Name

LUMBAR SPINE PHYSICAL EXAM

Date DOAI. WTAL SIGNS

Brachial B.P: Lt / Rt )_ Pulse_ RespirationsHeight Weight Temperature Age

2. POSTURAL ALIGNMENTtr Forward head (loss of lordosis) tr Head tilt R/L tr Knee (s) valgustr Gothicshoulders/rounded

Shoulders tr Elevated scapula (s) El Pes Cavustr Thoracicflattening/scapular

winging tr ted thoracic kyposis tr I't ray valgus (bunion) R/Ltr Thoracic-lumbar

hypertrophy/striations tr Pelvic unleveling tr Knee (s) varustr Lumbarhyperextension/

Striations tr Loss of lumbar lordosis tr Pes planustr Glutealhypotrophy/hupertrophy

tr Knees hyperextension tr Rearfoot valgus/varus3. ROM (active. active assisted and/or passive) (visual. inclinometer, other:

Lumbar Range of Motion(deerees) Location of complnt

Pain(0-4 Grade)

McKenzie Tests t pain = *1; J pain: -1Peripheralize= +2; No Change:0: Centrtlize: -2

Quality

Flexion / 6s 0 t 2 3 4 FIS: I Rep: +2+1, 0, - l -2: lOreps: +2+1. 0. - l -2 sham/dul l /pul lExtension t 3 0 0 r 234 EIS: I Rep: +2+1,0 , -1 -2 ; l0 reps : +2+1. 0 . - l -2 sharp/dull/pullL Lat Flex 1 2 5 0 t 2 3 4 Side Gliding: *2,*1,0,-1,-2; Limited Y / N: Blocked Y /N sham/dul l /oul lR Lat Flex / 2 5 0 1 2 3 4 Side Gliding: +2,+1,0,-1,-2; Limited Y / N: Blocked Y / N sharp/du l l /pu l l

4. OR'I'HOPEDIC E) LAM Gain Scale 0-4; Centralize -l: ralize: +1); OBJECTIVE: DD Mechanical,BP from Nerve RootLumbar L R Findines Test L R Findines

Facet: Nerve Tension: - / + T J .Kemp 0 t 2 3 4 0 r 2 3 4 Chin to chest= LBP 0 r 2 3 4 0 1 2 3 4Double SLR 0 t 2 3 4 0 r 2 3 4 Supine SLR (A P) 0 r 2 3 4 0 t 2 3 4 t (70\

Sacroiliac: Foot DF + SLR 0 1 2 3 4 0 t 2 3 4Yeoman 0 1 2 3 4 0 r 2 3 4 Hip IR + SLR 0 1 2 3 4 0 t 2 3 4Hibb 0 1 2 3 4 0 1 2 3 4 Well-lee Raise 0 r 2 3 4 0 r 2 3 4

Sittine SLR 0 1 2 3 4 0 t 2 3 4Waddell Non-organic LBP signs: Score | 5 D 3. Distraction: * "flip sign"

tr 4. 'Regional Neurologytr L Superficial Pain n 5. Exaggerationtr 2. Simulation Test: E Axial Cmpr; tr Trunk rotation

5. NEUROLOGICAL EXAMINATION: Red F-lugz Rule out Nerve Root lesionLevel Motor test: [cord level, nerve] Motor xl5 + I Reflex [cord level] DTR fWexler) Sensation Exam (1.Pin; 2.2-

pt 3.Vib;4.Semmes-W

L R L R L RTr2-L3 Iliopsoas -Hip Flexion lTl2-L3l /5t l5 Cremasteric (Ll,2l P I A P I A Tl2-L3 derm.L2.L4 Quadriceps - Knee Ext. [L3,4 femoral n.]

Hip adductors fL24 obturator n.l /5: tsPatellar [L2,13,L4]

t4: t4La-LAdermatome

L4 Tibialis Anterior [L4, deep peroneal n.l t1, t5 Patellar 1L2,13,L41 l4z l4 L4 dermatomeL5 Ext Hall Long [L5, deep peroneal n.]

Ext Dig Long/Brev [L5, deep peroneal n.]Gluteus Medius [L5, supr.slutn. l

-Js; -tsHamstring / (semitendinosis)lL4 . Ls , S l ,2 l

_14:' 14L5 dermatome

S1 Peroneus Lng/Brev [L5,S1 sup.peroneal n]Gastrocnemius-soleus ISl, inf. glut. n. i / 5 : t5

Achit les [S1]t4| l4

S1 dermatome

Vestibular: I wnl Cerebellum: [J wnl I D.Columnsr Ll wnl I Cerebrum: w n l : S O M A Labrinth: E vrnlPathological I Babinski (Corticospinal tract) / UMN I Clonus (L / R elb /-

| | knee)Spas t i c / f l acc id Para lys i s L /R UE/LE

Grlp / Plnc h StreDgth I Rlghr hrod: (Prtu induc.d Y/N) I Lef t h.rd: (Prtn lnduced Y/N)Dor nrrt L/R (Clrcle) | lst k/lbs: 2nd ks/br: 3rd kr/lbs I lst tslhs: 2nd kcrba: 3d kdbs

Circumference Upp Ext.: Brach / in. / cm ( " aboveelbow)

AnteBr . / in . /cm( "be lowe lbow)

