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Textbook
Introduction
1. Cardiopulmonary system
2. Pulmonary system
3. Neuromuscular system
4. Pediatrics
5. Musculoskeletal system
5.1 Anatomy of musculoskeletal system
5.2 Foundation content of musculoskeletal system
5.3 Upper extremity anatomy
5.4 Special tests of upper extremity
5.5 Differential diagnosis with interventions of upper extremity
5.6 Lower extremity anatomy
5.7 Special tests of lower extremity
5.8 Differential diagnosis with interventions of lower extremity
5.9 Spine, pelvis, and tempromandicular joint anatomy
5.10 Special tests of the spine, pelvis, and tempromandipular joint
5.11 Differential diagnosis with intervention of spine, pelvis, and TMJ
5.12 Other MSK conditions
5.13 Gait
5.14 Prosthetics and orthotics
5.15 Medications, imaging, and fractures
5.16 Surgical protocols
6. Other system
7. Non-systems
Wrapping up
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5.10 Special tests of the spine, pelvis, and tempromandipular joint
Achievable NPTE-PTA
5. Musculoskeletal system

Special tests of the spine, pelvis, and tempromandipular joint

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Special tests spine and pelvis

Cervical spine

  • Vertebral artery test
    • Patient supine with head supported and over edge of mat; therapist passively extends head/neck and hold for 30 seconds, progress to passively rotate and side-bending with extension-holding each position for 30 seconds
      • Tests the integrity of vertebrobasilar vascular system
    • Positive: symptoms of dizziness, dysphagia diplopia, ataxic gait, nystagmus- red flag and therapist does not progress with any movements of cervical spine
      • Vertebral artery test should always be performed prior to cervical spine mobilization- if not performed, this is considered sub-standard care and can be life-threatening

Image #163

  • Flexion rotation test
    • Patient in supine with maximal flexion of neck performed with rotation to left and right
      • Provocative test for atlantoaxial dysfunction or cervicogenic headache
      • Positive: reproduction of headache symptoms or loss of 10 degrees of mobility when comparing left and right rotation (when compared to each side)

Image #164

  • Spurling’s test (foraminal compression)
    • Patient sitting with head laterally bending towards involved side while therapist applies pressure straight down
      • Confirms cervical root dysfunction
    • Positive: pain and paresthesia in dermatomal pattern of cervical root

Image #165

  • Cervical compression test
    • Patient sitting and neck passively moved into lateral flexion and rotation to the non-painful side, followed by extension. Repeat the painful side.
      • Identifies intervertebral foramen and/or facet dysfunction
    • Positive: pain and paresthesia in dermatomal pattern of cervical root or localized pain in neck if facet dysfunction

Image #166

  • Distraction test
    • Patient sitting with head passively distracted
      • Identifies intervertebral foramen and/or facet dysfunction
    • Positive: decrease in symptoms or decrease in upper limb pain

Image #167

  • Lhermitte’s sign
    • Patient long sitting on mat; therapists passively flex patient’s head and hip while keeping knee in extension. Repeat with the other hip.
      • Identifies upper neuron lesions
    • Positive: electrical pain down spine and into upper or lower limbs

Image #168

  • Alar ligament test
    • Patient seated and therapist palpates C2 spinous process; the therapist passively flexes the upper cervical spine with lateral flexion and rotation
      • Tests integrity of alar ligament
    • Positive: Inability to palpate C2 and/or inability to feel movement at C2

Image #169

Thoracic spine

  • Rib sparing
    • Patient prone; beginning at upper ribs apply posterior/anterior force to rib moving through the entire rib cage. Also perform in a side-lying position.
      • Tests rib mobility
    • Positive: pain, excessive motion of rib, or restriction of rib

Image #170

Lumbar spine

  • Slump test
    • Patient sits with knees flexed and neutral neck and head; progress through the following steps- passively flex head and neck, passively extend knee, passively dorsiflex ankle of limb- repeat with opposite leg
      • Therapist will stop at a step if reproduction of symptoms occurs
        • Tests for neurological dysfunction of lower extremity
      • Positive: pain, paresthesias, numbness/tingling, and other neurological symptoms

Image #171

  • Prone instability test
    • Patient prone with torso supported on mate, legs off the edge with both feed supported on the ground. Therapist applies posterior/anterior springing throughout the lumbar spine to identify painful segments. Therapist then instructs patient to lift legs off floor and performs same posterior/anterior springing
      • Tests instability of lumbar spine
      • Positive: decreased pain during posterior/anterior springing with the legs raised compared to when the feet are supported on the ground

