Physical Medicine 204 Midterm

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Various tissue changes occur in each stage of healing, which determines the _________?

Goal of therapy


Damage to tissue results in chemical release of histamine, prostaglandin, bradykinin, free recitals, etc., which have the following effects:

1. Nocistimulation

2. Increased capillary permeability

3. Secondary cell damage


What is the approximate duration of the acute/inflammatory phase?

3 to 5 days


Which type of cells are present during the acute/inflammatory phase?

PMN (polymorphonucleus neutrophils), macrophages, and fibroblasts


The fibrin clot is formed during which phase?



Which cell breaks down and removes debris from the site of injury?



What are the main signs of inflammation?

Redness (rubor), pain (dollar), swelling (tubor), hot (calor), and loss of function (laesea)


Which type of cells is predominant during the subacute/proliferative phase?



Which stage of healing do we start to see the progression of collagen type fibers from type III to type I?



What is the approximate duration of the subacute/proliferative phase?

2 to 4 weeks


_______ may form during the subacute/proliferative phase.



We can gently _______ the tissue during the subacute/proliferative phase to help the tissue become stronger.



What cells are predominately present during the chronic/maturation/remodelling stage?

Fibroblasts and myofibroblasts


Fibroblasts and myofibroblasts ______ the tissue _______.

Pull; together/tighter


What is the approximate duration of the chronic/remodelling/maturation phase of healing?

6 to 18 months


In the late stages of healing, contraction of a scar near a joint and adhesions around a joint can cause ________ ?

Reduced ROM


What type of fibers can become more in line with rehabilitation?



Pain leads to muscle inhibition and disuse, which can lead to _________ .

Atrophy of muscle, ligaments, and bone


Atrophy of muscle, ligaments, and bone can result in altered ________ .

Movement patterns


Immobilized muscle can lose muscle strength at ________ .

8% per week to 5% per day


Weaker muscles, weaker connective tissues, and inefficient biomechanics can lead to?

Chronic or repeat injuries


Goals of rehabilitation try to promote?

Reduction of pain and promote function, ROM, coordination, general fitness, etc.


What are the therapeutic goals of the acute/inflammatory phase?

PRICE (protection, rest, ice, compression, elevation), prevent further injury, and control inflammation and pain


What are the therapeutic goals of the subacute/proliferative phase?

Do not aggravate healing tissue, control pain, gentle stretching (active and passive) and motion, and therapy to other adjacent areas not injured


In the subacute/proliferative phase, gentle stretching and motion helps to?

Prevent adhesions, maintain ROM, helps quality of scar being formed, and reduces congestion/swelling


What are the therapeutic goals of the chronic/remodelling/maturation phase?

Strengthen scar tissue and surrounding muscle, remove any trigger points, and to restore function, ROM, strength, muscles imbalances, coordination, and skill


The application of cold to the skin has an immediate _________ effect. Afterwards there is a long slow _______ effect.

Vasodilation; vasoconstriction


The ________ effect of applying cold to an area of skin is helpful in the acute/inflammatory phase of healing.



With cold application to the skin of the extremities, there is the _________ reaction after about 15- 20 minutes of application.

Lewis Hunting (alternating vasoconstriction and vasodilation)


Therapeutic application of cold slows down the ________ in peripheral nerves and local _______ rate, which leads to less _______ and _______. This results in less tissue damage.

Conduction; metabolic; pain; inflammation


What can happen if tissue becomes too cold for a prolonged period of time (longer than 15 minutes)?

Ischemia leading to necrosis


What is the management of prolonged severe cold exposure?

Rapid warming in core-temperature water


What is the test that is used to determine the vascular response to a cold stimuli?



What is an abnormal initial response for the Baruch test?

You scratch the skin, the skin blanches and it remains white


What is a normal initial response for the Baruch test?

You scratch the skin, the skin blanches, but then turns red


When is therapeutic cold application contraindicated for the Baruch test?

When the skin response remains white after the initial and secondary parts of the test


When is therapeutic cold application contraindicated?

Positive Baruch test, Reynaud's test, heart disease, peripheral nerve or vascular disease, compartment syndrome, psychological aversion to cold, cold allergies, and pernio (sequel to frostbite: tissue hypersensitive to cold)


What are the indications for cold therapeutic application?

Acute musculoskeletal injuries


What can the patient expect to feel during cold therapeutic application?

CBAN: cold, burning, aching, and numbness


Methods of cold application:

Cold packs, ice (cube) massage, ice towels, immersion/ice baths


When is an ice pack application best started?

Immediately after injury during the acute phase. It is also used in the subacute phase especially after activity


Ice massage cools tissue very rapidly and should not be used longer than _______ , usually until the area is numb.

10 minutes


What is the approximate depth of penetration of a hot pack?

1 cm


What is the approximate depth of penetration of continuous ultrasound?

5 to 8 cm


What is a caution about continuous ultrasound?

Burn: Deep tissue is not as sensitive to temperature as skin, it is possible to burn someone before they are aware. If the patient feels heat on the surface, you may have already burned deeper tissues. Never heat beyond comfortable warmth.


Examples of superficial heat applications:

Hydrocollators, microwaveable gel packs, electric heating pads


When is superficial heat beneficial?

During the chronic/remodelling/maturation phase and the late proliferation when when inflammation is no longer present


What are the physiological effects of therapeutic superficial heat?

Vasodilation, increased metabolic rate, sedative effect on nerves - less spasms and pain


Contraindications to therapeutic superficial and deep heat?

Acute/inflammatory phase, diagnosis of injury unknown, malignancy, deep infections, bleeding or clotting disorders, loss of sensation, decompressed heart disease, PVD, diabetes, inflammatory skin conditions, contact dermatitis, high fever, eyes, risk of cataracts, vascularization of cornea, burns of any kind, infants, and pregnant uterus.


What is one contraindication to therapeutic deep heat which is not contraindicated in superficial heat applications?

Growing epiphyses


What are the common indications for superficial and deep heat therapeutic applications?

Neuritis/neuralgis, and the following conditions following the inflammatory phase: contusion (bruise), sprain/strain, pain or spasm, tendonitis, synovitis, tenosynovitis, fibrosis, fasciitis, myofascitis, myofibrositis, buritis, arthritis,


________ therapeutic heat application is not indicated for superficial skin infections, boil, sty (eyelids), carbuncle, furuncle, and frostbite, but these conditions are indicated for ________ therapeutic heat applications.

Deep; superficial


What is the most commonly used deep heater?

Therapeutic ultrasound (continuous)


Therapeutic ultrasound uses a ________ , which helps to make better contact with the skin and it protects the crystal ultrasound head.

Coupling agent


When is a 100% duty cycle (continuous) method used for therapeutic ultrasound?

Later/chronic phases of healing as it produces heat


When is pulsed duty cycle (less than 100%) used for therapeutic ultrasound?

