Clinical Reasoning
Last Updated on Sunday, 12 June 2011 12:46 Written by Administrator Tuesday, 29 March 2011 06:11
Clinical Reasoning for functional stability of the lumbar spine
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Body Chart - one or more areas of pain
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Past History - misuse (incorrect technique), abuse (trauma), overuse (prolonged activity), disuse (atrophy due to 'fear-avoidance' behaviour) leading to deconditioning and hence reduced loading tolerance increasing the susceptibility to recurrences even with minor loading activity
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Current History - onset similar to past history, may be becoming progressively more frequent and more severe in nature, may be taking longer to settle than usual
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Aggravating Factors - unguarded movements e.g. cough/sneeze, twist/turn; can move into every position but don't like to stay in any one position for too long, and have trouble moving out of that position
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Special Questions - ask for X rays if you suspect spondylolisthesis due to Spina Bifida (patch of hair on back), or pars interarticularis fractures; question steroid use, prostate cancer, blood anomalies, infections, major weight loss, cauda equina/cord compression symptoms, osteoporosis, etc
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Physical Examination
Special Tests
- stork test
- walking + stair walking
- (dys)functional leg length discrepancy
- peripheral muscle length test on pelvic tilt (posterior tilt for rectus femoris, posterior tilt for hamstrings, and Thomas test)
- timing of peripheral muscle activation e.g. Gluteals vs. Hamstrings vs. Quadriceps
- Transverse Abdominal/Internal Oblique activation with leg and arm movements
- effect of changes in Latissimus Dorsi length on lumbar stability
- position of the Belly Button
- active straight leg raise for symphasis pubis instability/oblique abdominal muscle insufficiency
- multifidus activity and lumbar stability in
- prone lying hip extension (legs over end of bed)
- 4 point kneeling crossed extension
- rocking side to side and forward/backward, as well as alternating arm movements at 90 degrees flexion
clunk test' in side lying
after PPIVM's the movement pattern of restriction or excessive mobility may change dramatically
spasm during PAIVM's
Pressure Cuff biofeedback (inability to maintain the neutral zone)
Transverse/Internal Oblique and Multifidus with EMG testing (no onset, late onset, or prolonged onset?)
Somatic referred neck pain
Radicular referred neck pain
remember there are a spectrum of presentations and that these examples are only a sample of what may be expected in your subjective and physical examination. Therefore, it is up to you to develop clinical pictures that fit the features of the presentation. The structure of the clinical reasoning process will serve as guide to help you with your 'inductive' and 'deductive' reasoning
