Chapter VII You may have been reading this book from start to finish and if so, you will have come to realize that the assessment sections follow a similar pattern. Thirteen tips in this chapter cover the identification of bony landmarks, assessment of range of movements, and information that can be gained from palpation, but also include information on sleeping positions, the effect of daily activities on low back position, plus an example of a specialist back pain questionnaire. When you are treating a large number of clients, it can be tempting to minimize your assessment of the lumbar region in order to get on with treatment, especially if you know your client enjoys massage or manual therapy. Yet we all know that the bodywork profession has now moved into the era of evidence-based practice and so it is important to take baseline measurements. These do not need to be extensive, nor do they need to be elaborate, but they must give you some measure of your effectiveness. The tips in this chapter offer some suggestions. If, during the assessment, you believe that your subject may have a serious condition or a problem that is outside your scope of practice, then stop the assessment and refer them to another practitioner. Alternatively, if you have a willing colleague who is free from any low back complaints, then perhaps partner up with them to practice the assessment tips given here. You can then determine which of these tips might be most useful to you and the clients you treat. Let us begin this section on assessment tips for the lumbar spine by reminding ourselves about some key bony landmarks. The lumbar spine is located between the 12th thoracic vertebra (T12) and the sacrum. The five (sometimes six) vertebrae of the lumbar spine (L1–L5) have quadrate-shaped spinous processes that can be difficult to identify individually beneath the thick layer of fascia that lies over them. To identify the first lumbar vertebra (L1), locate the 12th thoracic vertebra and palpate inferiorly to this. The 12th thoracic vertebra is attached to the 12th rib, so it could be located by locating the 12th rib. The 11th rib, which rests almost horizontal to the 12th thoracic vertebra, is more prominent. To identify the fifth lumbar vertebra, locate the top of the sacrum and palpate superiorly to this. It can also be difficult to differentiate between the sacrum and the spinous process of the fifth lumbar vertebra, again due to the thick layer of overlying fascia. So an alternative is to locate the fourth lumbar vertebra, which is about parallel with the iliac crest. Place your hands on the waist of your subject and press down onto their iliac crests. In this position, your thumbs will fall approximately over the fourth vertebra. Note that there is good inter-rater reliability for palpation of the lumbar spine but poor inter-rater reliability (McKenzie and Taylor 1997), so always make your own assessment of each client you are treating rather than relying on the assessment of a colleague. Information gained from carrying out a postural assessment of the lumbar spine can help inform your treatment. It can be easy to forget or to overlook simple things. For example, the position and depth of skin creases provide a clue to whether the pelvis is level and whether there is any lateral flexion in the spine: the deeper the crease, usually the greater the degree of flexion to that side. However, skin creases also appear when we extend. So creases can also indicate increased lordosis or rotation. Test this for yourself. If you have a willing colleague with visible skin creases, stand behind them and notice that a crease will deepen when your subject extends and laterally flexes. You will need to consider the position of the thorax also, but for now, here are some reminders to some of the things to look for when observing the lumbar spine and pelvis, and questions you may ask yourself as you carry out the assessment. Does the spine appear vertical or is there any evidence of lateral curvature (a)? Is the lumbar musculature symmetrical or is there evidence of hypertonicity in erector spinae, for example (b)? Are the iliac crests level or does one side of the pelvis seem higher than the other (c)? Are skin creases symmetrical in height and depth? Are the posterior superior iliac spines level (d)? Are the ischia level? These cannot be seen, so you need to observe whether the buttock creases are level instead (e). Does the lumbar curve appear neutral (a) or is there evidence of hyperlordosis (b) or hypolordosis (c)? Is the abdomen flat or protruding? When researching the reliability of visual assessment of the lumbar spine, Fedorak et al (2003) asked therapists to assess whether lumbar spines were normal or whether there was increased or decreased lordosis. They found fair intrarater reliability but poor inter-rater reliability. It is therefore important for you to always make your own assessment of a client’s lumbar posture and especially if you