An Introduction to Clearing the Lumbar Spine

Getting in The Right AreaThis article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (22/04/2021)

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Introduction

The lumbar spine is one of the most common areas physiotherapists treat. Low back pain is the leading cause of injury and disability worldwide, and presents a huge economic burden to society. 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. 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.

Getting In The Right Area

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. 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.

Pain Sources When Looking At Clearing The Lumbar Spine

When looking at pain, there various ways to classify pain. You can look at pain behaviour for one, where pain can be classified as nociceptive, nociceptive inflammatory and neuropathic. Pain assessment is also valuable in understanding the clinical picture of the patient, and specific low back screening tools such as the STarT Back Tool 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. 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.

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.

i) The symptoms are obviously coming from the spine (Obvious Spinogenic Symptoms)

ii) The symptoms are obviously not coming from the spine (Obviously Not Spinogenic Symptoms)

iii) The symptoms are obviously not coming from the spine (Not Obvious Spinogenic Symptoms)

Obvious Spinogenic Symptoms

Some examples may include:

• 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:

• Clear mechanism of injury in a peripheral area
• No spinal history or complaints

Not Obvious Spinogenic

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.

From a subjective assessment point of view:

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

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. 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.

For more information on the comprehensive lumbar spine subjective assessment click here.

From an objective point of view:

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

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. 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.

Neurological Testing

Neurological testing, specifically 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.

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 radiculopathies will be lower lumbar instead of upper lumbar presentation.

Watch this video on myotome testing of the lower extremity.

Lumbar Range of Motion

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.

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.