Testing the Muscles of the Trunk and Pelvic Floor

Trunk Extension

Table 4-1

I.D.	Muscle	Origin	Insertion
89	Iliocostalis thoracis	Ribs 12 up to 7 (angles)	Ribs 6 up to 1 (angles) C7 vertebra (transverse processes)
90	Iliocostalis lumborum	Tendon of erector spinae (anterior surface) Thoracolumbar fascia Sacrum (posterior surface)	Ribs 6-12 (angles)
91	Longissimus thoracis	Tendon of erector spinae Thoracolumbar fascia L1-L5 vertebrae (transverse processes)	T1-T12 vertebrae (transverse processes) Ribs 2-12 (between angles and tubercles)
92	Spinalis thoracis (often indistinct)	Common tendon of erector spinae T11-L2 vertebrae (spinous processes)	T1-T4 vertebrae (or to T8, spinous processes) Blends with semispinalis thoracis
93	Semispinalis thoracis	T6-T10 vertebrae (transverse processes)	C6-T4 vertebrae (spinous processes)
94	Multifidi	Sacrum (posterior) Erector spinae (aponeurosis) Ilium (PSIS) and crest Sacroiliac ligaments L1-L5 vertebrae (mamillary processes) T1-T12 vertebrae (transverse processes) C4-C7 vertebrae (articular processes)	Spinous processes of higher vertebra (may span 2-4 vertebrae before inserting)
95, 96	Rotatores thoracis and lumborum (11 pairs)	Thoracic and lumbar vertebrae (transverse processes; variable in lumbar area)	Next highest vertebra (lower border of lamina)
97, 98	Interspinales thoracis and lumborum	Thoracis: (3 pairs) between spinous processes of contiguous vertebrae (T1-T2; T2-T3; T11-T12) Lumborum: (4 pairs) lie between the 5 lumbar vertebrae; run between spinous processes	See origin
99	Intertransversarii thoracis and lumborum	Thoracis: (3 pairs) between transverse processes of contiguous vertebrae T10-T12 and L1 Lumborum: medial muscles; accessory process of superior vertebra to mamillary process of vertebra below Lateral muscles: fill space between transverse processes of adjacent vertebrae	See origin
100	Quadratus lumborum	Ilium (crest and inner lip) Iliolumbar ligament	12th rib (lower border) L1-L4 vertebrae (transverse processes) T12 vertebra (body)
Other
182	Gluteus maximus (provides stable base for trunk extension by stabilizing pelvis)

Range of Motion

Thoracic spine: 0° to 10°

Lumbar spine: 0° to 25°

Lumbar Spine

The therapist distinguishes between Grade 5 and Grade 4 muscles by the nature of the response (see Figures 4-3 and 4-4). The Grade 5 muscle holds like a lock; the Grade 4 muscle yields slightly because of an elastic quality at the end point. The patient with Grade 5 back extensor muscles can quickly come to the end position and hold that position without evidence of significant effort. The patient with Grade 4 back extensors can come to the end position but may waver or display some signs of effort.

Alternative Grade 5 Sorensen Lumbar Spine Extension Test

The Biering-Sorensen test or Sorensen test is a global measure of back extension endurance capacity.¹

Position of Patient:

Prone with the trunk flexed off the end of the table at a level between the anterior superior iliac spine (ASIS) and umbilicus. The arms are folded across the chest. The pelvis, hips, and legs are stabilized on the table (Figure 4-5).

Position of Therapist:

Kneeling above patient so as to stabilize the lower limbs and pelvis at the ankles.

Test:

Patient lifts the trunk to the horizontal and maintains the position as long as possible. The therapist uses a stopwatch to time the effort, activating it at the “begin” command and stopping it when the patient shows obvious signs of fatigue and begins to falter.¹

Instructions to Patient:

“When I say ‘begin,’ raise your head, chest, and trunk from the table and hold the position as long as you can. I will be timing you. Let me know if you have any back pain.”