believe lumbar posture may be a contributing factor to symptoms and intend to perform postural assessment regularly in order to check progress. It is important to note that changes in posture do not necessarily correlate to pain or to changes in pain. For example, Franklin and Conner-Kerr (1998) found that although lumbar lordosis and sagittal pelvic tilt increased from the first to the third trimester of pregnancy, these changes were not related to back pain. When assessing a client who is significantly overweight, it can be difficult to determine the position of the pelvis from postural assessment alone. Palpation is usually necessary in order to locate the anterior superior iliac spines (ASIS) for example. However, not all clients feel comfortable with palpation and, again, palpating through adipose tissue in order to determine pelvic position in standing can be difficult. The following “trick” can help determine whether your subject is standing with their pelvis in a neutral (a), anterior (b), or posterior (c) pelvic position. 1. In standing, begin by demonstrating to your client how to perform a posterior pelvic tilt and, if necessary, help reposition their pelvis into a posterior position when they are resting supine (see Chapter 7, Tip 1 for information on how to do this). 2. Next, demonstrate an anterior pelvic tilt (again in standing position). 3. Once you are certain that your client understands how to change the position of their pelvis, ask them whether it feels easier to move into an anterior pelvic tilt or into a posterior pelvic tilt position. If a client finds it difficult to move into one of the pelvic positions, that could be because they are already in that position. A client: • Who finds it easier to move into an anterior pelvic tilt position is likely to be more posteriorly tilted. • Who finds it easier to move into a posterior pelvic tilt position is likely to be more anteriorly tilted. • Who can move easily between an anterior and a posterior pelvic tilt position could have a neutrally positioned pelvis. Backs dislike being retained in static postures, so when working with a client who sits for prolonged periods of time, it is useful to observe how they sit: • At work. • At home. • When relaxing. • When commuting. Observing the sitting posture your client adopts when they sit is useful because it provides information as to the position the spine and pelvis are in for prolonged periods. Once you have this information, you can easily work out which muscles are shortened and which are lengthened and therefore the kinds of exercises that are necessary to alleviate pain that may result from fatigue in soft tissues. Sometimes a client deliberately adopts a posture they find alleviates their back pain, and this is also useful to know. Sometimes they can sit for prolonged periods on one type of chair but not on another, and may not know what it is about chairs that makes the difference. Minor changes in the height and tilt of the chair seat can have profound effects on symptoms because they change the posture of the lumbar spine. TIP: One thing to remember is that when sitting upright: • Increasing hip flexion tends to decrease the lumbar curve. • Decreasing hip flexion tends to increase the lumbar curve. (Note this is not the case when a subject sits with a slumped posture, knees extended.) The chart which follows details the posture of the lumbar spine that corresponds with different sitting positions. Remember to observe prolonged recreational postures too. For example, rowing, drawing, writing, gaming, and watching television. For information about how seated postures alter lumbar spine apophyseal joints and intervertebral disk shape and function, please see Adams and Hutton (1985). Leaning forward to rest the arms on a desk produces flexion at the hip and spine, reducing the lordotic curve. Sitting upright and using a footstool produces flexion at the hip and spine, reducing the lordotic curve. Sitting on a low chair produces flexion at the hip and spine, reducing the lordotic curve. Resting the arms on the knees as when reading produces flexion at the hip and spine, reducing the lordotic curve. When slumped with knees extended, the pelvis tilts posteriorly and lumbar curve reduces. Sitting on the floor with a book or laptop as shown procures flexion of the hip and spine and reduces the lordotic curve. Leaning forward to drive results in either a neutral or a flexed lumbar spine depending on the degree of hip flexion: the greater the hips are flexed, the greater the degree of lumbar flexion.
Lumbar Assessment
Chapter 7 Lumbar Assessment
Tip 1: Identifying Key Bony Landmarks
Identifying the First Lumbar Vertebra
Identifying the Fifth Lumbar Vertebra
Tip 2: Postural Assessment of the Lumbar Region
Posterior View
Lateral View
Anterior View
Tip 3: A Trick for Identifying Pelvic Position
Tip 4: Assessing the Effect of Sitting Posture on the Lumbar Spine
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