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Observation involves an analysis of the entire patient in terms of how he or she moves and responds, in addition to the positions the patient adopts. Whether the clinician chooses to greet patients personally in the waiting room or in the examination room, the examination should begin with the initial contact.275 The patient's gait pattern and any antalgia can provide some important clues. Upper lumbar or thoracolumbar instability or hypermobility often can lead to facilitation of the upper lumbar segments, with resulting psoas hypertonicity.287,310 This may lead to reduced hip extension during gait, resulting in a shortened stride length on the involved side.95 Body weight and ground reaction forces, generated by rapid walking, can equalize the stride length by hypermobilizing or destabilizing the lumbosacral junction or the ipsilateral sacroiliac joint.95 The process is reinforced by the mechanical pull of the shortened iliopsoas, and this increases the stress on the upper lumbar spine, increasing the facilitation.
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Clinical
Pearl
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Muscle weakness and reduced walking capacity are among several functional deficits associated with a lumbar herniated NP.311,312 Weakness of the gastrocnemius is a clinical sign associated with involvement of the L5–S1 disk (neurologic level S1), whereas weakness of the extensor hallucis longus is a positive sign for involvement of the L4–5 disk (neurologic L5).
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Once in the examination room, the patient should be gowned appropriately to allow complete inspection of the lumbar spine and lower extremities. Although spinal alignment provides some valuable information, a positive correlation has not been made between abnormal alignment and pain.255,313 “Good posture” is a subjective term based on what the clinician believes to be correct, and it is highly variable (see Chap. 6).
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The shoulders and pelvis should appear fairly level, and the bony and soft tissue contours should appear symmetric. A horizontal line through the highest points of the iliac crests passes also through the spinous process of the fourth lumbar vertebra. The transtubercular plane to the tubercles on the iliac crest cuts the body of the fifth lumbar vertebra, and the upper margin of the greater sciatic notch is opposite spinous process of the first sacral vertebra. There should be no differences in the muscle bulk between both sides and regions of the erector spinae. Atrophy of the paraspinals is rare but may indicate a chronic inflammatory disease, such as ankylosing spondylitis or tuberculosis, or point to poliomyelitis or a myopathy.277 If atrophy of the paravertebral or extremity muscles is present, the clinician must determine whether it follows a segmental or nonsegmental pattern. A predominance of the thoracolumbar portion of the erector spinae may indicate poor stabilization of this area,134 or a rotational asymmetry.314 Asymmetric spasm of the paraspinals or gluteal muscles can make them appear more prominent compared with the normal side. The presence of spasm should alert the clinician to the presence of sciatica or a serious disease.277
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The inferior angles of the scapulae should be level with the seventh thoracic spinous process; the iliac crests should be level.315 The PSISs, medial malleoli, and lateral malleoli should all be level with their counterparts on the opposite side. Differences between the two sides may indicate a functional limb-length discrepancy (see Chap. 29). This discrepancy can be caused by altered bone length, altered mechanics, or joint dysfunction316 (Table 28-9).
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The thoracic and lumbar vertebrae should be vertically aligned. Curvature of the spine is referred to as scoliosis (see Chap. 6).
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Deformity, birthmarks, and hairy patches are all evidence of congenital deficits of the integumentary system and can indicate underlying anomalies in the systems derived from the same embryologic segments.317 A hairy patch or tuft that is located at the base of the lumbar spine may indicate spina bifida occulta or diastematomyelia.318
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Structural asymmetry in the lumbar region often is associated with pain. For example, patients with disk-related LBP commonly present with a pelvic shift or list when acute sciatica is present. In these cases, the patient may list away from the side of the sciatica, producing a so-called sciatic scoliosis.319 The lateral pelvic shift is perhaps the most commonly encountered. Under the McKenzie classification system (see Chap. 22), a derangement requires the presence of a relevant lateral shift deformity.286 Determining the presence of a lateral shift deformity may help speed up the recovery from a derangement by first correcting the lateral shift deformity.286 The direction of the list, although still controversial, is believed to result from the relative position of the disk herniation to the spinal nerve (Fig. 28-7). Theoretically, when the disk herniation is lateral to the nerve root, the patient may deviate the back away from the side of the irritated nerve, which has the effect of drawing the nerve root away from the disk fragment (Fig. 28-7). This movement is demonstrated dramatically in patients with extreme lateral disk herniations, whose efforts at side bending to the side of the herniation markedly exaggerate the pain and paresthesia.320 When the herniation is medial to the nerve root, the patient may list toward the side of the lesion, in an effort to decompress the nerve root321 (Fig. 28-7). It is also theorized that this is a protective position resulting from
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- irritation of a zygapophyseal joint;
- irritation of a spinal nerve or its dural sleeve, caused by disk herniation262 and the resulting muscle spasm322;
- spasm of the quadratus lumborum muscle and, occasionally, the iliacus muscle;
- the size of the disk protrusion. In a prospective study of 45 patients with a sciatic scoliotic list (Cobb's angle >4 degrees), Suk et al.320 found that the direction of sciatic scoliosis was not observed during surgery to be associated with the location of nerve root compression, but rather it was related to the side of disk herniation. Porter and Miller323 analyzed the mechanism of sciatic scoliosis and concluded that the herniated disk was thought to be reduced in size by stretching or inward bulging at the convex side of the scoliosis, and called this phenomenon autonomic decompression.323
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The clinician must first determine the presence of the shift and then determine its relevance to the presenting symptoms. To determine its relevance, a side-glide test sequence can be used. The side-glide test sequence is performed by manually correcting the shift by pushing the pelvis into its correct position286 (Fig. 28-8). If the side-glide produces either a centralization or peripheralization of the patient's symptoms, the test is considered positive for a relevant lateral shift.324 In addition, for a lateral shift to be significant, the patient must exhibit an inability to self-correct past midline when asked to shift in the direction opposite the shift.325 The relevant lateral shift must be corrected, using side-glides, before the patient attempts the McKenzie extension exercises.326 A lateral shift that is not deemed to be relevant or to be a deformity, per McKenzie's criteria, may be treated with only sagittal plane movements (e.g., extension principles).286
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Clinical
Pearl
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Riddle and Rothstein found that therapists agreed 60% of the time on the presence and direction of the lateral shift. A κ value of 0.26 was determined, indicating poor reliability.327 A similar study by Donahue et al. of 49 patients with LBP examined the amount of intertester agreement when assessing only the lateral shift. The amount of agreement was found to be 47%, statistically similar to that obtained by pure chance.325
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From the side, the clinician should observe that the ear lobe should be in line with the tip of the shoulder, and the peak of the iliac crest. The amount of lumbar lordosis is noted as to whether it is excessive or reduced. The lumbar lordosis should appear as a smooth and gentle curve, and there should be a gradual transition at the thoracolumbar junction.
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- An excessive lordosis may result in the pelvic crossed syndrome.134 In this syndrome, the erector spinae and the iliopsoas are found to be adaptively shortened, and the abdominal and gluteus maximus muscles are found to be weak. As a result, this syndrome can produce adaptive shortening of the PLL, lower back extensors, and hip flexor muscles and lengthening of the ALL and lower abdominals. An excessive lordosis may also indicate that the patient has a spondylolisthesis. With this condition, the whole spine often lies in a plane anterior to the sacrum. There may also be an associated mid or low lumbar shelf at the spinous processes, which, if not visible, can be palpated. An anterior pelvic tilt posture may also be caused by weakness of the abdominal muscles or an adaptively shortened iliopsoas or thoracolumbar fascia, with subsequent lengthening of the hamstring and gluteal muscles.134
- A flattened back may indicate that the patient has either a lumbar spinal stenosis or a lateral recessed stenosis. A flattened lordosis is caused by a posterior pelvic tilt, adaptive shortening of the hamstrings, and weakness of the hip flexor muscles.134
- A reversed lordosis, often referred to as a sway back, is caused by a thoracic kyphosis and a posterior pelvic tilt. This posture results in a stretching of the anterior hip ligaments, back extensors, and hip flexors; hip hyperextension; and compression of the vertebrae posteriorly.134 Kyphosis of the lumbar spine may also indicate damage to the SSL complex.
