625 Lumbar Exam Assessment

Lumbar spine schema

Observation

Functional Testing

Lumbar Active ROM

Hip/Knee/Ankle Clearing

Neurological Exam (if indicated)

Neurodynamic testing(if indicated)

Strength Testing/Muscle length

Special Testing

• SIJ Testing

• Leg length testing

• Prone Instability testing

Palpation

Accessory Testing

• PA: CPA, UPA

Physiologic Testing

• Flexion-Extension

• AP Translation

Objective exam

Observation- First, step back and look at Big Picture

Postural Exam

Postural Sway

Lateral

AP Views

Observation Postural Exam for Lumbopelvic Region

Assess landmarks and check symmetry

• Spinal curvatures

• Iliac crests, ASIS, PSIS, ischial tuberosities

• Trunk creases

• Weight bearing bias?

• Lower quarter alignment

  • Hip rotation

  • Genu varus? Valgus?

• Foot alignment

  • Achilles vertical?

  • Rearfoot? Midfoot?

If you correct the deviation, does that change symptoms or alignment?

• Example: if you correct rearfoot valgus (pronation), does that affect knee and lumbopelvic alignment or reduce symptoms?

Observation: Considerations for the Lumbar Postural Assessment

Lateral trunk shift

Decreased lordosis (kyphotic deformity)

Increased lumbar lordosis

How would these observations influence your hypotheses?

• Example: If (+) lateral trunk shift, what happens when patient self corrects? What would that tell you?

Functional Tests

Use of patient reported agg factor, i.e., squatting, tying shoe, etc.

General screen for lumbar spine & lower quarter

• Crossing legs

• Sit to stand

• Double leg squat

• Single leg stance

• Step Up/Down

• Single leg squat

Balance

How would these observations influence your hypotheses?

• May be useful to identify useful interventions, e.g., test/retest of functional “asterisks”/ “comparable signs

• May assist in differential diagnosis of primary pain generator

Functional Test: Single Leg Support

Purpose

• To test for balance, postural control, hip and core functional strength.

Observe

• Shoulder, Spine, Iliac Crests, Femur, Knee, Foot

Gait Critical events (lumbopelvic region/hip)

Initial contact: (heel first contact) 25 deg hip flexion; muscle activity= extensors

Loading response: (hip stability, controlled knee flex & ankle PF) 25 deg hip flex; muscle activity= extensors & abductors

Single limb support: (controlled tibial advancement) hip is now at 0 deg; muscle activity= abductors

Terminal stance: (ankle locked in DF w heel rise) 20 deg of hip ext; no muscle activity

Initial swing: (hip flex to 15 deg & knee flex 60 deg) 15 deg of hip flex; muscle activity= flexors

Mid-swing: hip flex increased to 25 deg; muscle activity= flexors initially, then hamstrings

Terminal- swing: 25 deg hip flex; muscle activity= hamstrings

Gait common deviations

Decreased hip extension

Trendelenburg pattern

External rotation of the foot

Increased lumbar lordosis

Lateral trunk shift

Flexed trunk

Spine vs Hip Differentiation Purpose

To screen the lumbar spine versus hip structures when it is unclear whether thelumbar spine or hip is primary source of symptoms

The screening tests helps to identify prioritize exam sequence by isolating spine vs hip movement to identify possible primary pain generator.

Please note: This is a screening test and is not a standalone test – a full hip or lumbar spine exam needs to reinforce findings.

Spine vs Hip Differentiation method

Patient Position:

• Standing in single limb facing the therapist with either hand(s) on chair or therapist's hands for support/balance.

Method:

• The patient actively rotates hip and trunk, and the PTinquires about reproduction of symptoms

• Next, the PT stabilizes the pelvis so that the hip joint remains stationary during lumbo-pelvic trunk rotation.

