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

2 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 1

EXAMINATION PROCEDURES (DAY 1) Neuoromotor sensory Screening Examination AROM with overpressure (standing/sitting); Standing Quadrant Stork (SI Fixation) & Standing

Unilateral Prone Instability Test (PIT) Segmental Examination transverse process through arc of motion (Sitting Flexed, Prone, Prone on Elbows) Observation of Curves

3 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 2

Motor Function L2-3 Hip flexors L3-4 Knee extensors L4 Ankle dorsiflexors L5 Hallux extension L5-S1 Ankle plantar flexors

MSR/DTR Quadriceps (femoral nerve, L2-4): Tap center quadriceps tendon with reflex hammer.

superior to calcaneal insertion with reflex hammer.

4 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) 3

Vascular Screen Abdominal Aorta Femoral Artery Dorsalis Pedis Posterior Tibial Functional Quick Tests Patient demonstrates activity that causes symptoms or therapist identifies functional activity

5 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 4

6 Postural Examination Bony Landmarks Posterior: Gluteal Folds - crease PSIS skin dimple Iliac Crests (IC) - elevate softtissue, apply inward pressure, lower hands until top of IC contacted Anterior Iliac Crests ASIS 5

Flexion Extension Side bending Quadrant sustained Lumbar AROM (w or w/o overpressure) Identify a Comparable Sign ** Remember to re-test after treatment!

7 Flexion Extension Side bending Quadrant sustained Lumbar AROM (w or w/o overpressure) 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 6

Goniometry: Flexion & Extension Flexion Patient assumes standardized foot position, goniometer placed Patient fully flexes trunk without bending knees.

support) Therapist records measurement at end-range to nearest degree Goniometry: Side bending Side bending Patient assumes standardized foot position, goniometer

8 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 sidebends trunk without bending knees. Therapist records measurement at end-range to nearest degree Repeat on opposite side 7

AROM Flexion With Overpressure Standardize patient positioning

knees straight Apply overpressure by adducting your arms Add

sources of pain or decreased ROM Note end-feel, range, pain and

positioning Ask the patient to fully extent his lumbar spine

9 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 8

Lumbar Quadrant Standardize patient positioning Stabilize the

Sustain for 5 seconds if needed Note end-feel, range, pain and

Painful Arc in Flexion 2. Painful Arc on Return from Flexion 3.

10 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 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 Range of Motion Assessment 9

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

Test 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

11 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 Stork / Gillet Test 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 10

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

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

12 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. 11

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 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

13 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 12

in full extension Hip Quadrant/Scour (FADDIR) Hip flex/add/ir

14 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 13

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

15 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 > 35 0 Hypomobility at one or more lumbar levels with spring testing Flynn, et al. Spine 2002 Childs et al. Annals Int Med

Prone Lumbar Central/Unilateral PA Segmentally palpate lumbar spine Note

Comparable sign ** Hip Internal ROM Internal rotation Abduct the left lower

horizontal plane Place the goniometer inferior to the lateral malleolus and zero

16 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 ~ 30 0 Flex the right knee to 90 0 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 15

Prone Instability Test P-A spring test for pain

pt s hips extended Positive finding previously painful

Flexion-Neutral-Extension Identify painful segments

17 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 16

MANUAL THERAPY PROCEDURES Lumbo-Pelvic (SI Regional) Supine Manipulation Lumbar Sidelying Rotational Manipulation Lumbar Sidelying Rotational Manipulation-Flexion Bias (towel roll) Lumbar Sidelying

18 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 17

Sacro-Iliac Region Manipulation: Supine with Alternate Operator Arm Position Treat the Right Side Same set up as

Rest your fingertips on the patient s sternum or the table.

L4-L5 interspace; place the patient s foot in the popliteal fossa as shown Grasp the patient s right arm and

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

19 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 18

Alternative S/L Neutral Lumbar Manipulation Gibbons & Tehan Close Right

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

at the L4-L5 motion segment Place your right thumb or finger on the

arm as demonstrated Log roll the patient towards you With your left arm

20 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 19

Long-Axis Distraction Manipulation (Hip & SI Region

Manipulation Left Rotation T12/L1 With the patient

arms on a pillow over your left shoulder Reach

lateral scapula Use your right pisiform to contact the

rotation with your left arm and body Engage the

21 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 20

FLEXIBILITY Muscle Balance Testing & Stretching (DAY 1) Piriformis (Above 90 degrees) Piriformis (Below 90 degrees) Piriformis above 90 degrees in supine Externally rotate and

22 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. 21

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

internal rotation Progress the technique by adding more adduction / internal rotation Once the restrictive barrier is engaged, use a sustained stretch or muscle energy

23 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 22

Opening in Supine: Pelvic Rock Posteriorly tilt the pelvis to flex the spine Reassess symptoms

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

pelvis / spine into more flexion Closing in Supine: Pelvic Rock Anteriorly tilt the pelvis in

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

24 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) 23

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

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

25 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 24

Stabilization Treatment Quadratus Lumborum Oblique Abdominals Side Support with Knees Flexed Side Support with Knees

relaxing the back, buttock, and lower extremities, the patient should use the arms to induce an extension or closing

cranial placement will typically produce extension higher in the spine while a more cephalad placement will

26 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 25

27 ROUND ROBIN PRACTICE 26

DIAGNOSIS ANTERIOR PELVIC ROTATION DIAGNOSIS DIAGNOSIS. Direct techniques to treat sacrum and pelvis somatic dysfunction (HVLA, MET)

DIAGNOSIS ANTERIOR PELVIC ROTATION DIAGNOSIS DIAGNOSIS. Direct techniques to treat sacrum and pelvis somatic dysfunction (HVLA, MET) American Academy of Osteopathy Convocation PHYSICIAN STUDENT Thursday, March 18, 2010 Friday, March 19, 2010 2:30 4:00 PM 8:00 9:30 AM 4:30 6:00 PM 10:00 11:30 AM Direct techniques to treat sacrum and