Acute/subacute phases of healing


With therapeutic ultrasound, ______ frequency produces heat deeper in the body, whereas the ______ frequency penetrates more superficially.

Lower (1MHz); higher (3MHz)


The intensity of therapeutic ultrasound is measured in?



When using therapeutic ultrasound, we would use increased intensity for?

Bigger body parts, lower frequency (1MHz), more heat desired when in the chronic phase


When using therapeutic ultrasound, we would increase the time with?

Bigger body parts, low percentage duty cycles (20%) as more time would be needed for physiological effect


Which areas of the body are contraindicated for continuous therapeutic ultrasound (produces heat)?

Over metal intrauterine device (IUD), autonomic ganglia, heart, central nervous system (spinal gutter is ok), pacemaker or other bioelectric equipment, rheumatoid arthritis, bony prominence, reproductive organs


What are the therapeutic effects of continuous ultrasound?

Vasodilation, heats up adhesions/contracture, sedation of peripheral nerves, and neuroma (a painful growth in nervous tissue)


Continuous ultrasound does not work on?

Calcified tendonitis/bursitis


What is the effect of continuous ultrasound on fat tissue?

Little resistance, heats slowly


What is the effect of continuous ultrasound on nerves and muscles?

Well absorbed, heats well


What is the effect of continuous ultrasound on bone?

Most resistant, heats fastest


With therapeutic ultrasound at the bone:muscle interface, there is a lot of ________ and _______ . There is the potential to cause a burn at this interface due to the one tissue type ______ a lot more than the other.

Friction; heat; vibrating


Cavitation is where O2 and CO2 come out of the tissue and can coalesce and cause tissue damage with therapeutic ultrasound. In order for this to happen, we would need to use an intensity of _______ Watts/cm2.

6 to 8


What are the therapeutic effects of pulsed ultrasound?

Increased scar strength, increased rate of scar formation, increased rate of healing, does not reduce inflammation, but useful in the acute/inflammation phase


What are the contraindications to pulsed ultrasound?

Bleeding disorders, malignancy, growing epiphyses, loss of sensation, CNS, over the heart, caution with PVD


When using therapeutic ultrasound, you need to keep the ultrasound head moving at _______ cm/sec.

2.5 to 5


Underwater ultrasound is used for _______ , and you must keep the ultrasound head 1cm away from the skin surface. You can also use higher intensities from 1.0 to 2.5 Watt/cm2.

Bony prominences (hands and feet)


Therapeutic ultrasound can also be used for _________ , which helps push drug into the tissues (with an advantage of more local absorption).



Interferential Current (IFC) uses _______ frequencies (which are crossed) that create interference patterns in the body; the nerves are affected by the resulting frequency.

Two medium


What are the two levels of Interferential Current (IFC) therapy?

Sensory and moror


What are the sensory level effects of Interferential Current (IFC)?

Promotes vasodilation, slows post-traumatic edema, and reduces pain (acute: lighter higher frequency; chronic stronger lower frequency)


What are the motor level effects of Interferential Current (IFC)?

Improves circulation, reduces edema (acute and chronic), and reduced muscle guarding (fatiguing muscle to reduce tension


What are the contraindications for Interferential Current (IFC)?

Pregnant uterus (lower back or abdomen), metastatic lesion, across the chest (heart), over carotid sinuses, venous or arterial thrombosis or thrombophlebitis, and/or over other currents used in body (nerve stimulator, pace maker, etc.)


With Interferential Current (IFC), moving the pads further apart creates a _______ current.



With Interferential Current (IFC), the patient will feel buzzing or tapping with the ________ level, and contraction ________ level.

Sensory; motor


What intensity is used for interferential current (IFC) to manage acute pain?

Mild sensory level


What intensity is used for interferential current (IFC) to manage more chronic cases with no muscle contraction?

Moderate sensory level


What intensity is used for interferential current (IFC) to manage muscle spasm or chronic pain?

Moderate motor level


Laser therapy only penetrates a few ________ .



Therapeutic effect of laser therapy are?

Cellular: increased ATP production, stimulation of macrophages, stimulation of fibroblasts to increase collagen production.

Altered nerve conduction and regeneration and vasodilation


Contraindications for laser therapy are?

Direct irradiation the eye, malignancy, hemorrhaging, locally to endocrine glands. Precaution with epilepsy and fever


Indications of laser therapy are?

Wound healing, fracture healing, and pain magagement


What intensity is used for interferential current (IFC) to manage acute edema (acute inflammation).

Mild motor level


Observation of the anterior posture follows the midline through the following structures:

Nose, manubrium, xiphod, and umbilicus


Asymmetry of the body contours in the standing anterior posture may indicate?

Muscle wasting, hypertrophy, nerve pathology, job related, etc.


In the anterior observed posture what is an abnormal finding of the clavicles?

Downward angle


The antecubital crease should face _______ in the standing anterior posture.



If the antecubital crease is pulled medially observed in the anterior posture, which muscle (s) could be responsible?

Tight pectoralis major


In the anterior observed posture, if the ribs are protruded on the concave side what could it be caused by?



In the anterior observed posture, what are the normal findings for the lower extremities?

Patella pointing straight forward and medial longitudinal arches present and symmetrical bilaterally


A pronated foot is known as?

Pes planus (flat foot)


A supinated foot is known as?

Pes cavus (arched foot)


The normal Fick angle is between _______ degrees relative to the sagittal plane and 2ndray (2ndtoe).

5 to 18


The ideal lateral postural plum line runs through the following structures:

Ear lobe, acromion, mid thorax, and slightly anterior to the hip and knee joint and lateral malleolus


A large gluteus maximus or fat over the buttock can give the false impression of _______ .

An exaggerated lordosis


Observing the posture in lateral view, knees are normally in _______ degrees flexion.

0 to 5


The ideal plumb line for the posterior observed posture should run through the following structures:

Spinous processes (C7) and gluteal cleft


Normal findings of the observed posterior posture are:

Vertical spinous processes, straight descending achilles tendons, forefoot straight (normal Fick angle), heel should be straight, other structures should be level and symmetrical (shoulders, scapula, gluteal folds, and popliteal crease).


If the palms are facing posteriorly, observed in the anterior posture, which muscle(s) could be responsible?

Tight pectorals major or forearm muscles


Uneven gluteal folds could indicate?

Muscle weakness, nerve root problem, or nerve palsy


Uneven popliteal creases could indicate?

Leg length discrepancy (LLD)


A medial bending achilles tendon if often seen with?

Pes planus


From an observed posterior posture, the heel angled inwards is known as _______ , and a heel angles outwards is known as ________ .

Rear-foot varus; rear-foot vulgus


The scapula is normally ____ inches from the spinous process in adults.



The scapula normally is between _______ spinous processes. Superior angle to inferior angle.

T2 to T7


The root of the spine of the scapular is at _____ level.