Spine vs Hip Differentiation outcome

Reproduction of symptoms when the lumbo-pelvic region rotates as a unit implicates a hip dysfunction

Reproduction of symptoms when the pelvis was stabilized implicates a dysfunction originating primarily from the spine

Lumbar biomechanics (couple/ non-neutral mechanisms)

Coupled motion

• Neutral Mechanics

  • Coupled motion in opposite direction

  • Example: Lateral flexion left and Rotation right

  • Non-coupled: Lateral flexion and rotation in the same direction

Non-neutral mechanics

• Coupled motion in opposite direction

  • Example: In Extension- Lateral flexion left and Rotation right

• Coupled motion in same direction

  • Example: Flexion- Lateral flexion left and Rotation left

Lumbopelvic rhythm

Movement of lumbar spine and pelvis during flexion-extension

• Flexion- Anterior tilt of pelvis

• Extension- Posterior tilt of pelvis

Don’t forget contributions of the hips on lumbopelvic motion.

• Better flexibility at the hips= less lumbar motion required

Lumbar AROM Exam Key Motions

Flexion

Extension

Lateral Flexion

Quadrant

Lateral glide (Shift correction)

Lumbar AROM Exam considerations

Standardize patient position in standing

Baseline symptoms

Moving to onset of pain, limit of motion, overpressure needed?

Lumbar AROM do before

Communicate with the patient before they begin moving!

What are you going to ask them to do?

What information do you want to know from them?

What symptoms are you willing to reproduce? When do you want them to stop the movement?

ROM Assessment

Progression of your exam is based on your assessment of the SINSS

General rule: AROM → PROM→ Overpressure

“Clearing” joint usually entails full ROM with overpressure

Advancing ROM vigor:

• Overpressure

• Repeated movement

• Sustained movement

Flexion + overpressure Indications

Assess mobility deficits, willingness to move, and end feel of lumbar AROM.

Can be a progression of the exam to identify comparable symptoms.

Flexion + overpressure methods

Patient Position:

• Standing with foot & patient position standardized.

Method:

• Ask the patient to fully flex the lumbar spine while keeping the knees straight. Apply overpressure by adducting your arms

Flexion + Overpressure notes

Assess end-feel, range of motion, symptoms/pain, and resistance

Observe for aberrant motions, Gower’s sign

Neurodynamic assessment option:

• Add neck flexion to differentiate adverse neural dynamics from other sources of pain or decreased ROM

Extension + overpressure Indications

Assess mobility deficits, willingness to move, and end feel of lumbar AROM.

Can be a progression of the exam to identify comparable symptoms

Extension + overpressure methods

Patient Position:

• Standing with foot & patient position standardized.

Method:

• Ask the patient to fully extend the lumbar spine. Apply overpressure as indicated.

Extension + Overpressure notes

Assess end-feel, range, pain and resistance

Observe extension motion, look for hinging at specific levels, or aberrant motion with return to neutral

Lateral flexion + overpressure indications

Assess mobility deficits, willingness to move, and end feel of lateral flexion.

Can be a progression of the exam to identify comparable symptoms

Lateral flexion + overpressure methods

Patient Position:

• Standing with foot & patient position standardized.

Method:

• Ask the patient to fully laterally flex the lumbar spine. Apply overpressure as indicated. Repeat the other direction.

Lateral flexion + overpressure notes

Assess end-feel, range, pain and resistance

Observe extension motion, look for hinging at specific levels, or aberrant motion with return to neutral

Lumbar Quadrant + Overpressure indications

Assess mobility deficits or symptoms with combined movement.

Can be a progression of the exam to identify comparable symptoms.

Lumbar Quadrant + Overpressure methods

Patient Position:

• Standing with foot & patient position standardized.

Method:

• The therapist stands behind and to the side of the patient. Guide the patient into Right Rotation, RSB and Extension of the lumbar spine. Stabilize the pelvis on the ipsilateral side and apply overpressure as indicated. Repeat the other direction.