Chest: Insp_ Exp_ ( ICS) Low Ext.: Thigh / iu. / cm (__" abovePatella)

Calf in. / cm below patella)

Revised l0/03

NAME DATE (Pe. 2 L-spine Exam)6. FUNCTIONAL TEST

Lower Quadrant Test Exam Findings

Single leg balance / Trendelenburg's sign Poor balance Weak glut. Medius

Repetitive Squat El Heel raises (tight gastroc / soleus) tr f V lordosisRepetitive Lunges E Lossof lumbar lordos is E L.ossofBalance t r T ightR/Lpsoas t r T ightRi Lquad t r T ightR/LTFLThomas Test Psoas tightness / hip ext / 10" Quad tightness / knee flex _ / 90' TFL tighfnessHamstring Flexibil ity / SLR / (90") tr LBP El Radicular SxLong sitting ) suPine revealed:Pelvic ti lt coordination Pass / Fail Lower abdominal weakness min / mod / maxCurl-up test Pass / Fail Upper abdominal weakness min / mod / maxHip extension Pattern Pass / Fail E Lumbar hyperextension / rotation tr Overuse of TFL tr V ed ROMSorrensen's Test Pass / Fail sec / 60 sec

Hip abduction pattern EI Overuse ofpsoas E Overuse oflTband tr Hip Hike (overuse of QL)

Hin Abduction L / R Adduction L / R Flexion L / R Extention L / R InternalRotation L/R Externa lRota t ion L /RNormal 50 30 135 30 40 60MM Glut nledius Adductor longus Iliopsoas Glut Max Adductor longus. brevis Glut nut obt. exlHip Test Exam Findine Test Exam FindinsFabere Inflammatory hip Ober's t TFL or tibial band contractureTrendelenberg Glut med weakness lcontralaterall Thomas t Hip flexor contractureHibb's SI vs. hip Psoas Contracture Tisht hip flexors

Knee F l e x L / R E x t L / R I R L / R I E R L / RNomral | 135 / 0 l 0 1 0MM lsemimemb/tend./biceps lQuad cannot be isolated cannot be isolatedKnee Test Exam Findins Test Exam FindineMcMurray Posterior meniscus tear Varus/Valzus stress latlmed collateral ligAolev Distraction Men scus vs Iieamentous lesion AnVpost draw sims Ant/oost cruciate lisAolev Compression Med al vs. lateral meniscus tear Bounce home MeniscusPatellar erindine Chondromalacia patlretropatellar OA Patella Battotement Edema

Ankle Dorsiflexion L / R Plan tar f lex ion L /R Inversion L / R Evers ion L /RNormal 20 50 35 l 5MM Tibialis anl EDL, EHL Gastroc. Soleus. Plantaris Tibialis post. FDL. FHL Peronius.lone. brev. tertiusAnkle Test Exam Findins Test Exam FindinsAnVoost Drawer Ant/post talofi bular li e Med/Lat stabilitv t Ant talofi bular/calcaneofi bular li ePronation / Pes Pl. (wl wlo metatarsalsia i loss) SupinationTinel's Ant. Tarsal Tunnel / Deeo Peroneal n. Tinel's Post. Tarsal Tunnel / Tibial n.Ass$smentt (Chcle:, Mechanical, Nerve root, Pathology); l-disc @ L_ rv/ o ndiation above / below lmee; Lsprain / strain / myofascitis /myositis; SIJ sprain L / R; Hip - synovitis, arthritis, bursitis,DD:Compliceting Factors: l Abnormal illness behavior; 2. Job dissatisfaction; 3. Past [Ix of>4 episodes; 4. Symptoms > I wk; 5. Severe painintensity; 6. New condition / injury related to pre-existing structural pathology or skeletal anomalyGoal Settitrg: Short-term Goals: Lotrg-trm Goals:

1- Decrcase paiE %in_days. L Furctional restoration.2. Ilcrease ROM %in_days. 2. Initiate Active / Home care.3. Deqease spasmin_days. 3, Rehabilitation / Stengthening.4. Retum to work iIl

_

days. 4. Education / "Back school"{ _Plan:

Other:

Theranv FrequencY RemarksChiro. manipulative therapy x/week x weeks: OtherIce/heat l5 minute rotations: on / off / on x 3 (= 1.25 br / sessiou)Interferential mm. stim. Acute: 80-100 cps / 10 min.; Chronic: 0-10 cps / 15 nfn.

I TractionD cerv. long axisI Lumb. long axisE Intersegnrental

Office: Pounds I _minutes

Home: Pounds / minutes

D Exercises! Flexion! Extensionn QFCE

_

(date)E Work hardening

Acute: Isometric w/in pain boundariesSubacute: Isotonic, passive ROM to boundary,

Initiate proprioception retrainingCluouic: Evaluate functional status (QFCE)

Initiate isokinetic. prosressive resistancef MRI / CT / Bone scanD X.R Lumbar. Thoracic. Cervical: Davis, 5-Series, 3-series, 2-seriesf- Lab Blood Test ; Uriue Test: UA, Cultwe,tr Restrict activities:

I WorkI ADL,s

Work: Regular dutyLight dutyTotal tenmorarv disability: days, weeks, month

Reeval for RTW davs. weeksProgress reeval 1 , 2 , 3 , a 6 , w e e k sReferral to:Disabilitv / impaimreut ratins