An Introduction to Clearing the Lumbar Spine: Difference between revisions

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== Introduction ==
== Introduction ==
The lumbar spine is one of the most common areas physiotherapists treat. [[Back School|Low back pain]] is the leading cause of injury and disability worldwide, and presents a huge economic burden to society<ref>Back Education Program. (2020, December 20). ''Physiopedia,'' . Retrieved 22:51, April 21, 2021 from https://www.physio-pedia.com/index.php?title=Back_Education_Program&oldid=262713.</ref>. Part of the reason for this is that many back pain complaints remain unresolved and poorly managed, and this may be due to many factors. This can become even more confusing when a patient is unsure about the history of their condition and the exact cause of their concern. Most of the patients presenting withlow back pain with or without radicular pain do not require immediate diagnostic imaging and can be managed effectively and an in primary care setting<ref name=":0">Diagnosis and management of low-back pain in primary care. Adrian Traeger, Rachelle Buchbinder, Ian Harris, Chris Maher. <abbr>CMAJ</abbr> Nov 2017, 189 (45) E1386-E1395; DOI: 10.1503/cmaj.170527</ref>. Most patients with acute non radicular back pain will have an improvement in their symptoms with simple treatment approaches such as education, lifestyle modification, heat, massage and some medication<ref>Parr, A., & Askin, G. (2020, December). Non-radicular low back pain: Assessment and evidence-based treatment. ''Australian Journal of General Practice''. Royal Australian College of General Practitioners. <nowiki>https://search.informit.org/doi/10.3316/informit.553846456305189</nowiki></ref>.       
[[Back School|Low back pain]] is the leading cause of disability worldwide.<ref>Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S et al. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext What low back pain is and why we need to pay attention]. Lancet. 2018;391(10137):2356-2367.</ref> It can have a significant impact on quality of life<ref>Chen S, Chen M, Wu X, Lin S, Tao C, Cao H, et al. [https://www.sciencedirect.com/science/article/pii/S2214031X21000590 Global, regional and national burden of low back pain 1990-2019: A systematic analysis of the Global Burden of Disease study 2019]. J Orthop Translat. 2021 Sep 10;32:49-58. </ref> and is associated with high direct and indirect costs (e.g. absenteeism from work, lost productivity).<ref>Nieminen LK, Pyysalo LM, Kankaanpää MJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108595/ Prognostic factors for pain chronicity in low back pain: a systematic review]. Pain Rep. 2021 Apr 1;6(1):e919. </ref> However, most patients who present with low back pain with or without radicular pain can be managed effectively in primary care settings.<ref name=":0">Diagnosis and management of low-back pain in primary care. Adrian Traeger, Rachelle Buchbinder, Ian Harris, Chris Maher. <abbr>CMAJ</abbr> Nov 2017, 189 (45) E1386-E1395; DOI: 10.1503/cmaj.170527</ref> 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.<ref>Parr, A., & Askin, G. (2020, December). Non-radicular low back pain: Assessment and evidence-based treatment. ''Australian Journal of General Practice''. Royal Australian College of General Practitioners. <nowiki>https://search.informit.org/doi/10.3316/informit.553846456305189</nowiki></ref> Physiotherapists, therefore, play a key role in the management of these patients.       


It therefor essential for a physiotherapists to have the skills to clear the lumbar spine effectively. We all know that the lumbar spine can refer symptoms to other areas of the body, particularly the leg. There are also cases where lumbar spine symptoms may be produced by other areas, making the clinical picture that the patient is presenting with a tricky area of clinical practice to navigate through.  
However, for some patients, particularly those with peripheral symptoms, it may not be clear if their pain is due to pathology in the lumbar spine or not. It is, therefore, essential that physiotherapists are able to undertake a comprehensive screening assessment and have the necessary clinical reasoning skills to either clear the lumbar spine or diagnose lumbar pathology.    