Winging of the scapula, with no rotation, if often due to:

Weak serratus anterior(more bilaterally) or scoliosis (more unilateral)


Elevation of the scapula, with no rotation, is due to:

Tight levator scapula/upper trapezius


Depression of the scapula, with no rotation, is due to:

Weak/long levator scapula/upper trapezius


Retraction of the scapula is often due to:

Tight rhomboids/middle trapezius


Protraction of the scapula is often due to:

Weak rhomboids/middle trapezius


Anterior tilt of the scapula is often due to:

Tight pectoralis minor


Upward rotation of the scapula is often due to:

Tight upper trapezius


Downward rotation of the scapula is often due to:

Tight levator scapula/rhomboids


What standing posture can increase spinal curves with lumbar lordosis increased?

Genu recurvatum


What is genu recurvatum?

Hyperextension of the knee


From the lateral view knees are normally in 0 to 5 degrees of flexion, which muscles can cause knees flexion greater than 5 degrees?

Tight hamstrings or gastrocnemius


If knees touch but feet are apart in a standing position:

Genu valgum


If feet together and knees do not touch (greater then 2 finger widths apart) in standing position:

Genu varus


One cannot easily correct their posture if

Joints are stiff or too mobile, muscles are imbalanced (in strength and length - weaker muscle is often lengthened)


Abnormal, weakened, or poor posture causes stress and wear on the _______, as well as _______ .

Articular surfaces; muscle fatigue and pain (weak and/or overly used)


Factors that are a risk to poor posture:

Muscle imbalance, excessive weight, emotional attitude, improper adolescence growth, respiratory conditions, muscle spasms, etc.


Upper and lower crossed syndrome patterns look at the pattern of:

Muscle strength in short muscles compared to the weak lengthened muscles.


Lower crossed syndrome has the following weak and lengthened (phasic) muscles:

Rectus abdominus, gluteus maximus and minimus (which is often inhibited)


Lower crossed syndrome has the following tight and short (tonic/postural) muscles:

Hip flexors (iliopsoas, psoas major, and rectus femoris), lumbar erector spinae, tensor fascia late, and quadrates lumborum.


Lower crossed syndrome can illicit pain in the lower back as well as:

Buttock pain, knee pain, and hamstring pulls (strain)


With the lower crossed syndrome, the ASIS and PSIS angle is _______ than the normal 10 degrees, resulting in an ________ tilt of the pelvis.

Greater; anterior


Weak lengthened muscles are _______ muscles, while short tight muscles are _______ muscles.

Phasic; tonic/postural


What is a solution for the lower crossed syndrome?

Strengthen the abdomen and gluteal muscles, stretch out the back and hip flexors, and do things to prevent it


The upper crossed syndrome has the following weak and lengthened muscles (phasic):

Lower and middle trapezius, rhomboids, serratus anterior, and crossed deep neck flexors


The upper crossed syndrome has the following tight and shortened (tonic/postural) muscles:

Pectoralis minor and major, sternocleidomastoid crossed with sub occipitals, upper trapezius and levator scapula


Common complaints of the upper crossed syndrome:

TMJ pain, neck pain, headaches, rotator cuff injuries, and shoulder blade pain


Phasic muscles are prone to:

Weakness, hypotonicity, inhibition, and prone to atrophy


Tonic or postural muscles are prone to:

Tightness, shortening, hypertonia, and are resistant to atrophy


What is a common cause of flat back posture (loss of lumbar lordosis)?

Weak lumbar extensors, weak hip flexors, tight hamstrings, tight rectus abdomius, and tight thoracic erector spinae


Pathological causes of thoracic kyphosis are:

Osteoporosis, compression fracture, ankylosing spondylitis, and TB


Humpback or Gibbus thoracic kyphosis is?

A localized SHARP posterior angulation, commonly from a fracture


Dowager's hump has a more _________ hump compared to a humpback or (Gibbus hump), and is commonly seen in elderly women due to osteoporosis.



In a swayback posture, the ______ is the most anterior region.



Causes of cervical lordosis (can look like lower crossed syndrome).

Lax muscles (abdominus), tight muscles (hip flexors and lumbar extensors)


Causes of lumbar lordosis:

Heavy abdomen, obesity, pregnancy, compensatory to thoracic kyphosis, spondylisthesis, and wearing high heels


There is two types of scoliosis and they are:

Structural and functional


Structural scoliosis is _______ , while functional scoliosis may be _______ .

Irreversible; fixable


Structural scoliosis does not _______ with forward bending or lateral flexion.



In structural scoliosis ribs are prominent posteriorly on the ______ side, and anteriorly on the _______ side.

Convex; concave


Common causes of structural scoliosis:

Idiopathic, osteopathic, neuromuscular (spinal cord injury)


Common causes of functional scoliosis:

Leg length discrepancy, muscle spasm, pain in the back or neck, habit.


_______ cm leg length discrepancy is quite common and not necessarily pathologic.

1 to 1.5


People with leg length discrepancy will complain of more pain with ______ as compared to ______ .

Standing/walking; running


When sitting with legs extended, and the patient reaches to touch their toes and can reach beyond their toes, what does this indicate?

Excessive hamstring flexibility


When sitting with legs extended, and the patient reaches to touch their toes, what can the body contour indicate?

Tightness or flexibility of the upper and lower back, hamstrings, and gastrocnemius and soleus muscles


When sitting with legs extended, and the patient reaches to touch their toes, what can be a cause of having the posterior pelvis not vertical (pelvis + back at 90 degrees) and greater than 90 degrees?

Short/tight hamstrings


Correcting posture tips:

Self-correct every 20 minutes (military posture - 10%), less sedentary, less sitting, exercise, strengthen muscles, fix stiff joints, fix sitting posture (ergonomics), address psychological issues


What is a structural cause of knees pointing straight ahead but the toes pointing outward beyond the 5- 18 degrees Fick angle?

Tibial torsion


What could be a functional causes of toes pointing outward beyond the 5- 18 degrees Fick angle?

Tight piriformis muscle (external rotator of the hip)


In regards to the principles of exercise, what does overload mean?

Exercising in a capacity that is above “normal” on a regular basis


How does one achieve overload?

By different combinations of frequency (how often), intensity (e.g., how much weight), duration (how long), and mode of exercise (types of exercises)


What does the application of overload achieve?

It enhances physiologic function to bring about a training response


If your exercise isn’t any more than what you do on a normal daily basis, then you will probably not get much ________ from the exercise. If you lift a light weight that is not heavier than what you would normally lift on a regular basis, you will not get any _________ gains.

Benefit; strength


What does FITT stand for?

Frequency, Intensity, Time, Type


When giving an exercise prescription you need to include information about?