Lumbar Quadrant + Overpressure notes

Sustain for 5+ seconds if needed

Note end-feel, range, pain and resistance

Use of Repeated Movement

It is okay to reproduce pain

• Use your SINSS assessment to guide decision making – How much/which of the symptoms are you willing to reproduce with your assessment?

The key is what the patient reports after (centralization, peripheralization, no effect)

If no worse/no better after technique then continue assessment

If worse after movements then stop

• Decrease force?

  • Loaded versus unloaded

• Static force?

• Change direction?

• Change plane?

  • Sagittal versus frontal

• Then continue your assessment

If better

• You have found your treatment direction

Use of repeated motion assessment and treatment will be covered during treatment of low back pain with radiating/referred symptoms lab.

Thoracic Screening indications

Begin screening of the thoracic spine as a source of the patient's symptoms or contributing factor

Thoracic screening method

Patient position:

• Sitting on the edge of the table with arms across their body.

Method:

• The therapist stands in front and to the of the patient. The therapist stabilizes the pelvis and hips by supporting the patient's knees. The patient is instructed to rotate are far as possible to the right. Apply overpressure at end range. Repeat motion to the left.

Thoracic screening Notes

Positive Finding: Reproduction of pain or familiar symptoms. If positive, a detailed exam of the thoracic spine and rib cage should be considered.

Lower Quarter Neurological Screening Exam

Choice of exam is dependent on hypothesis

Peripheral Central Segmental

Lower Quarter Neurological Screening Exam: Central

Upper Motor Reflexes

• Clonus

• Babinski

Deep Tendon Reflexes → hyperreflexia

Gait deviation

Gross lower quarter motor screen

Gross lower quarter sensory testing

Lower Quarter Neurological Screening Exam: Segmental

Myotome

Deep Tendon Reflexes → hyporeflexia

Dermatomal sensory testing

Lower quarter segnmental exam: sensory exam

L1: Groin/inguinal ligament region

L2: Mid-anterior thigh

L3: Medial knee (medial femoral condyle)

L4: Medial leg and foot (medial malleolus)

L5: Lateral leg and dorsum of foot (3rd MTP)

S1: Lateral edge of foot (lateral heel)

S2: Posterior thigh and leg (popliteal fossa in midline)

S3: Ischial tuberosity

Lower quarter segnmental exam: motor exam

L1-2: Hip flexion

L3: Knee extension

L4: Ankle dorsiflexion

L5: Great toe extension

S1: Ankle plantarflexion

S1-2: Toe flexion/Knee flexion

Positive finding: Significant weakness or diminished resistance relative to opposite side

Deep Tendon Reflexes

L3-4: Quadriceps

L5: Medial hamstring

S1: Gastroc-soleus

DTR’s may be facilitated by having patient grasp fingers and pull apart with maximum isometric effort (Jendrassik maneuver).

Lower Quarter Neurological Screening: Upper Motor Neuron Reflex Testing

Babinski Test

• Dorsiflexion of big toe= +

Clonus test

• 2+ beats= +

Telehealth Segmental Neuro Screen

Toe walking

Heel walking

Single leg sit to stand

Telehealth motor exam video

Straight Leg Raise (Neurodynamic Testing) Indications

The SLR assesses the free movement and mechanical sensitivity of the LS and sacral nerve roots and its associated peripheral nerves.

Useful for assessment of possible neurogenic symptoms in patient with possible lumbar disc herniation, lumbar low back pain with radiating or referred lower extremity symptoms.

The sensitivity and specificity of this test varies in the literature, but it generally considered to be a sensitive but not specific test for adverse neurodynamics.

Straight Leg Raise (Neurodynamic Testing) Method

Patient Position:

• The patient is supine with knees extended. A single pillow can be placed under the patient's head for comfort.

