An Introduction to Clearing the Lumbar Spine

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Introduction

Low back pain is the leading cause of disability worldwide. Most patients who present with low back pain with or without radicular pain can be managed effectively in primary care settings. In particular, patients who have acute non radicular back pain will typically note improvements in symptoms with simple treatment approaches such as education, lifestyle modification, heat, massage and some medication. Physiotherapists, therefore, play a key role in the management of these patients.

However, for some patients, particularly those with peripheral symptoms, it may not be clear if their pain is due to the lumbar spine or not. It is, therefore, essential that physiotherapists are able to undertake a comprehensive lumbar spine assessment and demonstrate strong clinical reasoning skills in order to either clear the lumbar spine or diagnose lumbar pathology.

Locating the Source of Pain

A number of structures have similar pain referral patterns as the lumbar spine, including the pelvic girdle and hip. Moreover, hip and lumbar issues can co-exist, which can further complicate the clinical picture.  Certain visceral structures can also refer pain to the lumbar spine (i.e. spinal masqueraders), so these must be considered in any differential diagnosis.

There are a number of red flags to consider when assessing spinal pain, including:

• Recent trauma and aged over 50 years
• History of cancer and a strong clinical suspicion
• Progressive symptoms
• Thoracic pain
• Weight loss
• Drug abuse
• Night pain
• Systemically unwell (fever)
• Night sweats

Finucane and colleagues developed a framework to guide clinicians when considering red flags and escalation of care. For more information on this, please click here. 

Classifying Pain

After clearing red flags, there are a number of ways to classify pain including:

• Pain behaviour (i.e. nociceptive, nociceptive inflammatory and neuropathic)
• Pain assessment
• Specific low back screening tools (e.g.STarT Back Tool)

These tools can be used early on in the assessment to help the therapist build a clinical picture of the patient, and to guide design making with regards to treatment pathways for patients who are categorised as low, medium or high risk patients. Even patients who are deemed at "high risk" of chronicity may benefit from non-pharmacological approaches such as exercise and spinal mobilisation etc.

Another way of clearing the lumbar spine during an assessment is to consider which of the following categories best describe the patient’s symptoms:

1. Obviously spinogenic symptoms - the symptoms are obviously coming from the spine. Examples may include:
   1. • Lumbar pain developed following a specific, defined incident
      • Pain refers to the leg during lumbar motion
2. Obviously not spinogenic symptoms - the symptoms are obviously not coming from the spine. Examples may include:
   1. • Clear mechanism of injury in a peripheral area such as an ACL tear
      • No spinal history or complaints
3. Not obvious spinogenic symptoms - the symptoms are not obviously coming from the spine. These are more challenging to classify. An example may be:
   1. • A patient who complains of right hip pain after a long run
      • As the lumbar spine can refer pain to the hip, it must be ruled in or out in the clinical assessment

Subjective Assessment for Not Obvious Spinogenic Symptoms

*Please note: This is not a comprehensive assessment guide, but rather focuses on specific points that are necessary to clear the lumbar spine. A detailed discussion of the subjective assessment for back pain is found here.

After clearing red flags, it is beneficial to map out areas of pain on a body chart. It has been found that body pain diagrams have adequate intraexaminer and interexaminer reliability for measuring pain distribution and location in patients with acute and chronic low back pain with or without radiculopathy. On the body chart, the therapist should identify:

• Areas that are currently problematic
• Areas that are not problematic
• Areas that may be problematic, but are not currently an issue, including previous low back pain or stiffness

When reviewing the body chart, a clear dermatomal or disc pattern may be evident, thus demonstrating a link to the lumbar spine.

It is important to relate body chart findings to the subjective history as well. When a patient complains of peripheral symptoms without a clear mechanism of injury, it will raise the level of suspicion that the lumbar spine is involved.

Objective Assessment for Not Obvious Spinogenic Symptoms

*Again please note, this is not a comprehensive assessment guide. Instead, this section discusses specific features of the assessment that can help to rule the lumbar spine in or out. For a detailed description of the lumbar spine assessment, please click here.

When conducting an objective assessment, it is essential to be consistent and ensure quality in your testing.

The objective assessment may include:

• Gait analysis
• Observation
• Palpation
• Range of motion testing
• Special tests that may include a neurological and neurodymanic assessment

It is necessary to ensure that the depth of testing matches the patient’s symptoms. For instance, testing lumbar range of motion once may not be sufficient for a patient who only develops symptoms after 20 minutes of running.

Myotome Testing

Neurological testing, specifically myotome can provide useful information about potential pathology in the lumbar spine such as:

• Nerve root irritation
• Mechanical compression of a nerve in the lumbar spine

When testing myotomes, it is important to:

• Be consistent
• Compare both sides
• Repeat tests to clarify results
• Ask the patient how it feels for him / her

Consider:

• Testing the patient in supine as this is less likely to be provocative
• Start testing distally (i.e. at the feet) as:
  • These movements are less provocative for the lumbar spine than hip flexion etc
  • Radiculopathies are more often lower lumbar than upper lumbar

The following video demonstrates lower limb myotome testing.

Lumbar Range of Motion Testing

Lumbar range of motion testing is demonstrated in the following video.

When testing range of motion, it is important to look at the quality of the movement and the patient’s pain response.

Range of motion testing is guided by the patient’s irritability - when it is not an obvious spinogenic issue, patients tend to be less irritable.

During flexion / extension, side bending testing, look for:

• Aberrant movements
• Gowers’ sign (see video below)
• Concordant peripheral pain
• Tightness

In less irritable patients, it may be necessary to do repeated movement testing, especially in hypomobile patients before applying overpressure in all directions, including the lumbar quadrant test (see video below).

Passive Accessory Vertebral Testing

For a clinician to be able to clear the lumbar spine, you would generally have had to cover central and bilateral unilateral Posterior Anterior vertebral mobilisations in the lumbar spine at an appropriate grade to clear he lumbar spine.

Provoking the Lumbar Spine to Clear it.

In some instances, a more unusual test may be to apply a dry needle into the paravertebral muscles that could in turn could elicit a lumbar pain response. If the left and right paravertebral muscles are needles and elicit no response, the lumbar spine may be further cleared.

Looking at Sensitive Nerves

Neurodynamic testing can be a very useful way to also link the peripheral symptoms with the lumbar spine, as it highlights the sensitivity of the nervous system. You can further differentiate specific parts of the nervous system to specific symptoms that the patient has experienced. Some patients may however have some degree of neural tension, so it is important to compare the left and the right side, and also differentiate their specific symptoms to just normal neural testing. Its always a good idea to start with the straightly raise first (with its variations), and then on move on to other neurodymic test such as the slump test after.

For more information on the comprehensive Lumbar Spine Assessment click here

Conclusions

We need to know that we are asking the right questions, and testing the right areas. We need to know that we are differentiating effectively to clinically reason in an accurate way, so we can assist our patients in the best possible way so that they could have the optimal treatment outcomes.