McKenzie ¹ recommended repeating the active movements, especially flexion and extension, 10 times to see whether the movement increases or decreases the symptoms.

If the examiner finds that side flexion and rotation are equally limited and extension is limited to a lesser extent, a capsular pattern may be suspected. A capsular pattern in one lumbar segment, however, is difficult to detect.

Because back injuries rarely occur during a “pure” movement, such as flexion, extension, side flexion, or rotation, some have suggested that combined movements of the spine should be included in the examination. The examiner may want to test the more habitual combined movements, such as lateral flexion in flexion, lateral flexion in extension, flexion and rotation, and extension and rotation. These combined movements may cause signs and symptoms different from those produced by single-plane movements, and they definitely are indicated if the patient has shown that symptoms are caused by a combined movement. For example, if the patient has a facet syndrome, combined extension and rotation is the movement most likely to exacerbate symptoms. Other symptoms that indicate facet involvement include absence of radicular signs or neurological deficit, hip and buttock pain, and sometimes leg pain above the knee, no paresthesia, and low back stiffness.

Testing of active ROM depends on the irritability of the patient. Full motion testing and combined or repetitive motion testing can be performed on patients who are not irritable. Patients whose pain is easily produced and who remain in pain for some time once the pain is produced should undergo a limited ROM test. Motion should be tested just until the onset of symptoms, and the painful directions of motion should be tested last.

PATIENT POSITION

The patient is standing.

EXAMINER POSITION

The examiner is positioned directly in front or in back of the patient so as to instruct the patient and observe motion.

Forward Flexion

TEST PROCEDURE

The patient is asked to bend forward and to try to touch the toes while keeping the knees straight. The examiner may use a tape measure to measure the increase in the distance between L1 spinous process and S1 on forward flexion. The examiner should note how far forward the patient is able to bend (i.e., to the midthigh, knees, midtibia, or floor).

INDICATIONS OF A POSITIVE TEST

For flexion (forward bending), the maximum ROM in the lumbar spine normally is 40° to 60°. If a tape measure is used, the measurement should increase about 7.5 cm (3 inches) if taken between the T12 spinous process and S1.

CLINICAL NOTES/CAUTIONS

• On forward flexion, the lumbar spine should move from its normal lordotic curvature to at least a straight or slightly flexed curve. If this change does not occur, some hypomobility probably is present in the lumbar spine either from tight structures or muscle spasm.

• In a patient with no back pain, when returning to the upright posture from forward flexion, the person first rotates the hips and pelvis to about 45° of flexion; during the last 45° of extension, the low back resumes its lordosis.

• In a patient with back pain, most movement usually occurs in the hips, accompanied by knee flexion; in some cases, the patient also uses hand support, working up the thighs.

• The examiner must differentiate the movement that occurs in the lumbar spine from that occurring in the hips or thoracic spine. Some patients can touch their toes by flexing the hips, even if no movement occurs in the spine. The degree of injury also has an effect. For example, the more severely a disc is injured (e.g., if sequestration has occurred rather than a protrusion), the greater is the limitation of movement.

• Often, an “instability jog” may be seen during one or more movements, especially flexion, returning to neutral from flexion, or side flexion. An instability jog is a sudden movement shift or rippling of the muscles during active movement, which indicates an unstable segment.

• If the patient bends one or both knees on forward flexion, the examiner should watch for nerve root symptoms or tight hamstrings, especially if spinal flexion is decreased when the knees are straight.

Extension

TEST PROCEDURE

The patient is asked to bend backward. While performing the movement, the patient should place the hands in the small of the back to help stabilize it.

INDICATIONS OF A POSITIVE TEST

Extension (backward bending) normally is limited to 20° to 35° in the lumbar spine.

CLINICAL NOTE

• Bourdillon and Day ² recommend having the patient do this movement in the prone-lying position to hyperextend the spine. They called the resulting position the “sphinx position.” The patient hyperextends the spine by resting on the elbows with the hands holding the chin and allows the abdominal wall to relax. The position is held for 10 to 20 seconds to see whether symptoms occur or worsen if already present.

Rotation

TEST PROCEDURE

The patient is instructed to rotate, or turn, to the left and then to the right, or vice versa, depending on which is the painful side (the painful side is tested last).

INDICATIONS OF A POSITIVE TEST

Rotation in the lumbar spine normally is 3° to 18° to the left or right is accomplished by a shearing movement of the lumbar vertebrae on each other.

CLINICAL NOTE

• Although the patient usually is in the standing position, rotation may be performed while the patient is sitting to eliminate or decrease pelvic and hip movement. If the patient stands, the examiner must take care to watch for this accessory movement and try to eliminate it by stabilizing the pelvis.