Therapist Position:

• Standing at the side of the patient on the side of the lower extremity being tested. The therapists distal hand grasps the patient's distal tibia and the therapists proximal hand grasps the femur just proximal to the knee.

Method:

• The therapist passively raises the LE, flexing the hip while maintaining an extended knee. The patient's femur should remain in a neutral rotation position. See next slide for additional detail on technique.

Straight Leg Raise (Neurodynamic Testing) Notes

Establish resting symptoms. Educate the patient to report any pain, numbness, tingling or any other symptoms that they feel during the test.

Maintain knee extension as you slowly, passively flex the hip. Monitor patient for onset of symptoms or any sensation, resistance. Note hip flexion ROM at onset of symptoms. (An inclinometer at the tibial tuberosity is a useful method for obtaining objective measurements.)

Once sensation or symptoms have been brought on, the examiner slowly lowers the leg until symptoms are “off” and add sensitizing maneuver (additional info on next slide):

• Dorsiflexion (tibial nerve bias - most common),also written in literature as Lasegue's test or Bragard's test

• Neck flexion, also written in literature asHyndman's sign, Brudzinski's Sign, Linder's Sign, or the Soto-Hall test.

• Plantar flexion/inversion and/or hip Internal rotation (peroneal nerve bias)

• Dorsiflexion/eversion (sural nerve bias)

Straight Leg Raise (Neurodynamic Testing) findings

Normal test:

• symmetrical stretch, ROM, or sensation on both sides. Common for asymptomatic individuals patients to report deep stretch in posterior thigh, knee, and/or calf/foot

Positive test:

• Difference in ROM

• Reproduction of patient’s primary complaint

A crossed straight leg raise is reproduction of the patients distal symptoms when the opposite leg is passively moved into the SLR position and has a relative high sensitivity for lumbar disc herniation

Straight Leg Raise (Neurodynamic Testing) pro tip

This test can be very provocative for patients with high irritability/severity, and neurogenic symptoms can make a latent appearance. Perform this test slowly, communicate with your patients, and defer when appropriate

Straight Leg Raise- Sensitizing Maneuvers indications

Symptoms are not reproduced with basic SLR

High level of suspicion of specific nerve involvement,i.e. common peroneal nerve

Further assesses nerve mechanosensitivity

Straight Leg Raise- Sensitizing Maneuvers Sensitization Sequence

Establish available range with SLR test.

Move SLR to R1/P1. Back off of R1/P1 a small amount, then add sensitizing movement at the ankle.

Always consider Severity & Irritability

Femoral Nerve Tension Test (PKB) indications

Assess the mechanical sensitivity of the femoral nerve.

Femoral Nerve Tension Test (PKB) methods

Patient Position:

• The patient is prone and close to the side of the table.

Therapist Position:

• Standing to the side of the patient, on the side to be tested.

Method:

• Instruct the patient to complete the motion actively first. Observe motion at the lumbar spine and pelvis. Question symptoms.

• Perform the test passively with one hand on the patients back. The hand on the back may feel tension develop. Observe for deviations.

• Question symptoms throughout the testing.

Femoral Nerve Tension Test (PKB) outcomes

Normal test:

• symmetrical stretch, ROM, or sensation on both sides.

• Common for asymptomatic individuals to report deep stretch in posterior thigh, knee, and/or calf/foot.

Positive test:

• Difference in ROM

• Reproduction of patient’s primary complaint

• Not unusual to reproduce anterior thigh muscle tension therefore questioning and comparison to uninvolved side is important

Slump testing indications

Assess the mechanosensitivity of the dura, spinal cord, and neurogenic structures associated with the lumbar & sacral nerve roots and associated peripheral nerves.

Slump testing method

Patient Position:

• The patient is seated on table with back of knees touching back of table/plinth. The patient’s hands are behind the back.

Therapist Position:

• Standing to the side of the patient, directly on the side to be tested.

Method:

• Ask the patient to slouch/slump as far as possible. The therapist then provides light overpressure to maintain the slump position.

