Lumbar spine examination

what are the lumbar spine impairment-based classification system categories?

• low back pain with mobility deficit (acute/subacute)

• low back pain with movement coordination impairments (acute/subacute/chronic)

• low back pain with LE referral (acute)

• low back pain with radiating pain (acute/subacute/chronic)

• low back pain with cognitive or affective tendencies (acute/subacute)

• low back pain with generalized pain (chronic)

what are the major differences between the CPG for neck pain and back pain?

the low back pain CPG has more categories and larger discriminations of acute, subacute, and chronic which can possibly be complicating / confusing

what are symptoms of LBP with mobility deficits?

• acute low back, buttock, or thigh pain

• unilateral pain

• onset of sx often linked to a recent unguarded/awkward movement or position

• may report sensation of stiffness

if a patient says “I have no idea how this started” or “I don’t know what I did to bring this on” that is more associated with which category? is this category associated with activity?

LBP with mobility deficits; it can be but it is often not

what are impairments of LBP with mobility deficits?

• lumbar ROM limitations

• restricted lower thoracic and lumbar segmental mobility

• low back and low back-related LE sx are reproduced with provocation of involved lower thoracic, lumbar, or SI segments

• sx reproduced with end-range spinal motions

• restricted motion w/ associated segmental motion

Your patient reports unilateral acute low back, buttock, and thigh pain. Their onset of symptoms are usually linked to unguarded/awkward movements and positions of their back. They also report a sensation of stiffness. Upon gross ROM assessment, you notice limitations in lumbar ROM, with their symptoms reproduced at end range of spinal motions. Upon segmental examination, you notice restricted lower thoracic and lumbar segmental mobility and restricted motion with the associated segmental motion. The patient also reports reproduction of their low back and lower extremity symptoms with provocation of certain lower thoracic, lumbar, and SI segments. 

low back pain with mobility deficits

what are symptoms of LBP with movement coordination impairments 

• recurring low back pain that is commonly associated with referred LE pain

• sx often include numerous episodes of low back and/or low back-related LE pain in recent years

is referred pain definitive of one specific category?

no it can occur in any of the LBP categories

what are impairments of LBP with movement coordination impairments?

• pain provoked with mid-range movements and may worsen w/ end-range movements or sustained end-range movements

• pain provoked w/ provocation of involved segments

• hypermobility may be present w/ segmental assessment

• movement coordination impairments

• decreased regional muscle strength and endurance

• neighboring mobility deficits

Your patient reports recurring episodes of low back pain and referred LE pain. They have had numerous episodes of LBP and low back-related LE pain in the recent years. Upon gross ROM assessment, you notice the pain is provoked with mid-range movements and worsens at end range and sustained end range movements. Upon segmental examination, you notice potential hypermobile segments with pain provocation, and neighboring mobility deficits in the adjacent segments. You also note decreased regional muscle strength and endurance.

LBP with movement coordination impairments

symptoms of LBP with related referred LE pain

• acute LBP w/ referral into buttock, thigh , or leg

• worse with flexion and sitting

impairments of LBP with related referred LE pain

• centralization or symptom reduction possible with specific postures

• reduced lordosis

• limited extension

• lateral shift may be present

• findings consistent with movement coordination impairments

Your patient presents with acute LBP and referred pain into the buttock, thigh, and leg. The pain is worse with flexion and sitting. Upon posture assessment, you notice reduced lumbar lordosis and a lateral shift. Upon gross ROM assessment, you notice limited extension. When putting the patient in different postures, you notice centralization of their symptoms. Your findings are consistent with movement coordination impairments.

LBP with related referred LE pain

symptoms of LBP with radiating pain

• LBP with associated radiating (vs broadly referred) pain

• LE paresthesias, numbness, and weakness may be reported

impairments of LBP with radiating pain

• radicular sx at rest or produced with initial to mid range spinal mobility, limb tension tests/SLR/slump tests

• chronic radiating pain more likely to produce with end-range

• nerve root signs MAY be present

• MAY have sensory, strength, or reflex deficits

• similarities to LBP w/ related referred pain

Your patient reports low back pain that radiates down into the lower extremity. They also report lower leg paresthesia, numbness, and weakness. They have radicular symptoms at rest, but when assessing gross ROM their symptoms are produced with initial to mid-range spinal movements. They have a positive SLR, slump, and limb tension tests such as Ely’s test. They have sensory and strength deficits consistent with a nerve root pattern and they have diminished reflexes. 