Side Flexion

TEST PROCEDURE

The patient is asked to run a hand down the side of the leg and not to bend forward or backward while performing the movement. The examiner can eyeball the movement and compare it with that on the other side. The distance from the fingertips to the floor also may be measured on both sides, and any difference should be noted.

INDICATIONS OF A POSITIVE TEST

Side (lateral) flexion, or side bending, is approximately 15° to 20° in the lumbar spine. As the patient side-flexes, the examiner should watch the lumbar curve. Normally, the lumbar curve forms a smooth curve on side flexion, and there should be no obvious sharp angulation at only one level. If angulation does occur, it may indicate hypomobility below the level or hypermobility above the level in the lumbar spine.

CLINICAL NOTES/CAUTIONS

• If a movement (e.g., side flexion) toward the painful side increases the symptoms, the lesion is probably intra-articular, because the muscles and ligaments on that side are relaxed.

• If a disc protrusion is present and lateral to the nerve root, side flexion to the painful side increases the pain and radicular symptoms on that side.

• If a movement (e.g., side flexion) away from the painful side alters the symptoms, the lesion may be articular or muscular in origin, or it may be a disc protrusion medial to the nerve root.

• In the spine, the movement of side flexion is a coupled movement with rotation. Because of the position of the lumbar facet joints, side flexion and rotation occur together, although the amount and direction of movement may not be the same.

• Patients often deviate into forward flexion instead of remaining in true side flexion. To prevent this, the patient can be cued to run the hand down the back of the thigh instead of the side of the thigh.

TRENDELENBURG’S TEST (MODIFIED)

PURPOSE

To assess for gluteus medius weakness or coxa vara; this test also may be used to assess for S1 nerve root lesions.

PATIENT POSITION

The patient stands, unsupported.

EXAMINER POSITION

The examiner is positioned so as to view the patient’s pelvic position.

TEST PROCEDURE

The patient is asked to balance on one leg and to go up and down on the toes four or five times.

INDICATIONS OF A POSITIVE TEST

While the patient balances on one leg, the examiner watches for Trendelenburg’s sign. A positive Trendelenburg sign is indicated if the ilium on the nonstance side drops instead of elevating, as it normally would when a person is standing on one leg. If the nonstance side drops, it is a positive test for a weak gluteus medius on the stance side. Both legs are tested. If the patient is unable to go up and down on the toes four or five times, the examiner should suspect an S1 nerve root lesion.

CLINICAL NOTES

• This is, in effect, a modified Trendelenburg’s test. A weak gluteus medius muscle or a coxa vara (abnormal shaft-neck angle of the femur) on the stance leg side may produce a positive sign on the nonstance side.

• The examiner should look for patient compensations when completing the test. The most common compensation is trunk side flexion toward the stance leg. The patient side flexes to move his or her center of gravity over the stance leg, thus decreasing the demand on the gluteus medius. Therefore, the test may appear normal because the ilium responds normally, but if the side flexion is corrected, the positive response occurs.

ADVANCED RESISTED MOVEMENTS OF THE LUMBAR SPINE

GENERAL INFORMATION

Provided neutral resisted isometric testing in sitting is normal or causes only a small amount of pain, the examiner can go on to other tests that place greater stress on the muscles. These tests often are dynamic and provide both concentric and eccentric work for the muscles supporting the spine. With all of the following tests, the examiner should make sure the patient can hold a neutral pelvis before doing that test. If excessive movement of the anterior superior iliac spines (ASISs) (supine) or posterior superior iliac spines (PSISs) (prone) is noted when the patient does any of the movements, the tests should be stopped. In normal individuals, the ASIS or PSIS does not move during these tests. Motivation may also affect the results.³

ISOMETRIC ABDOMINAL TEST 4–7

PURPOSE

To assess the endurance of the abdominal muscles.

PATIENT POSITION

The patient is supine with the hips at 45°, the knees at 90°, and the hands at the sides. Both feet rest flat on the table.

EXAMINER POSITION

The examiner is positioned so as to observe for altered mechanics.

TEST PROCEDURE

The patient starts the test in the patient position noted above. The examiner then sequentially asks the patient to move to the end position of each level of testing. The patient is instructed to hold the end position for as long as possible. Testing begins with the Trace Grade and progresses sequentially to the Normal Grade (see Table 8-1).