• The patient is then asked to flex the neck to end of range if possible. The position is maintained by the therapist.

• Maintaining flexion of the neck and trunk, the patient actively extends the knee. This can be done passively as well.

• The patient is asked to actively dorsiflex the ankle. This can be done passively as well.

• Neck extension is added to determine if symptoms ease

Slump testing outcome

Positive

• Reproduction of symptoms and/or

• Side to side motion loss w knee extension

Trunk and muscle strengthening and endurance exercise definition

Exercise training prescribed to restore or improve strength, endurance, or power of muscle groups

Specific trunk muscle activation definition

Exercise training prescribed to target deep trunk muscles (TVA, multifidus) using co-contraction to alter or restore control or coordination of lumbopelvic region

Movement control exercise definition

Exercise training prescribed to alter, restore, or retain control of functional movements and tasks, w/ feedback on movement patterns

General exercise definition

Exercise training prescribed to restore or improve overall strength or endurance of the major muscle groups of the UE/LE’s and trunk, including exercises for flexibility and mobility and aerobic/conditioning

Trunk mobility exercise definition

Exercise training prescribed to restore trunk ROM or to repeatedly move trunk in specific direction to achieve a reduction in symptoms

Aerobic exercise definition

Exercise training prescribed to restore or enhance capacity or efficiency of the cardiovascular system

Multimodal exercise definition

Exercise training that combines 2+ of the other exercise interventions

Assessment of Movement Control & Specific Trunk Muscle Activation: Common Test Positions

Sagittal Plane Test

• Positions:

  • Supine – heel slides

  • Supine – hip/knee flexion

  • Prone - hip extension with knee flexed

Transverse Plane Test

• Positions:

  • Supine – Hip Abd-ER (Bent knee fallouts)

  • Sidelying - Hip Abd-ER

  • Prone – Hip IR /ER

  • Q-ped – unilateral UE/ LE raises

Engaging the transverse abdominis (TA)The “hollow” goal

identify and perform TA contraction with patient able to proprioceptively feel contraction

Specific Trunk Muscle Activation/Motor Control Testing: Sahrmann Movement Control Lower Ab Progression: purpose

Assesses ability for patient to maintain lumbopelvic stability during LE movement

Specific Trunk Muscle Activation/Motor Control Testing: Sahrmann Movement Control Lower Ab Progression: method

Patient position:

• Supine hook lying

Method:

• Patient instructed to: “Contract lower abdominals by pulling the navel to the spine.”

• Use of biofeedback cuff (Pressure Biofeedback Stabilizer ©)

• Inflate to 40 mmHg

• Patient instructed to stabilize spine then move lower extremity according to progression

• Change in pressure < 10 mmHg considered WNL

Specific Trunk Muscle Activation/Motor Control Testing: Sahrmann Movement Control Lower Ab Progression: levels

1A: Hip flexed to > 90 deg and alternate foot lifted

1B: Hip flexed to 90 deg and alternate foot lifted

2: One hip flexed to 90 deg, the alternate foot lifted and slid to extend hip and knee

3: One hip flexted to 90 deg, the alternate foot lifted and extend without the leg touching the supporting surface

4: Slide both feet along supporting surface into extension and return to hooklying position (flexion)

5: Lift both feet off the supporting surface; with hips flexed to 90 deg, extend the knees and lower both lower extremities to the supporting surface

Lower Abdominal Movement Control Testing: Common compensations:

Posterior tilting of the pelvic or flattening of the lumbar spine

Anterior tilting of the pelvis or arching of the lumbar spine

Pelvic rotation

Valsalva

Alternative Planes for Movement Control Assessment

Supine heel slides

Supine bent knee fallouts

Sidelying hip ER/ABD (clams)

Prone ER/IR

Quadruped alternating arm/leg

The test can become the treatment!

