Lumbar Examination

Original Editors - Ben Vandoorne

Top Contributors - Rachael Lowe, Laura Ritchie, Vandoorne Ben, Naomi O'Reilly and Kai A. Sigel

Introduction

Interactive Spine - Lumbar Vertebral Spine - L7F19.jpg

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 specific 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.

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 catastrophization) 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.

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

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.

Patient Intake

  • Self‐report (present complaint (PC), history of present complaint (HPC), past medical history (PMH), drug history (DH), social history (SH))
  • Region‐specific questions
    • What is the patient’s age?
    • What is the patient’s occupation?
    • What was the mechanism of injury?
    • How long has the problem bothered the patient?
    • Where are the sites and boundaries of pain?
    • Is there any radiation of pain? Is the pain centralizing or peripheralizing
    • Is the pain deep? Superficial? Shooting? Burning? Aching?
    • Is the pain improving? Worsening? Staying the same?
    • Is there any increase in pain with coughing? Sneezing? Deep breathing? Laughing?
    • Are there any postures or actions that specifically increase or decrease the pain or cause difficulty?Is the pain worse in the morning or evening? Does the pain get better or worse as the day progresses? Does the pain wake you up at night?Which movements hurt? Which movements are stiff?
    • Is paresthesia (a “pins and needles” feeling) or anesthesia present?
    • Has the patient noticed any weakness or decrease in strength? Has the patient noticed that his/her legs have become weak while walking or climbing stairs?
    • What is the patient’s usual activity or pastime? Before the injury, did the patient modify or perform any unusual repetitive or high-stress activity?
    • Which activities aggravate the pain? Is there anything in the patient’s lifestyle that increases the pain?
    • Which activities ease the pain?
    • What is the patient’s sleeping position? Does the patient have any problems sleeping? 
    • Does the patient have any difficulty with micturition?
    • Are there any red flags that the examiner should be aware of, such as a history of cancer, sudden weight loss for no apparent reason, immunosuppressive disorder, infection, fever, or bilateral leg weakness?
    • Is the patient receiving any medication?
    • Is the patient able to cope during daily activities?

Special Questions

Red Flags

Although uncommon serious spinal conditions (such as those listed below) may present as LBP in approximately 5% of patients presenting to primary care office:[8][8].

[9]

During the investigation, you must pay attention to any ‘red flags’ that might be present indicating serious pathology. Koes et al (2006)[10] 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 as these may interfere with physiotherapy interventions.

Read more about the Flag System

Outcome Measures

Investigations

Has the patient had any other investigations such as radiology (Xray, MRI, CT, ultrasound) or blood tests?

Objective

The purpose of the objective examination (clinical testing) is to confirm or refute hypothesis formed from the subjective examination.

When assessing the lumbar spine, the examiner must remember that referral of symptoms or the presence of neurological symptoms often makes it necessary to “clear” or rule out lower limb pathology. Many of the symptoms that occur in the lower limb may originate in the lumbar spine. Unless there is a history of definitive trauma to a peripheral joint, a screening or scanning examination must accompany assessment of that joint to rule out problems within the lumbar spine referring symptoms to that joint.

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

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.

Posture

  • Scoliosis (static, sciatic, idiopathic)
  • Lordosis (excessive, flattened)
  • Kyphosis (thoracic)
Scoliosis
Increased Lordosis

Kyphosis
[11]

Other observations

  • body type
  • attitude
  • facial expression
  • skin
  • hair
  • leg length discrepancy (functional, structural)

Functional Tests

  1. Functional Demonstration of pain provoking movements
  2. Squat test - to highlight lower limb pathologies.  Not be done with patients suspected of having arthritis or pathology in the lower limb joints, pregnant patients, or older patients who exhibit weakness and hypomobility. If this test is negative, there is no need to test the peripheral joints (peripheral joint scan) with the patient in the lying position[12].

Movement Testing

  • AROM (flexion 40-60, extension 20-35, side flexion 15-20 - looking for willingness to move, quality of movement, where movement occurs, range, pain, painful arc, deviation)
  • Overpressure (at the end of all AROM if they are pain-free, normal end-feel should be tissue stretch)
  • Sustained positions (if indicated in subjective)
  • Combined movements (if indicated in subjective)
  • Repeated movements (if indicated in subjective)
  • Muscle Strength (resisted isometrics in flex, ext, side flex, rotation; core stabilty, functional strength tests)

Neurologic Assessment

Neurologic assessment is indicated where there is suspicion of neurologic deficit.