Examples of Frequency (FITT):

Number of times per day/week


Examples of Intensity (FITT):

Subjective descriptions “light, moderate”, 3 mph, 10 RM (amount of weight), etc


Examples of Time (FITT):

How many seconds/minutes; the “tempo” (how fast) of the movement


Examples of Type (FITT:

Active vs passive, weight-bearing, isometic vs isotonic, etc


In regards to the principles of exercise, what does specificity mean?

Depending on what your therapeutic goals are, the exercises that you prescribe should match those goals. The training effects of an exercise mat not carry over to the other activities.


Normally, range of motion (ROM) is maintained with _______ .

Daily activity


What happens as a result of immobilizing a limb in a cast?

Adaptive shortening of connective tissues and muscle


What is the term used to explain what happens to connective tissue and muscle as a result of immobilization over time?

Adaptive shortening


Adaptive shortening can happen anytime connective tissue is not subject to regular _______ .



What can happen after 2 week of immobilization to connective tissue?

Dense connective tissue is formed reducing ROM, as well as edema due to the loss of the pumping action, which can further reduce ROM


Reduced ROM can result from ________ .



What changes begin to happen when muscle is immobilized for 5-7 days?

Atrophy and reduced mitochondrial production, and other changes such as reduced muscle fiber size, reduced capillary density, and reduced oxidative capacity (less strength and endurance)


With prolonged periods of immobilization what can happen to the muscle?

Increased fibrosis and fatty tissue within the muscle as well as neural changes that can alter proprioception


________ and prolonged ________ postures can result in adaptive shortening (shortening of the muscle and connective tissue).

Inactivity; shortened-muscle


What are the 4 types of stretching?

Active, Passive, Proprioceptive Neuromuscular Facilitation, and active assisted stretching


What can help improve active muscle stretching?

Heating muscle beforehand


What are some ways we can heat the muscle before we do active stretching?

Heat packs, continuous ultrasound, exercise, and/or going for a walk or run


With active stretching, if you have significant ROM loss you need to have frequent ________ sessions throughout the day.



Each active stretch should take around _______ seconds and ______ repetitions.

15 to 30; 4 to 5


Contraction of the _______ can help during active stretching.

Antagonist (opposing muscle)


Passive stretching is when that patient is _______ .

Relaxed and the therapist preforms the stretch or the stretch is preformed with the use of equipment sustaining the stretch


When is passive stretching often useful?

In the acute stage: in the pain-free ROM


Equipment that helps with passive stretching is useful when _________ .

Prolonged stretching is needed in chronically shortened (yet strong) tissues


What are the 2 techniques for Proprioceptive Neuromuscular Facilitation (PNF) stretching?

Hold-Relax and contract-relax


With Proprioceptive Neuromuscular Facilitation (PNF) stretching you use the _______ .

Agonists and antagonist to help stretch a muscle


In the hold-relax Proprioceptive Neuromuscular Facilitation (PNF) technique the muscle is _______ .

Brought to the end range, maximum isometric contraction (5-10 sec), relax, then contraction of the opposing muscle to increase the stretch of the agonist


The hold-relax PNF technique is useful for?

Muscle spasm and increasing ROM


In the contract-relax PNF technique the muscle is ________ .

Brought to end range, concentric contraction (manual resistance by doctor as muscle shortens), relax, passive movement to end range


With active assisted stretching, the body part stretches actively, but an _______ force helps.

Outside (the other arm, the therapist, using objects like a broom or towel to increase the stretch)


If a scar/muscle strain is the cause of reduced range of motion, what would help the effectiveness of stretching in the subacute/proliferative phase of healing?

Stretching in the pain-free range of motion, then ice at the end to reduce any inflammation to the site of injury


In the chronic/remodelling/phase of healing, what would be an effective treatment modality to help with stretching an injury with a adherent/mature scar?

The application of heat and then stretching the tissue to tolerance


What other modality beside stretching would be beneficial for a muscle spasm or edema?

Interferential current


What are the contraindications for stretching?

Recent fracture, abnormal 'bony' end feel, infection, acute inflammation, extreme sharp pain, and tight tissue that contributes to stability


After stretching, any pain beyond tenderness, especially with edema indicates?

That the stretch was too aggressive or too early in rehabilitation


What caution is given to stretching after a period of immobilization?

Risk of tearing with stretching as the tensile strength of the connective tissue has been reduced (weaker ligaments, joint, tendons). We want to increase the ROM but must be careful not to compromise the weaker tissues


What are the indications for stretching?

Tightness of soft tissues, injury to prevent reduced ROM, Abnormal alignment or postural changes, muscle imbalances or spasms


Tips for stretching when there is an injury:

Stretch slowly to the point of tension, then release the stretch slowly


Generally, we do not want to stretch in the ______ phase, stretch in in the pain-free ROM in the _______ phase, and more stretch is applied in the _______ phase.

Acute/inflammatory; subacute/proliferative; chronic/remodelling/mature


In the subacute/proliferative phase, we hold the stretch for _____ seconds, with ______ repetitions.

15; 4 to 5


In the subacute/proliferative phase, we start with _____ stretching and progress to more ________ in the pain-free ROM.

Passive; active


In the subacute/proliferative phase, after stretching always apply ____ to the injured area. This will reduce any inflammation that may have been caused by stretching.

Ice (unless contraindicated)


In the chronic/remodelling/mature phase of healing, we ideally want to stretch ______ to be beneficial.

Several time a day


In the chronic/remodelling/mature phase of healing, we can stretch to a ______ and hold the stretch longer than in the subacute phase of ________ seconds with 4 to 5 repetitions.

Slight discomfort; 30 to 60


In the chronic/remodelling/mature phase of healing, we can introduce _________ stretching as well as active and passive. Heat is good in this phase, as well as ice if inflammation is not contraindicated.

Proprioceptive neuromuscular facilitation


Prolonged passive stretching is good for chronic injuries with reduced ROM, and typically we use ______ tension for _______ minutes ______ a day. _______ after stretching is common, so release the stretch slowly.

Light; 15 to 20; 1 to 2; stiffness


Resistance training helps to build?

Strength and endurance, muscle mass, bone density (with heavy resistance), strength of ligaments/joints, and joint stability


Other benefits to resistant training are:

Cross education, blood sugar control, and improved confidence/self-esteem


What is cross education?

Exercising the uninjured side has some gains in strength to the injured side


Contraindication for resistance training are:

Acute injury, unstable angina, uncontrolled hypertension, uncontrolled dysrhythmias, recent congestive heart failure, severe valvular disease, and hypertonic cardiomyopathy


Lifting weights increase ______ resistance with a result increase in blood pressure.



Endurance training focuses on ________, and strength training focuses on _______ . (Both practices to muscle fatigue fit the definition)

More repetitions with less weight; less repetitions with heavier weight


With resistance training, initially there is rapid gains in ________, while long term benefits are more _______ .

Strength and endurance; gradual


Normally we have muscle _______ to certain weights, and with strength training we can turn this protective muscle _______ off, and lift heavier weight.