LBP with radiating pain (but they don’t always have sensory, strength, and reflex deficits!!)

symptoms of LBP with cognitive/affective tendencies? what about impairments?

symptoms:

• acute or subacute LBP and/or low back-related LE pain

impairments:

• behavioral scale indicators (fear avoidance belief questionnaire FABQ, pain catastrophizing, depression)

True/false: LBP with cognitive/affective tendencies cannot have another category of LBP present

false: another category of LBP CAN be present, but the cognitive/affective predominance is likely to affect the responses/outcomes and cause a disproportionate behavioral response and may have kinesiophobia 

LBP with generalized pain syndrome symptoms

• low back and/or low back-related LE pain with symptom duration for longer than 3 months

• generalized pain not consistent with other impairment-based classification criteria presented in these clinical guidelines

LBP with generalized pain syndrome impairments?

• low back and/or low back related LE pain with symptom duration for longer than 3 months 

• generalized pain not consistent with other impairment-based classification criteria presented in these clinical guidelines

• behavioral scale indicators: FABQ, pain catastrophizing, depression

• may have underlying problem of other category (maybe multiple) but difficult to discern and assess response of any intervention

the primary problem with patients in the LBP with generalized pain category is ?

that they may have had a mechanical issue previously or currently but now that it has been so chronic, the CNS is now the primary problem because it is misinterpreting the pain and causing central sensitization or nociplastic pain

is there a hard timeline between what is acute vs chronic LBP?

no, 6 weeks is a general timeline but there is variability

LBP with leg pain means the pain is ?

distal to the knee

80-90% of lumbar load bearing goes through ___ and 10-20% goes through ___

disc-body-disc; facet joints

facet loading increases with aging because of what? what motion increases the compressive loading through the z joint surfaces?

loss of disc height and increasing irregularity of facet joint surfaces; extension

characteristics of lumbar IV discs?

• greatest proportion of water content loss during 2nd decade, but continuous and progressive 

• HNPs most common in the 40s when the NP is still hydrated but changes affected load distribution, plus fissure/openings in the annulus may develop

• by age 60, HNP are not as common because the NP and AF become more alike and more likely to be upper lumbar 

pain studies indicate that ___ can refer pain into the buttock and thigh

any structure in the lumbar spine 

pain that is ___ is most consistent with nerve root origin, but other structures may refer distally, including z joints

distal to the knee

does location of pain have diagnostic value?

no

facet joint pain patterns

• lumbar region: L1-L5

• low lumbar/gluteal region: L2-S1

• posterior thigh: L3-S1

• lateral thigh: L2-S1

• anterior thigh: L3-S1

• groin: L3-S1

what are the most common lumbar nerve root pain descriptors based on the McGill Pain Questionnaire?

• aching

• tiring-exhausting

• sharp

• stabbing

• numbness

• shooting 

difference between somatic referred pain and radiating pain

somatic referred pain:

• perceived remote from the site of pathology

• no neuro loss

• often, not always predictable (not basis of diagnosis)

radiating pain:

• in distribution of single nerve root

• MAY have neuro loss 

• deep lancinating severity 

differences between nerve roots and peripheral nerves?

• nerve roots are not built for mechanical stress like peripheral nerves are

• nerve roots have incomplete perineurium and no epineurium

• nerve roots have tightly arranged parallel fibers vs loosely arranged fibers with abundant fat and connective tissue of peripheral nerves

what are general thoughts on lumbar spine pain patterns?

• there is a tendency for pain patterns but variances occur

• can support clinical impressions but not the basis for diagnosis or specific anatomical attribution

what is discography and what is it best used for?

an imaging and pain provocation procedure not commonly used anymore where the patient is partially sedated, they have a large needle inserted into the disc across multiple levels that injects a contrast agent into the disc to pressurize it with the intent to get a comparable sign and look at the distribution of contrast in the disc; it is best used to see internal disc derangement

what is internal disc derangement? is there nerve root compression with this? is it more common in younger or older individuals?

when the internal architecture of the disc has been changed and there is derangement of the NP surrounded by lamellae where you see fissures in the lamellae but no damage to the outer disc ; there is no nerve root compression with internal disc disruption; younger individuals 

what things are included in a lower quadrant scan exam?

• movement and neurological screens

• peripheral joint screens with particular interest in the hip

• neurotension with SLR

• pain provocation battery for SI

• changes of position and patient movement

patients presenting with ___ are potentially those with the greatest risk of having an underlying problem so have reasonable suspicion

LBP

what are difference etiologies for low back pain?