== Getting In The Right Area ==
== Locating the Source of Pain ==
Its all about connecting the dots, but first you need to find the dots. We know that the lumbar spine may refer down into the leg, but at the same time, that other non lumbar structures may produce symptoms that can be masked as low back pain. It is also important to have a sound knowledge of visceral structures that may refer into the lumbar spine, and these are referred to as [[Spinal Masqueraders]].These visceral symptoms present as low back pain, through the presentation of a non mechanical referred pain<ref>Spinal Masqueraders. (2020, November 17). ''Physiopedia,'' . Retrieved 23:22, April 21, 2021 from https://www.physio-pedia.com/index.php?title=Spinal_Masqueraders&oldid=259676.</ref>. It is important to have a sound understanding of the lumbar spine in terms of its anatomy, the  different lumbar presentations and their signs and symptoms and of course different pain presentations when it comes to the lumbar spine.
A number of structures have similar pain referral patterns as the lumbar spine, including the pelvic girdle and hip.<ref>Riley SP, Swanson BT, Cleland JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8353316/ The why, where, and how clinical reasoning model for the evaluation and treatment of patients with low back pain]. Braz J Phys Ther. 2021 Jul-Aug;25(4):407-414. </ref> Moreover, hip and lumbar issues can co-exist, which can further complicate the clinical picture.<ref>Prather H, Cheng A, Steger-May K, Maheshwari V, Van Dillen L. [https://www.jospt.org/doi/full/10.2519/jospt.2017.6567 Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain]. J Orthop Sports Phys Ther. 2017;47(3):163-72.  </ref> Certain visceral structures can also refer pain to the lumbar spine - i.e. [[Spinal Masqueraders|spinal masqueraders]]<ref>Walcott B, Coumans J, Kahle K. Diagnostic pitfalls in spine surgery: masqueraders of surgical spine disease. Neurosurgical Focus. 2011;31(4).</ref> - so these too much be considered in a differential diagnosis.  


== '''Pain Sources When Looking At Clearing The Lumbar Spine''' ==
There are also a number of red flags to check for when assessing spinal pain, including:<ref>Finucane L. An Introduction to Red Flags in Serious Pathology Course. Plus. 2020.</ref>
When looking at pain, there various ways to classify pain. You can look at [[Pain Behaviours|pain behaviour]] for one, where pain can be classified as nociceptive, nociceptive inflammatory and neuropathic<ref>Pain Behaviours. (2020, May 20). ''Physiopedia,'' . Retrieved 23:30, April 21, 2021 from https://www.physio-pedia.com/index.php?title=Pain_Behaviours&oldid=238652.</ref>. [[Pain Assessment|Pain assessment]] is also valuable in understanding the clinical picture of the patient, and specific low back screening tools such as the [[STarT Back Screening Tool|STarT Back Too]]<nowiki/>l may be employed early on to build the clinical picture of your patient even further, and to guide design making with regards to treatment pathways for patients who are categorised as low, medium or high risk patients<ref>STarT Back Screening Tool. (2020, November 27). ''Physiopedia,'' . Retrieved 23:38, April 21, 2021 from https://www.physio-pedia.com/index.php?title=STarT_Back_Screening_Tool&oldid=260588.</ref>. It is important to note that even patients that are deemed "high risk" of chronicity may still benefit from non-pharmacological approached such as exercise, and spinal mobilisation to name a few<ref name=":0" />.


Another simple way of looking at clearing the lumbar spine when being presented with a list of symptoms is to classify or group the symptoms into one of three boxes.
* Recent trauma and aged over 50 years<ref>Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red Flags for Low Back Pain Are Not Always Really Red. J Bone Jt Surg. 2018;100(5):368–74.</ref>
* History of cancer and a strong clinical suspicion<ref>Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-8.</ref>
* Progressive symptoms
* [[Thoracic Back Pain|Thoracic pain]]
* Weight loss
* [[Intraveneous Drug Abuse|Drug abuse]]
* Night pain
* Systemically unwell (fever)
* Night sweats


i) The symptoms are obviously coming from the spine (Obvious Spinogenic Symptoms)
Finucane and colleagues developed a framework to guide clinicians when considering red flags and escalation of care.<ref>Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. [https://www.jospt.org/doi/10.2519/jospt.2020.9971 International framework for red flags for potential serious spinal pathologies]. J Orthop Sports Phys Ther. 2020;50(7):350-72.</ref> For more information on this, please click [[Spinal Malignancy|here]]. 


ii) The symptoms are obviously not coming from the spine (Obviously Not Spinogenic Symptoms)
=='''Classifying Pain'''==
After clearing red flags, there are a number of ways to classify pain including:


iii) The symptoms are obviously not coming from the spine (Not Obvious Spinogenic Symptoms)
* [[Pain Behaviours|Pain behaviour]] (i.e. nociceptive, nociceptive inflammatory and neuropathic)<ref>Pain Behaviours. (2020, May 20). ''Physiopedia,'' . Retrieved 23:30, April 21, 2021 from https://www.physio-pedia.com/index.php?title=Pain_Behaviours&oldid=238652.</ref>
* [[Pain Assessment|Pain assessment]]
* Specific low back screening tools (e.g. [[STarT Back Screening Tool|STarT Back Tool]])