Image #172/#173

  • Quadrant test
    • Patient standing
      • Facet dysfunction: instruct patient to lateral bend to left, rotate to right, and maximally extend to compress facet joint on left. Repeat on the opposite side.
      • Intervertebral foramen: instruct patient to lateral bend left, rotate left, and maximally extend to close intervertebral foramen on left. Repeat on the opposite side.
        • Tests compression of neural structures at facet and intervertebral foramen
      • Positive: pain or paresthesias in dermatomal pattern or localized pain if facet dysfunction

Image #

  • Bicycle test
    • Patient positioned on stationary bike. In erect posture, patient rides bike at set pace/speed with time observed; patient then rides bike at set pace/speed in slumped position with time observed
      • Differentiates between intermittent claudication and spinal stenosis due to position
    • Positive: Individuals with spinal stenosis will tolerate riding bike with slumped posture longer than when in erect posture

Neurological dysfunction

  • Lower limb tension tests- assists with identifying peripheral nerve injury by placing the lower limb in positions of that will stress nerve
  • Straight leg leg raise (SLR)- test sciatic and tibial nerve
    • Hip: flexion and abduction
    • Knee: extension
    • Ankle: dorsiflexion
    • Foot: n/a
    • Toes: n/a
  • Straight leg leg raise 2 (SLR 2)- test tibial nerve
    • Hip: flexion
    • Knee: extension
    • Ankle: dorsiflexion
    • Foot: eversion
    • Toes: extension
  • Straight leg leg raise 3 (SLR 3) - test sural nerve
    • Hip: flexion
    • Knee: extension
    • Ankle: dorsiflexion
    • Foot: inversion
    • Toes: n/a
  • Straight leg leg raise 4 (SLR 4) - test common fibular nerve
    • Hip: flexion and internal rotation
    • Knee: extension
    • Ankle: plantar flexion
    • Foot: inversion
    • Toes: n/a
  • Straight leg leg raise 5 - Well leg (SLR 5) - test spinal nerve root
    • Hip: flexion
    • Knee: extension
    • Ankle: dorsiflexion
    • Foot: n/a
    • Toes: n/a

Sacroiliac

  • Gillet’s test
    • Patient standing; therapist places one thumbs under posterior iliac spine (PSIS) of unilateral extremity and other thumb in center of sacrum. The patient then flexes knee and hip while the therapist palpates PSIS and observes for movement.
      • Assess posterior movement of ilium
    • Positive: no movement of ilium or sacrum (ilium has lost mobility)
  • Gaenslens’s test
    • Patient side-lying at edge of mat with bottom leg maximally flexed at hip and knee. Therapist passively extends uppermost limb
      • Tests for sacroiliac dysfunction
    • Positive: pain in sacroiliac joint
  • Long sitting
    • Patient supine with therapist palpating medial mallelous- therapist observes alignment. The therapist then asks the patient to come to a long sitting position to observe if alignment at medial mallelous is still present.
      • Tests for leg length discrepancy due to sacroiliac joint
    • Positive: one leg observed longer when coming in long sitting position compared to supine position
  • Sidelying compression test
    • Patient side-lying with side of dysfunction facing upward toward therapist. Therapist palpates iliac crest and then applies force down through ilium for up to 30 seconds
      • Identifies sacroiliac dysfunction
    • Positive: reproduction of pain
  • Supine iliac gapping
    • Patient supine with therapist crossing their arms and placing their hands on patient’s anterior superior iliac spine (ASIS)- each hand on the medial aspect of the ASIS and pushing out laterally
      • Identifies sacroiliac dysfunction
    • Positive: sacral symptoms relieved

Temporomandibular joint (TMJ)

A bilateral synovial joint with articulation between mandible and cranium. Articular disc lies between areas of articulation in which there is no vascularization or neural supply. Disc ligaments act to prevent sagittal plane movement. Movements of the TMJ are a combination of axis rotation and sliding movements. Types of movement are seen below:

  • Elevation (Closing):
    • Contraction of the masseter, temporalis, and medial pterygoid muscles raises the mandible.
  • Depression (Opening):
    • Relaxation of the elevator muscles and contraction of the digastric, geniohyoid, and mylohyoid muscles lowers the mandible.
  • Protrusion (Forward Movement):
    • Contraction of the lateral pterygoid muscles moves the mandible forward.
  • Retrusion (Backward Movement):
    • Contraction of the posterior fibers of the temporalis muscles moves the mandible backward.
  • Lateral Deviation (Side-to-Side Movement):
    • Contraction of the lateral pterygoid muscle on one side moves the mandible toward that side.

Special tests of TMJ

  • TMJ compression
    • Patient sitting or supine; therapist stabilized patient’s head with one hand while the other hand pushes mandible superiorly causing a compressive load to the TMJ
      • Assess pain of the retrodiscal tissues
    • Positive: pain in the TMJ
Mandibular joint
Mandibular joint
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