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The type of footwear that the patient habitually wears can be a factor. For example, high-heeled footwear has a tendency to modify the pelvic angle and increase the lordosis.328
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There is some disagreement as to when in the examination the palpation assessment should occur, with some authors preferring to perform this portion at the end.329 The order of examination procedures should reflect awareness of the patient's potential discomfort and proceed from least to most invasive.275 For instance, a patient who reports difficulty when lying on his or her stomach should be examined in the prone position only if necessary, saving this position for the end of the examination. For patients who are able to attain all positions without significant distress, it is most convenient for the clinician to perform procedures as gravity suggests, moving from the standing position to seated, supine, side-lying, and then prone.275
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Whenever it is performed, palpation of the lumbar spine area should be performed in a systematic manner, and in conjunction with palpation of the pelvic area, which is described in Chapter 29, and the hip area, which is described in Chapter 19. Palpation of the lumbar region is best performed with the patient in a prone position but may also be performed on a seated patient. The examiner should begin by assessing the soft tissues for an increase in focal temperature.275
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Clinical
Pearl
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A study by Deyo et al.228 found that palpation of soft tissue and bony tenderness had both poor reproducibility and specificity.
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As previously mentioned, in most individuals, the midpoint of an imaginary line drawn between the iliac crests represents the L4–5 interspace and the level of the L4 transverse process. The transverse processes of L3, L2, and L1 each lie two finger-breadths superior to the vertebra, respectively.330 Alternatively, they can be found at the level of the lower pole of the spinous process of the vertebra immediately above or below. The lumbar zygapophyseal joints of each motion segment are located approximately 2–3 cm (0.8–1.2 inches) lateral from the spinous processes. The reference point indicating the position of L4 is marked on the patient. The spinous process of L5 is just inferior to this point. The L5 spinous process is short, sharp, and thick compared with those of L4 and L3. The clinician should move superiorly from the L5 spinous process, carefully palpating each segmental level. Evidence of tenderness, altered temperature, muscle spasm, or abnormal alignment during palpation can highlight an underlying impairment.
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Palpation of the posterior aspect of the lumbar spine is best achieved by placing the patient in a relaxed prone position, or bent over the treatment table.
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- The clinician moves the index and middle fingers quickly down the spine, feeling for any abnormal projections or asymmetries of the spinous processes. Any alterations in the alignment of the spinous processes in a posteroanterior (P-A) direction, particularly at the L4–5 or L5–S1 segmental level, may indicate the presence of a spondylolisthesis.331 Specific pain elicited with P-A pressure over the segment serves as further confirmation. Asymmetry of the spinous processes in a P-A direction may also indicate wedging of a vertebral body or a complete loss of two adjacent IVD spaces.277 Absence of a spinous process may be associated with spina bifida. Side-to-side alterations in the spinous process may indicate the presence of a rotational asymmetry of the vertebra.314
- The SSLs should be palpated. The ligament is usually supple, springy, and nontender. Because this ligament is the most superficial of the spinal ligaments and farthest from the axis of flexion, it has a greater potential for sprains.72
- Palpation of the transverse processes of T12 and L5 presents difficulties. That of L3 is easy to feel, being usually the longest of all transverse processes; it is usually possible to feel those of L1, L2, and L4. That of L5 is covered by the posterior ilium.332
- Patients with localized tenderness over the zygapophyseal joints without other root tension signs or neurologic signs may have zygapophyseal joint pain.333 This source can be confirmed if the patient responds well to intra-articular joint injections or to blocks of the medial branches of the posterior (dorsal) rami.333,334
- A well-localized and tender point at the gluteal level of the iliac crest, 8–10 cm from the midline, may indicate the presence of Maigne's syndrome.322 Maigne's syndrome is characterized by sacroiliac joint, low lumbar, and gluteal pain, with occasional referral to the thigh, laterally or posteriorly.
- Normally, the skin can be rolled over the spine and gluteal region with ease. Tightness or pain produced with skin rolling may indicate some underlying pathology.335 The source of the signs and symptoms is an irritation of the medial cutaneous branch of posterior (dorsal) rami of the T12 or L1 spinal nerves, as it passes through a fibro-osseous tunnel at the iliac crest.322
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- The inguinal area, located between the ASIS and the symphysis pubis, should be palpated carefully for evidence of tenderness, which may be indicative of a hernia, an abscess, sprain of the ligament, or an infection, if the lymph nodes are swollen and tender.
- In some patients, the anterior aspect of the vertebral bodies may be palpable when the patient is positioned supine with the hips flexed and feet flat on the bed. Tenderness of the anterior aspect of the vertebral bodies may indicate an irritation of the ALL, which may indicate the presence of an anterior instability.13
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Clinical
Pearl
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Evaluation of the abdominal, inguinal, popliteal arteries, and distal pedal pulses is dependent on the patient's profile and presentation.275 As a general rule, the abdominal aorta should be assessed for possible enlargement via auscultation and palpation in any patient over the age of 50 with acute onset of LBP.275
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Active Range of Motion
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Normal active motion, which demonstrates considerable variability (Table 28-10) between individuals, involves fully functional contractile and inert tissues and optimal neurologic function.147,336–339 It is important to note that ROM may be affected by age and sex, whereas occupation and body mass index have little or no influence on motion.340 In addition it has also been determined that total sagittal ROM, flexion angle, and extension angle decline as age increases.341 However, it is the quality of motion and the symptoms provoked, rather than the quantity of motion, that are more important. The reproducibility (precision) of an individual's effort is one indicator of optimum effort. Measurements should not change significantly (<5 degrees) with repeated efforts.342 The capsular pattern for the lumbar spine is normal trunk flexion, a decrease in lumbar extension with rotation, and side bending equally limited bilaterally.343
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A good view of the spine is essential during motion testing. External measurement of vertebral motion may not reflect the true intervertebral movement because of skin movement error,344 but it is less invasive than a radiograph and more practical. Although limited spinal motion is not strongly associated with any specific diagnosis, this finding may help in the planning or monitoring of the physical therapy intervention.228
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Clinical
Pearl
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Among the spinal motion tests, rotation, side bending, and fingertip-to-floor distance show the strongest associations with the severity of back pain.344
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While standing, the patient performs flexion, extension, and side bending to both sides (Fig. 28-9A–D). If full active ROM is attained without the production of symptoms, combined motions are introduced (see the next section). If these motions fail to reproduce the symptoms, the clinician need not assess passive motions. However, resisted motions may produce further clinical findings.275 Pain induced by active ROM may implicate a number of tissues including muscle and tendon, ligament and capsule, and bone and nerve. The key to deciphering which offending structure is involved lies in determining the type of pain produced and whether active, passive, and/or resisted motions are provoking. Injuries involving noncontractile tissues such as ligaments, facet capsules, and IVDs are provoked by loading the structure actively or passively, whereas resisted isometric muscle contraction is typically unprovoking, unless, in the case of disk herniation, “abdominal canister” (i.e., transversus, obliques, rectus, multifidi, pelvic floor, and diaphragm) contraction increases intrathecal pressure.275
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The active ROM tests should be observed in front of and behind the patient. At the end of each of the active motions, passive overpressure is applied to assess the end-feel, and resistance tests are performed with the muscles in the lengthened positions.
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The clinician should consider having the patient remain at the end range of each of the motion tests for 10–20 seconds, if sustained positions were reported to increase the symptoms. If repetitive or combined motions were reported in the history to increase the symptoms, the patient is asked to perform repeated motions. McKenzie286 advocates the use of sustained or repeated movements of the spine in an attempt to affect the nuclear position. These movements are performed either to peripheralize the symptoms lateral from the midline or distally down the extremity or ideally to centralize the symptoms to a point more central or near midline. One study of 87 patients with leg and LBP295 found that those patients who demonstrated excellent outcomes with the McKenzie-based interventions had reported centralization during the initial examination. Another study296 found a significant correlation between positive diskograms and peripheralization and centralization, with the incidence of an adequate annulus being significantly greater in the centralizing patients with positive diskograms than in their peripheralizing counterparts.