Table 8-1

Isometric Abdominal Test Grading

Grade	MMT Score	Patient Position
Normal	5	With the hands clasped behind the neck, able to raise the upper body until the scapulae clear the table (20- to 30-second hold)
Good	4	With the arms crossed over the chest, able to raise the upper body until the scapulae clear the table (15- to 20-second hold)
Fair	3	With the arms straight, able to raise the upper body until the scapulae clear the table (10- to 15-second hold)
Poor	2	With the arms extended toward the knees, able to raise the upper body until the top of the scapulae lift from the table (1- to 10-second hold)
Trace	1	Unable to raise more than the head off the table

MMT, Manual muscle test.

INDICATIONS OF A POSITIVE TEST

The number of seconds the patient holds the contraction before cheating (e.g., holding the breath, altered mechanics) or the onset of fatigue is recorded as the manual muscle test (MMT) score. The grading for this isometric abdominal test is described in Table 8-1.

RELIABILITY/SPECIFICITY/SENSITIVITY ⁵

Reliability (interrater) ICC = 0.25

DYNAMIC ABDOMINAL ENDURANCE TEST ^5,⁸

PURPOSE

To assess the endurance of the abdominal muscles.

PATIENT POSITION

The patient lies supine with the hips at 45°, the knees at 90°, and the hands at the sides. The feet are flat on the table.

EXAMINER POSITION

The examiner is positioned so as to observe for altered mechanics.

TEST PROCEDURE

A line is drawn 8 cm (patients over age 40) or 12 cm (patients under age 40) distal to the fingers. The patient tucks in the chin and curls (flexes) the trunk to touch the line with the fingers and repeats as many curls as possible using a cadence of 25 repetitions per minute.

INDICATIONS OF A POSITIVE TEST

The number of repetitions possible before cheating (e.g., holding the breath, altered mechanics) or the onset of fatigue is recorded as the score.

CLINICAL NOTE/CAUTION

• This test places significant stress upon the lumbar discs, so if disc pathology is suspected, the examiner should consider whether it is advisable to do the test.

RELIABILITY/SPECIFICITY/SENSITIVITY ⁵

Interrater ICC = 0.78

ISOMETRIC EXTENSOR TEST ^5,^9,¹⁰

PURPOSE

To test the strength of the iliocostalis lumborum (erector spinae) and multifidus.

PATIENT POSITION

The patient is prone lying.

EXAMINER POSITION

The examiner is positioned so as to observe for altered mechanics.

TEST PROCEDURE

The patient attempts to extend the spine as far as possible by lifting up the head and trunk. Depending on how the patient does the test (the aim is to get the highest score possible) and how long the position is held (see Table 8-2), the examiner records the MMT score. The patient holds the end position as long as possible.

Table 8-2

Isometric Extensor Test Grading

Grade	MMT Score	Patient Position
Normal	5	With the hands clasped behind the head, extends the lumbar spine, lifting the head, chest, and ribs from the bed/floor (20- to 30-second hold)
Good	4	With the hands at the side, extends the lumbar spine, lifting the head, chest, and ribs from the bed/floor (15- to 20-second hold)
Fair	3	With the hands at the side, extends the lumbar spine, lifting the sternum off the bed/floor (10- to 15-second hold)
Poor	2	With the hands at the side, extends the lumbar spine, lifting the head off the bed/floor (1- to 10-second hold)
Trace	1	Only slight contraction of the muscle with no movement

MMT, Manual muscle test.

INDICATIONS OF A POSITIVE TEST

The examiner times how long the patient can hold the extended position. The test is graded as described in Table 8-2.

RELIABILITY/SPECIFICITY/SENSITIVITY ⁵

Interrater reliability: ICC = 0.24

INTERNAL/EXTERNAL ABDOMINAL OBLIQUE TEST ^6,¹¹

PURPOSE

To check the combined action of the internal oblique muscle of one side and the external oblique muscle on the opposite side.

PATIENT POSITION

The patient is supine lying with the hands by the side.

EXAMINER POSITION

The examiner is positioned so as to observe for altered mechanics.

TEST PROCEDURE

The patient is asked to lift the head and the shoulder on one side and reach over and touch the fingernails of the other hand or to flex and rotate the trunk. Depending on how the patient does the test (the aim is to get the highest score possible) and how long the position is held (see Table 8-3), the examiner records the MMT score. The patient holds the end position as long as possible. The patient’s feet should not be supported, and the patient should breathe normally.

