NMSK 2 Revision - Lecture notes 1-12 PDF

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exam revision...

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NMSK Objective Tests Compare symptoms before, after and during each test!!!!!! Ask patient if they experience any of the 5 D’s or 3 N’s Does the patient need to complete all tests (irritability) -

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Posture Gait Palpation o L4: iliac crest, straight across onto spine o T11/T12: palpation feels springy since they are ‘floating ribs’ o T3: in line with spine of the scapula o T7: in line with the inferior angle of the scapula Active range of movement o Lumbar: (standing)  Flexion: reach to touch toes (overpressure: hands on L1 and L5 and push apart) – fingers on spinous processes to determine RoM – have thumbs on both PSIS’s to determine how they move in relation to each other  Extension: arch back with hands on back of thighs (overpressure: hands sternum and lumbar spine whilst blocking their knee with yours)  Side flexion: reach down the side of your leg making sure your heel doesn’t lift off the ground (overpressure: hand on higher shoulder and opposite iliac crest) o Thoracic: (sitting)  Flexion: hands around neck, instruct patient to tuck their shoulders down onto their chest (overpressure: push directly down on their shoulders)  Extension: hands around neck, elbows up and ask patient to look towards ceiling – clinician supporting upper, middle and lower thoracic spine for their respective ranges (overpressure: apply slight pressure to elbows for each section of the spine)  Side flexion: hands on ears and elbows raised out to the side (overpressure: push directly down on the higher shoulder)  Rotation: opposite hands to opposite shoulder with arms crossing chest (overpressure: block their knees with yours and have your hands on their shoulder and round their ribs and ask patient to breathe out) o Cervical: (sitting)  Flexion: (slowly)  Extension: support head, grip round top of head and chin and monitor for nystagmus  Side flexion: one hand on head, the other on their shoulder  Rotation: hands over ears for overpressure Muscle length o QL, upper traps, erector spinae, levator scap., iliosoas Muscle strength o QL, upper traps, erector spinae, levator scap., iliosoas Lumbar instability o On a wobble cushion  Instruct patient to grow tall  Instruct patient to straighten their leg whilst palpating their lumbar stabilisers  Get patient to move arms up and down  Get patient to move arms and legs together o In standing  Heel of ground  Foot off ground  Single leg march

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 Double leg march o Supine/crook (knees @ 90)  Neutral lumbar spine (get patient to arch their back and then sink their back into the plinth and find the mid-point)  Can the patient keep a neutral lumbar spine when sliding their heels up and down the plinth o All 4’s  Find lumber spine neutral then explain what you are going to do – see if the patient can keep a neutral spine whilst not thinking about it  See how long they can hold their spine in neutral  Prescription is the length of time they can hold their spine in neutral x5  Tell patient to push thoracic/cervical spine towards the ground then to pull it towards the ceiling to determine whether they can keep their lumbar spine in neutral  Instruct patient to drop their bum towards their heels PAIVM’s o Aim the force along the line of the spinous process o Unilateral (cervical)  Come to edge of erector spinae  Aim pressure towards trachea to stop slipping off process  Compare sides o Transverse PA: palms flat on patients back, sideways movement with thumb on spinous process o Lumbar (prone)  Central PA: pisiform grip  Unilateral PA: hands in ‘W’ position  Rotation: mid lumbar flexion to create space between vertebrae o Cervical (standing at top of bed)  C1: aim pressure towards the eyes  C2: out of dip onto prominent process  C3  C4: base of the dip  C5 coming out of the dip  C6: extend head a little and the process should disappear (only do if appropriate to SIN value)  C7 o Thoracic (stand at top of bed for T1-T3 then side for the rest)  Can feel the first rib to the side of the transverse process  PPIVM’s o Side lying (maybe a small towel in between lumbar spine and plinth o One finger on spinous processes of L4/5 o One foot on top of the other o Bottom knee of the patient on the top hip of the clinician o Take patients feet and have their legs across your waist and lean in o Find L4 and flex hip by swaying with patients legs Quadrant o Lumbar (standing)  Extension, side flexion and rotation  Hand on their opposite shoulder, block their nearest knee with yours and have your forearm at their back parallel with the ground o Cervical (sitting)  Hands on top of head and around chin  Extension, rotation, lateral flexion Neural tissue provocation tests (NTPT’s) o Sciatic nerve (supine)

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Patients foot propped on clinicians shoulder, hip flexion, knee extension, dorsiflexion, hip adduction and hip medial rotation (add cervical flexion as the sensitising movement)  Compare to the other side  Tightness in the posterior thigh could indicate the sciatic nerve; could also indicate tight hamstrings, gastrocnemius (isolate sciatic nerve with hip medial rotation and adduction as well as cervical rotation)  To differentiate from facet joint dysfunction, do not add hip medial rotation or adduction as this may implicate the facet Tibial test (supine)  Straight leg raise with dorsiflexion (isolate from gastrocnemius by adding hip medial rotation and adduction) Peroneal test (supine)  Deep: straight leg raise with plantarflexion  Superficial: straight leg raise with plantarflexion and inversion Femoral nerve (side lying)  Hip flexion, knee extension, thoracic flexion  Neutral cervical spine (can flex and extend as a sensitising movement) Median nerve (supine)  Knee under their elbow  GH abduction, GH lateral rotation  Radioulnar supination, wrist extension, MCP, PIP, DIP extension of fingers and thumb  Hand on plinth and take elbow into extension  Sensitisers: opposite ear to opposite shoulder, cervical flexion or GH extension  Elbow extension last due to possible guarding from biceps/triceps Radial nerve (supine)  Diagonally on plinth with shoulder off plinth  GH abduction, GH medial rotation  Full pronation  Sensitisers: opposite ear to opposite shoulder, cervical flexion, depress scapula by pushing their should with your hip Ulnar nerve (supine)  GH abduction, GH lateral rotation, pronation, wrist extension, MCP/PIP/DIP extension, elbow flexion, keep scapula down and abduct further (could also do straight leg raise after this)

