Transcript Thoracic and Lumbar Spine Clinical Evaluation

Thoracic and Lumbar
Spine Clinical Evaluation
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Clinical Evaluation
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History:
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Location of Pain:
Pain radiating into extremities
 Peripheral paresthesia or numbness:
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Result of impingement or pressure on nerve root exiting
intervertebral foramen or dural irritation proximal to pain
site
Pain Locations:
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Lumbar pain – possible ambiguous cause
Sacroiliac pathology – pain around PSIS or radiating pain in
hip/groin
Piriformis spasm – symptoms of sciatic nerve dysfunction
Clinical Evaluation
Clinical Evaluation
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History:
 Onset of Pain:
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Acute
Chronic
Insidious pain onset
Note: Patient may
describe a single incident
that initiated pain,
although trauma is
probably an accumulation
or repetitive
stresses/microtrauma
Clinical Evaluation
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History:
 Mechanism of Injury:
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Movement: Flexion,
Extension, Lateral
Bending, Rotation
Blunt Trauma: Direct
blow to
lumbar/thoracic area
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Contusions
Compressive Stress:
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Hyperextension of
spine
Clinical Evaluation
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History:
 Pain Consistency:
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Constant Pain:
Unyielding (does not
improve with various
position of patient’s
spine)
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Example pathology –
Inflammation of dural
sheath
Clinical Evaluation
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History:
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Pain Consistency:
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Intermittent Pain:
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Mechanical Origin – certain spinal positions may ↑ or ↓
pain symptoms
 Compression/stretching of nerve root – Increase pain
 Positioning (flexion, traction) – lessen the pressure on
involved structure
Clinical Evaluation
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History:
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Bowel or bladder signs:
Does the patient have any bowel or bladder
problems?
 Incontinence: Loss of bowel or bladder control
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May indicate lower nerve root lesions (cauda equina
syndrome), or spinal cord injury
Description: urinary incontinence may range from
occasionally leaking urine (during cough/sneeze) to having
sudden episodes of strong urinary urgency
Clinical Evaluation
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History:
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Bowel or Bladder Signs:
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Cauda Equina Syndrome:
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Nerves within the spinal canal have been damaged
Result: nerves supplying the muscles of the legs, bladder, bowel
and genitals do not function properly
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Patients experience numbness, loss of sensation and pain in the
legs, buttocks and pelvic region (damage usually permanent)
Causes:
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Spina bifida (abnormality in closure of spinal canal)
Tumors
Injury (spinal fractures)
Intravertebral disc herniation
Vascular (blood vessel) problems or infections of the cauda
equina
Clinical Evaluation
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History:
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History of spinal injury:
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Previous injuries:
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Structural degeneration
Predisposition to injury
Changes in activity:
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Exercise habits (intensity
levels, duration,
frequency)
Footwear, running
surfaces
New bed
Clinical Evaluation
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General Inspection:
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Frontal Curvature:
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Alignment of lumbar,
thoracic, cervical vertebrae
with patient lying prone or
standing
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Normal alignment –
straight
Abnormal alignment:
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Scoliosis – lateral
curvature (lumbar
and/or thoracic spine)
Clinical Evaluation
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General Inspection: Scoliosis
 Signs and symptoms:
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Uneven shoulders
One shoulder blade appears more
prominent
Uneven waist / 1 hip higher vs.
