Axial: Lumbar Examination

What are the general guidelines for treating acute LBP?

NSAIDs, Therapeutic Exercise, Staying Active, and Spinal Manipulation

What are the general guidelines for treating subacute LBP?

NSAIDs, Therapeutic Exercise, Staying Active, and Spinal Manipulation

What are the general guidelines for treating Chronic LBP?

Therapeutic Exercise, NSAIDs, Spinal Manipulation, and Acupuncture

What is centralization pain?

pain moving toward the back

What is peripheralization pain?

Pain moving away from the back

If someone is having changes in pain in their LB when coughing, sneezing or laughing then what may be going on?

Intrathecal pressure changes (covering of the spinal cord)

What is considered the “gold standard” for measuring disability of the lumbar spine?

Oswestry

What score on the Oswestry would be considered minimal disability?

0-20

What score on the Oswestry would be considered moderate disability?

21-40

What score on the Oswestry would be considered severe disability?

41-60

What score on the Oswestry would be considered crippling affecting all aspects of life?

61-80

What score on the Oswestry would be considered bed-bound or exaggerating symptoms?

81-100

What screening tool is useful for chronic and disabling lower back injuries?

Start Back Screening Tool

What does the Start Back Screening Tool consist of?

9 items:

8 agree/disagree and one assessing distress

What are the two subscales of the Fear Avoidance Belief Questionnaire

Work (FABQw) and the Physical Activity (FABQpa)

If a pt presents with decreased lordosis, what does this do to the rest of the spine?

Increases Kyphosis

If someone presents with one foot more pronated than the other during standing, what does this indicate?

A leg length discrepancy of the pronated foot being longer than the supinated

Is palpation the most reliable means of assessment?

Nope, but can be done

Should asymmetry be assumed pathological or non-pathological?

Non-pathological

What is the difference between compensated and uncompensated Trendelenberg?

Compensated involved a lateral trunk lean; uncompensated involves a lateral shift of the pelvis

How would you screen the SI joint?

Compression and distraction

How would you screen the hip joint?

Scour, FABER, and muscle length tests

What are the two painful positions which we can use regional localization to rule in/out the hip, SI and lumbar spine?

Pain with weight bearing and forward flexion

If a patient has pain when weight shifting to the R, how would you unload just the hip?

Lift pelvis with contact through ASIS and Ischial Tuberosity

If a patient has pain when weight shifting to the R, how would you unload the ipsilateral SI joint?

Contact at the ILA with hypothenar eminence

If a patient has pain when weight shifting to the R, how would you unload the lumbar spine with traction to screen?

Have pt cross their arms and apply a cranial lift of the upper spine in standing or sitting

If you are performing regional localization with weight shifting and discover that lifting at the ASIS and Ischial Tuberosity does alleviate pain, what does this likely indicate?

Hip dysfunction

If you are performing regional localization with weight shifting and discover that lifting at the ILA with the hypothenar eminence does not reduce pain, and you have already checked the hip joint, what does this likely indicate?

Lumbar dysfunction

If pt is experience pain with forward flexion, how would you use regional localization to check for a hip impairment?

Forward bend into slight pain, than manually move pelvis into a posterior pelvic tilt

If pt is experience pain with forward flexion, how do you check for SI impairment using regional localization?

Bend forward into pain, then apply pressure at base of sacrum anteriorly

If pressing sacrum anteriorly for regional localization alleviates pain, what does this do?

Causes nutation at the sacrum and slight extension at L5

If patient is still experiencing pain with forward flexion and you’ve used regional localization to rule out the hip and SI joint, how do you proceed?

Apply pressure anteriorly at individual lumbar spinal levels to see if this alleviates pain while pt is standing in slight lumber flexion (just into pain)

When taking ROM of the spine with inclinometers and the dials move toward each other, do you add or subtract the values?

Add

When taking ROM of the spine with inclinometers and the dials move away from each other, do you add or subtract the values?

Subtract

What are the 5 main aberrant motions we should be aware of when taking lumbar ROM measurements?

1. Altered lumbopelvic rhythm

2. Deviation from sagittal plane

3. Catch or judder - sign of instability

4. Painful arc

5. Arms walking up

What is the normal ROM in the lumbar spine for flexion?

60

What is the normal ROM in the lumbar spine for extension?

25

What is the normal ROM in the lumbar spine for lateral flexion?

25

What is the normal ROM in the lumbar spine for rotation?

45 (goni)

If a pt is highly irritable, but you need to examine PROM of the lumbar spine, what is a good option?

Perform seated

When performing PPIVMs and PAIVMs of the lumbar spine, where do you start?

L5/S1 junction and move up

When performing PPIVMs for the lumbar spine flexion and extension, which direction should the patient’s painful side be in?

Typically painful side up

When performing PPIVMs for the lumbar spine flexion and extension, where are the PT’s hands placed?

Cranial hand palpates the interspinous space of the level being tested, and the caudal hand grasps the distal legs/feet

When performing PPAIVMs for the lumbar spine, where is the PT’s cranial hand placed?

Cranial hand palpates the interspinous space of the level and provides slight stabilization of the superior segment IF NEEDED

When performing PPAIVMs for the lumbar spine, where is the PT’s caudal hand placed?

On posterior lumbar spine and inferior segments

When performing PPIVMs for lumbar SB, what is the cranial hand palpating? What about the caudal hand?

Interspinous space at the level being tested; Grasping around distal legs

When performing lumbar rotational PPIVMs, what are the PT’s hands doing?