Inhibition; inhibition


With initial strength training, there is a change to the number of _______ and _______ firing. We can increase these numbers, as well as our ability to synchronize _______ activation, with strength training and lift heavier weight.

Motor units; motor neurons; motor unit


The long term benefits to resistance training are:

Muscle hypertrophy (more sarcomeres with strength training, more mitochondria with endurance training) and stronger joints and ligaments


What does 1RM stand for?

1 repetition maximum (maximum weight at 1 repetition)


What does 10RM stand for?

When you can lift a maximum amount of weight of one type of exercise 10 times, but not the eleventh


What is an isometric contraction?

Muscle tension without change in muscle length, minimal movement in the joint - useful early in rehabilitation


What is an isotonic contraction?

Variable speeds/force during the movement. Consists of concentric tension (muscle generating tension while shortening - flexion) and eccentric contraction (muscle generating tension while lengthening - extension)


What is isokinetic contraction?

Constant speed with variable force, using specialized equipment


Isometric exercise are often used ________ in the rehabilitation program, as it minimizes stress the injured area.



Strength gain in isometric contraction is ______ to the position in ROM.



If you want to gain strength with isometric contraction you need to?

Exercise in 20 degree increments in the ROM


During strength training, when the muscle maximally contracts isometrically the force in the muscle prevents?

Further blood flow, and without continuous blood flow the muscle fatigues very easily. In this case hold the contraction for 5 seconds, and relax for 60 seconds.


What should you avoid doing with isometric exercises?

Valsalva maneuver: as is causes large BP fluctuations during maximal contractions (which prevent further blood flow)


Generally, with isotonic exercises, you do them 2 to 3 times weekly with a day in-between for _______ .



Isotonic exercises should be in the pain-free range of motion, with a rest of _______ seconds between sets if exercising to fatigue.

30 to 60


What is rating of perceived exertion?

A scale used by patient to determine how hard the exercise was for them (i.e., moderate level would fatigue a muscle in 10 to 15 reps)


What is DOMS?

Delayed onset muscle soreness


______ before resistance training can prevent injury.

Warm-up (not stretching)


Ensure ________ when resistance training.

Muscle balance


Isometric contraction are often used in the _______ phase, with progression to ________ in the chronic/remodelling/maturation phase.

Subacute/proliferative; isotonic


History taking follows the mnemonic:



What is the common quality of muscle pain?

Cramping, achy, and dull


What is the common quality of joint/ligament pain?

Dul and achy


What is the common quality of nerve root pain?

Sharp and shooting


What is the common quality of peripheral nerve pain?

Sharp, bright, and lightning-like


What is the common quality of headache pain?

Throbbing and pulsating


What is the common quality of sympathetic nerve pain?

Burning, pressure-like, stinging, achy


What is the common quality of bone pain?

Deep, nagging, boring, and dull


What is the common quality of fracture pain?

Sharp, severe, and intolerable


What is the common quality of vascular pain?

Throbbing and diffuse (PVD)


History taking: intensity is usually recored as?

On a scale of 1 to 10, 10 being the worst


What is claudication?

A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries. Pain after walking, no pain when rested, but pain again after walking again.


What common condition is characterized by progressive pain during the day?

Congestion in the joint


What common condition is aggravated by sitting and forward flexion?

Intervertebral disc lesion


What common condition is aggravated by extension and relieved by sitting and bending forward?

Facet joint pain


What common condition is characterized by periodic pain on activity?

Mechanical adhesions


Red flags in patient history that indicate a need for referral to a physical for cancer are:

- persistent pain at night

- constant pain anywhere in the body

- unexplained weight loss (e.g., 4.5 to 6.8 kg (10 to 15 lbs) in two weeks or less)

- loss of appetite

- unusual lumps or growths

- unwarranted fatigue


Red flags in patient history that indicate a need for referral to a physical for cardiovascular conditions are:

- Shortness of breath

- Dizziness

- Pain or feeling of heaviness in the chest

- Pulsating pain anywhere in the body

- Constant and severe pain in the lower leg (calf) or arm

- Discoloured or painful feet

- Swelling (no history of injury)


Red flags in patient history that indicate a need for referral to a physical for gastrointestinal/genitourinary conditions are?

- frequent or severe abdominal pain

- frequent heartburn or indigestion

- frequent nausea or vomiting

- change in or problems with bowels and/or bladder function (e.g., urinary tract infection)

- unusual menstrual irregularities


Red flags in patient history that indicate a need for referral to a physical for neurological conditions are:

- changes in hearing

- frequent or severe headaches with no history of injury

- problems with swallowing or changes in speech

- changes in vision (e.g., blurriness or loss of sight)

- problems with balance, coordination or falling

- faint spells (drop attacks)

- sudden weakness


Miscellaneous red flags in patient history that indicate a need for referral to a physical are:

- fever or night sweats

- recent severe emotional disturbances

- swelling or redness in any joint with no history of injury

- pregnancy


Yellow flag symptoms in the patient history indicate?

A more extensive examination


Some yellow flag conditions are:

  • Bilateral symptoms: can mean more systemic
  • Abnormal signs and symptoms (unusual patterns of complaint)
  • Symptoms peripheralizing: moving down the extremity over time
  • Neurological symptoms (nerve root peripheral nerve)
  • Multiple nerve root involvement
  • Abnormal sensation patterns (do not follow dermatome or peripheral nerve patterns)
  • Saddle anesthesia
  • Upper motor neuron symptoms (spinal cord) signs
  • Autonomic nervous system symptoms (palpitations, dizziness)

With examination, one should test the _______ side first.



The mnemonic for examination is?



What does HIPPI in HIPPI-RONEL examination mnemonic stand for?

History, inspection, percussion, palpation, instrumentation


What does RONEL in HIPPI-RONEL examination mnemonic stand for?

ROM, orthopaedic tests, neurological tests, X-ray, lab work


During examination, inspection can tell you about ________ , and you should look for ________ .

Behaviour, facial expression, and posture; deformities, discolouration, and signs of inflammation


If patient has a good range of motion you can add ______ to see how much further they can go.

Gentle overpressure


What is the normal end feel for knee flexion?

Soft tissue approximation


What is the normal end feel for elbow extension?

Bone to bone


What is the normal end feel for finger extension?

Tissue stretch


A dislocated joint may have an _______ end feel.



Differences in ROM between AROM and PROM may be due to?

Spasm, muscle deficiency, neurological deficit, contractures, and pain


ROM hypomobility can result from:

Myofascial hypomobility or capsular/ligamenteous hypomobility


Causes of myofascial hypomobility are?

Adaptive shortening, hypertonicity of muscles (increased tension resist stretching), adhesions, and scarring


Causes of capsular/ligamenteous hypomobility are?