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During the active motions, the clinician notes the following:
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- Curve of the spine. The curve of the spine in flexion, extension, and side bending should be smooth. An angulation occurring during flexion or extension could indicate an area of instability or hypomobility. In side bending, an angulation indicates hypomobility below the level or hypermobility above the level in the lumbar spine.335
- Presence of any deviations during or at the end of range. Failure to recover from flexion smoothly may indicate instability.345 This typically occurs at the endpoint of flexion, as the patient begins to return to the erect stance and has to extend the lumbar spine by walking the hands up the thighs or by using a series of jerking motions. Trunk deviation during flexion is believed to be associated with a disk herniation, with the direction of the deviation being determined by the relative position of the compression on the nerve. How the disk responds to movements depends on the activity. For example, walking appears to move the NP into a more central location, whereas prolonged sitting appears to displace the disk into a less advantageous position.346
- Provocation of symptoms. The clinician should determine whether the symptoms are neurologic or nonneurologic, and how far the distribution of pain extends. Leg pain provoked by any motion other than flexion is not a good prognostic sign343; neither is posterior leg pain, reproduced with extension, rotation, or side bending, as this usually indicates a significant prolapse or extrusion.
- Any gross limitations of motion. Gross limitation of both side bends may indicate ankylosing spondylitis or significant osteoarthritis.
- Any dysfunctional movement patterns. This involves an assessment of the typical pattern and muscle activation strategies. Active spinal movement, commonly reveals good ranges of spinal mobility but with aberrant quality of motion commonly associated with a sudden acceleration, hesitation, or lateral movement within the midrange of spinal motion.185 Both O'Sullivan13 and Sahrmann347 have devised classification schemes to categorize movement patterns:
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O'Sullivan classifies instabilities according to directional patterns of clinical instability, although he admits that these classifications have not been scientifically validated.13
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- Flexion pattern. The flexion pattern is the most common. It is characterized by complaints of central back pain that is aggravated during flexion–rotational movements, and an inability to sustain semiflexed positions. On observation, there is often a loss of segmental lordosis at the level of the “unstable” motion segment, which is more noticeable in standing. This loss of lordosis is increased in flexed positions. Movements into forward flexion are associated with a tendency to flex more at the symptomatic level than at adjacent levels and, usually, are associated with an arc of pain into flexion and an inability to return from flexion to neutral without use of the hands to assist in the movement. During backward bending, extension above the symptomatic segment, with an associated loss of extension at the involved segment, often is observed. Functional activities, such as squatting, sitting with knee extension or hip flexion, and sit to stand, reveal an inability to control a neutral lordosis and a preponderance to segmentally flex at the unstable motion segment. Specific muscle tests reveal an inability to perform the abdominal hollowing maneuver (see “Clinical Instability of the Lumbar Spine” section) at the unstable motion segment. The patient may also be unable to actively produce a neutral lordotic lumbar spine posture.
- Extension pattern. The extension pattern is characterized by complaints of central back pain that is aggravated during extension–rotational movements, and an inability to sustain positions such as standing, overhead activities, fast walking, running, and swimming. On observation, there is often an increase in segmental lordosis at the level of the “unstable” motion segment in standing, which is often associated with an increase in segmental muscle activity at this level. Extension activities reveal segmental hinging at the involved segment, with a loss of segmental lordosis above this level and an associated postural sway. Forward bending movements often reveal a tendency to hold the lumbar spine in lordosis, with a sudden loss of the lordosis midway through the flexion range and an arc of pain. On returning from the flexed position, there is often a tendency to hyperextend the lumbar spine segmentally before the upright posture is achieved, with pain on returning to the upright position. Specific muscle testing reveals an inability to perform the abdominal hollowing maneuver. The patient also is often unable to initiate a posterior pelvic tilt independent of hip flexion and activation of the gluteals, rectus abdominis, and external obliques.
- Recurrent lateral shift pattern. The lateral shift is usually unidirectional, occurs recurrently, and is associated with unilateral LBP. The patient typically stands with a loss of lumbar segmental lordosis at the involved level and an associated lateral shift at the same level. The lateral shift is accentuated when standing on the foot ipsilateral to the shift and is observed during gait as a tendency to transfer weight through the trunk and upper body rather than through the pelvis. Sagittal spinal movements reveal a shift further laterally at midrange flexion, which is commonly associated with an arc of pain. Sit to stand and squatting are associated with a tendency toward lateral trunk shift during the movement, with increased weight bearing on the lower limb ipsilateral to the shift. Specific muscle testing reveals an inability to perform the trunk raise, with dominance of activation of the quadratus lumborum, lumbar erector spinae, and superficial multifidus on the side ipsilateral to the shift and an inability to activate the segmental multifidus on the contralateral side to the lateral shift.
- Multidirectional pattern. This pattern is the most serious and debilitating of the patterns and is frequently characterized by high levels of pain and functional disability. All weight-bearing positions are normally painful, and locking of the spine occurs frequently with positions of sustained flexion, rotation, and extension. These patients exhibit great difficulty in assuming neutral lordotic spinal positions, and an inability to perform the abdominal hollowing maneuver.
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Sahrmann categorizes a number of movement impairment syndromes that can present in the lumbar spine as a result of an imbalance of flexibility and strength. The intervention for each of the syndromes involves a correction of these imbalances.
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- Flexion syndrome. This syndrome is characterized by lumbar flexion motions that are more flexible than hip flexion motions. The syndrome is typically found in the 8–45-year-old age range and results in pain with positions or motions associated with lumbar flexion, because of adaptive shortening of the gluteus maximus, hamstrings, or rectus abdominis.
- Extension syndrome. This syndrome is characterized by lumbar extension motions that are more flexible than hip extension motions. Patients with this syndrome are usually older than 55 years of age, and the symptoms are increased with positions or motions associated with an increase in lumbar lordosis, because of adaptive shortening of the hip flexors and lumbar paraspinals and weakness of the external oblique muscles.
- Lumbar rotation. This syndrome is characterized by pain that is unilateral or greater on one side and is increased with rotation to one side. No attempt is made to equate the side of rotation with the side of the symptoms. It is theorized that this syndrome is produced when one segment of the lumbar spine rotates, side bends, glides, or translates more easily than the segment above or below it. This syndrome is associated with spinal instability and can result from habitual motions or positions that involve rotation to one side, a leg-length discrepancy (see Chap. 29), or a muscle imbalance between the oblique abdominal muscles.
- Lumbar flexion with rotation. This syndrome is characterized by pain that is unilateral or greater on one side and is increased with the combined motion of lumbar flexion and rotation. Many of the characteristics of the lumbar flexion and lumbar rotation syndromes can be applied to this syndrome.
- Lumbar extension with rotation. This syndrome is characterized by pain that is unilateral or greater on one side and is increased with the combined motion of lumbar extension and rotation. Many of the characteristics of the lumbar extension and lumbar rotation syndromes can be applied to this syndrome.
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There is no gold standard to measure ROM of the lumbar spine. The majority of published data concerning normal ranges of motion exists without concomitant data on the subjects' demographic background, specifically with respect to age, gender, and occupation. Methods to objectively measure lumbar motion have included337
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- Measuring the ROM visually (eyeballing). This method is endorsed by the American Academy of Orthopaedic Surgeons.348 Although this seems to be the fastest and easiest method, its validity is questionable.349
- Using a tape measure, measuring the distance from a bony landmark to the floor at the end of available motion. This test provides only a gross measurement of the lumbar motion.350
- Goniometric measurement. The goniometer, also known as the universal goniometer, is the most accessible and least costly device. It should be noted that goniometric measurement of the lumbar spine often incorporates some thoracolumbar motion. It should also be noted that researchers have found poor intra- and interrater reliability for all goniometric measurements of the thoracolumbar spine.351–353Table 28-11 lists the suggested landmarks used when assessing lumbar ranges of motion with a goniometer.
- Schöber technique. This technique is used only to measure flexion. The first sacral spinous process is marked, and a mark is made about 10 cm above this mark. The patient then flexes forward, and the increased distance is measured. If there is normal motion of the lumbar spine with absence of disease, there should be an increase of 4–5 cm. The obvious limitation with this technique is that it only measures flexion.
- The modified Schöber technique,354 which measures the change in distance between two skin markings over the lumbar spine during flexion or extension. A point is marked midway between the two PSISs, which is the level of S2. Points at 5 and 10 cm above that level are marked, and the distance between the three points is measured. The patient is asked to bend forward or backward, and the distance is remeasured. The distance between the two measurements is an indication of the amount of motion occurring in the lumbar spine. This method also is prone to error, because it can measure only lower lumbar levels and may not reflect the amount of motion available in the whole lumbar spine.355 Various studies have shown this technique to have overall good interrater reliability.355,356
- The fluid (bubble) goniometer. This device consists of a fluid-filled circular tube attached to or embedded in a flat platform with a 360-degree scale. With the joint in a neutral position, the device is either strapped to the distal aspect of an extremity or manually held in place on the patient, as can be the case when measuring trunk movement. Although many clinicians appreciate the ease of use and elimination of landmark estimation required by the universal goniometer, this device still exhibits problems with reliable positioning, particularly if attached with a strap or when used on obese patients.275 Landmarks used are similar to those of the goniometer's active arm.