other
Leaning to one side
Back pain and difficulty breathing
(severe scoliosis)
Causes:
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Idiopathic (85% of cases)
Underlying neuromuscular disease,
leg-length discrepancy, birth
defect, fetal development
(congenital)
Not caused by poor posture, diet,
exercise, or the use of backpacks
Clinical Evaluation
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Diagnosis:
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Angle: X-ray
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Normal Spine (0
degrees)
Scoliosis: (> 10
degrees)
Complications:
(severe scoliosis)
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Lung and heart
damage:
compression of rib
cage against heart,
lungs
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> 70 degrees
Back problems
Clinical Evaluation
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General Inspection:
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Scoliosis Test: Adam’s Forward Bend Test
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Patient Position: Standing with hands held in front (arms
straight)
Evaluation Procedure: Patient bends forward, sliding hands
down the front of each leg
Positive Test:
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Asymmetrical hump along lateral aspect of thoracolumbar spine
One shoulder blade appears more prominent
Uneven hips
Implications:
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Functional scoliosis: scoliosis present when patient stands
straight, disappears during flexion
Structural scoliosis: present during both standing and with
flexion
Clinical Evaluation
Clinical Evaluation
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General Inspection:
 Sagital Curvature:
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Normal Alignment:
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Lordotic cervical
Kyphotic thoracic
Lordotic lumbar
Kyphotic sacral
Clinical Evaluation
Clinical Evaluation
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General Inspection:
 Observation of GAIT:
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Spinal pain –
influence on walking
and running gait
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Slouching
Shuffling
Shortened gait
Clinical Evaluation
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General Inspection:
 Skin Markings:
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Café-au-lait spots:
presence of darkened
areas of skin
pigmentation
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Normal (benign)
Collagen disease
Neurofibromatosis 1
 95% of patients
will display spots
Clinical Evaluation
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General Inspection:
 Skin Markings: Sign of Neurofibromatosis-1
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Neurofibromatosis-1:
Autosomal dominant disease
 Characterized by formation of neurofibromas (tumors
involving nerve tissue) in the skin, subcutaneous
tissue, cranial nerves, and spinal root nerves
 Implications: growth of tissue along the nerves – puts
pressure on affected nerves and cause pain and severe
nerve damage
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Loss of nerve function (sensation, movement)
Clinical Evaluation
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General Inspection:
 Breathing patterns:
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Irregular breathing (i.e. shallow respirations, pain)
Injury to thoracic vertebrae
 Pressure on thoracic nerves
 Trauma to ribs, costal cartilage
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Bilateral comparison of skin folds:
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Asymmetry of natural folds
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Causes: muscle imbalance, ↑ or ↓ kyphosis, scoliosis
Clinical Evaluation
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General Inspection:
 Kyphosis:
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Abnormal forward rounding
of the upper back (> 40 to 45
degrees)
Round back or hunchback
Causes:
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Developmental problems,
degenerative diseases
(arthritis), osteoporosis with
compression fractures,
trauma
Severe cases:
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Can affect lungs, nerves,
causing pain and other
problems
Clinical Evaluation
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General Inspection:
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Kyphosis Test: Forward
bend test
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Patient bends forward
from the waist while ATC
views the spine from the
side
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With kyphosis, the rounding
of the upper back may
become more obvious in this
position
Postural kyphosis – the
deformity corrects itself when
patient lies on their back
Clinical Evaluation
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Postural kyphosis:
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May improve on its own
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Structural kyphosis:
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Caused by spinal abnormalities
Scheuermann's disease:
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Exercises to strengthen back muscles, correct posture, and
sleeping on a firm bed
Developmental disorder that causes a stooped forward or bentover posture
Affects between 0.5% and 8% of the general population
Osteoporosis-related kyphosis:
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Multiple compression fractures
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Low bone density
Clinical Evaluation
Clinical Evaluation
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General Inspection:
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Movement and Posture:
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Poor posture (standing,
sitting, bending)
Lordotic Curve:
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Reduction:
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Muscle spasm
Hamstring tightness
Increased:
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Hip flexor tightness
Abdominal weakness
Clinical Evaluation
Clinical Evaluation
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General Inspection:
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Standing Posture:
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Lateral shift in trunk and pelvis
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Erector Spinae Muscle Tone:
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Nerve root impingement (lateral shift ↓ pressure)
Unilateral hypertrophy or atrophy
Faun’s Beard:
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Spina bifida occulta
Clinical Evaluation
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General Inspection: Spina Bifida
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Birth defect that occurs when the tissue surrounding the developing
spinal cord doesn't close properly
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Spina Bifida Occulta:
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Mildest form, results in a small separation in one or more of the
vertebrae of the spine (spinal nerves usually not involved – most
patients have no signs/symptoms or neurological problems)
Inspection: Faun’s Beard, a collection of fat, a small dimple or a
birthmark on the newborn's skin above the spinal defect
Complications:
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Minor physical disabilities
Mental strain
Severity:
 Size and location of the neural tube defect
 Does skin cover the area?
