Lumbar Spine Assessment

Chapter 10, p. 319

Low Back Pain (LBP)

90% of all Americans Minor insultsmajor injuries Maintain normal lordotic and kyphotic curves

to avoid injury

Clinical Anatomy—p.319

5 vertebrae=lumbar spine P.320, fig. 10-2

– Facets– Processes– Foramen– “Scotty Dog”

Evaluation—p329

Primary role of ATC:– On-field evaluation:

Rule out (R/O) bony trauma which has, or may, damage to spinal cord

– Clinical evaluation: Evaluate specific cause of injury and devise a rehabilitation

plan

Historyp. 329

Location of pain:– Localized or radiating?

Onset of pain:– Acute, chronic, insidious?

Consistency of pain:– Constant/intermittent?– Improves/Worsens with

activity? Mechanism:

– Flex, ext, rotation, lat. Flex– Direct blow/trauma

Historyp. 330

PMH of injuries/surgery? Smoker? Bowel/bladder symptoms?

– Incontinence or frequency

– Immediate referral Referral history

– Time in the medical system?

– # of physicians seen?

Inspection/Observationp. 333

Sagittal curvature Scoliosis Frontal curvature Normal curves Standing posture Shoulders Head Walking posture (gait)

Observation/ Inspection

Paravertebral muscles Symmetry / spasm PSIS level Overall attitude

Palpation—p. 335

Transverse processes Spinous processes PSIS Paravertebral

musculature– Symmetry– spasm

Functional testing—p.337

Gross ROM assessment only

Trunk Extension = 45º– Lordosis should increase

Trunk Flexion = 9045º– Lordosis should decrease

Rotation Lateral flexion Symmetry > Goniometry

Pathologies/Injuriesp. 353

Muscle strains—p.353 Facet joint syndrome-

p.353 Disk lesion—p. 354 Spondylopathies—p.292

Muscle Strains—p.284

Pain localized to paraspinal musculature & PSIS

Spasm probable Limited flex. & ext. (pain) No radiating pain May not correlate to

specific mechanism

Facet Joint Syndrome-p.353

Table 10-10,p.354 ~40% of all LBP Vague symptoms that mimic

other pathologies Common with repeated spine-

loading activities Localized pain \ Often improves with activity Nerve entrapment may result

from compensatory posturing

Worsened by:– Repeated spine-loading

activities (ext, side bending, rotation)

– Poor LE flexibility– Poor Trunk strength

Disk lesion—p.354, Table 10-11 (355)

Crack in annulus fibrosus herniation of nucleus pulposus

Pressure on nerve rootpain/burning sensation

“Bulge” pathology Radiating pain into

buttocks and down leg MRI for best diagnosis

Altered standing posture Symptoms with activity Bilateral or unilateral

symptoms Usually acute onset

Spondylopathies—p.357, Table 10-13 (359)

Vertebral defect May occur at any

age/sports Congenital? Stress fx? Common is sports with

forced hyperextension Generally occurs at L4-

L5 or L5-S1 levels

Spondylolysis—p. 358 (Fig. 10-26)

Defect at pars interarticularis Unilateral or bilateral Signs/ Symptoms:

– NL spinal alignment– LBP during & after activity– Localized lumbar spine pain– NL flex; restricted ext.– (-) neuro. Test

X-rays show “collared” Scotty Dog

Spondylolysthesis—p.358 (fig.10-28)

May occur with spondylolysis

Anterior displacement of proximal vertebrae on distal

Pain more intense/constant than spondylolysis

Neuro signs sometimes (+) if displacement worsens

Possible step-off deformity X-rays show “decapitated”

Scotty Dog (+) Stork test

Straight leg raise test (SLR)—p.347, fig. Box 10-9

Supine with knees extended PROM hip flexion to point of

discomfort or end of range hip flexion and move into

passive dorsiflexion (+) = pain reproduced and

recurs with reduced SLR (-) =pain reproduced but does

not return with reduced SLR

If pain does not recur:– Tight hamstrings

Well-leg SLR testp.348, Box 10-10

Supine with knees extended

Passively raise one leg– Similar to SLR test– Raise leg with symptoms – Provocation test

(+)=Symptoms felt in the other leg (“well” leg)

Valsalva maneuverp. 344, Box 10-6

Increasing intrathecal pressure to reproduce symptoms

(+)=Reproduced symptoms :Radiating pain or

Numbness

Kernig’s Test—p. 346

Box 10-8 Provocation test to elongate

the spinal cord Active SLR until point of pain

(knee straight) Flex knee @ point of pain (+)= pain in LB or radiating

pain in LE Brudzinski’s Test=Kernig with

cervical flexion

Hoover testp.351, Box 10-13

Tests compliance & effort “Malingering” Procedure:

– Supine with knees extended– Active hip flexion– Pressure should be felt on

opposite leg as SLR is attempted

(+)=No pressure=low effort

Babinski testp. 383, Box 11-3

Tests presence of upper motor neuron pathology

Blunt device moved across plantar aspect of foot from calcaneus to 1st metatarsal head (great toe)

– (-)=toe flexion– (+)=great toe extension with

splaying of other toes Normally (+) in newborns

Hamstring flexibility

Tripod sign 90-90 position for testing Tight hamstrings

pelvic tiltStretched extensorsPain/spasm

Strength tests

Isometric strength tests Held for 60 sec. Flexor strength testing Extensor strength testing

Lifting Technique

Maintain natural curves– Sitting, standing, walking,

lifting 10:1 ratio Use large LE muscles Keep items close to body Hip = axis (not LS) Avoid rotating spine Get help when needed