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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Lumbar Spine Examination • Palpation • Posture • Neurological examination ○ DTRs ○ Sensation • Key muscle testing • Squat test • Neurodynamic testing—slump, straight leg raise (SLR), prone knee bend (PKB) when appropriate • AROM of lumbar spine ○ Flexion: ~60 degrees ○ Extension: ~35 degrees ○ Lateral Flexion: 25–30 degrees Lumbar Spine Special Tests • Lumbar Quadrant Test (Kemp) Purpose: To determine if the lumbar spine is the source of the patient's symptoms. Local pain suggests a facet cause, while radiating pain into the leg is more suggestive of nerve root irritation. ○ Place the lumbar spine in hyperextension ○ Move patient into combined ipsilateral lateral flexion and rotation to end range toward affected side ○ Apply overpressure through the shoulders ■ A positive test is a reproduction of the patient’s pain ■ Modest diagnostic accuracy measure—56–58%
• Other special tests ○ To test for lumbar instability: Prone segmental instability test ■ Passive Lumbar Extension Test (PLE): Patient in prone position and clinician passively elevates legs with knees extended to 12 inches while gently pulling the LEs ○ To test for muscle tightness: SLR, Ober test, Thomas test Clinical Nonmusculoskeletal Presentation • Pain usually accompanied by full and painless ROM without limitations • When the pain has been present long enough to cause muscle guarding and splinting, then subsequent biomechanical changes occur • Systemic back pain is not relieved by recumbency • Bone pain from cancer (CA) tends to be more continuous, progressive, and prominent when the client is recumbent • Pancreatic neoplasm and posterior penetrating ulcers ○ Systemic backache that causes the client to curl up, sleep in a chair, or pace the floor at night ○ Back pain that is unrelieved by rest or change in position or pain that does not fit the expected mechanical or neuromusculoskeletal pattern should raise a red flag
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