 Do the spinal nerves come out of the affected area of the spinal cord?
Clinical Evaluation
Clinical Evaluation
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Palpation: Thoracic Spine
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Spinous Processes
Supraspinous Ligaments:
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Fills space between the spinous processes
Costovertebral Junction:
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Articulation between ribs and thoracic vertebrae
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Trapezius:
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Only palpable on slender individuals
Origin to insertion
Rhomboids and levator scapulae lie deep to middle/upper traps
Paravertebral Muscles
Scapular Muscles
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1 – Spinous Processes
2 – Supraspinous
Ligaments
3 – Costovertebral
Junction
4 – Trapezius
5 – Paravertebral
Muscles
6 – Scapular Muscles
Structure
Landmark
Cervical vertebral bodies
Same level as spinous processes
C1 transverse process
One finger’s breadth inferior to mastoid process
C3-C4 vertebrae
Posterior to hyoid bone
C4-C5 vertebrae
Posterior to thyroid cartilage
C6 vertebrae
Posterior to cricoid cartilage; moves during flexion and
extension of cervical spine
C7 vertebrae
Prominent posterior spinous process
T1 vertebrae
Prominent protrusion inferior to cervical spine
T2 vertebrae
Posterior from jugular notch of the sternum
T3 vertebrae
Even with the medial border of the scapular spine
T7 vertebrae
Even with the inferior angle of the scapula
L3 vertebrae
Posterior from the umbilicus
L4 vertebrae
Level with the iliac crest
L5 vertebrae
Typically demarcated by bilateral dimples, but variable
from person to person
S2
At level of the posterior superior iliac spine
Clinical Evaluation
C7
T1
T2
T3
T4
T5
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1 – Spinous Processes
2 – Step-off Deformity
3 – Paravertebral Muscles
Clinical Evaluation
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Spondylolisthesis:
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Forward slippage of a vertebrae on the one below it
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Affects 5-6% of males, 2-3% of females
Causes:
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L4 and L5 / L5 and S1
Strenuous physical activity (weightlifting, gymnastics, football)
Types:
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Developmental:
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May exist at birth, or may develop during childhood (generally not
noticed until later in childhood/adult life)
Acquired:
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Degeneration: caused by the daily stresses that are put on spine
(i.e. carrying heavy items, physical sports)
 Connections between the vertebrae weaken
Single or repeated force
Clinical Evaluation
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Spondylolisthesis:
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Grade 1:
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Grade 2:
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75%
Grade 4:
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50%
Grade 3:
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25% of vertebral body has
slipped forward
100%
Grade 5:
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Vertebral body completely
fallen off
(i.e.,spondyloptosis)
Clinical Evaluation
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Symptoms:
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May be asymptomatic
Low back pain (especially
after exercise)
↑ lordosis
Pain/weakness in one or
both legs
↓ ability to control bowel/
bladder functions
Tight hamstrings
Advanced spondylolisthesis:
changes may occur in the
way patient stands/walks
Clinical Evaluation
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Palpation: Sacrum and Pelvis
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Median sacral crests
Iliac crests:
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Posterior superior iliac spine
Gluteals
Ischial tuberosity
Greater trochanter
Sciatic nerve:
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Palpate laterally from PSIS to find iliac crests and anteriorly to locate
ASIS (level of symmetry)
Place thumb on ischial tuberosity and 3rd finger on the PSIS. 2nd finger
will fall into sciatic notch (nerve most superficial as it passes by ischial
tuberosity)
Pubic symphysis
1 – Median sacral crests
2 – Iliac crests
3 – PSIS
4 – Gluteal muscles
5 – Ischial tuberosity
6 – Greater trochanter
7 – Sciatic nerve
8 – Pubic symphysis
1 – Iliac crest
2 – Tensor fascia latae
3 – Gluteus medius
4 – Iliotibial band
5 – Greater trochanter