• mechanical LBP: 97% of cases

• nonmechanical spinal disease: 1%

• visceral disorder: 2%

red flags for cancer/infection

• history of cancer

• unexplained weight loss

• immunosuppression

• urinary infection

• IV drug use

• prolonged history of corticosteroids

• not improved w/ conservative care

red flags for spinal fracture

• history of trauma

• prolonged history of corticosteroids

• minor fall/heavy lift in person with OP or older person

red flags for cauda equina syndrome or other neurological compromise

• acute urinary retention or overflow incontinence

• loss of anal sphincter tone or fecal incontinence

• saddle anesthesia

• bilateral/progressive motor weakness in LEs

true/false: majority of LBP cases have antatomically identifiable causes

false! majority have unidentified LBP with a mechanical behavior/pattern to the symptoms

characteristics of spondylolysis/spondylolisthesis?

• most asymptomatic

• most stable

• no exam procedures w/ high psychometric values 

• when identified by imaging, presumption is that it is the origin of sx

what are treatments for spondylolysis/spondylolisthesis?

• relative rest

• stabilization motor control exercises

• address any other imbalances

characteristics of stenosis

• generally worse with walking, standing, and extension

• walking distance tolerance often predictable and may be enhanced by flexed posture (like leaning over a shopping cart or uphill)

• better w/ rest and flexion

• often adopt a resting flexed posture

• initially no neuro findings but may progress w/ decreased reflexes, strength, and sensation

• decreased balance and wider base of support

• a dynamic disorder meaning you may not see symptoms until they are moving around

• often will have a wide BOS due to loss of proprioception

• distal to proximal progression

what do people usually say or complain about when they have a central stenosis?

• my legs feel heavy

• I can walk a distance, legs get really heavy or feel like concrete, and then I have to sit down

• when I sit down and rest, I feel better but if I get up and walk the same thing happens

• sometimes relief with a flexed posture 

• they do not like extension 

• will likely lose hip extension eventually 

• off balance so they have to walk with a wide BOS 

symptoms of stenosis that manifest in the LEs are typically ___ vs the ___ that is characteristic of acute radiculopathy

fatigue, heaviness, and achiness vs deep lancinating pain 

a ___ stenosis is more likely to present as LBP with radiating pain whereas a ___ stenosis is more likely to have bilateral symptoms

lateral; central

is stenosis an imaging only diagnosis?

no, it is diagnosed by subjective history, clinical exam procedures, and correlates with imaging findings but not diagnosed only by imaging as many people will appear to have central stenosis on imaging but are asymptomatic

disc bulges are herniations are common after what age? what are characteristics of these herniations?

age 40; 

• most are asymptomatic 

• routinely found on MRI

• only if overt nerve root compression is found then pain is more likely to be present 

do internal disc disruptions always have symptoms?

no they can also occur with or without symptoms and there may be no specific clinical indicators, only back pain

characteristics of the spinal mechanical lesion?

• aberrant segmental motion influencing afferent input and efferent output

• difficult to be precise or definitive

• may be related to too much or too little movement at a segment

• not uniquely descriptive (segments that move too much or too little may be asymptomatic)

what are the theoretical effects of the spinal mechanical lesion?

• abnormal afferent input from dysfunctional spinal segment

• information relayed to higher centers may or may not be perceived as pain

• altered motor recruitment pattern

• may be inhibitory or excitatory

• may precipitate cascade of dysfunction

___ and ___ are more valuable than MRI findings

diligent patient history and physical exam 

correlation of nerve root compression on MRI and a positive SLR is ?

modest (low correlation of objective neuro deficits on exam and nerve root compression on MRI

components of a scan exam

• observation

• motion

• neurological testing:

  • sensation

  • MMT

  • reflexes

  • dural/neurotension tests

• segmental stress and pain provocation/reduction tests

  • lumbopelvic distraction

  • SI joint pain provocation tests

  • lumbar PA pressures

• peripheral joint active/passive/resisted ROM (proximal to distal)

characteristics of sacral insufficiency fractures

• “silent epidemic”

• older females w/ LBP, inguinal, or pubic pain

• increased pain with weight bearing and decreased pain with rest

• low energy or no trauma

• sacral tenderness and + SI pain provocation tests 

• can be radiographically occult

what is the value of a hip exam with low back pain?

• postural assessment may reveal short hip flexors/hyperlordotic posture or generally flexed posture consistent with hip motion loss

• hip relationship to LBP is much more prevalent in older adults

• loss of hip motion affects lumbosacral junction/lumbar spine

detailed biomechanical exam components

• special tests

  • may include assessment for directional preference

• passive accessory movements

  • lumbar PIVMs

  • passive innominate motion

  • hip PAMs

characteristics of the lateral shift assessment

• may fit into either scan or detailed exam

• if large, persistent, or part of severe limiting pain, may require being addressed early/immediately 

• visual appearance

• determine if pathomechanical barrier is present (side glide limitations and pain response)

lumbar radiculopathies have historically been detected with what?

a neurological screening:

• manual muscle tests “myotomes”

• muscle stretch reflexes (“DTRs"“)

• sensory testing (“dermatomes”)

• SLR

what are the problems with MMT?

