is Complicated to Use MillerCopyright

98 Farfan s Simplified After studying Farfan s reasoning and torsion test you will discover that the entire concept can be boiled down to knowing if the patient is left handed, ambidextrous or right handed Just ask the patient Guess and impress! MillerCopyright

99 Side Posture Screening and FAIR Tests

100 Tripod Sign Radicular Pathology vs. Hamstring Tension? Tripod Name? Flip Test Recliner Sign (Miller) Tripod Sign Related to Lung Disorders

101 Hamstring Tension The second photo is a side note at this point and will be covered in greater detail when tests in the prone posture are discussed

102 Kernig s Note the leg not being moved!

103 Lasegue s vs. Kernig s

104 Braggard s Palmer is to chiropractic what Don t do fast SLR Lateral disc

105 Fajersztajn s sterling is to silver Is speed as important here? CSLR Medial disc

106 Homan s DVT The knee is key Efficiency If Supine SLR Bragard s Lasegue s Differential Homan s The combination can be performed sitting

107 Dejerine s Space Occupying Lesions Head and/or Spinal Symptoms Cough, Sneeze, Bear Down (Valsalva s) Easiest to perform?

108 Valsalva s Space Occupying Lesions Part of Dejerine s

109 What if the patient cannot get into the Modified Slump position? Do the original version of the Slump Test in steps Maximum SLR

110 Record Keeping Soto-Hall Lindner s L Hermitte s Brudzinski s Seated Adams Compression Fracture Bechterew s SLR / Lasegue's CSLR Tripod Hamstring Tension Kernig s Bragard s Fajersztajn s Homan s Dejerine s Valsalva s Fortin s Finger Sign They can All be recorded based on performing the one procedure!

111 Fall Back You can back up or fall back to Maximum Straight Leg Raising if you wish to confirm the Slump test or need and alternate test

112 Maximum Straight Leg Raising Test SLR Braggard's Lindner s Dejerine s Cough Bonnet s Piriformis

113 Maximum Straight Leg Raising Test

114 Sphinx and Prone Knee Flexion PROCEDURE FIVE

115 Combine Sphinx and Pheasant's Tests

116 Sphinx Test Tests Lumbar Extension and Extension of the Spine Above this Level Narrows the Spinal Canal Combine with Prone Knee Flexion

117 Pheasant Test Same Position as Prone Knee Flexion Lumbosacral Pain a Sign of Lumbar Instability

118 Tests Replicated or Observed During the Combined Sphinx Pheasant Tests Sphinx Pheasant Test Nachlas Test Femoral Stretch Test Ely s Test Quadriceps Tension

119 Nachlas L/S and/or SI Joint Pathology Note approximation of the heel to the buttocks

120 Ely s Test Hip Flexion Contracture Note; hip flexion with heel approximating the buttocks

121 Femoral Stretch Test Same position as Nachlas Femoral Stretch creating paresthesia in the anterior thigh and/or lower leg

122 Quadriceps Tension Note the distance between the heel and the buttock

123 Yeoman s and Femoral Stretch Tests PROCEDURE SIX

124 Yeoman s and Femoral Stretch Tests MillerCopyright

125 Yeoman s Test Tests for Anterior SI Ligament Sprains Replicates Gaenslen s and Lewin-Gaenslen s Tests Psoas Sign MillerCopyright

126 Femoral Stretch Test Tests for Femoral Never Irritation Replicates Gaenslen s and Lewin-Gaenslen s Tests Psoas Sign MillerCopyright

127 Psoas Sign MillerCopyright

128 Comparison: Yeoman-Psoas MillerCopyright

129 Tests Replicated or Observed During Yeoman s Test (side note) Gaenslen's (supine) Lewin-Gaenslen's (side posture) Psoas Sign (side posture) MillerCopyright

130 Hibb s and Patrick's Tests PROCEDURE SEVEN

131 Hibb s Test Tests for Hip Joint Pathology Early and SI Joint Pathology Late Better than Patrick s Test Why? Obturator Sign MillerCopyright

132 Hibb s and Patrick s Tests Hibb s Patrick FABER

133 Obturator Sign MillerCopyright

134 Tests Replicated or Observed During Hibb s Test Obturator Sign MillerCopyright

135 What is wrong with the previous slide? MillerCopyright

136 Fluid Motion Test PROCEDURE EIGHT

137 Fluid Motion Test Tests for SI Joint Fixation-Subluxation Not Leg Length Dependent MillerCopyright

138 This Examination Format Separates the Doctor from the Technicians MillerCopyright

139 Rotation/Side Posture Screening & FAIR/Piriformis Tests PROCEDURE NINE

140 MillerCopyright

141 Side Posture Screening and FAIR Tests

142 Side Posture Screening Like Vertebral Artery Tests You Are Screening by Simulating the Adjusting Position

143 And FINALLY ROM

144 Range of Motion Indirect Testing Cervical Range of Motion Thoracic Lumbosacral Range of Motion

145 Flexion Brach Plex/Slump Extension 70 Max For../Sphinx Rotation Max For Comp Lateral Bend Brachial Plexus

146 Flexion degrees Slump Extension degrees Sphinx Rotation degrees Kemp s Side Posture/FAIR Lateral Bend degrees Kemp s

147 Flexion 80 Slump Extension 35 Kemp s/sphinx Lateral Bending 25 Kemp s Rotation is considered a primary component of thoracic range of motion

148 Extremity Examination K. Jeffrey Miller, DC, FACO, MBA

149 Apley s Scratch Test Shoulder Range of Motion Test Symmetry is the key here Identification of a lateral scapula

150 Mazion s Test Glenohumeral Joint pathology or dysfunction This isolates the glenohumeral joint A chiropractic test, John Mazion was one of the first chiropractic orthopedists, he taught many of my ortho classes