6 – Trochanteric
bursa
1 – Pubis
2 – ASIS
3 – AIIS
4 – Sartorius
5 – Rectus femoris
Clinical Evaluation
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Active Range of Motion:
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Flexion and Extension:
Measured with patient standing
 Distance from the fingertips to the floor can be
measured (accuracy affected by tightness of
hamstrings and calf muscles and scapular
protraction)
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Gravity assists with movement
More accurate than hook-lying position
 Abdominal muscles have to overcome weight of the
trunk
Clinical Evaluation
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Active Range of Motion:
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Lateral Bending:
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Patient standing (feet shoulder width apart and the hand
opposite the direction of the movement resting on the ilium)
Patient bends trunk laterally (attempt to tough fingertips to the
ground)
Distance between the ground and fingertips is measured
Rotation:
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Patient is sitting position (stabilizes pelvis and lower extremity)
Patient rotates shoulder girdles and spinal column (attempt to
look behind one’s back)
Movement primarily occurs in thoracic spine
Clinical Evaluation
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Passive Range of Motion:
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Flexion:
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Extension:
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Patient in hook-lying position
Examiner brings the knees to the chest by lifting under the
knees and thighs and flexing the hip and thoracic spine
Patient prone (hands flat on table at shoulder level – push-up
position)
Patient extends arms, lifting the torso (hips and legs remain of
table)
Rotation:
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Patient in hook-lying position
Patient’s pelvis and legs are rotated to bring lateral portion of
the knee towards the table (shoulders remain flat)
Spinal Ligaments Stressed During Passive Range of
Motion Testing
Motion
Ligaments Stressed
Flexion
Posterior Longitudinal Ligament,
Supraspinous Ligament, Interspinous
Ligament, Ligamentum Flavum
Extension
Anterior Longitudinal Ligament
Rotation
Interspinous Ligament, Ligamentum
Flavum
Lateral Bending Interspinous Ligament, Ligamentum
Flavum
Clinical Evaluation
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Beevor’s Sign:
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Test for thoracic nerve inhibition
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Patient performs an abdominal curl-up from hook-lying position
Normal Findings: abdominal muscles receive concurrent
innervation from T5-T12 nerve roots (umbilicus does not move)
Positive Test: umbilicus is pulled toward the head
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Characteristic of spinal cord injury between T6 and T10 levels
 Upper abdominal muscles (rectus abdominis) are intact at
the top of the abdomen but weak at the lower portion, patient
is asked to do a sit up – only the upper muscles contract
(umbilicus pulled toward the head)
Clinical Evaluation
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Resistive Range of Motion:
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Flexion:
Patient position – supine with knees flexed and feet
flat on table
 Stabilization – pelvis
 Resistance – applied to the superior sternum as
patient lifts the scapulae off the table
 Muscles tested – rectus abdominis, internal oblique,
external oblique
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Clinical Evaluation
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Resisted Range of Motion:
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Extension:
Patient position – prone with arms interlocked
behind the head
 Stabilization – lower lumbar region
 Resistance – applied to upper thoracic spine as
patient lifts head, chest, and arms off table
 Muscles tested – iliocostalis lumborum, iliocostalis
thoracis, longissimus thoracis, spinalis thoracis,
semispinalis thoracis, rotators, latissimus dorsi
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Clinical Evaluation
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Resisted Range of Motion:
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Rotation:
Patient position – supine (hands interlocked behind
head)
 Stabilization – opposite ASIS
 Resistance – anterior aspect of shoulder as it is
rotated off the table
 Muscles tested – internal oblique, external oblique
(opposite side), rotators, multifidi
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