Hard neuro -

Dermatomal testing o With cotton wool Myotomal testing o Dysfunction may be due to pain or neural o S1 first (in standing – can patient stand on tip toes?): plantarflexion o C1 (sitting): neck flexion o C2 (sitting): neck extension o C3 (sitting): neck lateral flexion o C4 (sitting): shoulder elevation o C5 (sitting): shoulder abduction o C6 (sitting): elbow flexion/wrist extension/finger extension o C7 (sitting): elbow extension/wrist flexion o C8 (sitting): finger flexion o T1 (sitting): finger abduction/adduction o S2 (sitting): knee flexion o T2-T12: intercostals o L2 (supine): hip flexion

L3 (supine): knee extension L4 (supine): dorsiflexion L5 (supine): great toe extension S2 (sitting Knee extension (L3): patient prone with testing knee at 90 (mid-range) with clinicians arm under their knee o Ankle dorsiflexion (L4): patient supine, cross wrists over to cause dorsiflexion and inversion for tibialis anterior o Great toe extension (L5): patient supine, finger on the nail o Plantarflexion (S1/S2): patient standing, do this before the patient gets on the plinth by standing on their tip toes  Can be done in supine if patient cannot stand Reflexes o Patellar tendon  Patient supine with clinicians arm under leg concerned o Achilles  Patient prone with clinicians knee under that of the patients that is flexed  Cup calcaneus and have forearm along the sole of the foot  Clinician should be standing at the patients knee facing away o o o o o

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Minimum provocative testing (NO OVERPRESSURE!) o Take to the end of range and sustain position o Whilst doing the movements instruct the patient to count to 10 to monitor speech o Cervical  Rotation: patient supine, one hand underneath head to cradle occiput, whilst also touching the bed to allow the patient to relax o Extension  Instruct patient to have their shoulders off the end of the plinth  Lock both hands under occiput  Step stance, bend knees and lower the head  Count to 10 when in extension and when back to neutral  Remind patient to get up slowly SIJ tests (just looking for symptom reproduction, not ROM!) o Anterior gapping (supine)  Cross hands and place each on the respective ASIS and push apart with a sharp movement o Posterior gapping (supine)  Hands on sides of hips and push outer sides of pelvis to open PSIS  Can also do this in side lying with a pillow between the patient’s knees o Anterior glide (supine)  Aim force towards the sacrum  Heel of hand over ASIS and stable the other ASIS o Posterior shear (stretches anterior ligaments of hip and SIJ)  Hip flexed and apply force straight through the femur o FABER (supine)  (hip flexion, abduction and external rotation) ankle on shin, stabilise opposite ASIS whilst pushing knee towards the floor o Pelvic torsion (diagonally supine)  Leg off of the bed  Hip flexion and get patient to hold this knee  Push legs apart o Sacral shear (prone)

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 Heel of hand on posterior aspect of sacrum and just push straight down o Leg length discrepancy (supine)  Take bum off plinth with knees flexed then straighten legs and monitor position of medial malleoli o Active straight leg raise (ASLR) (supine)  Apply posterior gapping movement to determine whether the patient has a reduced forced closure o Baers point (supine  ASIS and umbilicus – apply pressure straight down, 1/3 of the way from ASIS  This trigger point can reproduce symptoms o Hip quadrant (supine)  Full knee flexion, hip medial rotation, hip adduction until patient either feels pain or uncomfortable tightness  Pain before tightness would indicate positive test Slump o Check patients symptoms o Instruct patients to drop their shoulders as if they were going to try and squeeze into small box, but keeping their head up o Same movement, but with cervical flexion o Incorporate thoracic and lumbar flexion, keeping the patients head up o Same movement as above, but include cervical flexion o Instruct patient to sit up straight and raise their symptomatic leg o Incorporate slump and ask patient to straighten leg o Same movement as above, but incorporate cervical flexion  Reproduction of symptoms on last test indicates sciatic nerve McKenzie tests o Flexion in standing (FIS)  Instruct patient to flex lumbar spine (same as ARoM movement) o Repeated flexion in standing  Repeat 5x o Extension in standing  Instruct patient to extend lumbar spine (same as ARoM movement) o Repeated extension in standing  Repeat 5x o Flexion in lying  Instruct patient to hug their knees and roll them back using their knees to flex lumbar spine o Repeated flexion in lying  Repeated 5x o Extension in lying  Instruct atient to push up from plinth/they can also rest on their elbow o Repeated extension in lying  Repeat 5x o Side glide in standing  Push hips one way and shoulders the other o Repeated side glide in standing  Repeat 5x Static tests o o o o o

Sitting slouched Sitting erect Standing slouched Standing erect Lying prone in extension

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Long sitting

Extra tests o Clonus  Patient supine, take patients foot from max plantarflexion rapidly into max dorsiflexion (positive test is jittery movement) o Babinski  Patient supine, stroke the bottom of the patients foot (positive test is outward fanning of toes)

Subjective indicators -

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Facet o Unilateral presentation o >age o Occupation/hobbies: sustained postures o Sudden onset o Pain in weight bearing o Aggravating factors: extension, lateral flexion, rotation o Pain mechanism: peripheral nociceptive inflammatory/mechanical Intervertebral disc o Uni/bilateral presentation o...