Diastasis Recti Abdominus (DRA) Assessment: indication

Suspicion of ventral abdominal hernia, regardless of gender.

Diastasis Recti Abdominus (DRA) Assessment: method

Measured at 3 locations:

• At umbilicus

• 4.5 cm above umbilicus

• 4.5 cm below umbilicus

Method:

• Patient lies in supine hook lying, arms extended at her side.

• Patient asked to curl up with outstretched arms until scapulae lift from table and maintain for 10-20s while PT palpates.

Diastasis Recti Abdominus (DRA) Assessment: outcome

Positive Test: > 2 fingertips or 2.5 cm

Trunk Muscle Activation, Strength & Endurance tests

Double leg lowering

Prone plank

supine bridge

side plank/bridge

Trunk Muscle Activation, Strength & Endurance: Double leg lowering: purpose

Assess muscle strength of trunk flexors

Trunk Muscle Activation, Strength & Endurance: Double leg lowering: method

Patient Position:

• Supine

Method:

• PT assists patient to raising legs to vertical position (until sacrum begins to lift off the table/posteriorly tilted pelvic)

• Patient maintains posterior pelvic tilt as they lower the legs

Trunk Muscle Activation, Strength & Endurance: Double leg lowering: outcome

PT observes when patient loses contact of back against table/anterior pelvic tilt

Pelvic tilt > 50 deg in males and > 60 deg in females correlates with chronic LBP

Prone instability test: indications

Identify patients who will respond well to a stabilization program

Prone instability test: method

Patient Position:

• Patient is lying prone on the edge of the table with feet on the floor.

Therapist Position:

• The therapist is standing to the side of the patient with hands set-up for CPA mobilization.

Method:

• The therapist performs a PA motion on the most comparable lumbar segment with the patient's trunk and leg muscles relaxed.

• The patient is asked to lift the feet off the floor (actively lifting the legs). The therapist reapplies the PA to the most comparable segment and assess symptom response.

Prone instability test: outcome

A positive test= pain substantially reduced or alleviated with CPA while lifting the legs.

SIJ testing reliability

No “gold standard” for identification of SIJD vs LBP

SIJ alignment or motion tests → poor reliability

• standing flexion

• prone knee flexion

• supine long sitting

• sitting PSIS

SIJ Testing: 5 tests

Need 3 out 5 positive= High likelihood it is SIJ pain

Thigh thrust

sacral thrust

distraction

compression

Gaeslen

SIJ test: Thigh thrust

Patient: Supine, leg at 90

PT: hand under sacrum, hand over knee

Movement: push leg directly down, compression on SIJ

SIJ test: Distraction provocation

Patient: Supine

PT: hands cupped over ASIS

Movement: push directly down, distracting SIJ

SIJ test: Gaeslen’s provocation

Patient: Supine, leg at 90, other leg off table

PT: hand over shin, hand over knee (leg off table)

movement: simultaneously push leg into flexion/down, other leg down, torsion of sacrum

SIJ test: Compression provocation

Patient: sidelying, hips stacked

PT: hand over hip (middle finger at ASIS)

Movement: push directly down, compressing SIJ

SIJ test: sacral thrust provocation

Patient: prone

PT; heel of hand over sacrum

Movement: directly down

Leg length assessment purpose

Identify presence of leg length discrepancy

• True versus functional?

Leg length assessment

Patient Position:

• The patient is supine with the hips and knees flexed.

Method:

• Therapist stands at the patient’s feet and places thumbs on the distal portion of the medial malleoli.

• The patient is instructed to bridge the pelvis off the table and return to start position.

• The therapist then passively extends the patient’s legs and assesses the position of the malleoli.

• Step 1: visual assessment.

• Step 2: If noted visual discrepancy is note then use tape measure.