- The inclinometer technique recommended by the American Medical Association.342 Inclinometers are small angle measuring devices that work like a plumb line, operating on the principle of gravity. An appropriate inclinometer should include a large enough dial to allow easy reading of 2-degree increments. The inclinometer technique can record regional movement of the lumbar spine rather than the combined movement of the spine and hip357 and has been proved to correlate well with measurements taken from a radiograph.351,358 For example, to measure lumbar flexion, two inclinometers are used, aligned in the sagittal plane. The center of the first inclinometer is placed over the T12 spinous process. The center of the second one is placed over the sacrum, midway between the PSISs. The patient is asked to flex the trunk as far as possible, and both inclinometer angles are recorded. The lumbar flexion angle is calculated by subtracting the sacral (hip) from the T12 inclinometer angle.
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Whatever technique is chosen, the same technique must be used subsequently when reassessing ROM.
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The first 60 degrees of forward bending typically result from flexion of the lumbar motion segments, which is followed by an additional movement at the hip joints of approximately 25 degrees.62 The patient is instructed to tuck the chin toward the chest and bend forward at the waist, keeping the knees extended, while attempting to touch the toes.275 The clinician should note any change in an existing scoliotic curve, deviation away from the midline which may suggest guarding due to disk pathology, patient apprehension or assistance (use of hands on knees), which may suggest instability, lack of motion between spinal segments, and whether the normal lordosis decreases as expected.
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The lumbar flexion movement can be repeated with the patient sitting, as this test can help screen for the presence of rotoscoliosis.359
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McKenzie286 advocates the testing of lumbar flexion motion in supine as well as in the standing position. In the standing position, flexion of the lumbar spine occurs from above downward, so pain at the end of the range is likely to indicate that L5–S1 is affected. Bringing the knees to the chest in the supine position (Fig. 28-10) produces a flexion of the lumbar spine from below upward, so that pain at the beginning of the movement may indicate that L5–S1 is affected.286
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Trunk deviation during flexion is believed to be associated with an IVD herniation, with the direction of the deviation determined by the relative position of the compression on the nerve.360 Deviations during flexion may also result from neuromeningeal adhesions, hypomobile segment(s) on the contralateral side, hypermobile segment(s) on the ipsilateral side, a structural scoliosis, and a shortened leg on the ipsilateral side.360 Passive ROM is tested with the patient seated on the examination table. The patient is instructed to keep the arms to the side, while the clinician grasps his or her shoulders and flexes the patient forward at the waist, keeping the pelvis firmly on the table. The clinician should note the end-feel and any change in an existing scoliotic curve, lack of motion between spinal segments, and whether the normal lordosis decreases as expected.
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The patient is instructed to place his or her hands on the posterior iliac crests to provide support and then extend backward from the waist, keeping the knees extended and the gaze toward the ceiling (Fig. 28-9B). The clinician notes if the arc of extension is even throughout the lumbar spine or more pronounced at a specific spinal segment.275 Pure lumbar extension in standing involves the patient leaning back at the waist. Lumbar extension is often the stiffest and most uncomfortable movement for the patient. Thus, patients with LBP tend to use the protective guarding mechanism against the compression and shearing forces, generated by simply hyperextending the hips. By applying a compressive force through the patient's shoulders during the backward bending, the clinician can induce a small increase in the lumbar lordosis. Passive ROM is tested with the patient seated on the examination table. The patient is instructed to place his or her hands across the chest. The clinician supports the upper back with one arm and the sacrum with the other hand and then extends the patient backward in an arching motion rather than a leaning motion. The clinician notes the end-feel or any altered symptoms.
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The standing patient is instructed to lean to the side by sliding the palm of the hand down the outside of the thigh, without flexing forward or extending backward, and keeping the palm on the lateral thigh or hip. The clinician notes if the arc of bending is even or more pronounced at a specific spinal segment as well as whether the patient unintentionally rotates the torso to accommodate motion.275 Side-bending ROM has been found to be a good indicator of the degree of LBP234 and disability.235 In acute spinal derangements, such as a unilateral posterolateral IVD protrusion or unilateral zygapophyseal joint derangement, lumbar side bending may be significantly reduced or absent on one side (usually toward the involved side). Arthritic conditions of the spine tend to demonstrate a symmetric loss of side bending to both sides.
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The common method of measuring the amount of side bending is to record the distance between the fingertip and the floor at the end of the side bend, but this is merely an estimation of the flexibility of the whole spine rather than the lumbar spine.337 Thus, it is recommended that lumbar spine movement in side bending be measured using the inclinometer technique.342
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The patient may be seen to lift one foot or bend the knees during the side-bending movements and should be reminded to maintain the feet on the floor during measurement. At the end of the side-bending motion, overpressure is applied on the shoulder (see Figs. 26-9C–D). Passive ROM is tested with the patient seated on the examination table. The patient is instructed to cross the arms across the chest. The clinician places one arm across the upper back and the other hand on the contralateral iliac crest. The clinician then bends the patient to each side, keeping the opposite crest from rising off the table. As with extension, an arching motion rather than a leaning motion is desired. The end-feel is noted or any altered symptoms.
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Axial rotation of the spine usually is assessed in the sitting position to eliminate motion occurring from the hips. The patient, keeping the knees together, twists at the waist to each side. Patients frequently tend to side bend or extend the torso, so the clinician must take care in preventing such motion. Axial rotation of the trunk commonly includes movement of both thoracic and lumbar segments of the spine. Overpressure may be applied at the end of range (Fig. 28-11). Normal range could indicate normalcy, hypermobility, or instability. Restricted range will be in either a capsular or a noncapsular pattern. Pain with this maneuver can implicate a nonorganic source, an annular tear, a ligament tear, or a zygapophyseal joint dysfunction.360 Passive ROM is tested with the patient seated on the examination table. The patient is instructed to place his or her hands across the chest, and the clinician grasps the shoulders and rotates the patient's torso. Alternately, the clinician may use a shoulder–scapula contact. End-feel is noted or any altered symptoms.
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Combined Motion Testing
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The combined motion tests of the lumbar spine are used to detect biomechanical impairments. Although combined motion tests do not provide information as to which segment is at fault, they may provide information as to which motion or position reproduces the pain.361
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Combined motion tests can reproduce the pain in a structure that is either being compressed or stretched362:
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- A reproduction or increase in symptoms with flexion and side bending away from the side of the symptoms may implicate pain in a structure that is being stretched.
- A reproduction or increase in symptoms with extension and side bending toward the side of the symptoms may implicate pain in a structure that is being compressed.
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Combined motions can be performed as repetitive motions or as sustained positioning. For example, the patient can be asked to repetitively perform the combined motion of flexion and right side bending to assess for what McKenzie describes as a derangement syndrome, or the clinician can position the patient in flexion and right side bending (Fig. 28-12) to assess for what McKenzie describes as a dysfunction syndrome. Alternatively, the clinician can ask the patient to maintain the position of flexion and right side bending to assess for a postural dysfunction.286
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The six-position test is a screening tool that I have found to be particularly useful with the acute patient, in helping to determine the position of comfort for the patient and for focusing the examination and intervention. The reliability or validity of these tests has yet to be established, but they are based on applied anatomy and biomechanics. The patient is placed in the following positions:
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Supine with the hips and knees extended (Fig. 28-13). In individuals with adaptive shortening of the rectus femoris and the iliopsoas (a common finding), this position is manifested by an inability of the posterior thighs to rest on the table. Pain in this position may indicate a lumbar extension or lumbar rotation syndrome (see “Intervention Strategies” section), especially if the next position relieves the symptoms.347
Supine in the hook-lying position, with the hips and knees flexed and the feet flat on the bed (Fig. 28-14). This is typically the most comfortable position for the patient with acute LBP, except in cases of severe stenosis or spondylolisthesis.
Supine with both knees held against the chest (Fig. 28-15). This position rotates the pelvis posteriorly and widens the intervertebral foramina of the lumbar segments.294 This is normally a comfortable position for patients who have spinal stenosis, lateral recess stenosis, or a lumbar extension syndrome.
