Lumber Assesment

LUMBER ASSESMENT
AYESHA RAZZAQ
INTRODUCTION
• The first aim of the physiotherapy examination for a patient presenting with back pain is to
classify the patient according to the diagnostic triage recommended in international back
pain guidelines[1]. Serious (such as fracture, cancer, infection and ankylosing spondylitis) and
specific causes of back pain with neurological deficits (such as radiculopathy, caudal equina
syndrome)are rare[2] but it is important to screen for these conditions[1][3]. Serious conditions
account for 1-2% of people presenting with low back pain and 5-10% present with specifics
causes LBP with neurological deficits[4]. When serious and specific causes of low back
pain have been ruled out individuals are said to have non-specific (or simple or mechanical)
back pain.
KOES BW, VAN TULDER M, LIN C-WC, MACEDO LG, MCAULEY J, MAHER C. AN UPDATED OVERVIEW OF CLINICAL GUIDELINES FOR THE MANAGEMENT OF NON-SPECIFIC LOW BACK
PAIN IN PRIMARY CARE. EUR SPINE J 2010;19:2075–94
JUMP UP↑ HENSCHKE N, MAHER CG, REFSHAUGE KM, ET AL. PREVALENCE OF AND SCREENING FOR SERIOUS SPINAL PATHOLOGY IN PATIENTS PRESENTING TO PRIMARY CARE SETTINGS
WITH ACUTE LOW BACK PAIN. ARTHRITIS RHEUM 2009;60:3072–80.
↑ JUMP UP TO:3.0 3.1 VAN TULDER M, BECKER A, BEKKERING T, ET AL. CHAPTER 3. EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARE.
EUR SPINE J 2006;15(SUPPL 2):S169–91
JUMP UP↑ O'SULLIVAN, P. AND LIN, I. ACUTE LOW BACK PAIN BEYOND DRUG THERAPIES. PAIN MANAGEMENT TODAY, 2014, 1(1):8-14
• Non-specific low back pain accounts for over 90% of patients presenting to primary
care[5] and these are the majority of the individuals with low back pain that present to
physiotherapy. Physiotherapy assessment aims to identify impairments that may have
contributed to the onset of the pain, or increase the likelihood of developing persistent pain.
These include biological factors (eg. weakness, stiffness), psychological factors (eg.
depression, fear of movement and catastrophisation) and social factors (eg. work
environment)[6]. The assessment does not focus on identifying anatomical structures (eg. the
intervertebral disc) as the source of pain, as might be the case in peripheral joints such as the
knee[6]. Previous research and international guidelines suggest it is not possible or necessary
to identify the specific tissue source of pain for the effective management of mechanical back
pain[1][3][7].
• 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.
•
KOES BW, VAN TULDER MW, THOMAS S. DIAGNOSIS AND TREATMENT OF LOW BACK PAIN. BMJ
2006;332:1430–34.
↑ JUMP UP TO:6.0 6.1 M.HANCOCK. APPROACH TO LOW BACK PAIN. RACGP, 2014, 43(3):117-118
JUMP UP↑ HANCOCK MJ, MAHER CG, LATIMER J, ET AL. SYSTEMATIC REVIEW OF TESTS TO IDENTIFY THE DISC,
SIJ OR FACET JOINT AS THE SOURCE OF LOW BACK PAIN. EUR SPINE J 2007;16:1539–50
INTRODUCTION
• Low back pain (LBP) is a common, disabling condition with

