Hello I'm Dr. Shay Bess, I'm a board-certified orthopedic surgeon
as well as the spine surgeon with the Rocky Mountain Scoliosis and Spine Clinic
on the campus of Presbyterian/St. Luke's Medical Center
I'm here today to speak about physical examination procedures
physical therapists can use in determining whether
to refer a patient to the spine specialist these procedures can be
broken down into
eight categories posture range of motion
skin gait motor strength sensory conditions
reflexes and a range of motion of the extremities
in assessing posture we look for normal lordosis
C1 through C7 to be approximately 20 to 40 degrees
any condition of torticollis commonly known as wry neck
should be noted in the thoracolumbar region
normal kyphosis should be between T5 and T7
and again should be roughly between 20 and 40 degrees
and lordosis the lumbar spine should be approximately forty to sixty degrees
we also look for any real prominence including
gibbus deforminty on Adam's Forward Bend
as well as vertebral rotation and also check the spine with a scoliometer
for
thoracic or lumbar prominences flat back deformity
or a loss of normal lordosis in the lumbar spine
is also a potential indicator of problems next we perform test
on the range of motion the spine in the extremities
from the cervical region we test for Spurling's
or creation of extremity pain by extending the neck
and rotating the chin toward the affected extremity this is an indicator of nerve
root compression
and we also ascertain any sternocleidomastiod or
trapizus pain including any soft tissue or bony anomalies
then turning to the thoracolumbar region we check for flexion pain
which is an indicator disc with their problems as was extension pain
which may show us vacepulator problems after checking for range in
motion the lumbar spine
we then turn to evaluation and the skin scars
can the notes problems including previous surgery as well as previous
trauma
hairy patches and skin dimpling may also indicate
underlying bony or neurologic anomalies
a simple gait analysis can also uncover a spinal condition namely
is their gait unsteady this may be due to pain
or cervical stenosis turned over gait
or a side to side lurch type gait is due to weakness
of the gluteus medius and gluteus minimus motor strength is a good indicator of
spinal problems
motor strength is graded I'm a scale of 0 to 5
with 0 being no evidence of contractivity of
the motor fibers and five being
normal strength in that muscle distribution
the cervical and lumbar dermatomes are useful
in assessing and locating a corresponding
nerve root that maybe compressed
or affected reflexes are tested next
and they are graded on a scale from 0 to 4 plus
zero indicates a absence of the reflex 2
indicates a normal reflex and four plus indicates hyperactivity
with associated clonus of the lower extremities again the reflexes
follow a normal dermatome that corresponds
to that respective nerve root. In addition
to testing the reflexes of the lower extremeties
we also test the reflexes around the umbilicus region
we want to do a stroke all four quadrants
that's surround the abdomen and correspondingly
the umbilicus should move toward the stimulus
or the area that is being tested a lack
over a reflex or pull away from the region that is being stroked or
tested indicates an upper motor neuron lesion
and should then be investigated via
advanced imaging next the Hoffman test
is performed by striking either the volar or
or dorsal aspects of the middle finger
and observing the reflex contraction of the thumb or
index finger a positive hoffman's reflex
indicates presence of a upper motor neuron lesion
most likely emanating from spinal cord compression we next
test the planter aspects of the foot evaluating for a Babinski sign
normally when stroking the bottom or plantar aspect
the foot the toes will flex down
however in the case of a positive Babinski sign
the toes splay upgoing rather than down going
up going toes or a positive
Babinski sign indicates a potential
upper motor neuron lesion lastly we test
ankle clonus which case tension
on the Achilles ligament will cause a
rhythmic contraction causing the foot to alternate between
dorsiflexion and plantar flexion again
this most commonly indicates an upper motor neuron lesion
next we test for nerve tension signs
in performing a straight leg raise if raising away
and dorsiflexing the foot causes pain that radiates from the back
into the leg indicates there is a space
occupying lesion impacting the disc
which most commonly is caused by a herniated lumbar
disc in the event there is a contra lateral straight leg raise
namely by raising the right leg
causes left leg pain it's indicative of severe compression
above the contra lateral nerve root
cervical nerve tension is tested by the Spurling sign
or creation above upper extremity pain
by extending the neck and rotating the chin
toward the affected extremity this will then cause
nerve root pain in that involve extremity
if them by placing the ipsilateral hand onto the head
and turning the head to the contralateral shoulder this relieves the pain
this again indicates that the nerve is being compressed
and then we turn the head go away from the nerve root
which relieves decompression pain
carpal tunnel or median nerve compression at the wrist
and cubital tunnel or ulnar nerve compression
at elbow are assessed with Falen's
Tinel's at the wrist and elbow
osteo-arthritis of the hip is evaluated by
internal rotation of the hip if groin pain is present
then hip osteoarthritis is indicated with internal rotation of the hip
osteoarthritis of the knee is evaluated for joint line tenderness
at the knee lastly a vascular examination is performed by
evaluating for the Dorsalis pedis and posterior tibial pulses
these are graded from range from 0 to
2 zero indicates absence of a pulse
one indicates be diminished but palpable pulse and two
indicates a normal pulse also as part of the vascular examination
a visual examination should note for hair loss
shiny skin edema or toenail changes
all over which are indicative vascular insufficiency
spinal conditions are serious proper assessments critical
we encourage you to follow this protocol for assessing spinal conditions
in your patients
in