Supine with one hip and knee extended, the patient raises the other knee to the chest without using the arms (Fig. 28-16). Once the leg is elevated, the patient grasps it with both hands and pulls it toward the chest. Holding the left knee against the chest invokes a position of lumbar flexion and left side bending, which widens the intervertebral foramen on the right and narrows the intervertebral foramen on the left. Holding the right knee against the chest invokes a position of lumbar flexion and right side bending, which widens the intervertebral foramen on the left and narrows intervertebral foramen on the right.294 Given the amount of rotation induced with this maneuver, this test is often positive even when the position of both knees to the chest does not provoke symptoms. Occasionally though, one side may be pain free and can be used as an introductory exercise.
Prone lying with the legs straight (Fig. 28-17). This is typically comfortable for patients with an IVD protrusion, but uncomfortable for patients with spinal stenosis, spondylolisthesis, and an extension or a rotation syndrome347 (see “Intervention Strategies” section).
Prone lying with passive knee flexion applied by the clinician (Fig. 28-18). This is a confirmatory test for the previous position, if it increases the symptoms in patients with spinal stenosis, spondylolisthesis, and an extension or a rotation syndrome347 (see “Intervention Strategies” section).
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The results from these tests should provide the clinician with information on the effect that pelvic tilting in a non–weight-bearing position has on the symptoms. If anterior pelvic tilting appears to aggravate the patient's symptoms, initial positions and exercises that promote posterior pelvic tilting are advocated. If posterior pelvic tilting appears to aggravate the patient's symptoms, initial positions and exercises that promote an anterior pelvic tilt are advocated.
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Optimum control of the spine and pelvis requires a carefully controlled, dynamic system where the strategy of activation of the trunk muscles matches the functional task. Resisted motions of the lumbar spine can be categorized into those that provide valuable information regarding the origin of lumbar pathology (key muscle testing) and those that assess basic strength parameters, such as dynamic and static motor control.275
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Gross strength of the trunk can also be assessed by applying a resisting force to the patient's upper back during resisted extension and the shoulders during flexion, lateral bending, and rotation.275 The clinician notes the presence and type of pain produced and the degree of effort exerted.
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The key muscle tests are used as part of the lower quarter scanning examination (see Chap. 4), because they examine the integrity of the neuromuscular junction and the contractile and inert components of the various muscles.343 With the isometric tests, the contraction should be held for at least 5 seconds to demonstrate any weakness. If the clinician suspects weakness, the test is repeated two to three times to assess for fatigability. The larger muscle groups, such as the quadriceps, hip extensors, and calf muscles, must be tested by repetitive resistance against a load to sufficiently stress the muscle–nerve components.
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Standing Up on the Toes (S1–2)
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The patient raises both heels off the ground (Fig. 28-19). The key muscles tested during this maneuver are the plantar flexors. These are difficult muscles to fatigue, so the patient should perform 10 heel raises unilaterally, with the arms supported by the clinician. In addition to observing for fatigability, the clinician should look for Trendelenburg's sign. A positive Trendelenburg's sign occurs when, during unilateral weight bearing, the pelvis drops toward the unsupported limb; this can indicate a number of conditions, including a hip impairment (coxa vara) or a gluteus medius weakness (see Chap. 19).
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Unilateral Squat While Supported (L3–4)
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The patient performs unilateral squats while supported (Fig. 28-20). The key muscles being tested during this maneuver are the quadriceps and hip extensors. Neurologic weakness of the quadriceps (L3–4) is relatively rare and often suggests a nondiskogenic lesion, such as a neoplasm, especially if the weakness is bilateral.360
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The patient walks toward, or away from, the clinician while weight bearing through the heels (Fig. 28-21). The key muscles being tested during this maneuver are the dorsiflexors (L4). Approximately 40% of IVD lesions affect this level, about an equal amount as those that affect the L5 root.33 An IVD protrusion of the L4–5 disk can irritate the fourth root, the fifth root, or, with a larger protrusion, both roots. The dorsiflexors can also be tested in supine (Fig. 28-22).
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With palsy, the patient is unable to raise the thigh off the table. Palsy at this level should always serve as a red flag for the clinician, because IVD protrusions at this level are rare, but this is a common site for metastasis.363 Painful weakness of hip flexion may indicate the presence of a fractured transverse process, metastatic invasion, acute spondylolisthesis, acute segmental articular dysfunction, a major contractile lesion of the hip flexors (rare), or a hip joint pathology. The patient's hip is actively raised off the treatment table to approximately 30–40 degrees of flexion. The clinician then applies a resisted force proximal to the knee into hip extension (Fig. 28-23), while ensuring that the heel of the patient's foot is not contacting the examining table. Both sides are tested for comparison.
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Knee Extension (L3–4)
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The clinician positions the patient's knee in 25–35 degrees of flexion and then applies a resisted flexion force at the middistal shaft of the tibia (Fig. 28-24). Both sides are tested for comparison. Alternately, knee extension can be tested with the patient prone. The patient's leg is positioned in approximately 120 degrees of knee flexion, taking care to do this passively. The clinician rests the superior aspect of his or her shoulder against the posterior aspect of the patient's ankle and grips the edges of the examining table. A force to flex the patient's knee is applied while the patient resists. Both sides are tested for comparison.
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Hip Extension (L5–S1)
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The patient's knee is flexed to 90 degrees, and his or her thigh is lifted slightly off the examining table by the clinician, while the other leg is stabilized. A downward force is applied to the patient's posterior thigh (Fig. 28-25), while the clinician ensures that the patient's thigh is not in contact with the table. Both sides are tested for comparison.
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The patient's knee is flexed to 70 degrees, and an extension isometric force is applied just above the ankle (Fig. 28-26). Both sides are tested for comparison.
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Great Toe Extension (L5)
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The patient is asked to hold the big toe in a neutral position. The clinician then applies resistance to the toe (Fig. 28-27) and compares the two sides.
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Ankle Eversion (L5–S1)
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The patient is asked to place the feet at 0 degree of plantar and dorsiflexion relative to the leg. A resisted force is applied by the clinician to move each foot into inversion (Fig. 28-28), and a comparison is made.
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Muscle Stretch Reflexes
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The reflexes should be assessed and graded accordingly, with any differences between the two sides noted. The tendon should be struck directly once the patient's muscles and tendons are relaxed.
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The patient is positioned sitting, with the legs hanging freely. Alternatively, both knees can be supported in flexion, with the patient placed in supine (Fig. 28-29).
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Hamstring Reflex (Semimembranosus: L5, S1; and Biceps Femoris: S1–2)
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The patient is positioned prone, with the knee flexed and the foot resting on a pillow. The clinician places a thumb over the appropriate tendon and taps the thumbnail with the reflex hammer to elicit the reflex.
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Achilles Reflex (S1–2)
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The patient is positioned so that the ankle is slightly dorsiflexed with passive overpressure (Fig. 28-30).
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Pathologic reflexes occur in the presence of motor cortex, brain stem, or corticospinal tract lesions (upper motor neuron lesions), wherein the motor response to a sensory stimulus is not modulated. The following pathologic reflexes are described in Chapter 3:
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- Babinski;
- Clonus;
- Oppenheim.
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A thorough evaluation of the sensory system is quite an involved process, due to the number of ascending pathways carrying information to the brain.275 The clinician checks the dermatome patterns of the nerve roots, as well as the peripheral sensory distribution of the peripheral nerves (see Chap. 3). Dermatomes vary considerably between individuals.
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There are a number of reflexes that occur in response to stimulation of the skin, known as the superficial reflexes. Three of these, the cremasteric (L1–2), Geigel (L1–2), and anal (S2–5), are pertinent to nerves exiting the lumbar spine.275 Performance of these superficial reflex tests involves either stroking or pricking the skin of the upper inner thigh (cremasteric and Geigel) or perianal tissue and noting the presence of muscle contraction by the cremasteric (elevation of the testicles), iliopuepartal (elevation of the clitoral prepuce), or external sphincter muscles (also known as anal wink), respectively. It is important to remember that without correlation from the history and physical examination findings, absence of a superficial reflex may not ultimately be clinically significant.