  • Measurement method: ASIS to medial malleolus

  • > 20 mm warrants intervention

SIJ test: FABER provocation

reproduction of comparable SIJ sign w/ FABER= +

FABER can be provocative test for:

• SIJ

• Intra-articular hip pathology

• GTPS

Location of symptoms matters

Palpation steps

1. begin superficially

2. Collect data w/ hands to understand hypothesis

   • Swelling

   • Hyper/hypotrophy

   • Spasm

   • Asymmetries

3. Be consistent in “schema”

   • Superficial skkin

   • Surrounding musculature

   • Spinous process alignment

Palpation: Lumbopelvic Region: Anterior

Iliac Crest to ASIS

Abdominal Region

• Umbilicus: Generally at the level of L3/4. Typically Aorta divides into the common iliac arteries.

• Diastasis Recti: May be present in peripartum patients. This may have been observed during abdominal testing.

  • Palpate along the linea alba and note any changes to the abdominal wall. Generally a midline gap of > 2.5 cm is considered a diastasis.

• Palpate any abdominal incisions for quality of tissue mobility

Palpation: Lumbopelvic Region: posterior

Lumbar paraspinals: start w light palpation, followed by skin rolling, gradually progressing depth of palpation

• Iliac Crest to PSIS (consider muscle attachments to the pelvis)

  • Quadratus lumborum, Gluteus Maximus, and Gluteus Medius

• Sacrum, Coccyx, Ischial tuberosity, Sacrotuberous Ligament

• Boney alignment of T11-S1

Passive Accessory Intervertebral Motion Testing (PAIVM): Movements are tested

Through the range of motion that is available

With a progression of graded pressures to determine range of motion available and end-feel. Based on SINSS

Compared with joints above and below. If unilateral pressures, then compared to opposite side

Passive Accessory Intervertebral Motion Testing (PAIVM): testing

Patient positioned for comfort and spine in neutral position

Establish baseline symptoms in position

Begin with grade II

Utilize 3-4 progressive, gentle oscillations to reach the limit

Always consider pain, resistance, and end feel

Continual assessment of symptoms with testing

If symptoms reproduced, note time to ease

Prone Lumbar Central PA purpose

Evaluate segmental mobility (mobility deficits) of lumbar spine

Prone Lumbar Central PA techniques

Segmentally palpate lumbar spine. Standing on the same side of pain

Palpate the patient’s spinous process with the pisiform of the “palpating hand” (usually your dominant hand)

Place the 1st webspace of the opposite hand around the “palpating hand” (see photo)

Using your body, apply gentle pressure straight downward directed in a posterior to anterior direction

• Position your sternum over the direction of your force

Gradually progress into resistance. Use 3-4 oscillatory passes working toward limit of motion.

• Consider patient SINSS.

Note end-feel, range, pain, resistance

Prone Lumbar Central PA findings

Note end-feel, range, pain and resistance

Describe/document as hypomobile, hypermobile, normal

Use as a comparable sign **

Prone Lumbar Unilateral PA purpose

Evaluate segmental mobility of lumbar spine.

Prone Lumbar Unilateral PA technique

Segmentally palpate lumbar spine. Standing on the same side of pain

Thumbs are positioned back to back and positioned between the spinous processes about one centimeter lateral to the midline. Target is the facet joint.

• Thumbs between L4-5 spinous process means you are pressing on the L4 inferior articular process and the L4-5 facet joint is being compressed

Apply gentle pressure straight downward directed in a posterior to anterior direction

• Position your sternum over the direction of your force

Gradually progress into resistance. Use 3-4 oscillatory passes working toward limit of motion.

• Consider patient SINSS.

Note end-feel, range, pain and resistance

Prone Lumbar Unilateral PA findings

Note end-feel, range, pain and resistance

Describe/document as hypomobile, hypermobile, normal

Use as a comparable sign **

Passive Physiological Intervertebral Motion Testing (PPIVM) purpose

Assess the segmental mobility of the lumbar spine in side lying

Flexion

Extension

AP “joint play”