'''Obvious Spinogenic Symptoms'''
These tools can be used early on in the assessment to help the therapist build a clinical picture of the patient, and to guide decision making with regards to treatment pathways for patients who are categorised as low, medium or high risk patients.<ref>STarT Back Screening Tool. (2020, November 27). ''Physiopedia,'' . Retrieved 23:38, April 21, 2021 from https://www.physio-pedia.com/index.php?title=STarT_Back_Screening_Tool&oldid=260588.</ref> Even patients who are deemed at "high risk" of chronicity may benefit from non-pharmacological approaches such as exercise and spinal mobilisation etc.<ref name=":0" />


Some examples may include:
Another way of clearing the lumbar spine during an assessment is to consider which of the following categories best describe the patient’s symptoms:<ref name=":1">Rainey N. An Introduction to Clearing the Lumbar Spine Course. Plus. 2021.</ref>
* Pain in the back
* Restricted lumbar range of motion
* Pain produced in limb with lumbar range of motion
'''Obviously Not Spinogenic'''


Some examples may include:
# Obviously spinogenic symptoms - the symptoms are obviously coming from the spine. Examples may include:
* Clear mechanism of injury in a peripheral area
## Lumbar pain developed following a specific, defined incident
* No spinal history or complaints
## Pain refers to the leg during lumbar motion
'''Not Obvious Spinogenic'''
# Obviously not spinogenic symptoms - the symptoms are obviously not coming from the spine. Examples may include:
## Clear mechanism of injury in a peripheral area such as popping at the knee indicating an ACL tear
## No spinal history or complaints
# Not obvious spinogenic symptoms - the symptoms are not obviously, but have the potential to be, coming from the spine. These are more challenging to classify. An example may be:
## 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


This is really the tricky part to figure out. It is really important that we employ a strong clinical assessment approach when trying to link peripheral symptoms to the lumbar spine.
== Subjective Assessment for Not Obvious Spinogenic Symptoms ==
<nowiki>*</nowiki>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 [[Subjective Assessment of the Lumbar Spine|here]].


'''''From a subjective assessment point of view:'''''
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.<ref>Southerst D, Côté P, Stupar M, Stern P, Mior S. The reliability of body pain diagrams in the quantitative measurement of pain distribution and location in patients with musculoskeletal pain: a systematic review. J Manipulative Physiol Ther. 2013;36(7):450-9. </ref> On the body chart, the therapist should identify:<ref name=":1" />


<nowiki>*</nowiki>Please note: This is not a comprehensive assessment guide, but rather some specific aspects highlighted pertaining to clearing the lumbar spine.
* 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


Its all in the details. A clear and concise history taking is essential to the success of the patient interview. Its always a great idea to clear red flags, and there are clinical frameworks that provide clinicians with a clear clinical-reasoning pathway to determine if a of red flags should be a concern or not with regards to lumbar pathology<ref>Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International Framework for red flags for potential serious spinal pathologies. journal of orthopaedic & sports physical therapy. 2020 Jul;50(7):350-72.</ref>. A body chart is really helpful tool to use here, as it helps us to clear out the involved areas in the body that are involved from those that are not involved. You can also use the body chart to identify areas that may be problematic but not a current issue. We may want to clear any previous low back pain or stiffness, and make a note of that. This way, it may elude to a possible link between a peripheral symptom and a spinal issue. The body chart can also highlight peripheral neurological symptoms and specific patterns indicated on the body chart drawing. These may be a clear dermatomal pattern, or a disc pattern that show us and the patient some important links to connect the peripheral symptoms to the lumbar spine. You also want to make sure about the mechanism of injury of the complaint. If there are peripheral symptoms without a clear mechanism of injury, it should raise our suspicion about the involvement of the lumbar spine.
When reviewing the body chart, a clear dermatomal or disc pattern may be evident, thus demonstrating a link to the lumbar spine.


For more information on the comprehensive lumbar spine [[Subjective Assessment of the Lumbar Spine|subjective assessment click here.]]
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.<ref name=":1" />


'''From an objective point of view:'''
== Objective Assessment for Not Obvious Spinogenic Symptoms ==
<nowiki>*</nowiki>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 [[Lumbar Assessment|here]]. 