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Neurodynamic Mobility
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The neurodynamic mobility tests to help confirm a lumbar disk herniation include straight leg raising (SLR), bilateral SLR, crossed SLR sign, slump test, prone knee bend (femoral nerve stretch), and bowstring tests, which are described in Chapter 11.
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The lower the angle of a positive SLR test, the more specific the test becomes and the larger the disk protrusion found at surgery.228,364 A limited SLR at 60 degrees is moderately sensitive for herniated lumbar disks but nonspecific, because limitation often is observed in the absence of disk herniations.228,365,366 Crossed SLR is less sensitive but highly specific.365–367 Thus, the crossed SLR test suggests concordance with the diagnosis, whereas ipsilateral SLR is more effective in ruling out the diagnosis.
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The femoral nerve stretch test (see Chap. 11) is probably the single best screening test to evaluate for a high lumbar radiculopathy. This test has been shown to be positive in 84–95% of patients with high lumbar disks,154,368,369 although the test may be falsely positive in the presence of an adaptively shortened iliopsoas or rectus femoris or any pathology in or about the hip joint, sacroiliac joint, and lumbar spine.
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Differing Philosophies
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The next stage in the examination process depends on the clinician's background. Clinicians who are heavily influenced by the muscle energy techniques of the osteopaths use position testing to determine the segment on which to focus. Other clinicians omit the position tests and proceed to the combined motion and passive physiologic tests.
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Position testing in the lumbar spine is an osteopathic technique used to determine the level and type of zygapophyseal joint dysfunction.100,332,335,370–372 Position testing is performed with the patient in three positions: neutral (Fig. 28-31), flexion (Fig. 28-32), and extension (Fig. 28-33). The transverse processes are then layer palpated (Fig. 28-34). The findings and possible causes for the position testing are outlined in Tables 28-12 and 28-13.
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Passive Physiologic Intervertebral Mobility Tests
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The passive physiologic intervertebral mobility (PPIVM) tests are most effectively carried out if the combined motion tests locate a hypomobility, or if the position tests are negative, rather than as the entry tests for the lumbar spine.373,374 Judgments of stiffness made by experienced physical therapists examining patients in their own clinics have been found to have poor reliability.375
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The passive physiologic movement tests are performed into
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- flexion;
- extension;
- rotation;
- side bending.
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The adjacent spinous processes of the segment are palpated simultaneously, and movement between them is assessed as the segment is passively taken through its physiologic range.
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The test is used for acute and subacute patients who have pain in the cardinal motion planes. For these tests, the patient is in the side-lying position, facing the clinician. The clinician may locate the patient's lumbosacral junction using one of the following methods:
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- by locating the L5 spinous process and then moving inferiorly;
- by locating the PSIS and moving superiorly and medially;
- by locating the spinous process of T12 and counting down to the correct level using the spinous processes.
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Once located, the neutral position of the spine for flexion and extension is found by palpating the L5 spinous process and alternatively flexing and extending the hips until it is felt to rock around the flexion and extension point.
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The patient is close to the clinician, with the underneath leg slightly flexed at the hip and knee. A small pillow or roll can be placed under the patient's waist to maintain the lumbar spine in a neutral position with respect to side bending. The test can be performed by flexing one or both of the patient's legs, but it is generally easier to use one leg. The clinician, facing the patient, palpates between two adjacent lumbar spinous processes in the interspinous space (Fig. 28-35) with the cranial hand, while the other hand grasps the patient's lower legs (Fig. 28-36).
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The patient's lower extremities are moved into hip and lumbar flexion and returned to neutral by the clinician, as the motion between segments is palpated. Using this general technique, the clinician works up and down the lumbar spine, getting a sense of the overall motion available.
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Although there is a high degree of variability in patients, segmental motion should decrease from L5 to L1.62 A generalized hypermobility demonstrates more motion in all of the segments, whereas an isolated hypermobile segment demonstrates more motion at only that level. Each segment is checked sequentially, while moving the lumbar spine passively from neutral to full flexion.
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For the mid and upper lumbar segments, this technique can be modified for the larger patient by performing it with the patient sitting up.
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Although flexion and extension can be tested together, it is more accurate to assess them separately. The patient is positioned as for flexion testing but is oriented diagonally on the bed so that the pelvis is close to the edge, and the shoulder further from the edge. A small pillow or roll can be placed under the patient's waist to maintain the lumbar spine in a neutral position with respect to side bending. The clinician locates two adjacent spinous processes with his or her cranial hand, while the caudal arm flexes the patient's knees as much as possible before extending the patient's hips (Fig. 28-37). As the patient's knees move off the table, the clinician supports them on his or her thighs. When the patient's legs are on the table, the clinician's caudal arm is used to produce the hip and the lumbar extension. The pelvis motion is felt, and the spine is returned to its neutral position each time.
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The patient is placed in the side-lying position, with the knees and hips flexed, the thighs supported on the table and the lower legs off the table. The lumbar spine should be in a neutral position in relation to flexion and extension. The clinician, facing the patient, places his or her cranial arm between the patient's arm and body and palpates the interspinous spaces, while the caudal hand grasps under the patient's body (Fig. 28-38). As the patient's trunk is lifted toward the ceiling, the superior spinous process should be felt to move away from the table, as the lumbar spine is side bent toward the table. The opposite direction of sidebend is tested with the patient side-lying on the opposite side. The technique can also be performed using the patient's legs with the direction of the leg lift representing the direction of the side bending. For example, with the patient in the right side-lying position, right side bending (and left rotation) is introduced by lowering the feet and ankles off the table. The procedure is repeated for the other side, and the two sides are compared.
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The patient is positioned as described for extension testing in spinal neutral, with both knees being just off the table. A small pillow or roll can be placed under the patient's waist to maintain the lumbar spine in a neutral position. The interspinous spaces are palpated with the cranial hand, which is placed along the lower thoracic spine, with a reinforced index finger resting against adjacent spinous processes from underneath (Fig. 28-39).
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The patient's pelvis is stabilized by the caudal hand, while the patient's thorax is rotated toward and away from the clinician, using the cranial hand. As the patient's thorax is rotated away, the spinous process of the upper segment should be felt to rotate toward the table, compared with the spinous process of the lower segment.
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The spine is returned to neutral each time, and the clinician progresses up the spine. The process is repeated with the patient side lying on the opposite side.
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Unfortunately, the PPIVM tests do not completely exclude such intersegmental impairments as minor end-range asymmetric hypo- or hypermobilities, because the application of side bending or rotation in neutral does not fully flex or extend the zygapophyseal joints, nor is it possible to fully flex or extend both zygapophyseal joints simultaneously. In order to completely flex a particular joint, the opposite joint has to move out of the fully flexed position by using side bending and allowing the increased superior glide of the superior zygapophyseal joint on the opposite joint.
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Passive Physiologic Accessory Intervertebral Mobility Tests
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The passive physiologic accessory intervertebral mobility (PPAIVM) tests investigate the degree of linear or accessory glide that a joint possesses and are used on segmental levels where there is a possible hypomobility, to help determine if the motion restriction is articular, periarticular, or myofascial in origin. In other words, they assess the amount of joint motion, as well as the quality of the end-feel. The motion is assessed in relation to the patient's body type and age and the normal range for that segment and the end-feel is assessed for pain, spasm or hypertonicity, or resistance to motion.
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Several techniques have been proposed over the years to assess segmental mobility of the T10–L5 segments, including P-A pressure techniques (see later discussion). The PPAIVM techniques outlined here are used to confirm the findings of the PPIVM tests, by testing the joint glides of that segmental level, to confirm or refute whether a hypo- or hypermobility exists. Spinal locking techniques may be used to help localize these techniques to a specific level, or to a specific side of the segment. Descriptions of the symmetric techniques follow.
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A pillow or towel roll should be placed under the lumbar spine of the patient if side bending of the lumbar spine appears to be occurring when the patient is placed in the side lying position.
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The patient is in the side lying position, close to the edge of the bed, with the spine supported in the neutral position, the thighs on the table, and the head resting on a pillow. The clinician faces the patient and locates the suspected segment using palpation. The superior segment is stabilized using the cranial hand (see Fig. 28-40). The clinician now flexes the patient's lumbar spine, using the patient's legs, as in the PPIVM test, until motion is felt at the superior spinous process of the monitored segment.