• inconsistencies in techniques

• lack of knowledge of exact muscle action

classic neurological exam procedures have ___ accuracy when detecting radiculopathies

limited accuracy (no single test is highly accurate)

what is the general consensus on clinical neurological exam findings?

• they have higher specificity, meaning it is useful when there are positives, but if there are negatives you can’t rule out a serious pathology

• clinical neuro exam deficits typically correspond with MRI findings in radiculopathies of L4/5 and L5/S1

• clinical neuro exam does not predict normal/abnormal NCV

• if MRI findings do not match clinical neuro exam, addition of NCV can clarify

what is the general consensus of the SLR exam procedure?

• a positive SLR was associated with lumbar nerve root impingement on MRI, but results are variable and it must be used with other findings

• compared to electrophysiologic studies, SLR was highly sensitive and not very specific 

• overall, the research on its psychometric values, testing positions, and interpretations of positives were highly variable

• movement of nerve roots starts at 30 degrees of hip flexion

• greatest value is provoking distal symptoms at lower ranges of hip flexion for greatest specificity and diagnostic value

• it is the first thing you do when the patient is supine because it determines other exam procedures if you get a positive

the SLR is less discriminative and diagnostically accurate in what population?

older individuals (over 60 years old)

the primary interest of doing the SLR test is? it is only a true positive neurotension test if what 3 things occur?

the angle of hip at which symptoms occur/worsen, and the location of pain provocation;

• symptoms provoked distal to the knee

• lower angles of hip flexion

• specificity lost when hamstrings tensioned

can a SLR be used as an SI test or mechanosensitivty test?

it cannot be used as an SI test, but may be used to assess mechanosensitivity apart from its original diagnostic purpose

the SLR is only applicable to ___ radiculopathies because?

lower lumbar radiculopathies; because it tensions L4-S3 (sciatic nerve) so it does not apply to upper lumbar radiculopathies

characteristics of femoral nerve tension test

• tensions L2-4

• potentially affected by rectus femoris length

• caution with interpretation subjectivity (stretch sensation vs pain and compare sides)

• tests more for upper lumbar radiculopathies which are not as common

older individuals tend to have ___ lumbar radiculopathies whereas younger individuals tend to have ___ lumbar radiculopathies

upper; lower

what is a crossed “well” SLR? what is it used to help diagnose? what are the psychometrics?

when you do a SLR and the other side has symptoms; radiculopathy; more specific than sensitive, meaning that if it is present, a radiculopathy is likely (doesn’t happen very often though)

what is the hypothesis of a crossed well SLR?

the contralateral SLR is caused by traction effect on the nerve root, and the direction of herniated fragment tensions nerve root on the opposite side, producing contralateral symptoms

what is the compression overload test? what are the psychometrics and should you trust them?

a new exam procedure for a HNP; high sensitivity and specificity; you should be cautious with these results because its a new study

what is the general consensus of PIVMs in the lumbar spine?

• reliability values are modest overall with mobility assessment only

• mobility assessment + sx provocation likely more accurate

• most experienced practicitioners find high value but interpret with caution

• palpation of lumbar spinous processes are notably inaccurate but with experienced manual therapists it is moderately better

when should you do PIVMs in your exam?

they are most confirmatory at the end of the exam because they have limited value when done in isolation with no working hypotheses yet

what are signs of symptoms of lumbar instability? are these signs more specific or sensitive?

• instability catch: painful arc on return to upright from flexion or needing to climb back up the thighs

• painful catch sign: supine SLR and lowering with sudden lumbar pain

• lack of hypomobility in PIVMS/PAIVMS assessment

• hypermobilty present in PIVMs/PAIVMs assessment

• rotary and translational instability in PIVMs/PAIVMs assessment

• aberrant movement pattern (Gowers/reveral of lumbopelvic rhythm)

all have moderate to high specificity and low sensitivity

which is more specific as a sign of lumbar instability: lack of hypomobility or presence of hypermobility in PIVMs/PAIVMs? what would strengthen the positive likelihood ratio?

lack of hypomobility is more specific; if there was lack of hypomobility AND lumbar flexion over 53 degrees although that is usually just someone who is hypermobile overall

what is the prone instability test and what are its psychometrics?

