Shirley Sahrmann's Lumbar Flexion Syndrome

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Introduction

There is rapidly growing acceptance among clinicians and researchers that the development of movement-based diagnostic frameworks is the way forwards in managing chronic and recurrent low back pain (LBP). The systems most supported by evidence are those that examine interrelationships between altered patterns of muscle recruitment and motor control strategies and establish a direction-based mechanism of provocation or relief of symptoms.In the lumbar spine this approach is now well established. In the management of non-specific low back pain the subgrouping and classification of patients’ symptoms based on the assessment of movement and motor control has become more important than trying to identify a pathology based diagnosis.

A majority of spinal dysfunction is the result of cumulative microtrauma caused by impairments in alignment in stabilization and in movement patterns of the spine. In the properly functioning spine the balanced isometric support and control provided by the trunk muscles prevent these impairments. One of the causes lumbar pain is lumbar flexion syndrome using S.Sharmann's classification. Lumbar flexion syndrome with and without radiating symptoms is more often found in men than women and in young individuals. Acutely herniated disk problems are most often associated with flexion.A patient can experience back pain of varying degrees of severity and acuity, as well as varying degrees of radiating symptoms. Pain problems include herniated disk disease, lumbosacral strain, lumbago, and degenerative disk disease.

Physical examination and movement impairments

Standing position the following tests are performed with the patient in a standing position: position effects and forward bending.

1. Position effects. In the standing position the patient has less symptoms than when he or she is sitting.
2. Forward bending. The lumbar spine is often flat; it flexes more readily than the hips, and this movement increases the symptoms (Figure 3-41, A and B). To confirm a positive test for lumbar flexion the patient performs forward bending with hip flexion only when the hands are on a raised table to support the body. The therapist notes the effect of this movement on the symptoms. If the patient has radicular symptoms, there may be an increase of symptoms, even with the corrected forward bending.

Supine position the following tests are performed with the patient in a supine position: position effects, hip and knee flexion, and bilateral hip and knee flexion.

1. Position effects. In the supine position the patient is often able to keep his hips and knees extended without increasing his symptoms. If compression contributes to his symptoms, he may need to flex his hips and knees.
2. Hip and knee flexion. At the end of this movement,passively pulling his knee to his chest may increase his symptoms because of the associated lumbar spine flexion.
3. Bilateral hip and knee flexion. At the end of this movement passively pulling his knees to his chest may increase his symptoms because of the associated lumbar spine flexion.

Prone position the following tests are performed with the patient in a prone position:position effects and knee flexion.

1. Position effects. The prone position may decrease symptoms.
2. Knee flexion. At the initiation of this movement there may be posterior pelvic tilt, but this finding is not common.

Quadruped position the patient allows the lumbar spine to become flat or slightly extended. The patient rocks backward making certain the motion is hip flexion not lumbar flexion.

Standing position the patient sits and performs knee extension. Using the back of the chair as support the patient performs isometric back extension. If the hamstring muscles are particularly short the patient sits with his or her foot on a footstool, stretching the hamstring muscles for 15 to 20 minutes at a time. The patient leans forward using hip flexion and not lumbar flexion and performs the sit-to-stand motion without lumbar flexion.

Physical treatment

The keys to preventing and alleviating spinal dysfunction are (1) to have the trunk muscles hold the vertebral column and pelvis in their optimal alignments and (2) to prevent unnecessary movement. To achieve these goals, the muscles must be the correct length and strength and be able to produce the correct pattern of activity. During movement of the extremities, optimal isometric contraction of the trunk muscles is needed to appropriately stabilize the proximal attachments of the limb muscles. Also treatment includes patient education, analysis and correction of daily activities and prescription of specific exercises.