<nowiki>*</nowiki>Please note: This is not a comprehensive assessment guide, but rather some specific aspects highlighted pertaining to clearing the lumbar spine.
When conducting an objective assessment, it is essential to be consistent and ensure quality in your testing.  


Once again, its all in he details, but even more so in the objective exam, its all about the quality and consistency of your testing. The objective testing procedure may include gait analysis, observation, palpation, range of motion testing and special tests that may include a neurological and neurodymanic assessment<ref>Albazli K, Alotaibi M, Almoallim H. Low-Back Pain. InSkills in Rheumatology (pp. 127-138). Springer, Singapore.</ref>. There are many aspects areas of the objective examination to cover, and the order of assessment may be different between clinicians. It is important to perform an appropriate dept of testing to match the symptoms of the patient. If a runner only start getting their symptoms after 20 min of running, a simple one repetition range of motion test may not be rigorous enough to elicit their symptoms. 
The objective assessment may include:


''Neurological Testing'' 
* Gait analysis
* Observation
* Palpation
* Range of motion testing
* Special tests (e.g. neurological and neuro-dynamic tests)<ref>Albazli K, Alotaibi M, Almoallim H. Low-Back Pain. InSkills in Rheumatology (pp. 127-138). Springer, Singapore.</ref>


Neurological testing, specifically [[Myotomes|Myotome]] testing may be very useful in telling us what is going on with the pathoanatomy related to the lumbar spine, and this may indicate the patient prognosis, and how they may respond to treatment. It is also useful that if the patient has a clear myotome test, you know that you can proceed with the rest of the examination in a rigorous manner. Nerve roots may be irritated, and there may be mechanical compression being applied on a specific nerve for a variety of reasons<ref>Nisargandha MA, Parwe S, Wankhede SG, Shinde PU, Phatale SR, Deshpande VK. Nerve Conduction Studies on Patients of Sciatica. Int J Biol Med Res. 2017;8(3):6050-2.</ref>. 
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 to elicit concordant symptoms in a patient who only develops pain after 20 minutes of running.<ref name=":1" />


It is important to be consistent in the myotome testing comparing both sides and repeating the testing to clarify their answers to the questioning. This will ensure that we are clear when we say there is a myotome issue. It may also be a good idea to start at the feet, at most [[Radiculopathy|radiculopathies]] will be lower lumbar instead of upper lumbar presentation.   
=== Myotome Testing ===
Neurological testing, specifically [[Myotomes|myotome]] testing, can provide useful information about pathoanatomy in the lumbar spine, which can indicate prognosis. When testing myotomes, it is important to:<ref name=":1" />  
* Be consistent
* Compare both sides
* Repeat tests to clarify results
* Ask the patient if she / he notices any strength deficits during testing


Watch this video on myotome testing of the lower extremity. 
Consider:<ref name=":1" />


{{#ev:youtube|ptO9ZvsUPDg}}
* Testing the patient in supine as this is less likely to be provocative for the lumbar spine
* Start testing distally (i.e. at the feet) as:
** These movements are less provocative for the lumbar spine than proximal movements such as hip flexion
** Radiculopathies are more often associated with the lower lumbar spine than the upper lumbar spine
The following video demonstrates lower limb myotome testing. {{#ev:youtube|UodWTD_IRb8}}<ref>Functional Pain Management Society. Myotome testing by an expert. Available from: https://www.youtube.com/watch?v=UodWTD_IRb8 [last accessed 06/7/2021]</ref>


=== Lumbar Range of Motion Testing ===
Lumbar range of motion testing is demonstrated in the following video.


{{#ev:youtube|6ZV7y-L8QwY}}<ref>Functional Pain Management Society. Lumbar range of motion examination by an expert. Available from: https://www.youtube.com/watch?v=6ZV7y-L8QwY [last accessed 06/7/2021]</ref>


''Lumbar Range of Motion''
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.<ref name=":1" />


We want to be clear and specific here, looking carefully at quality of movement and their pain response. It is also important to communicate these finding with the patient, so they can be aware of the issues that may be picked up, further validating the peripheral link to the lumbar spine if applicable. Overpressure is then applied in those patients that have low irritability, where they have not have had any range deficits in the lumbar spine, or any pain or stiffness response.
During flexion / extension, side bending testing, look for:<ref name=":1" />