Table 8-3

Internal/External Abdominal Oblique Test Grading

Grade	MMT Score	Patient Position
Normal	5	Flexes and rotates the lumbar spine fully with the hands behind the head (20- to 30-second hold)
Good	4	Flexes and rotates the lumbar spine fully with the hands across the chest (15- to 20-second hold)
Fair	3	Flexes and rotates the lumbar spine fully with the arms reaching forward (10- to 15-second hold)
Poor	2	Unable to flex and rotate fully
Trace	1	Only slight contraction of the muscle with no movement
None	0	No contraction of the muscle

MMT, Manual muscle test.

INDICATIONS OF A POSITIVE TEST

The number of seconds the contraction is held before cheating (e.g., holding the breath, altered mechanics) or the onset of fatigue is recorded as the score. The test is graded as described in Table 8-3.

CLINICAL NOTE

• This test also can be done dynamically, to test endurance, by counting the number of repetitions to each side the patient is able to do before cheating.

RELIABILITY/SPECIFICITY/SENSITIVITY

Unknown

DOUBLE STRAIGHT LEG LOWERING TEST ^6,^11–13

PURPOSE

To assess the strength of the abdominal muscles.

PATIENT POSITION

The patient lies supine and flexes the hips to 90° and then straightens the knees.

EXAMINER POSITION

The examiner is positioned so as to palpate the ASIS on one side and to observe for altered mechanics.

TEST PROCEDURE

The patient positions the pelvis in neutral (i.e., the PSISs are slightly superior to the ASISs) by doing a posterior pelvic tilt and holding the spinous processes tightly against the examining table. The straight legs then are eccentrically lowered.

INDICATIONS OF A POSITIVE TEST

As soon as the examiner feels the ASIS start to rotate forward during the leg lowering, the test is stopped and the examiner holds the patient’s legs in that position while measuring the angle (plinth to thigh angle). The test must be done slowly, and the patient must not hold the breath. The test is graded as described in Table 8-4.

Table 8-4

Double Straight Leg Lowering Test Grading

Grade	MMT Score	Patient Position
Normal	5	Able to reach 0° to 15° from the table before the pelvis tilts
Good	4	Able to reach 16° to 45° from the table before the pelvis tilts
Fair	3	Able to reach 46° to 75° from the table before the pelvis tilts
Poor	2	Able to reach 75° to 90° from the table before the pelvis tilts
Trace	1	Unable to hold the pelvis in neutral at all

MMT, Manual muscle test.

CLINICAL NOTES/CAUTIONS

• This test should be performed only if the patient receives a grade of “normal” in the dynamic abdominal endurance test or the abdominal isometric test.

• This is an abdominal eccentric test that can put a great deal of stress on the spine; therefore, the examiner must make sure the patient is able to hold a neutral pelvis before doing the exercise. If the patient cannot hold neutral spine or if the patient is symptomatic with the test, the test should not be completed. This test also causes greater abdominal activation than curl-ups.

RELIABILITY/SPECIFICITY/SENSITIVITY

Unknown

DYNAMIC HORIZONTAL SIDE SUPPORT (SIDE BRIDGE OR SIDE PLANK) TEST ^14,¹⁵

PURPOSE

To test the quadratus lumborum muscle.

PATIENT POSITION

The patient is side lying, resting the upper body on the elbow.

EXAMINER POSITION

The examiner is positioned so as to observe for altered mechanics.

TEST PROCEDURE

To begin, the patient is side lying with the knees flexed to 90°. The examiner asks the patient to lift the pelvis off the examining table and straighten the spine. The weight of the body is supported by the forearm and elbow proximally and the lateral knee distally. If the patient can do the first test easily, the test can be made more difficult by having the patient keep the legs straight and then lift the knees and pelvis off the examining table with the feet as the base, so that the whole body is straight.

INDICATIONS OF A POSITIVE TEST

The patient should not roll forward or backward when doing the test. The examiner times how long the patient can hold the position without cheating. The test is graded as described in Table 8-5.

Table 8-5

Dynamic Horizontal Side Support (Side Bridge) Test Grading

Grade	MMT Score	Patient Position
Normal	5	Able to lift the pelvis off the examining table and hold the spine straight (10- to 20-second hold)
Good	4	Able to lift the pelvis off the examining table but has difficulty holding the spine straight (5- to 10-second hold)
Fair	3	Able to lift the pelvis off the examining table but cannot hold the spine straight (<5-second hold)
Poor	2	Unable to lift the pelvis off examining table

MMT, Manual muscle test.

CLINICAL NOTES

• The test may also be done dynamically, to test endurance, by having the patient repeat the side bridging as many times as possible on each side.

• McGill et al.¹⁵ reported that the side bridge should be able to be held 65% of the extensor time for men and 39% for women, and 99% of the flexor time for men and 79% for women.