Helpful Hints

• Low levels of endurance of back muscles are reported as cause and effect of low back pain.²

• The Sorensen test has been validated as a differential diagnostic test for low back pain.3,4 Individuals with low back pain have significantly lower hold times than those without low back pain. In subjects with low back pain, the mean endurance time ranges from 39.55 to 54.5 seconds in mixed-gender groups (compared with 80 to 194 seconds for men and 146 to 227 seconds for women without pain).²

• The mean endurance time for all subjects (with and without low back pain) in one study was 113 ± 46 seconds.² Men had higher mean endurance than women.

• Because average endurance times have not been established for older individuals, caution should be exercised when testing individuals aged 60 years and older.

• A significant difference was found in the endurance time across the age groups,² indicating that a decrease in endurance time should be expected with increasing age. Some age-based norms are listed in Table 4-2.

Table 4-2

AGE-BASED NORMS FOR SORENSEN TEST

Age	Mean Hold Time in Seconds (SD)* Males	Mean Hold Time in Seconds (SD) Females
19-29	140⁵	130⁵
30-39	140⁵	120
35-39	97 (43)²	93 (55)²
40-44	101 (57)²	80 (55)²
40-49	110⁵	90⁵
45-49	99 (58)²	102 (64)²
50-54	89 (55)²	69 (60)²
50-59	90⁵	80⁵
60+	80⁵	90⁵

² Data from 508 subjects with and without back pain that comprised equal groups of blue and white collar male and female subjects. Modified Sorensen test performed (arms at sides).

⁵ Data from 561 healthy, nonsmoking subjects in Nigeria without low back pain, performing a modified Sorensen test (arms at sides).

^*Numbers in parentheses refer to standard deviation (SD). The standard deviation is only available for some age groups.

• More recent data suggest that normative values vary by specific populations and by specific anthropomorphic characteristics such as body mass index and torso length.2,5

• The multifidus demonstrates more electromyogram (EMG) activity and faster fatigue rates than the iliocostalis lumborum.⁶

Thoracic Spine

Grade 5 (Normal) and Grade 4 (Good)

Position of Patient:

Prone with head and upper trunk extending off the table from about the nipple line (Figure 4-6).

Position of Therapist:

Standing so as to stabilize the lower limbs at the ankle.

Test:

Patient extends thoracic spine to the horizontal.

Instructions to Patient:

“Raise your head, shoulders, and chest to table level.”

Grading

Grade 5 (Normal):

Patient is able to raise the upper trunk quickly from its forward flexed position to the horizontal (or beyond) with ease and no sign of exertion (Figure 4-7).

Grade 4 (Good):

Patient is able to raise the trunk to the horizontal level but does it somewhat laboriously.

Lumbar and Thoracic Spine

Grade 3 (Fair)

Position of Patient:

Prone with arms at sides.

Position of Therapist:

Standing at side of table. Lower extremities are stabilized just above the ankles.

Test:

Patient extends spine, raising body from the table so that the umbilicus clears the table (Figure 4-8).

Instructions to Patient:

“Raise your head, arms, and chest from the table as high as you can.”

Grading

Grade 3 (Fair):

Patient completes the range of motion.

Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)

These tests are identical to the Grade 3 test except that the therapist must palpate the lumbar and thoracic spine extensor muscle masses adjacent to both sides of the spine. The individual muscles cannot be isolated (Figures 4-9 and 4-10).

Grading

Grade 2 (Poor):

Patient completes partial range of motion.

Grade 1 (Trace):

Contractile activity is detectable but no movement.

Grade 0 (Zero):

No contractile activity.

Helpful Hints

• Tests for hip extension and neck extension should precede tests for trunk extension.

• When the spine extensors are weak and the hip extensors are strong, the patient will be unable to raise the upper trunk from the table. Instead, the pelvis will tilt posteriorly while the lumbar spine moves into flexion (low back flattens).

• If the hip extensor muscles are Grade 4 or better, it may be helpful to use belts to anchor hips to the table, especially if the patient is much larger or stronger than the testing therapist.