Adaptive shortening, adhesions of the connective tissue, scarring/fibrosis of the connective tissue, arthritis/arthrosis, capsular patterns (indicator that the joint is tight)


Hypermobility of joints are more susceptible to?

Extra ROM


Hypermobility of joints can be caused by?

Sprains/tears, joint effusion, chronic pain, recurrent injury (leads to more stretching), paratenositis, and early osteoarthritis


What are we testing with RROM?

The muscle and nerve that supplies it. We want to see if it has good contraction (isometric) without moving the joint


Muscle testing tests the motor strength and is graded out of ______ .



When testing motor strength, what does a grade of 5+ indicate?

Normal (100%): complete ROM against gravity with maximal resistance


When testing motor strength, what does a grade of 4 indicate?

Good, (75%): complete range of motion (ROM) against gravity with some (moderate) resistance


When testing motor strength, what does a grade of 3+ indicate?

Fair+: complete range of motion (ROM) against gravity with minimal resistance


When testing motor strength, what does a grade of 3 indicate?

Fair (50%): complete range of motion (ROM) against gravity


When testing motor strength, what does a grade of 0 indicate?

No contraction palpated


When assessing pain in ROM, what indicates a ligament/capsular sprain?

Pain when stretched (AROM & PROM), but less pain with RROM


When assessing pain in ROM, what indicates a muscle sprain?

Pain when stretched (PROM) and during contraction (AROM & RROM)


When assessing pain in ROM, what indicates a articular joint dysfunction?

Pain when the joint surfaces are compressed, less pain with traction of the joint


When is a neurological exam indicated?

If the patient feels any numbness, weakness, heaviness, or tingling


Neurological testing includes?

Dermatomes (sensory), muscle tests (myotomes and peripheral nerves), deep tendon reflexes, superficial (abdominal, rooting, cremaster) and pathological reflexes (plantar reflex for UMN lesion)


Grading for deep tendon reflexes:

  • 0 – Absent (areflexia) do the jenderassick maneuver
  • 1 – Diminished (hyporeflexia)
  • 2 – Average (normal)
  • 3 – Exaggerated (brisk) (can be normal)
  • 4 – Clonus (UMN lesion – stroke), very brisk (hyperreflexia)

Sensory testing of dermatomes tests the following sensations:

Light touch, superficial pain, temperature, vibration, proprioception, and pressure


Which sensation(s) cross at the level of the spinal cord up the lateral spinothalamic tract?

Pain and temperature


Which sensation(s) cross at the level of the spinal cord up the anterior spinothalamic tract?

Crude touch


Which sensation(s) cross at the level of the spinal cord up the posterior column?

Proprioception, vibration, and fine touch


When should palpation be in the examination schedule?

Later in assessment, because of pain and referred pain (we may lose the sensitivity of other tests if palpation is done early)


What should we feel for in palpation?

Tissue tension (effusion/spasm), muscle tone (spastic, rigidity, flaccidity), fibrous bands, tissue thickness, swelling (gel-like = blood, softer/mobile = inflammation, boggy/spongy = synovial swelling)


What are some cautions to orthopaedic tests?

Can cause pain, apprehension, worsen stability, and can cause fracture in osteoporosis or pathological states


What are the characteristics of a lesion that should be recored to properly document a lesion found on palpation?

Location, size, shape, mobility, texture, borders, tenderness


Where is an upper motor lesion located?

In the spinal cord and higher


Where is a lower motor lesion located?

Nerve rootless, nerve root, nerve plexus, and peripheral nerves


What are the characteristics of a lower motor lesion?

Flaccid, hypotonicity, reduced or absent deep tendon reflexes, no pathological reflexes (all should be normal), and weakness at the level of injury


What are the characteristics of a upper motor lesion?

Spastic, hypertonicity, hyperreflexia/clonus of deep tendon reflexes, positive pathological reflexes (plantar reflex, etc.), and weakness below the level of injury


What is clonus?

A sign of an upper motor lesion


Characteristics of nerve root injuries:

Less weakness and less muscle wasting when compared to peripheral nerve injuries


Characteristics of peripheral nerve injuries:

More weakness, faster onset of weakness, more muscle wasting when compared to nerve root injuries


Both nerve root injuries and peripheral nerve injuries will have:

Lower motor neuron lesion signs (reduced reflexes and tone, and weakness)


When comparing nerve root injury to peripheral nerve injury, which will have upper motor neuron lesion signs and symptoms?



When comparing nerve root injury to peripheral nerve injury, which of the following is true with regards to onset and severity of the neurologic weakness?

Nerve root injuries demonstrate less weakness and have a slower onset of weakness


When the patient only has lower back pain, consider:

Mechanical lower back pain: may be a muscle strain, ligament sprain, facet joint, or sacroiliac joints


When the patient has back pain with buttock or thigh pain, consider:

Mechanical lower back pain: lumbar and SI joint often refer to the buttock and posterior leg (facet joints can refer to the thigh)


Mechanical back pain is affected by?

Posture or movement


When the patient has back pain and with pain below the knee (back of leg), consider:

Disk injury (most common cause)


If the history suggests disc injury with anterolateral leg pain, which vertebral level is affected?

L4 disc injury (L5 root)


If the history suggests disc injury with posterior/lateral foot pain, which vertebral level is affected?

L5 disc injury (S1 root)


If the patient has back pain with pain radiating to the front of the leg, it is less likely to be related to?

Sciatic nerve pain


What are the indications for an X-ray?

  1. Trauma
  2. Unexplained weight loss of 4.5kg or more over preceding 6 months
  3. Unrelenting pain at rest (can be pathological)
  4. Evolving neurological deficit suggestive of intervertebral disc pathology, stenosis (bony), or tumor
  5. History of cancer, corticosteroid use, IV drug use, use of blood thinners, and known endocrine disease
  6. Pinpoint bony tenderness of the spinous process
  7. Painless loss of joint play indicating a transitional segment, block vertebra, or spinal fusion
  8. Step defect suggestive of spondylolisthesis (tucked in defect)
  9. Significant scoliosis as observed on physical exam
  10. Patient over age 50
  11. Suspected spinal instability

Upon inspection what could cause unequal crest height?

Bone length difference, pronated foot, sacroiliac joint issues, or abnormal hip/knee position


Upon inspection, when a patient has gluteal atrophy what could cause less contraction when asked to contract?

Pressure on inferior gluteal nerve or on L5 or S1 or S2 nerve roots


When a patient has low back pain and an antalgic posture that leans AWAY from the side of pain it is suggestive of:

Intraarticular lesion, and low back pain with pain radiating down the leg then nerve root compression


When a patient has low back pain and an antalgic posture that leans TOWARDS the side of pain it is suggestive of:

Articular and/or muscular causes, a disk herniation medial to the nerve root


Which nerves does the cremaster reflex test?

L1 and L2


Which nerves does the superficial abdominal reflex test?

T7 to L2


When preforming muscle testing, what is done?