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Using the index and middle fingers of the caudal hand, the clinician straddles the transverse processes of the inferior segment and pulls the segment inferiorly, using the caudal hand and forearm (Fig. 28-41), thereby indirectly assessing the full superior linear glide of the superior segment. The quality and quantity of the joint glide are assessed.
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The patient and clinician are positioned as in the PPIVM test, with the patient being positioned diagonally on the bed, hips forward, knees well flexed, and head resting on a pillow.
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Having located the suspected level, the clinician extends the patient's spine to that level by pushing the patient's legs across the table until the monitoring finger detects motion at the superior spinous process. The superior spinous process of the segment is pinched (see Fig. 28-42) and the joint complex is passively taken into full extension by straddling the transverse processes, as for the flexion technique, and pushing the caudal vertebra anteriorly (see Fig. 28-43). At the end of the available range, the transverse processes of the inferior segment are glided in a cranial direction to test the full linear glide. The quality and quantity of the joint glide are assessed.
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The patient and clinician are positioned as in the PPIVM test, with the patient's hips forward, knees well flexed, and head resting on a pillow. The side on which the patient lies is determined by the intent of the technique.
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- To test the ability of the segment to side bend ipsilaterally (close), the patient lies on the side to be tested.
- To test the ability of the segment to side bend contralaterally (open), the patient lies with the side to be tested uppermost.
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Having located the suspected level, the clinician extends or flexes the patient's spine to that level by pushing the patient's legs across the table until the monitoring finger detects motion at the superior spinous process.
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The clinician places the axilla of his or her caudal arm over the iliac crest of the patient, while the index and middle fingers of the hand are placed over the spinous processes of the inferior vertebra (Fig. 28-38). The clinician firmly squeezes the patient's pelvis and upper thigh with the caudal arm and applies a force in an inferior direction toward the patient's feet, while the middle finger of the caudal hand pushes the spinous process superiorly.
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The quality and quantity of the joint glide are assessed and compared with the other side.
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The patient is positioned as in the PPIVM test. A small pillow or roll can be placed under the patient's waist to maintain the lumbar spine in a neutral position. The patient's pelvis and the inferior aspect of the caudal spinous process are fixed using the caudal arm and hand, respectively (Fig. 28-44). The thumb of the other hand is placed on the superior aspect of the cranial spinous process.
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As the patient's thorax is rotated away, the spinous process of the upper segment should be felt to rotate toward the table, compared with the spinous process of the lower segment. The quality and quantity of the joint glide are assessed. The spine is returned to neutral each time, and the clinician progresses up the spine. The process is repeated with the patient side lying on the opposite side.
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Functional Assessment Tools
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Disability and the patient's ability to function may actually be more significant to health care costs than pain alone.376 Several instruments have been produced in the past 30 years, which can provide reliable and valid methods to quantify a patient's functional status.377
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Overall, no instrument is probably used more often for assessment of the low back than the Oswestry Low Back Disability Questionnaire (OLBDQ),378 which has been widely researched and validated by investigators of spinal disorders (see Chap. 5).
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The Roland–Morris Disability Questionnaire (RDQ)379 (Table 28-14) is a health status measure, designed to be completed by patients to assess physical disability due to LBP. The RDQ was derived from the Sickness Impact Profile (SIP), which is a 136-item health status measure covering all aspects of physical and mental function.380 Twenty-four items were selected from the SIP, and each item was qualified with the phrase “because of my back pain” to distinguish back pain disability from disability resulting from other causes—a distinction that patients are, in general, able to make without difficulty.380,381
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Patients are asked to place a check mark beside a statement if it applies to them that day, and the score is calculated by adding up the number of items checked. Scores, therefore, range from 0 (no disability) to 24 (maximum disability). RDQ scores have been found to correlate well with other measures of physical function, including the physical subscales of 36-item Short Form Health Survey (SF-36), the SIP, and the OLBDQ.380
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The Physical Impairment Index (PII), designed by Waddell et al.235 is a series of seven tests, each scored positive or negative based on published cutoff values (Table 28-15) that tend to provide a measurement of physical impairment in patients with LBP. The final score of the PII ranges between zero and seven, with higher numbers indicating greater levels of impairment. Fritz and Piva382 in a study of 78 patients with acute (<3 weeks duration) LBP found the PII to have a high interrater reliability (intraclass correlation coefficient = 0.89), and its validity was generally supported by the pattern of correlations. The minimum detectable change on the index was approximately one point.
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Fear Avoidance Beliefs Questionnaire (FABQ)383 (see Chap. 4) was developed, based on theories of fear and avoidance behavior, and focused specifically on patients' beliefs about how physical activity and work affected their LBP. Each item of the FABQ is scored 0–6, with higher numbers indicating increased levels of fear avoidance beliefs. Two subscales are contained within the FABQ: a seven-item work subscale (score range 0–42) and a four-item physical activity subscale (score range 0–24). The subscales of the FABQ have shown good reliability,384 and previous studies have found the FABQ work subscale to be associated with current and future disability and work loss in patients with chronic383,385,386 and acute387 LBP.
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The patient either stands or lies prone depending on the intent of a loaded or unloaded assessment. Multiple directions of repeated end-range lumbar testing is targeted. Movements may include extension, flexion, or side flexion. Movements are repeated generally for 5–20 attempts until a definite centralization or peripheralization occurs. Centralization of symptoms is considered a positive finding for diskogenic symptoms. In a study by Donelson et al.,296 the presence of centralization had a sensitivity of 92% and specificity of 64% (LR+ 2.6; LR− 0.12) as a predictor for symptomatic disks.
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The Single-Legged Squat
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The single-legged squat (Fig. 28-20) can be used as an indicator of lumbopelvic–hip stability. The test is functional, requires control of the body over a single weight-bearing lower limb and is frequently used clinically to assess hip and trunk muscular coordination and/or control.388
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The patient lies in the prone position. The patient is asked to extend his or her lumbar spine while keeping the pelvis in contact with the treatment table. A positive test for diskogenic symptoms is moderate or major loss of extension. In a study by Laslett et al.389 using visual observation only found that a loss of extension in predicting symptomatic disks had a sensitivity of 27% and specificity of 87% (LR+ 2.01; LR− 0.84).
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Neurodynamic Mobility Testing
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The slump, straight (Well) leg raise, bowstring, double straight leg raise, and prone knee flexion tests are described in Chapter 11.
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Milgram's test is as much an assessment of abdominal muscle strength as it is intrathecal irritability.275 With legs fully extended, the supine patient is asked to actively raise both feet approximately 2 inches off the table and maintain this position for at least 10 seconds and up to 30 seconds (Fig. 28-45). The inability to perform this test due to muscle weakness is not considered a positive finding within the context of this test, but should nevertheless still be charted.275
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Posteroanterior Pressures
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P-A pressures, advocated by Maitland,390 are applied over the spinous, mammillary, and transverse processes of this region. The clinician should apply the P-A force in a slow and gentle fashion using the index and middle fingers of one hand, while monitoring the paravertebrals with the other hand (see Fig. 28-46).
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Although these maneuvers are capable of eliciting pain, restricted movement, or muscle spasm, or a combination, they are fairly nonspecific in determining the exact level involved, or the exact cause of the symptoms, and have been found to have poor interrater reliability in the absence of corroborating clinical data.391,392 In a single-group repeated-measures interrater reliability study by Hicks et al.393 to determine the interrater reliability of common clinical examination procedures proposed to identify patients with lumbar segmental instability, a consecutive sample of 63 subjects (38 women, 25 men; 81% with previous episodes of LBP) with current LBP was examined by three pairs of raters. The results of the study agreed with other studies, suggesting that segmental mobility testing is not reliable. In fact, in this study, the prone instability test (see later), Beighton–Horan Ligamentous Laxity Scale, and the presence of aberrant motion with trunk ROM demonstrated higher levels of reliability.
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Clinical
Pearl
++
The Beighton–Horan Ligamentous Laxity Scale394 measures the following five elements:
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- passive opposition of the thumb to the flexor aspect of the forearm (one point per hand);
- passive hyperextension of the fifth metacarpophalangeal joint beyond 90 degrees (one point per hand);
- hyperextension of the elbows by 15 degrees or more (one point per arm);
- hyperextension of the knees (one point per leg);
- forward flexion of the trunk with the knees extended and palms flat on the floor (one point).
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All elements are added together to give an overall ligamentous laxity score ranging from 0 (tight) to 9 (hyperlax).