Cranial hand palpating interspinous space of level being tested with forearm resting along pt’s rib cage while caudal hand is on posterior lumbar spine. Cranial hand applies an AP force while the caudal hand applies a PA force

How do you screen lumbar strength with a neutral spine?

Seated with manual hand pressure for all planes of motion

What are the 3 STRENGTH tests beyond neutral for lumbar spine?

Trunk flexion, trunk rotation, and trunk extension

When performing trunk flexion, what would be considered a grade 3?

Hands at sides while able to lift scapulas off plinth

When performing trunk flexion, what would be considered a grade 4?

Arms crossed at chest and able to lift scapulas off plinth

If you wanted to perform the Trunk Rotation strength assessment with the R elbow leading, which EAO and IAO would be active during this motion?

Right EAO; Left IAO

If you wanted to emphasize the erector spinae, multifidi, rotatores, and glutes during the Trunk Extension strength test, then where would you place your counter-force for the pt?

At the ankles

If you wanted to emphasize thoracic and lumbar musculature only during the Trunk Extension strength test, then where would you place your counter-force for the pt?

At the pelvis

For the Prone Plank Test for muscular Endurance assessment, what is considered a grade 5?

120 s

For the Prone Plank Test for muscular Endurance assessment, what is considered a grade 4?

<90 s

For the Prone Plank Test for muscular Endurance assessment, what is considered a grade 3

Can assume the position but not hold

For the Prone Plank Test for muscular Endurance assessment, what is considered a grade 2?

Can assume position but not hold from KNEEs

What degree angle is used for the Flexor Endurance Test for the lumbar spine?

60

How much of the pt’s body should be hanging off the plinth when performing the Extensor Endurance Test?

Everything cranial to their ASIS

What should you include when at your clinical for your pt when performing the Extensor Endurance Test?

A chair

What is all included in the McGill’s core endurance test?

Anterior (similar to Flexor Endurance Test), Side Bridge Test (Side Plank) b/l, and Extensor Endurance Test

Poor core endurance is associated with what?

LBP

What are the 3 main options for assessing motor control for LBP pts?

Sahrmann Core Stability Test, Biofeedback Stabilizer, and Kendall’s Double Leg Lowering

How is Sahrmann Core Stability Test level 1b performed (indicated with the use of a + sign)

Perform level 1 hooklying with single heel slide

Explain the progression from level 1 to level 5 of the Sahrmann Core Stability Test

1. Up up position

2. One heel slide

3. One heel glide

4. Two heel slide

5. Two heel glide

How can you perform a quick screen for L4?

Heel walk

How can you perform a quick screen for S1-2?

Toe Walk

How can you perform a quick screen for L3-4?

Squat

What are the 4 main length tests we reviewed for the lumbar spine?

90-90 HS Test, Ely’s Test, Ober’s Test, and Modified Thomas

Why would a PT use the Ober’s Test on a low back pain pt?

To assess hip abduction and laterally hip stability effect on the low back

If you want to assess the facets in the low back, what position do you move the patient into?

Extension, ipsilateral SB, and contralateral rotation

If you want to assess the nerve roots in the low back, what position do you move the pt’s spine into?

Extension, ipsilateral SB and rotation

A pt with low back pain with radiating pain, what are the main “special tests” we should utilize?

Slump, SLR, myotomes, dermatomes, and DTRs

What is the best order by Magee and Flynn for the proper order of tensioning for the SLUMP test?

Slump thoracic and back → Neck flexion → knee extension → Active release of neck flexion

How do you perform the femoral nerve tension test?

Pt starts in s/l with thoracic and cervical flexion while holding bottom hip in flexion and ankle in plantarflexion. PT pulls top leg in a 90-90 position into hip extension to symptoms, then have pt extend neck.

What would you do to modify the Femoral Nerve Tension Test to turn it into an Obturator Nerve Test?

Add abduction

When performing a straight leg raise, which hand is on top?

The testing hand

When performing a SLR, how do you “zero in” adduction?

Have the pt squeeze your wrist with their ankles

If a pt has symptoms down the opposite leg during a SLR, do they have a greater or poorer prognosis?

Poorer

Which direction should the hip be in during the SLR test?

Medial rotation and adduction

What degree range must symptoms be between to confirm the SLR is testing neural tension?

35-70

What is TEeD?

Tibial nerve with eversion, dorsiflexion and great toe extension

What is PImP?

Peroneal nerve with Inversion, plantarflexion, and medial rotation of the hip

What is SID?

Sural nerve with inversion and dorsiflexion

What are TED, SID and PIP related to?

All branches off the sciatic nerve

How do you use the Bowstring Sign?

Perform a SLR until symptoms → keep thigh in same position and flex knee 20 degrees (reduces symptoms) → Use thumb to push popliteal space to re-establish painful symptoms

How do you do perform the alternative bowstring sign test?

Pretension popliteal space before SLR, release pressure with thumb after symptoms to see if they reduce

What is known as the “Spurlings of the lumbar spine”?

Quadrant Test

When performing myotome testing, how long do you hold OR how many times can you repeat the test?

>5 s OR 5-7x

What LE action is associated with the L1-L2 myotome?

Hip Flexion

What LE action is associated with the L3 myotome?

Knee Extension

What LE action is associated with the L4 myotome?

Ankle Dorsiflexion

What LE action is associated with the L5 myotome?

Great toe extension

What LE action is associated with the S1 myotome?

Plantarflexion

What LE action is associated with the S2 myotome?

Knee Flexion 

How do you assess the L3-4 DTR?

Patella

How do you assess the L4-5 DTR?

Posterior Tibialis

How do you assess the L5-S1 DTR?

Hamstring

How do you assess the S1-S2 DTR?

Achilles