''Passive Accessory Vertebral Testing''
* Aberrant movements
* Gowers’ sign (see video below)
* Concordant peripheral pain
* Tightness


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.
In less irritable patients, it may be necessary to do repeated movement testing, especially in hypomobile patients before applying overpressure in all directions. The lumbar quadrant test should also be included  (see video below).<ref name=":1" />


''Provoking the Lumbar Spine to Clear it.''
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|TOQ9TFwMIc4|250}}<ref>The Student Physical Therapist. Gower's Sign. Available from: https://www.youtube.com/watch?v=TOQ9TFwMIc4 [last accessed 20/5/2021]</ref> </div>
  <div class="col-md-6"> {{#ev:youtube|BgDokpTKME8|250}}<ref>The Student Physical Therapist. Lumbar Quadrant Test. Available from: https://www.youtube.com/watch?v=BgDokpTKME8 [last accessed 20/5/2021]</ref> </div>
</div>


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.      
=== Passive Accessory Vertebral Testing ===
To clear the lumbar spine, test passive accessory vertebral motion both centrally and unilaterally. The depth and intensity of testing will depend on the patient’s irritability. The right and left sides should feel the same for both the clinician and patient.<ref name=":1" />


''Looking at Sensitive Nerves''   
{{#ev:youtube|jhqPp9JGq9s}}<ref>Functional Pain Management Society. Lumbar accessory mobility testing by an expert. Available from: https://www.youtube.com/watch?v=jhqPp9JGq9s [last accessed 06/7/2021]</ref>


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.              
=== Dry Needling ===
In some instances, dry needling can be used to assess the lumbar spine. If you are licensed to do so, it is possible to insert a needle into the paravertebral muscles to the lamina and assess for a lumbar pain response. If both sides are equal, and no pain response is elicited, this further clears the lumbar spine.<ref name=":1" />       


For more information on the comprehensive [[Lumbar Assessment|Lumbar Spine Assessment click here]]      
=== Neurodynamic Testing ===
Neurodynamic tests are used to test the sensitivity of the neural system. They are often used to assess patients who may have entrapment neuropathies. These tests elongate the nerve bed in order to increase strain on neural structures.<ref>Baselgia LT, Bennett DL, Silbiger RM, Schmid AB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5324720/ Negative neurodynamic tests do not exclude neural dysfunction in patients with entrapment neuropathies]. Arch Phys Med Rehabil. 2017;98(3):480-86.</ref> Neurodynamic tests of the lumbar spine include the straight leg raise and the slump test.               
 
When testing neurodynamics:<ref name=":1" />
 
* Assess the straight leg raise before the slump test
* Compare left and right sides
* Check for the patient’s concordant pain
* Differentiate between the musculoskeletal system and the neural system - e.g. if symptoms are produced with dorsiflexion during the straight leg raise, re-check for symptoms with dorsiflexion with the leg in a neutral position in supine  
 
{{#ev:youtube|R8Z1qI7N6Zw}}<ref>Clinical Physio. Lower Limb Tension Tests | Clinical Physio. Available from: https://www.youtube.com/watch?v=R8Z1qI7N6Zw [last accessed 20/5/2021]</ref>


== Conclusions ==
== 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.       
When attempting to clear the lumbar spine, particularly in patients where there is no obvious spinogenic pain, it is essential that therapists:       
 
* Obtain a thorough history
* Grade objective tests based on a patient’s irritability - testing must be sufficient to elicit a response
* Be consistent and repeat tests to ensure results are accurate
* Be able to interpret assessment findings in order to rule the lumbar spine in or out


== References  ==
== References  ==


<references />
<references />
[[Category:Course Pages]]
[[Category:Plus Content]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Lumbar Spine - Assessment and Examination]]

Latest revision as of 10:13, 11 January 2023

Original Editor - Pierre Roscher based on the course by Nick Rainey

Top Contributors - Pierre Roscher, Jess Bell, Kim Jackson, Tarina van der Stockt, Oyemi Sillo and Olajumoke Ogunleye  

Introduction[edit | edit source]

Low back pain is the leading cause of disability worldwide.[1] It can have a significant impact on quality of life[2] and is associated with high direct and indirect costs (e.g. absenteeism from work, lost productivity).[3] However, most patients who present with low back pain with or without radicular pain can be managed effectively in primary care settings.[4] 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.[5] 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 pathology in the lumbar spine or not. It is, therefore, essential that physiotherapists are able to undertake a comprehensive screening assessment and have the necessary clinical reasoning skills to either clear the lumbar spine or diagnose lumbar pathology.