both musculoskeletal and non musculoskeletal contributions.
It has been reported that greater than 80% of individuals will
experience LBP within their lifetime and 20-30% of
individuals are affected with these symptoms at any point in
time
2006;332:1430–34.
• back pain are common presentations in primary care.
• Many cases of back pain are due to benign functional or postural
causes but a thorough history and examination are essential to
assess the cause , any associated psychological difficulties (eg,
depression, anxiety or somatisation disorder) and any functional
impairment, including restrictions with work, leisure and domestic
activities.
2006;332:1430–34.
LOCALIZATION OF THE SYMPTOM
• Symptoms are grouped under the headings lumbago, backache and sciatica. These terms are
used as follows: •
• Lumbago: a sudden attack of severe low back pain, causing some degree of fixation and
twinges on attempted movement.
• • Backache: discomfort in the lower back.
• • Sciatica: pain that radiates strictly from the buttock to the posterior thigh and calf. It is
restricted to a specific dermatome (L4, L5, S1 or S2) and may be accompanied by
paraesthesia and motor and/or sensory deficit. In practice, however, the term is used
inaccurately if pain and paraesthesia are felt in the anterior part of the thigh and/or
lower leg (L2–L3).
2006;332:1430–34.
GENERAL EXAMINATION OF THE SPINE
• The examination should begin as soon as first see the patient and
continues with careful observation during the whole consultation.
• It is essential to observe the patient's gait and posture. Inconsistency
between observed function and performance during specific tests may
help to differentiate between physical and functional causes for the
patient's symptoms.
2006;332:1430–34.
INSPECTION
• Examination of any localised spinal disorder requires inspection of the
entire spine.
• Look for any obvious swellings or surgical scars.
• Assess for deformity: scoliosis, kyphosis, loss of lumbar lordosis or
hyperlordosis of the lumbar spine. Look for shoulder asymmetry and
pelvic tilt.
• Observe the patient walking to assess for any abnormalities of gait.
2006;332:1430–34.
• Observe for abnormal gait and posture, which may provide clues as to
the nature and severity of the problem.
• Superficial landmarks include:
• L4: iliac crests.
• S2: dimples at posterior superior iliac spines.
2006;332:1430–34.
• Assess curvature: kyphosis, scoliosis.
• Ask the patient to bend forwards: postural scoliosis resolves; a
structural scoliosis does not disappear and therefore needs further
assessment. A lumbar scoliosis may be associated with a prolapsed
intervertebral disc. Disappearance of a scoliosis when sitting suggests
that the scoliosis may be secondary to shortening of a leg. Idiopathic
scoliosis leads to short stature with the trunk short in proportion to the
limbs.
2006;332:1430–34.
• Assess curvature: kyphosis, scoliosis.
• Ask the patient to bend forwards: postural scoliosis resolves; a
structural scoliosis does not disappear and therefore needs further
assessment. A lumbar scoliosis may be associated with a prolapsed
intervertebral disc. Disappearance of a scoliosis when sitting suggests
that the scoliosis may be secondary to shortening of a leg. Idiopathic
scoliosis leads to short stature with the trunk short in proportion to the
limbs.
2006;332:1430–34.
• Lumbar curvature: flattening or reversal of the normal lumbar
lordosis as in a prolapsed intervertebral disc, osteoarthritis of the
spine and ankylosing spondylitis.
• An increase in the lumbar curvature may be normal or due to
spondylolisthesis, or secondary to an increased thoracic curvature or
a flexion deformity of the hip.
2006;332:1430–34.
• Look for any other abnormalities (eg, café-au-lait spots) which may
suggest neurofibromatosis, a fat pad or hairy patch suggestive of
spina bifida, or scarring suggestive of previous thoracotomy or spinal
surgery.
• Functional overlay:
• Ask the patient to sit up on the couch. A genuine patient will have to flex the
knees or they will fall back on the couch with pain.
• Axial loading: apply pressure to the head. Overlay is suggested if this
aggravates the back pain.
2006;332:1430–34.
PALPATION
• Check for bone tenderness of the spine: tenderness may indicate serious
pathology such as infection, fracture or malignancy.
• Ask the patient to lean forwards: tenderness between the spines of the
lumbar vertebrae and at the lumbosacral junction and over the lumbar
muscles may occur with prolapsed intervertebral disc and mechanical back
pain.
• Check for tenderness over the sacroiliac joints. This may also occur in cases
of mechanical back pain and with inflammation of the sacroiliac joints.
• A palpable step at the lumbosacral junction may indicate spondylolisthesis.
2006;332:1430–34.
PERCUSSION
• Ask the patient to bend forward. Lightly percuss the spine from the
root of the neck to the sacrum.
• Significant pain is a feature of infections, fractures and neoplasms.
• An exaggerated response may be a feature of a non-organic problem.
2006;332:1430–34.
MOVEMENTS
• Flexion:-
• Observe carefully, as hip flexion can account for apparent motion in a
rigid spine.
• Flexion may be recorded by the distance between the fingers and the
ground (most normal people can reach within 7 cm of the floor) or the
level that the person can reach (eg, mid-tibia).
• The overall flexion is due to a combination of thoracic, lumbar and hip
movements and does not distinguish between them.
2006;332:1430–34.
• Schober's test:When the spine flexes, the distance between each pair of
