LUMBAR SPINE

CHAPTER 8


LUMBAR SPINE


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Précis of the Lumbar Spine Assessment*




History (sitting)


Observation (standing)


Examination



Active movements (standing)



Passive movements (only with care and caution)


Peripheral joint scan (standing)



Special tests (standing)



Resisted isometric movements (sitting)



Special tests (sitting)



Resisted isometric movements (supine lying)



Peripheral joint scan (supine lying)



Myotomes (supine lying)



Special tests (supine lying)



Reflexes and cutaneous distribution (anterior and side aspects)


Palpation (supine lying)


Resisted isometric movements (side lying)



Special tests (side lying)



Joint play movements (side lying)



Peripheral joint scan (prone lying)



Myotomes (prone lying)



Resisted isometric movements (prone lying)



Special tests (prone lying)



Reflexes and cutaneous distribution (prone lying)


Reflexes and cutaneous distribution (posterior aspect)


Joint play movements (prone lying)



Palpation (prone lying)


Resisted isometric movements (quadriped position)



Diagnostic imaging



*The assessment is shown in an order that limits the amount of movement the patient must do but ensures that all necessary structures are tested. After any assessment, the patient should be warned that symptoms may be exacerbated by the assessment.




SELECTED MOVEMENTS



ACTIVE MOVEMENTS image




GENERAL INFORMATION


The range of motion (ROM) that occurs during active movement is the summation of the movements of the entire lumbar spine, not just movement at one level, along with hip movement. If the problem is mechanical, one or more of the movements will be painful.


While the patient is doing the active movements, the examiner looks for limitation of movement and possible causes, such as pain, spasm, stiffness, or blocking. If the patient reports that a sustained position increases the symptoms, the examiner should consider having the patient maintain the position (e.g., flexion) at the end of the ROM for 10 to 20 seconds to see whether the symptoms increase. Likewise, if the patient history indicates that repetitive motion or combined movements cause symptoms, these movements should be performed, but only after the patient has completed the basic movements.


The greatest motion in the lumbar spine occurs between the L4 and L5 vertebrae and between L5 and S1. Considerable individual variability is seen in the ROM of the lumbar spine. In fact, little obvious movement occurs in the lumbar spine, especially in the individual segments, because of the shape of the facet joints, the tightness of the ligaments, the presence of the intervertebral discs, and the size of the vertebral bodies.


McKenzie1 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.





Forward Flexion





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.


• Similarly, muscle twitching during movement or complaints of something “slipping out” during lumbar spine movement may indicate instability.


• 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





CLINICAL NOTE




• Bourdillon and Day2 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.




Side Flexion





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) image















ISOMETRIC ABDOMINAL TEST47 image







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).







ISOMETRIC EXTENSOR TEST5,9,10 image










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.






INTERNAL/EXTERNAL ABDOMINAL OBLIQUE TEST6,11 image










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.







DOUBLE STRAIGHT LEG LOWERING TEST6,1113 image











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.






DYNAMIC HORIZONTAL SIDE SUPPORT (SIDE BRIDGE OR SIDE PLANK) TEST14,15 image












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.




PERIPHERAL JOINT SCANNING EXAMINATION



PERIPHERAL JOINT SCAN16 image






EXAMINER POSITION


The examiner’s position varies, depending on the joint to be scanned.







Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on LUMBAR SPINE

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