Locating the Source of Pain[edit | edit source]

A number of structures have similar pain referral patterns as the lumbar spine, including the pelvic girdle and hip.[6] Moreover, hip and lumbar issues can co-exist, which can further complicate the clinical picture.[7] Certain visceral structures can also refer pain to the lumbar spine - i.e. spinal masqueraders[8] - so these too much be considered in a differential diagnosis.

There are also a number of red flags to check for when assessing spinal pain, including:[9]

  • Recent trauma and aged over 50 years[10]
  • History of cancer and a strong clinical suspicion[11]
  • 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.[12] For more information on this, please click here. 

Classifying Pain[edit | edit source]

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

These tools can be used early on in the assessment to help the therapist build a clinical picture of the patient, and to guide decision making with regards to treatment pathways for patients who are categorised as low, medium or high risk patients.[14] Even patients who are deemed at "high risk" of chronicity may benefit from non-pharmacological approaches such as exercise and spinal mobilisation etc.[4]

Another way of clearing the lumbar spine during an assessment is to consider which of the following categories best describe the patient’s symptoms:[15]

  1. Obviously spinogenic symptoms - the symptoms are obviously coming from the spine. Examples may include:
    1. Lumbar pain developed following a specific, defined incident
    2. 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 popping at the knee indicating an ACL tear
    2. No spinal history or complaints
  3. Not obvious spinogenic symptoms - the symptoms are not obviously, but have the potential to be, 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[edit | edit source]

*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.

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.[16] On the body chart, the therapist should identify:[15]

  • 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.[15]

Objective Assessment for Not Obvious Spinogenic Symptoms[edit | edit source]

*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 (e.g. neurological and neuro-dynamic tests)[17]

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 to elicit concordant symptoms in a patient who only develops pain after 20 minutes of running.[15]

Myotome Testing[edit | edit source]

Neurological testing, specifically myotome testing, can provide useful information about pathoanatomy in the lumbar spine, which can indicate prognosis. When testing myotomes, it is important to:[15]

  • Be consistent
  • Compare both sides
  • Repeat tests to clarify results
  • Ask the patient if she / he notices any strength deficits during testing

Consider:[15]

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

The following video demonstrates lower limb myotome testing.

[18]

Lumbar Range of Motion Testing[edit | edit source]

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

[19]

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.[15]

During flexion / extension, side bending testing, look for:[15]

  • 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. The lumbar quadrant test should also be included (see video below).[15]

[20]
[21]

Passive Accessory Vertebral Testing[edit | edit source]

To clear the lumbar spine, test passive accessory vertebral motion both centrally and unilaterally. The depth and intensity of testing will depend on the patient’s irritability. The right and left sides should feel the same for both the clinician and patient.[15]

[22]

Dry Needling[edit | edit source]

In some instances, dry needling can be used to assess the lumbar spine. If you are licensed to do so, it is possible to insert a needle into the paravertebral muscles to the lamina and assess for a lumbar pain response. If both sides are equal, and no pain response is elicited, this further clears the lumbar spine.[15]

Neurodynamic Testing[edit | edit source]

Neurodynamic tests are used to test the sensitivity of the neural system. They are often used to assess patients who may have entrapment neuropathies. These tests elongate the nerve bed in order to increase strain on neural structures.[23] Neurodynamic tests of the lumbar spine include the straight leg raise and the slump test.

When testing neurodynamics:[15]

  • Assess the straight leg raise before the slump test
  • Compare left and right sides
  • Check for the patient’s concordant pain
  • Differentiate between the musculoskeletal system and the neural system - e.g. if symptoms are produced with dorsiflexion during the straight leg raise, re-check for symptoms with dorsiflexion with the leg in a neutral position in supine  

[24]

Conclusions[edit | edit source]

When attempting to clear the lumbar spine, particularly in patients where there is no obvious spinogenic pain, it is essential that therapists:

  • Obtain a thorough history
  • Grade objective tests based on a patient’s irritability - testing must be sufficient to elicit a response
  • Be consistent and repeat tests to ensure results are accurate
  • Be able to interpret assessment findings in order to rule the lumbar spine in or out

References[edit | edit source]