  • Testing myotomes and peripheral nerves
  • Isometric, at least 5 seconds
  • Graded e.g. 5/5

What is a trigger point?

A spot or point in a muscle that refers a sensation, be it pain or weakness, to another area of the body


Where does the trigger point Iliocostalis Lumborum refer to?

Below T12 ribs lateral to spine to buttock


Where does the trigger point Longissimus refer to?

Beside spine down to gluteal fold


Where does the trigger point Multifidus refer to?

Lateral to spine, sacrum to gluteal cleft, posterior leg, and lower abdomen


Where does the trigger point Abdominals refer to?

Below xiphisternum and along anterior rib cage down along inguinal ligament to gentials


Where does the trigger point Serratus posterior inferior refer to?

Lateral to spine in T9-T12 posterior rib area


What are the common conditions that cause lower back pain?

Lumbar sprain/strain: most common, disk herniation, lumbar stenosis, spondylolisthesis, cauda equina syndrome, and sacroiliac joint dysfunction


What is a strain?

A muscle that has been abnormally stretched


What is a sprain?

Wrench or twist of the ligaments (an ankle, wrist, or other joint) violently so as to cause pain and swelling but not dislocation, can be a ligament tear


What are the risk factors for a lumbar sprain/strain?

  • Obesity
  • Smoking
  • Poor conditioning
  • Poor lifting technique

What are the characteristics of a lumbar sprain/strain?

  • Usually self-limited (~6 weeks)
  • Pain rarely referred below the knee
  • Increased pain with activity, relieved by rest
  • Mechanism – often bending or lifting

What are the examination findings of a lumbar sprain/strain?

  • Can have limited ROM with pain
  • Strains will have pain with isometric RROM
  • Tenderness and spasm in lumbar area
  • No neurologic findings
  • Muscles respond to spasm with pain

What happens in degenerative disc disease?

Nucleus pulposus becomes fibrotic, sclerosis of the subcondral bone of the vertebrae, loss of disc height


Pain characteristics of degenerative disc disease?

  • Often: continuous ache, that can come and go
  • Positional: worse with sitting or twisting, better with standing/walking
  • Pain/spasm in the lower back, +/- pain in buttock & thighs
  • Not a lot of positive orthopedic tests

What is the classical mechanism of injury for disc herniation?

Bending and twisting (half of the annulus fibrosis fibers are slackened when twisting)


Characteristics of disc herniation pain are:

Usually 15- 40 years old, back with leg pain (with leg pain predominating), increased pain with twisting, sitting, lifting, bending


What is the most common space occupying lesion and the most common cause of pain radiating below the knee?

Disc herniation


With disc herniation, which level of nerve root is affected?

Usually the nerve root below, a really big herniation can affect more then one nerve root


Most disc herniations have referred leg pain (can be without neurologic findings as well). Most common lumbar disc herniation sites are:

98% of all disc lesions are L4/5 or L5/S1

  • Anterolateral leg pain - L4 disc injury (L5 root)
  • Posterior/lateral foot pain - L5 disc injury (S1 root)

Evaluation of disc herniation findings are:

  • Antalgic posture (usually lean away from side of pain)
  • ROM usually limited – Extension often reduces pain
  • Focus on the L5 and S1 neurologic examination

When evaluating disc herniation, what are the findings of L5 neurological exam? (L5 nerve root compression)

Weakness of dorsiflexion of great toe, numbness in the lateral lower leg, and reflexes are intact


When evaluating disc herniation, what are the findings of S1 neurological exam? (S1 nerve root compression)

Weakness of foot eversion, numbness: back of calf, and lateral or plantar foot, and absent Achilles reflex


What are some special test that can help rule in/out disc herniation?

Straight leg raise (reliable, especially if leg pain is reproduced below 45⁰), Valsalva, Kemp’s test (seated or standing), Well Leg Raise, and Slump Test


With disc herniation, extension often reduces pain due to?

Centralization of pain (as compared to peripheralization of pain when in flexion or rotation)


Treatment for disc herniation can follow general rehabilitation, but avoid peripheralization. Treatment can be:

  • Prone Extension exercises (going from a flat position to up on your elbows)
  • Other extension exercises: Sitting, standing, prone press up
  • Other exercises can be incorporated (e.g. bird dog, curl up) later but spine must be kept neutral or slightly extended

Characteristics of lumbar stenosis are:

  • Usually 50+ years old
  • Back pain with diffuse leg pain
  • Can be unilateral or bilateral
  • Leg pain can be with walking (claudication), with relief from:
    • After resting 15 minutes, or
    • With a flexed posture
  • Often multiple levels are affected

Examination findings in lumbar stenosis are:

  • Neurologic findings across dermatomes
  • Further walking possible when trunk is flexed
  • X-ray or CT scan indicated, MRI is better for soft tissue encroachment

Treatment for lumbar stenosis is:

  • Many will improve or stabilize without treatment
  • Therapies for pain and spasm control
  • Exercises should focus on stabilization in neutral or flexion: (seated or standing) posterior pelvic tilts, knee to chest, etc
  • Severe neurologic deficit or failure to conservative treatment – surgical consultation is warranted

Lumbar stenosis can be caused by:

Bone growth, disc herniation, ligament thickening, tumour growths, and injury (fracture, dislocations)


Characteristics of spondylolisthesis are:

  • Most common type: isthmic = “spondylolytic spondylolisthesis” in the young
  • May not have any symptoms
  • May only have pain on extension
  • Often a stress fracture at the pars interarticularis – often secondary to sports requiring repeated hyperextension (gymnastics)
  • Degenerative spondylolisthesis occurs in the older adult
  • Stenosis may occur

Examination findings in spondylolisthesis are:

  • May see increased extension at the sacrum and a prominent spinous process at L5 (most common level)
  • May have increased pain with lumbar extension while standing on one leg
  • May feel better sitting or in flexion
  • Diagnosis is usually made from lateral x-ray; oblique x-rays can identify a fracture of the pars interarticularis

Treatment for spondylolisthesis can include:

  • Usually grade 1 is stable (and asymptomatic)
  • Grade 3 or 4 requires a surgical consultation
  • Focus spinal stability exercises in neutral or a flexed position
  • Spinal manipulation is often effective

Cauda equina is a __________ .

Medical emergency


Characteristics of caudal equina are:

  • Compression of the cauda equina
  • Bowel or bladder dysfunction, saddle anesthesia
  • Causes: disc herniation, tumour, fracture (MVA), infection, narrowing of the spinal canal

What is the mechanism of sacroiliac joint dysfunction?