vertebral spines increases. Schober's test can be used to provide a
quantitative evaluation of flexion of the lumbar spine.
• A tape with a 15 cm mark is placed vertically in the midline upwards from the
level of the dimples at the level of the posterior superior iliac spines). Mark
the skin at 0 and at 15 cm and then ask the patient to flex as far forward as
they can.
• Record where the 15 cm mark on the skin strikes the tape. The increased
distance along the tape is due only to flexion of the lumbar spine and is
normally about 6-7 cm (less than 5 cm should be considered as abnormal).
• Flexion in the thoracic spine may be measured with the upper point 30 cm
from the previous zero mark. Thoracic flexion is normally only about 3 cm.
2006;332:1430–34.
• Extension:-
• Ask the patient to arch their back; pain and restricted extension are
particularly common in a prolapsed intervertebral disc and
spondylolysis.
• Maximum range is thoracic 25° and lumbar 35
2006;332:1430–34.
• Lateral flexion:Ask the patient to slide their hands down the side of
each leg in turn and record the point reached, either in centimetres
from the floor or the position that the fingers reach on the legs.
• The contributions of the thoracic and lumbar spine are usually equal.
2006;332:1430–34.
• Rotation:
• The patient should be seated and asked to twist round to each side.
• The normal range is 40° and is almost entirely thoracic; lumbar
contribution is 5° or less.
• Performing the test with the patient's arms folded across their chest
gives a more accurate assessment.
2006;332:1430–34.
SUSPECTED PROLAPSED
INTERVERTEBRAL DISC
• Femoral stretch test:With the patient prone and the anterior thigh
fixed to the couch, flex each knee in turn. This causes pain in the
appropriate distributions by stretching the femoral nerve roots in L2-
L4.
• The pain produced is normally aggravated by extension of the hip.
• The test is positive if pain is felt in the anterior compartment of the
thigh.
2006;332:1430–34.
NEUROLOGICAL INVOLMENT
• Test the patellar (L3, L4) and Achilles (L5, S1) reflexes.
• Root pressure from a disc may affect myotomes and dermatomes in a
selective fashion; record any muscle wasting (compare girths of calf
and thigh muscles
2006;332:1430–34.
• Myotomes:
• L2, L3: hip flexion and internal rotation.
• L4, L5: hip extension and external rotation.
• L3, L4: knee extension.
• L5, S1: knee flexion.
• L4, L5: ankle dorsiflexion.
• S1, S2: ankle plantar flexion.
• L4: ankle inversion.
• L5, S1: ankle eversion.
2006;332:1430–34.
• Dermatomes:
• L2: upper thigh.
• L3: knee.
• L4: medial aspect of the leg.
• L5: lateral aspect of the leg, medial side of the dorsum of the foot.
• S1: lateral aspect of the foot, the heel and most of the sole.
• S2: posterior aspect of the thigh.
• S3-S5: concentric rings around the anus, the outermost of which is
S3.
2006;332:1430–34.
SPECIAL TEST
ACTIVE SIT-UP TEST
Purpose: To assess the strength of the trunk and hip flexors.
Test Position: Hooklying.
Performing the Test: The examiner stabilizes the feet of the patient. The patient maintains arms straight
ahead and performs a sit up. The fingers of the patient are to touch (not hold on) both knees and maintain
that position for 5 seconds. A positive test is when the patient is unable to maintain that position for 5
seconds.
Diagnostic Accuracy: Unknown.
Importance of Test: The test is useful in determining the contribution of abdominal and hip flexor weakness
to the patient's symptoms. Decreased core strength is a common impairment in individuals with low back
pain.
2006;332:1430–34.
CROSSED STRAIGHT LEG RAISE TEST
• Purpose of Test: To test for the presence of a disc herniation.
Test Position: Supine.
Performing the Test: The examiner will passively flex the patient’s uninvolved hip while maintaining the knee in full extension. A positive test is
considered when the patient reports reproduction of pain in the involved limb at 40 degrees of hip flexion or less in the uninvolved limb. The
examiner should make note of the degree of hip flexion where the patient reported pain or reproduction of symptoms.
Diagnostic Accuracy: Sensitivity: .29, Specificity: .88 ("The test of Lasegue. Systematic review of the accuracy in diagnosing herniated discs").
Importance of Test: Disc herniations are a common problem in patients with low back pain. During this test the examiner is placing a traction force on
the uninvolved nerve root, which places tension on the involved nerve root as well, reproducing the pain the patient presented with. Normally, patients
can reach 70-90 degrees of hip flexion before a sensation of tightness occurs in the posterior thigh. If pain is felt significantly earlier, the patient
could potentially be suffering from a disc herniation. (Interesting fact: The SLR primarily puts a stretch on the L5-S1 nerve root segment due to the
nerve segments of the sciatic nerve). It should be noted that a painful, stretching, or other neurological symptom may be produced by this test as a
result of neural tension due to adhesions while traveling throughout the body. Compare the results of the test with the pain for which the patient
sought treatment. Also, utilize the angle at which symptoms were produced to help differentiate the source of the patient's pain.
KOES BW, VAN TULDER MW, THOMAS S. DIAGNOSIS AND TREATMENT OF LOW BACK PAIN. BMJ 2006;332:1430–34.
JUMP UP↑ HANCOCK MJ, MAHER CG, LATIMER J, ET AL. SYSTEMATIC REVIEW OF TESTS TO IDENTIFY THE DISC, SIJ OR FACET JOINT AS THE SOURCE OF LOW BACK PAIN.
EUR SPINE J 2007;16:1539–50
STRAIGHT LEG RAISING(SLR)
• Purpose: neural tension test