[13]
  • Myotomes
[14]
    • L2: Hip flexion
    • L3: Knee extension
    • L4: Ankle dorsiflexion
    • L5: Great toe extension
    • S1: Ankle plantar flexion, ankle eversion, hip extension
    • S2: Knee flexion
  • Dermatomes
[15]
  • Reflexes
[16]
    • Patellar (L3–L4) (commonly used in clinical practice)
    • Medial hamstring (L5–S1) (rarely used in clinical practice)
    • Lateral hamstring (S1–S2) (rarely used in clinical practice)
    • Posterior tibial (L4–L5)(rarely used in clinical practice)
    • Achilles (S1–S2) (commonly used in clinical practice)

Circulatory Assessment

If indicated it may be necessary to perform a haemodynamic assessment.

Palpation

[17]

It is crucial for a reliable diagnosis and intervention of treatment to adequately palpate the lumbar spinous processes.

Within the scientific world, there has been a debate about the palpation of the spinous processes because scientists assumed that often different persons indicated the processes in a different place (Mckenzie et al)[18]. However, Snider et al (2011)[19] have 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 processes.

Furthermore, this investigation has proven that it is more useful to indicate different points instead of just 1 point. Also it has been proven that a manual examination to detect the lumbar segmental level is highly accurate when accompanied by a verbal subject response (Philips 1996).[20]
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)[21]. Anatomical abnormalities might also cause problems. The abnormality of the 12th rib leads, for example, to a negative palpatory accuracy in the region L1-L4 for all therapists. [22]

Passive Intervertebral Motion / PPIVMs

[23]
[24]
[25]
[26]
[27]
  • Muscle Tone

Clear Adjacent Joints

[28]
  • Thoracic spine - seated rotation with combined movements and overpressure
  • Sacroiliac joints - various tests have been described to clear the SIJ such as Gillet test, sacral clearing test, cluster tests
  • Hips - PROM with overpressure
  • Knees and ankles - should also be cleared for restrictions that may affect movement patterns

Special Tests

For neurological dysfunction:

For lumbar instability:

[29]
  • H and I test
  • Passive lumbar extension test
  • Prone segmental instability test
  • Specific lumbar torsion test
  • Test for anterior lumbar spine instability
  • Test for posterior lumbar spine instability

For joint dysfunction:

  • Bilateral straight leg raise test
  • One-leg standing (stork standing) lumbar extension test
  • Quadrant test

For muscle tightness:

Other tests:

Brief Examination

If you have little time a brief examination of patients with back pain has two basic purposes.

  1. Firstly it will help screen patients for possible serious spinal pathology even though taking a good history is much more important.
  2. Secondly it will improve patient satisfaction and effectiveness of the consultation.

It is suggested that the following be performed as a bare minimum:

  1. Inspect – general appearance, gross structural deformities
  2. Active movements – flexion (significant limitation often pathological), extension, side flexion
  3. Myotomes– rise from a knee squat (L3/4), walk on heels (L4/5) and walk on toes (S1/2).
  4. SLR (if leg pain or if you feel is needed for reassurance) +/- slump test

Obviously, if the history raises concerns that there may be non-spinal pain, structural deformity, widespread neurological disorder or serious spinal pathology it is appropriate to examine the patient more fully as per normal clinical practice.

What Next?

Lumbopelvic disorders are not a homogeneous group of conditions, and subgrouping or classification of patients with back pain has been shown to enhance treatment outcomes[30][31]. Classification of lumbopelvic disorders should adequately define the primary signs and symptoms and guide therapeutic interventions. The examination allows us to arrive at a diagnosis and impairment classification for the condition. These classification systems help us to avoid the pitfalls of attempts to identify the pathoanatomic cause of the patient’s symptoms.