• When the back extensors are strong and the hip extensors are weak, the patient can hyperextend the low back (increased lordosis) but will be unable to raise the trunk without very strong stabilization of the pelvis by the therapist.

• If the neck extensors are weak, the therapist may need to support the head as the patient raises the trunk.

• The position of the arms in external rotation and fingertips lightly touching the side of the head provides added resistance for Grades 5 and 4; the weight of the head and arms essentially substitutes for manual resistance by the therapist.

• If the patient is unable to provide stabilization through the weight of the legs and pelvis (such as in paraplegia or amputee), the test should be done on a mat table. Position the subject with both legs and pelvis off the mat. This allows the pelvis and limbs to contribute to stabilization, and the therapist holding the lower trunk has a chance to provide the necessary support. (If a mat table is not available, an assistant will be required, and the lower body may rest on a chair.)

• The Modified Sorensen test is the Sorensen test but performed with arms at the patient’s sides.

Elevation of the Pelvis

Table 4-3

ELEVATION OF THE PELVIS

I.D.	Muscle	Origin	Insertion
100	Quadratus lumborum	Ilium (crest and inner lip) Iliolumbar ligament	Rib 12 (lower border) L1-L4 vertebrae (transverse processes, apex) T12 vertebra (body; occasionally)
110	Obliquus externus abdominis	Ribs 5-12 (interdigitating on external and inferior surfaces)	Iliac crest (outer border) Aponeurosis from 9th costal cartilage to ASIS; both sides meet at midline to form linea alba Pubic symphysis (upper border)
111	Obliquus internus abdominis	Iliac crest (anterior 2/3 of intermediate line) Thoracolumbar fascia Inguinal ligament (lateral 2/3 of upper aspect)	Ribs 9-12 (inferior border and cartilages by digitations that appear continuous with internal intercostals) Ribs 7-9 (cartilages) Aponeurosis to linea alba
Others
130	Latissimus dorsi (arms fixed)
90	Iliocostalis lumborum

Range of Motion

Approximates pelvis to lower ribs; range not precise

Grade 5 (Normal) and Grade 4 (Good)

Position of Patient:

Supine or prone with hip and lumbar spine in extension. The patient grasps edges of the table to provide stabilization during resistance (not illustrated).

Position of Therapist:

Standing at foot of table facing patient. Therapist grasps test limb with both hands just above the ankle and pulls caudally with a smooth, even pull (Figure 4-13). Resistance is given as in traction.

Test:

Patient hikes the pelvis on one side, thereby approximating the pelvic rim to the inferior margin of the rib cage.

Instructions to Patient:

“Hike your pelvis to bring it up to your ribs. Hold it. Don’t let me pull your leg down.”

Grading

Grade 5 (Normal):

This motion, certainly not attributed solely to the quadratus lumborum, is one that tolerates a huge amount of resistance that is not readily broken when the muscles involved are Grade 5.

Grade 4 (Good):

Patient tolerates very strong resistance. Testing this movement requires more than a bit of clinical judgment.

Grade 3 (Fair) and Grade 2 (Poor)

Position of Patient:

Supine or prone. Hip in extension; lumbar spine neutral or extended.

Position of Therapist:

Standing at foot of table facing patient. One hand supports the leg just above the ankle; the other is under the knee so the limb is slightly off the table to decrease friction (Figure 4-14).

Test:

Patient hikes the pelvis unilaterally to bring the rim of the pelvis closer to the inferior ribs.

Instructions to Patient:

“Bring your pelvis up to your ribs.”

Grading

Grade 3 (Fair):

Patient completes available range of motion.

Grade 2 (Poor):

Patient completes partial range of motion.

Grade 1 (Trace) and Grade 0 (Zero)

These grades should be avoided to ensure clinical accuracy. The principal muscle involved in pelvic elevation, the quadratus lumborum, lies deep to the paraspinal muscle mass and can rarely be palpated. In people who have extensive truncal atrophy, paraspinal muscle activity may be palpated, and possibly, but not necessarily convincingly, the quadratus lumborum can be palpated.