  1. ↑ Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367.
  2. ↑ Chen S, Chen M, Wu X, Lin S, Tao C, Cao H, et al. Global, regional and national burden of low back pain 1990-2019: A systematic analysis of the Global Burden of Disease study 2019. J Orthop Translat. 2021 Sep 10;32:49-58.
  3. ↑ Nieminen LK, Pyysalo LM, Kankaanpää MJ. Prognostic factors for pain chronicity in low back pain: a systematic review. Pain Rep. 2021 Apr 1;6(1):e919.
  4. ↑ 4.0 4.1 Diagnosis and management of low-back pain in primary care. Adrian Traeger, Rachelle Buchbinder, Ian Harris, Chris Maher. CMAJ Nov 2017, 189 (45) E1386-E1395; DOI: 10.1503/cmaj.170527
  5. ↑ Parr, A., & Askin, G. (2020, December). Non-radicular low back pain: Assessment and evidence-based treatment. Australian Journal of General Practice. Royal Australian College of General Practitioners. https://search.informit.org/doi/10.3316/informit.553846456305189
  6. ↑ Riley SP, Swanson BT, Cleland JA. The why, where, and how clinical reasoning model for the evaluation and treatment of patients with low back pain. Braz J Phys Ther. 2021 Jul-Aug;25(4):407-414.
  7. ↑ Prather H, Cheng A, Steger-May K, Maheshwari V, Van Dillen L. Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain. J Orthop Sports Phys Ther. 2017;47(3):163-72.  
  8. ↑ Walcott B, Coumans J, Kahle K. Diagnostic pitfalls in spine surgery: masqueraders of surgical spine disease. Neurosurgical Focus. 2011;31(4).
  9. ↑ Finucane L. An Introduction to Red Flags in Serious Pathology Course. Plus. 2020.
  10. ↑ Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red Flags for Low Back Pain Are Not Always Really Red. J Bone Jt Surg. 2018;100(5):368–74.
  11. ↑ Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-8.
  12. ↑ Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.
  13. ↑ Pain Behaviours. (2020, May 20). Physiopedia, . Retrieved 23:30, April 21, 2021 from https://www.physio-pedia.com/index.php?title=Pain_Behaviours&oldid=238652.
  14. ↑ STarT Back Screening Tool. (2020, November 27). Physiopedia, . Retrieved 23:38, April 21, 2021 from https://www.physio-pedia.com/index.php?title=STarT_Back_Screening_Tool&oldid=260588.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 Rainey N. An Introduction to Clearing the Lumbar Spine Course. Plus. 2021.
  16. ↑ Southerst D, Côté P, Stupar M, Stern P, Mior S. The reliability of body pain diagrams in the quantitative measurement of pain distribution and location in patients with musculoskeletal pain: a systematic review. J Manipulative Physiol Ther. 2013;36(7):450-9.
  17. ↑ Albazli K, Alotaibi M, Almoallim H. Low-Back Pain. InSkills in Rheumatology (pp. 127-138). Springer, Singapore.
  18. ↑ Functional Pain Management Society. Myotome testing by an expert. Available from: https://www.youtube.com/watch?v=UodWTD_IRb8 [last accessed 06/7/2021]
  19. ↑ Functional Pain Management Society. Lumbar range of motion examination by an expert. Available from: https://www.youtube.com/watch?v=6ZV7y-L8QwY [last accessed 06/7/2021]
  20. ↑ The Student Physical Therapist. Gower's Sign. Available from: https://www.youtube.com/watch?v=TOQ9TFwMIc4 [last accessed 20/5/2021]
  21. ↑ The Student Physical Therapist. Lumbar Quadrant Test. Available from: https://www.youtube.com/watch?v=BgDokpTKME8 [last accessed 20/5/2021]
  22. ↑ Functional Pain Management Society. Lumbar accessory mobility testing by an expert. Available from: https://www.youtube.com/watch?v=jhqPp9JGq9s [last accessed 06/7/2021]
  23. ↑ Baselgia LT, Bennett DL, Silbiger RM, Schmid AB. Negative neurodynamic tests do not exclude neural dysfunction in patients with entrapment neuropathies. Arch Phys Med Rehabil. 2017;98(3):480-86.
  24. ↑ Clinical Physio. Lower Limb Tension Tests | Clinical Physio. Available from: https://www.youtube.com/watch?v=R8Z1qI7N6Zw [last accessed 20/5/2021]
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