References

  1. 1.0 1.1 1.2 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
  2. 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.
  3. 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
  4. O'Sullivan, P. and Lin, I. Acute low back pain Beyond drug therapies. Pain Management Today, 2014, 1(1):8-14
  5. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430–34.
  6. 6.0 6.1 M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118
  7. 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.
  8. 8.0 8.1 Deyo, R. et al. What Can the History and Physical Examination Tell Us About Low Back Pain? JAMA. 1992. 268(6):760-766.
  9. Physiotutors. Low Back Pain Guideline: Screening & History-Taking (Part 2). Available from: https://www.youtube.com/watch?v=QVBxB59Y4Y4
  10. Koes B.W. van Tulder M. W., Thomas S.; diagnosis and treatment of low back pain; BMJ volume 332, 17 June 2006; 1430-1434
  11. Physiotutors. Observation and Posture Analysis. Available from: https://www.youtube.com/watch?v=Zp5iC3Ioq7U
  12. Magee, D. Lumbar Spine. Chapter 9 In: Orthopedic Physical Assessment. Elsevier, 2014
  13. Scott Bainbridge. Lumbar Spine Examination. Available from: http://www.youtube.com/watch?v=IijlOJPHk1s[last accessed 19/08/15]
  14. Physiotutors. Myotomes Lower Limb | Peripheral Neurological Examination. Available from: https://www.youtube.com/watch?v=ptO9ZvsUPDg
  15. Physiotutors. Dermatomes Lower Limb | Peripheral Neurological Examination. Available from: https://www.youtube.com/watch?v=SzAyUsA25MQ
  16. Physiotutors. Lower Limb Deep Tendon Reflexes | Peripheral Neurological Examination. Available from: https://www.youtube.com/watch?v=kFkRa17hlVc
  17. tsudpt11's channel. Maitland Lumbar PAIVM (skeletal model). Available from: http://www.youtube.com/watch?v=t0OCzavA6SY[last accessed 19/08/15]
  18. McKenzie AM, Taylor NF. Can physiotherapists locate lumbar spinal levels by palpation? Physiotherapy 1997;83: 235-9.
  19. Karen T. Snider, Eric J. Snider, Brian F. Degenhardt, Jane C. Johnson and James W. Kribs; palpatory accuracy of lumbar spinous processes using multiple bony landmarks. Journal of Manipulative and Physiological Therapeutics; 2011
  20. Phillips D. R.; Twomey L. T.; A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure; manual therapy, March 1996, pages 82-87
  21. 3. Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am J Emerg Med 2007;25:291-6.
  22. Karen T. Snider, Eric J. Snider, Brian F. Degenhardt, Jane C. Johnson and James W. Kribs; palpatory accuracy of lumbar spinous processes using multiple bony landmarks. Journal of Manipulative and Physiological Therapeutics; 2011
  23. Physiotutors. Passive Intervertebral Assessment Lumbar Spine Flexion in Sitting | PIVMs. Available from: https://www.youtube.com/watch?v=BpzQQLPv07g
  24. Physiotutors. Passive Intervertebral Assessment Lumbar Spine Flexion in Sidelying | PIVMs| PIVMs. Available from: https://www.youtube.com/watch?v=Z0_77OiM0ek
  25. Physiotutors. Passive Intervertebral Assessment Lumbar Spine Extension in Sitting | PIVMs. Available from: https://www.youtube.com/watch?v=L_kOnCUHGvo
  26. Physiotutors. Passive Intervertebral Assessment Lumbar Spine Extension in Prone | PIVMs. Available from: https://www.youtube.com/watch?v=usHEQFvi8io
  27. Physiotutors. Lumbar Spine Extension-Rotation Intervertebral Joint Play | 2D Gap Assessment. Available from: https://www.youtube.com/watch?v=oeoRP3ZiXQw
  28. Physical Therapy Nation. Lumbar and SIJ Examination. Available from: http://www.youtube.com/watch?v=EL5tXj81Q8M[last accessed 19/08/15]
  29. Ed Schrank. Lumbar Stability Tests. Available from: http://www.youtube.com/watch?v=jDoZ4d09M9Q[last accessed 19/08/15]
  30. Brennan GP, Fritz JM, Hunter SJ, et al. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial, Spine 31(6):623–631, 2006.
  31. Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to identify patients with low back pain most likely to respond to spinal manipulation: a validation study, Ann Intern Med 141(12):922–928, 2004.