151 Dugas Test Shoulder Dislocation Unlikely to see Why? Replicated during Mazion s Test Just listed here as a secondary test because of replication

152 Impingement Test Impingement Pathology The shoulder motion is the same as Mazion s and Duga s Impingement can be from tissues and/or bony structures

153 Apley s Supraspinatus Test Rotator Cuff Can be adapted for biceps tendon Bursitis is a DDx

154 Supraspinatus Test Supraspinatus Rotator Cuff Test Tendonitis or Tear Note the position of the thumbs and the abducted arms Nice for bilateral comparison

155 Speed s Test Biceps Test for Tendonitis or Tear Hand position-supination Arms less abducted than supraspinatus test

156 Acromioclavicular Stress AC Joint Test Most Common area for Shoulder Degenerative Arthritis Shearing motion This Maneuver can also be Therapeutic

157 Cozen s Test Lateral Epicondylitis Test Same Mechanism as C6 Motor Test

158 Reverse Cozen s Test Medial Epicondylitis Test Same Mechanism as C7 Motor Test

159 Valgus Stress Medial Collateral Ligament Test This test should be performed with the arm straight and a second time with the elbow flexed by 30 degrees Why?

160 Varus Stress Lateral Collateral Ligament test This test should be performed with the arm straight and a second time with the elbow flexed by 30 degrees Why?

161 Finkelstein s Test Test for Stenosing Tenosynovitis Should Always be Performed when Symptoms of CTS are Present

162 Ellis Test Test for Wrist Flexor Tendonitis Great test for early detection of pathology that can lead to CTS This is hard to find a reference for. Art Croft was mine.

163 Phalen s Test Carpal Tunnel Syndrome The testing positioning is held for 1-2 minutes Some sources say 30 sec to 1 minute

164 Reverse Phalen s Test Carpal Tunnel Syndrome The testing positioning is held for 1-2 minutes Some sources say 30 sec to 1 minute

165 Anthropometry Measure circumference 4 inches above and below the elbow Swelling - edema Musculature / atrophy

166 Hibb s Test Tests for Hip Joint Pathology Early motion tests the hip Late motion tests SI joint Better than Patrick s Test Why? (2 reasons) Obturator Sign

167 Obturator Sign

168 Comparison: Hibb s-obturator

169 What is wrong with the previous slide?

170 Tests Replicated or Observed During Hibb s Test Obturator Sign

171 Patrick s Test Hip Joint Tests Rotation Less Accurate Than Hibb s External Internal rotation is usually lost before external rotation Obturator Sign

172 Suprapatellar Compression Superficial Patellar Edema Clark s/patellar Grind Squat Pressure Quick Test

173 Valgus Stress Test Tests the Medial Collateral Ligament of the Knee Better at 30º of Flexion Hand placement on lower leg determines the leverage on the joint

174 Varus Stress Test Tests the lateral Collateral Ligament of the Knee Better at 30º of Flexion Hand placement on lower leg determines the leverage on the joint

175 Lachman s Test Testing anterior cruciate ligament More accurate than the anterior drawer test The lower leg should not touch the table Lately I have changed my hand placement. I grasp the tibia with both hands and allow the patient s body weight to be the stabilizing factor to the femur.

176 Anterior Draw Test Tests the Anterior Cruciate Ligament

177 Posterior Draw Test Tests the Posterior Cruciate Ligament

178 Slocum s Test External Tibial Rotation Tests anteromedial rotational instability Same position as Hughston s Posterolateral Drawer, different direction of rotation/pull It is all about the foot placement

179 Hughston s Posterior Lateral Drawer Tests posterolateral rotational instability Same position as Slocum s Test External Tibial Rotation, different direction of rotation/pull It is all about the foot placement

180 Slocum s Test Internal Tibial Rotation Tests anterolateral rotational instability Same position as Hughston s Posteromedial Drawer, different direction of rotation /pull It is all about the foot placement

181 Hughston s Posteromedial Drawer Tests posteromedial rotational instability Same position as Slocum s Test Internal Tibial Rotation, different direction of rotation/pull It is all about the foot placement

182 McMurray s Test Tests for Torn Meniscus in the Knee Palpate the joint margin while flexing and extending the knee Feeling a click may indicate a tear The Patient may be More Exact in Reporting a Positive Finding, the doctor may not feel the click

183 Thessaly s test Meniscal tear Better that most meniscal tests Weight bearing Easier the Duck walking for most patients

184 Hughston s Plica Test Tests for the Presence of a Plica in the Knee Very similar to McMurray s Test Palpate the medial edge of the patella Foot placement is key here as well

185 Bounce Home Test Tests for Torn Meniscus in the Knee and Joint Locking

186 Allis For determining structural deficiencies The Femoral and Tibial differences can be assessed Picture 1 femoral defect Picture 2 tibial defect

187 Ankle Anterior Drawer Same Principles as any Drawer test Anterior Instability

188 Ankle Posterior Drawer Same Principles as any Drawer Test Posterior Instability

189 Ankle Valgus Stress Same Principle as any Valgus Stress Medial Instability Less likely to see due to Malleolus and strength of the deltoid ligament

190 Ankle Varus Stress Same Principle as any Varus Stress Lateral Instability Medically - a lateral ankle sprain is considered the most common musculoskeletal injury. One in every ten thousand people per day

191 Anthropometry

192 Anthropometry Six inches above and below the knee for circumference Musculature - atrophy Swelling - edema Leg length ASIS to either malleolus Either works just be consistent This test is far from accurate Extremity alignment study