a test for lumbar instability where the patient lifts legs up into extension and pain is provoked, then the LEs are raised from the floor with a PA applied to the spinous process (positive test is if the pain is reduced in the second step); moderate sensitivity AND specificity

what is the passive lumbar extension test? what are the psychometrics?

a test for lumbar instability where the patient is prone with LEs raised from the table 30 cm (positive test is strong LBP or a heavy feeling “my back feels like its coming off”); 84.2% sensitive and 90.3% specific but more investigation of the test is warranted

what is the lumbar rocking test? what are the psychometrics?

a (not good) test for lumbar instability where you are inducing a gentle jerk to the lumbar spine after locking hip and pelvis in hyper-flexed position by gently pushing the knees onto the abdomen (positive test is if the subject complains of severe pain in lumbar region while pushing knee onto the abdomen); highly sensitive and not very specific but caution with use and interpretation

what are bridging tests?

• used by some for testing “stability”

• prone, supine, side bridging are more pain tolerance and endurance dictated motor control tests rather than true instability tests

what is the general consensus on diagnosing lumbar instability with clinical tests

there is no consensus in diagnosing lumbar instability with clinical tests

what is the general consensus on the instability questionnaire?

• considered positive 6 or more “yes items” (highly sensitive, not very specific)

• if 10 or more, then more sensitive and specific

• modest value, more research needed

what are the 2 subtypes of instability

• mechanical instability

• functional instability

mechanical instability characteristics

• excessive translatoric / angular motion

• malailignment

• demonstrated by imaging

• may be accompanied by neurological signs/sx

• may include intractable pain

• more readily attributable patho-anatomical origin of excessive movement

• typically imaging correlation to sx

functional instability characteristics

• more subtle

• not consistently identified by imaging

• loss of control during active movement

• suggested by clinical tests/history

• inconsistency of persistent sx 

• lack of corresponding hypomobility or other alternate explanation

• poor motor control

• often lack of response to initial interventions

• occassinally, subjective descriptions of movement

• categorization is more subjective and possibly less accurate

summary findings of lumbar instability

• clinical exam procedures of modest value at best

• likely detect more obvious cases

• more subtle and more common instabilities (those more likely responsive to PT) less likely to be detected by clinical tests

• less likely to have confirmatory findings with more subtle presentations 

• general impressions based on totality of clinical features

• abundant subjectivity 

what is the general consensus of directional preference?

• overall maybe as much as 70% of patients with LBP will have directional preference

• derivation of McKenzie approach

• exam bridging to treatment with significant prognostic value

what is centralization/peripheralization

• related to directional preference but not synonymous

• tendency of symptoms to intensify or be distributed more distally or proximally based on spinal movements or positions

• also derivation of McKenzie methodology

• evidence to suggest correlation to the disc, but not consistent with original McKenzie model of derangement

• centralization has high specificity with it being discogenic in nature

• if patient has stress or psychological issues, they are more likely not to respond well to centralization/peripheralization

what conditions can mimic L1 radiating/referred pain ?

hip joint conditions and athletic pubalgia

what conditions can mimic L2 radiating/referred pain ?

occult femoral neck fx, iliopsoas bursitis/tendinopathy

what conditions can mimic L3 radiating/referred pain ?

greater trochanteric pain syndrome, ITB pain syndrome, external snapping hip syndrome

what conditions can mimic L4 radiating/referred pain ?

knee conditions

what conditions can mimic L5 radiating/referred pain ?

piriformis syndrome, tibial/fibular stress syndromes, exertional compartment syndrome

what conditions can mimic S1 radiating/referred pain ?

hamstring conditions, ischiofemoral impingement, ischiogluteal bursitis, SI joint, plantar fascitis

what clinical tools/questionnaires may assist in pain phenotyping? why is it important to phenotype pain?

• painDETECT

• DN4

• central sensitization inventory (CSI)

neuropathic pain and nociplastic pain is associated with greater functional impairment and higher psychological distress

what are the 3 pain phenotypes

• nociceptive pain: localized pain proportional to mechanical triggers with no neurological features

• neuropathic pain: burning pain, dyesthesia, positive neurodynamic tests, higher disability scores

• central sensitization: widespread pain, hyperalgesia, disproportionate symptom patterns, and atypical pain distribution 

does osteoporosis have a major impact on LBP or the ODI? why is this important?

no but osteoporotic fractures are more strongly associated with reduced performance (single leg standing, sit to stand 5x, max walking speed and step length); there is possible value of including physical function tests as part of assessment especially in older adults or those with a history of OP (not just relying on self-report questionnaires)