Procedure: Pt. lies supine with knee extended. Examiner lifts entire leg to flex
the hip until pt. c/o pain or tightness in back or posterior leg.
+ Result: 1) pain primarily in back, indicates anterior disc herniation or central
lesion 2) pain primarily in leg, indicates lateral lesion
•
2006;332:1430–34.
LINDNRE’S SIGN

Procedure: Pt. supine as examiner performs SLR, then drops leg back down
slightly until symptoms are relieved. Pt. then asked to flex the neck.
+ Result: 1) symptoms reproduced in lumbar region, leg or arm, indicating
stretching of dura mater of spinal cord or lesion of spinal cord 2) if pain does
not increase, lesion is within lumbosacral or sacroiliac joints
2006;332:1430–34.
BRAGARD’S TEST

Procedure: Pt. supine as examiner performs SLR, then drops leg back down
slightly until symptoms are relieved. Pt. then asked to DF ankle.
+ Result: increased pain, indicating stretching of dura mater of spinal cord or
lesion of spinal cord
2006;332:1430–34.
SLUMP TEST

Procedure: Pt. seated on edge of table with hands behind back. Test is
performed in progressive step: 1) pt. slumps forward into thoracic and lumbar
flexion 2) cervical spine and head are flexed 3) ankle is DF 4) knee is
extended
+ Result: 1) positioning increases symptoms 2) when pressure from cervical
spine flexion is released, knee is able to extend further or symptoms
decrease.
2006;332:1430–34.
WELL LEG RAISE
• Purpose: tests for space occupying lesion (often disc protrusion)

Procedure: Pt. lies supine with knee extended. Examiner lifts entire leg to flex
the hip until pt. c/o pain.
+ Result: pain occurs on CL side of lifted leg, indicating medial disc protrusion
2006;332:1430–34.
BOWSTRING TEST
• Purpose: neural tension test of sciatic nerve

Procedure: Pt. supine as examiner carries out SLR to pain. Examiner maintains
position while flexing the knee 20 degrees (reducing symptoms), then uses
thumb to apply pressure to popliteal area (increases radicular symptoms)
+ Result: radicular symptoms occur, indicating sciatic nerve involvement
2006;332:1430–34.
QUADRANT TEST
• Purpose: tests for facet joint dysfunction

Procedure: Pt. stands with examiner standing behind and supporting shoulders
while pt. extends spine. Overpressure is applied into extension while pt. side
flexes and rotates toward painful side. Movement is continued until limit of
range is reached or symptoms are produced.
+ Result: symptoms are produced, indicating facet joint dysfunction
2006;332:1430–34.
MCKENZIE SIDE GLIDE
• Purpose: tests for joint dysfunction

Procedure: Pt. stands with examiner standing to one side and grasping pt's
pelvis with both hands. Examiner places shoulder against pt's lower thorax
(using shoulder to block) and pulls pelvis toward herself. Position is held for 10
- 15 seconds. Repeat on opposite side
+ Result: increased neurological symptoms on affected side, indicates joint
dysfunction
2006;332:1430–34.
PRONE LUMBAR INSTABILITY TEST
• Purpose: tests for lumbar instability syndrome

Procedure: Pt. lies prone with hips on edge of table and feet on floor. Pt.
asked to lift legs together off of floor.
+ Result: hyperextension of spine causes pain in leg, indicating spinal
instability
2006;332:1430–34.

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LUMBER ASSESMENT

• Low back pain (LBP) is a common, disabling condition with

Test Position: Hooklying.

Diagnostic Accuracy: Unknown.

Test Position: Supine.

• Purpose: neural tension test

• Purpose: neural tension test

• Purpose: neural tension test

• Purpose: neural tension test

• Purpose: tests for space occupying lesion (often disc protrusion)

• Purpose: neural tension test of sciatic nerve

• Purpose: tests for facet joint dysfunction

• Purpose: tests for joint dysfunction

• Purpose: tests for lumbar instability syndrome

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