Substitution

The patient may attempt to substitute with trunk lateral flexion, primarily using the abdominal muscles. The spinal extensors may be used without the quadratus lumborum. In neither case can manual testing detect an inactive quadratus lumborum.

Helpful Hints

• The quadratus lumborum hikes the ipsilateral hip when the spine is fixed.

• It should be noted that the quadratus lumborum may have functions other than hip hiking, such as maintaining upright posture, though these functions have been less well studied. Quadratus lumborum strength has also been linked to low back pain and thus may deserve closer analysis.⁶

Trunk Lateral Endurance

Side Bridge Endurance Test

Quadratus lumborum oblique and transverse muscles are elicited without generating large compression forces on the lumbar spine.7,8

Position of Patient:

Side-lying with legs extended, resting on the lower forearm with the elbow flexed to 90°. Upper arm is crossed over chest.

Position of Therapist:

Standing or sitting in front of patient holding a stopwatch. Patient is given feedback regarding posture; the hips and trunk should be level throughout the test (Figure 4-15).

Test:

Patient lifts hip off the table, holding the elevated position in a straight line with the body on a flexed elbow. This position is maintained until the patient loses posture form, fatigues, or complains of pain. The therapist times the effort.

Instructions to the Patient:

“When I say ‘go!’ lift your hip off the table, keeping it in a straight line with your body for as long as you can. I will be timing you.”

Helpful Hint

Despite the high reliability of the side bridge test, significant changes in hold times must be observed to confidently assess a true change in strength. Therefore, the patient’s rating of perceived exertion (RPE) would help inform clinical decision making.⁹ Mean hold times range from 20 to 203 seconds (mean 104.8 seconds) for the right side bridge test and from 19 to 251 seconds (mean of 103.0 seconds) for the left side bridge test.⁹ Males demonstrated longer endurance times than females.

Trunk Flexion

Range

0° to 80°

Table 4-4

TRUNK FLEXION

I.D.	Muscle	Origin	Insertion
113	Rectus abdominis (paired muscle)	Pubis Lateral fibers (tubercle on crest and pecten pubis) Medial fibers (ligamentous covering of symphysis attaches to contralateral muscle)	Ribs 5-7 (costal cartilages) Sternum (xiphoid ligaments)
110	Obliquus externus abdominis	Ribs 5-12 (interdigitating on external and inferior surfaces)	Iliac crest (outer border) Aponeurosis from 9th costal cartilage to ASIS; both sides meet at midline to form linea alba
111	Obliquus internus abdominis	Iliac crest (anterior 2/3 of intermediate line) Thoracolumbar fascia Inguinal ligament (lateral 2/3 of upper aspect)	Ribs 9-12 (inferior border and cartilages by digitations that appear continuous with internal intercostals) Ribs 7-9 (cartilages) Aponeurosis to linea alba
Others
174	Psoas major
175	Psoas minor

Trunk flexion has multiple elements that include cervical, thoracic, and lumbar motion. Measurement is difficult at best and may be done in a variety of ways with considerable variability in results.

The neck flexors should be eliminated as much as possible by asking the patient to maintain a neutral neck position with the chin pointed to the ceiling to avoid neck flexion.

Grade 5 (Normal)

Position of Patient:

Supine with fingertips lightly touching the back of the head (Figure 4-18).

Position of Therapist:

Standing at side of table at level of patient’s chest to be able to ascertain whether scapulae clear table during test (see Figure 4-18). For a patient with no other muscle weakness, the therapist does not need to touch the patient. If, however, the patient has weak hip flexors (refer to page 206), the therapist should stabilize the pelvis by leaning across the patient on the forearms (Figure 4-19).

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Tags: Daniels and Worthinghams Muscle Testing Techniques of Manual

Aug 25, 2016 | Posted by admin in RHEUMATOLOGY | Comments Off

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Testing the Muscles of the Trunk and Pelvic Floor

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