An Introduction to Clearing the Lumbar Spine

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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