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As a screening tool, the P-A pressures have their uses and can help detect the presence of excessive motion or spasm. However, caution should be exercised when making clinical decisions related to the assessment of motion at a specific spinal level using P-A accessory motion testing. Consider the following example with the patient positioned prone:
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- A P-A pressure is applied simultaneously to both transverse processes of the L3 segment. Biomechanically, this produces a relative extension movement of the L2–3 segment, while producing a flexion movement of the L3–4 segment.
- If the spinous process of L3 is pushed to the right, inducing a left rotation of L3, this produces a relative right rotation of L2 on L3, but a left rotation of L3 on L4.
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Anterior Stability Test
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The patient is in the side-lying position. To test the lower three segments (L3–5), the patient's hips are placed in approximately 70 degrees of flexion and the knees are flexed (Fig. 28-47A). This position is to prevent tightening of the posterior lumbar ligaments, particularly the SSL, which could stabilize the lower three segments and produce a false-negative test result.373 The clinician stands facing the patient, resting his or her thighs against the patient's knees. The upper segments are stabilized using the cranial hand and the other hand over it. The inferior interspinous space is palpated. The clinician pushes with the thighs, through the patient's knees, along the line of the femur (Fig. 28-47B). This produces a posteriorly directed force to the pelvis, sacrum, and lumbar spine. Any posterior movement of the inferior segment, which is actually a relative anterior movement of the superior segment on the inferior segment, is noted and compared with the next segmental level. There should be little or no movement. To test the upper two segments (L2 and L1), the lumbar spine is flexed by flexing the hips to approximately 100 degrees, and the procedure is repeated. A positive test is one in which there is excessive movement or pain, or both.
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Lateral Stability Test
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This test does not rely on the objectivity of the end-feel. Instead, an indirect shearing maneuver is used, and the reproduction of pain is considered a positive test.360,373 The patient lies in the side-lying position facing the clinician, with the lumbar spine positioned in neutral and the hips and knees flexed to approximately 45 degrees. The clinician, using the fleshy part of one forearm, applies a downward pressure to the lateral aspect of the patient's trunk at the level of the L3 transverse process (Fig. 28-48). This produces a lateral translation of the entire lumbar spine in the direction of the bed. The pressure is applied until an end-feel is detected. The test is repeated with the patient side lying on the opposite side.
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Prone Instability Test.393
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The patient is positioned prone so that the trunk rests on the bed and their feet rest on the floor, with the hips flexed and the trunk muscles relaxed. The clinician applies a P-A pressure (approximately 4 kg or thumbnail blanching) over the most symptomatic spinous process and any reproduction of symptoms is noted. The clinician then releases the P-A pressure, and the patient is asked to hold onto the sides of the table and to slightly lift his or her feet off the floor (Fig. 28-49). This maneuver produces a cocontraction of the global abdominal, gluteal, and erector spinae muscles. While the patient maintains their feet off the floor, the clinician reapplies the P-A pressure over the same spinous process level. If a dramatic reduction or the complete elimination of the symptoms compared to the first application of P-A pressure is noted (the muscle activity must be able to effectively stabilize the segment), it is considered a positive prone instability test. According to Hicks et al.,393 patients with LBP, who present with a negative prone instability test, are unlikely to respond to a stabilization exercise program.
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Passive Lumbar Extension Test.395
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The passive lumbar extension test is used to help detect lumbar spinal instability. The patient lies in the prone position, with the clinician standing at the foot of the bed. The clinician grasps the patient's ankles and, while applying a gentle traction force, raises both of the patient's lower extremities concurrently to a height of approximately 30 cm from the bed, while maintaining the knees extended (Fig. 28-50). Pain, apprehension, or a sense of heaviness in the low back are considered positive findings for this test. The test has been shown to have a sensitivity of 84.2% and a specificity of 90.4%.395 The positive likelihood ratio of the test was 8.84 (95% confidence interval = 4.51–17.33).395
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Clinical
Pearl
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A recent systematic review396 found that the majority of clinical tests routinely employed to diagnose structural lumbar segmental instability demonstrated only limited ability to do so. However, the same study reported that the passive lumbar extension test may be useful in orthopaedic clinical practice to diagnose structural lumbar segmental instability.
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Plain radiography should be limited to patients with clinical findings suggestive of systemic disease or trauma. Guidelines recommend plain radiography for patients with fever, unexplained weight loss, a history of cancer, neurologic deficits, alcohol or injection–drug abuse, an age of more than 50 years, or trauma.397 A major diagnostic problem with LBP is that many anatomic abnormalities seen on imaging tests, including myelography, CT, and MRI, are common in healthy individuals.398,399 The high prevalence of these abnormalities in the absence of symptoms suggests that making causal inferences may be hazardous. In the absence of corresponding clinical findings (from the history and physical examination), these anatomic derangements seem to be irrelevant and inconsequential.400
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Bulging disks viewed on MRI are commonly implicated as the cause of symptoms. However, bulging disks are more common than not after the age of 50 years and often have little, if any, association with symptoms.400
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Examination Conclusions
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Following the examination, a working hypothesis, or diagnosis, can be established based on a summary of all of the findings. For example, the tests and measures can help to determine
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- the presence of a medical diagnosis, such as a spinal stenosis, ankylosing spondylitis, or an IVD protrusion;
- the presence of nonorganic signs. Inconsistencies occurring during the history and examination, which seem to be lacking in any somatic or organic base, have become known as nonorganic findings (see “Psychogenic Pain” section in Chap. 5). Nonorganic findings do not necessarily imply a nonexistent or fictitious condition. Waddell401 developed a series of tests designed to elicit nonorganic responses from patients in whom psychosocial factors are suspected (see Chap. 5).
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A pathology-based or biomechanical approach to LBP is based on the notion that LBP results from a deviation of the lumbopelvic complex from its normative physiologic and anatomic state and that by identifying a structural fault, and then correcting that fault, will lead to a dissipation of the signs and symptoms. Tables 28-16, 28-17, and 28-18 summarize the typical findings in a patient with a biomechanical diagnosis, highlighting both the similarities and the differences between each. The difficulty in identifying a pathoanatomic cause for most patients with LBP has prompted efforts to identify alternative methods of subgrouping, or classifying, affected individuals based on clusters of examination findings. In 1995, Delitto et al.402 published a treatment-based classification system (see Chap. 22) which proposed four classifications for patients with higher levels of disability, each with a distinct set of examination findings and an associated intervention strategy thought to optimize outcomes for patients in the category. The information gathered from the physical examination and patient self-reports of pain (pain scale and pain diagram) and disability (modified Oswestry Questionnaire) was used to determine whether the patient's condition would be amenable to physical therapy or whether care from another practitioner would be required. The problem with this classification system was that the clusters of examination findings used to make classification decisions and intervention strategies were principally derived from expert opinions and limited available evidence. In 2006, Fritz et al. published a report in an effort to update this decision-making algorithm. Inclusion criteria were age 18–65 years, referred to physical therapy with a primary complaint of LBP less than 90 days in duration with or without referral of symptoms into the lower extremity, and an Oswestry score greater than or equal to 25%. Patients were excluded if a lateral shift or acute kyphotic deformity was visible, if symptoms could not be reproduced with lumbar ROM or palpation, or when signs of nerve root compression were present (positive SLR test and reflex or strength deficits). Patients who were pregnant or had undergone prior surgery to the lumbosacral region were also excluded. A total of 123 patients were included in the trial. The goal of this RCT study was to test the hypothesis that a patient with LBP who received interventions matched to the patient's classification would have better outcomes than those receiving unmatched interventions. The individual examination items used in the study included standing AROM, repeated extension in standing, repeated flexion in sitting, sustained extension in prone, a recording of the presence of centralization and/or peripheralization, SLR findings, assessment of aberrant movements during flexion/extension, prone instability test with P-A forces applied (see “Special Tests” section), and prone P-A glides. After completion of the baseline examination, patients were randomized into one of three intervention groups (manipulation, specific exercise, or stabilization) and referred to physical therapy. Reliability of ROM, centralization/peripheralization judgments with flexion and extension and the instability test was moderate to excellent. Reliability of centralization/peripheralization judgments with repeated or sustained extension or aberrant movement judgments was fair to poor. Overall agreement on classification decisions was 76% (κ = 0.60, 95% confidence interval 0.56, 0.64), with no significant differences based on level of experience (Table 28-19).
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