Lumbar Assessment

Original Editors - Ben Vandoorne

Top Contributors - Admin, Rachael Lowe, Kim Jackson, Laura Ritchie, Jess Bell, Vandoorne Ben, Carin Hunter, Naomi O'Reilly, Kai A. Sigel, Lucinda hampton, Evan Thomas, Simisola Ajeyalemi, Aminat Abolade, WikiSysop, Wanda van Niekerk, 127.0.0.1 and Rishika Babburu  

Notes on Assessment

Assessment of the lumbar spine should allow clinical reasoning to include appropriate data collection tests from those listed below.  

Examination procedures should be performed from standing-sitting-lying and pain provocation movements saved until last.

The subjective assessment (history taking) is by far the most important part of the assessment with the objective assessment (clinical testing) confirming or refuting hypothesis formed from the subjective.

Subjective

The subjective examination is one of most powerful tools a clinician can utilize in the examination and treatment of patients with LBP. The questions utilized during this process can improve the clinician’s confidence in identification of sinister pathology warranting outside referral, screening for yellow flags which may interfere with PT interventions, and assist in matching PT interventions with a patient’s symptoms.  History not only is the record of past and present suffering but also constitutes the basis of future treatment, prevention and prognosis.

Detailed page on subjective assessment of the lumbar spine

Patient Intake

• Self‐report (patient history, past medical history, drug history, social history)
• Performance‐based outcome measures
• Region‐specific questions

Special Questions

Red Flags

Although uncommon, non musculoskeletal conditions (such as those listed below) may present as LBP in approximately 5% of patients presenting to primary care offices (see table).

• Cauda equina syndrome
• Cancer
• Ankylosing spondylitis
• Lumbar stenosis
• Lumbar disc herniations
• Vertebral fracture
• Spinal infection
• Abdominal aortic aneurysm
  

 During the investigation you must pay attention to any ‘red flags’ that might be present indicating serious pathology.  Koes et al (2006) mentioned the following ‘red flags’:

• Onset age < 20 or > 55 years
• Non-mechanical pain (unrelated to time or activity)
• Thoracic pain
• Previous history of carcinoma, steroids, HIV
• Feeling unwell
• Weight loss
• Widespread neurological symptoms
• Structural spinal deformity

Read more about red flags in spinal conditions

Other Flags

It is also important to screen for other (yellow, orange, blue and black) flags.

Investigations

• Radiological Considerations
  

Objective

Observation

Movement Patterns

How does the patient enter the room? A posture deformity in flexion or a deformity with a lateral pelvic tilt, possibly a slight limp, may be seen.
How does the patient sit down and how comfortably/ uncomfortably does he or she sit?  How does the patient get up from the chair? A patient with low back pain may splint the spine in order to avoid painful movements.  What is the facial expression?

Posture

• Scoliosis (static, sciatic, idiopathis)
• Lordisis (excessive, flattened)
• Kyphosis (thoracic)

Other observations

• Skin
• Hair
• Sweating

Functional Tests

Functional Demonstration of pain provoking movements

Movement Testing

• AROM (flexion, extension, side flexion looking for range, pain, painful arc, deviation)
• Overpressure (at the end of all AROM to examine for pain and end feel)
• Combined movements (to explore all combinations of movement)
• Passive Intervertebral Motion 
• Muscle Strength

Neurologic Assessment

• Myotomes
• Dermatomes
• Reflexes
• Neurodynamic testing

Palpation

It is crucial for a reliable diagnosis and intervention of treatment to adequately palpate the lumbar processi.
Within the scientific world there has been a debate about the palpation of the processi spinosi because scientists assumed that often different persons indicated the processi on a different place (Mckenzie et al). However, Snider et al (2011) has shown that the indicated points of the different therapists lie that the distance between the indicated points of the different therapists is much smaller than it had always been claimed. Obviously there were differences because some therapists have more experience and others have more anatomical knowledge. Also the difference in personality between the therapists led to differences in locating the processi.
Furthermore, this investigation has proven that it is more useful to indicate different points instead of just 1 point. Also it’s proven that a manual examination to detecte the lumbar segmental level is highly accurate when accompanied by a verbal subject response (Philips 1996)
There are of course elements that hinder the palpation. For example, a BMI (body mass index) of 30kg/m2 considerably diminishes the accuracy (Ferre et al). Anatomical abnormalities might also cause problems. The abnormality of the 12th rib leads, for example, to a negative palpal accuracy in the region L1-L4 for all therapists .

Clear Adjacent Joints

• Thoracic spine - seated rotation with combined movements and overpressure
• Sacroilliac joints - sacral clearing test, cluster tests
• Hips - PROM with overpressure
  

Special Tests

• Active Sit-Up Test
• Alternate Gillet Test
• Crossed Straight Leg Raise Test
• Extensor Endurance Test
• FABER Test
• Fortin's Sign
• Gaenslen Test
• Gillet Test
• Gower's Sign
• Lumbar Quadrant Test
• POSH Test
• Posteroanterior Mobility
• Prone Knee Bend Test
• Prone Instability Test
• Resisted Abduction Test
• Sacral Clearing Test
• Seated Forward Flexion Test
• SIJ Compression/Distraction Test
• Slump Test
• Sphinx Test
• Spine Rotators & Multifidus Test
• Squish Test
• Standing Forward Flexion Test
• Straight Leg Raise Test
• Supine to Long Sit Test

Order of Assessment

Standing

Sitting

Supine

Prone