  • Straightening up from a flexed position, often while lifting an object
  • Missing the step off a curb or stair (can jar joint)

Characteristics of pain from sacroiliac joint dysfunction are:

  • Pain over SI joint area; may radiate down the back of the leg does not mean disk herniation.
  • If sprained – pain is often sharp and stabbing, and relieved somewhat with sitting or lying
  • If subluxated the pain may not vary as much with posture

Examination findings from sacroiliac joint dysfunction are: (patient need to be totally relaxed during examination)

  • Yeoman’s test or compressing or distraction of the joint may increase pain
  • Compressing/Distracting test: Squish and Gap tests
  • Reflex inhibition of gluteus medius leading to Trendelenburg gait/lurch
  • Quadratus Lumborum may be recruited to compensate for weak gluteus medius, and thus may develop trigger points that refer to SI area
  • Overactive piriformis often accompanies weak gluteus medius

Management of sacroiliac joint dysfunction is:

  • If sprained – PRICEwith ice and an SI joint brace; avoid joint manipulation
  • If subluxated – joint manipulation can offer dramatic relief
  • Long term: strengthening of core muscles can help prevent re-occurrence

Rehabilitation goals of the spine in the acute/inflammatory phase includes:

Reduce pain, reduce spasm, reduce edema, achieve neutral posture, maintain conditioning,


Rehabilitation treatment of the spine in the acute/inflammatory phase includes:

  • Physical therapy modalities (pain, spasm, swelling)
  • Soft tissue mobilization (gentle massage, trigger point therapy)
  • Gentle joint mobilization (pain free)
  • Instructions on posture
    • Neutral=position in the middle of pain free range of anterior and posterior pelvic tilting
  • Home care: heat (or ice), relative rest, positions of rest

Rehabilitation goals of the spine in the subacute/proliferative phase includes:

Increase ROM, learn pelvic neutral in different positions, restore proprioception, increase muscle endurance, maintain conditioning, decrease pain, spasm, and edema


Rehabilitation treatment of the spine in the subacute/proliferative phase includes:

  • AROM exercises
  • Mobilization/manipulation
  • Early pelvic neutral exercises
  • Body mechanics
  • Early proprioception exercises
  • Early strength exercises

Exercises that can help with ROM (subacute/proliferative phase when treating the spine are:

Knee to chest (holding abdominal contraction to stabilize spine), cat-camel, spinal twists, mechanics of lifting or bending (neutral posture, requires hamstring flexibility, core muscle strength), or Golfer's lift


Golfer's lift is used for:

Repetitive light lifting


Rehabilitation goals of the spine in the chronic/remodelling/maturation phase includes:

  • Maintain normal ROM
  • Maintain neutral during exercises/activities
  • Increase strength/endurance while in neutral
  • Stability during multiplanar activities

Rehabilitation treatment of the spine in the chronic/remodelling/maturation phase includes:

  • Continue ROM exercises
  • Mobilization/manipulation
  • Aggressive strength/endurance exercises

Which exercise for the lower back would help strengthen the gluteal maximums muscle?



Which exercise for the lower back would help strengthen the lumbar erector spinae in a neutral position?

Bird dog


Which exercise for the lower back would help strengthen abdominal muscles?

Abdominal bracing


Which exercise for the lower back would help strengthen oblique abdominal and quadrates lumborum muscles?

Side bridging


Which exercise for the lower back would help strengthen rectus abdominus muscle?



Which action and muscle tests the L1 - L2 myotome?

Hip flexion and psoas and iliacus


Which action and muscle tests the L3 myotome?

Knee extension and quadriceps


Which action and muscle tests the L4 myotome?

Ankle dorsiflexion and tibias anterior


Which action and muscle tests the L5 myotome?

Toe extension and extensor hallucis longs and extensor digitorum longus


Which action and muscle tests the S1 myotome?

Ankle eversion and peroneus longs/brevis


For the deep tendon reflexes of the lower limb, which nerve roots are tested for the achilles tendon reflex?



For the deep tendon reflexes of the lower limb, which nerve roots are tested for the patellar reflex?

L3 and L4


What does the valsalva maneuver test for? (Increased pain is a positive test)

Increased intrathecal pressure (from a space occupying lesion like a herniated disc)


What does the Well Leg Raise test for?

Intervertebral disc protrusion, usually medially to the nerve root


What is a positive Well Leg Raise finding?

Lifting the uninjured side reproduces the radiating pain contralaterally


What does the Straight Leg Raise test for?

Mainly disc herniation, hamstring tightness, entrapment of the piriformis muscle, and SI joint pain


What are the positive tests of the Straight Leg Raise test?

  • Back pain only, indicates: likely a disc herniation (likely a smaller lesion) that is more central
  • Primarily leg pain, indicates: disc herniation that is compressing the neurological tissue is more lateral
  • The L5-S1 nerve roots are fully stretched by 70⁰, pain after this is likely joint pain (facets, or sacroiliac). However, hypermobile individuals may not have a positive test until 120⁰ - compare right and left sides

What does a positive Slump Test indicate?

Tension of central nervous system or meninges


What is the positive finding of the Slump Test?

Less pain with farther knee extension with neck extended compared to knee extension with neck flexed


What does a positive Brudzinski-Kernig test indicate?

Meningeal irritation, nerve root involvement, or dural irritation


What is the positive finding of the Brudzinski-Kernig test?

Reduction in pain when the knee is flexed when hip flexion is maintained (hands are cupped behind head - chin to chest)


What are the positive findings and indications of the Nachlas test?

  • Unable to bend past 90⁰indicatesknee pathology
  • Unilateral neurological pain in the lumbar area, buttock, posterior thigh or anterior thigh may indicateL2 or L3 nerve root lesion
  • Pain in the anterior thigh indicatestight quadriceps muscles or femoral nerve stretch
  • Anterior torsion of the ilium indicatestight rectus femoris (which could lead to sacroiliac or lumbar pain)

What does the seated/standing Kemp Test test for?

Nerve root impingement or facet joint pathology with only local pain


What is the positive finding of the seated/standing Kemp Test?

Radiating pain into the ipsilateral lower extremity


What is the positive finding of the Gapping Test?

Unilateral gluteal or posterior leg pain


What does a positive Gapping Test indicate?

Sprain of the anterior sacroiliac ligament

Note: pushing on the ASIS may illicit pain from the pressure of the doctor’s hands


What is the positive finding of the Squish Test?

Pain (loss of mobility from one side to the other)


What does a positive Squish Test indicate?

Sacroiliac joint pathology (tests the posterior sacroiliac ligaments)


How is the Gaenslen's Test preformed?

The patient is supine with the test hip off the edge of the examination table; the knee of the non-tested side is brought to the chest, then the test leg is slowly lowered into extension.

Dr: can add overpressure to the hip/sacroiliac joint extension with one hand on the bent leg and one on the extended thigh


What is the positive finding of the Gaenslen's Test?

Pain in the sacroiliac joint


What does a positive Gaenslen's Test indicate?

Sacroiliac joint pathology

Note1: this test may cause pain from hip joint pathology

Note2: the test may be done side-lying with the doctor passively extending the hip