Lumbar Spine

Orthopaedic Assessments

The Lumbar Spine

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Agenda –

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Applied anatomy of the lumbar spine ● Introduction to the following joint play terms: – Loose Packed (Resting) Position – Closed Packed Position ● Review ● Kinematics Patient History Observation Examination ● Active movements ● Passive movements ● Resisted isometric (Active free, active resisted) movements Special Tests Joint Play

JOINT PLAY

Loose (Resting) vs. Close Packed Position ●

Joint Play – – –

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The small amount of ROM that can be obtained by the therapist (passively) The “play” cannot be elicited under voluntary control Joint dysfunction signifies a loss of joint play movement

For a joint to have full, pain-free voluntary movement, joint play movement is necessary.

Loose Packed (Resting) Position ●

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The position in which a respective joint is under the least amount of stress The ligaments of the joint are at their greatest laxity and passive separation of the joint surfaces are at their greatest

Close Packed Position ●

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The position in which a respective joint is under the greatest amount of stress (joint surfaces are tightly compressed) The ligaments of the joint are maximally tight; joint surfaces cannot be separated by distractive forces

Lumbar Spine ●

Resting Position –

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Close Packed Position –

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Midway b/w flexion & extension

Extension

Capsular Pattern – –

Side flexion & rotation equally limited Extension

Role of the lumbar spine: Supports the upper body ● Transmits weight of the upper body to the pelvis and lower limbs ● Should always be included when examining the spine, the hip and/or sacroiliac joints ●

Applied Anatomy ●

10 (five pairs) facet joints Superior facets face medially and backward ● Inferior facets face laterally and forward Shape and orientation of facets direct movement ●

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Rotation is minimal

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Forward flexion is greatest

Psoas major –ORIGIN •Transverse processes of L15, bodies of T12-L5 and intervertebral discs below bodies of T12-L4 –INSERTION •Middle surface of lesser trochanter of femur –ACTION •Flexes and medially rotates hip; acting bilaterally increases lumbar lordosis; unilaterally – assists in same side lateral flexion

Anatomy - Muscles

Anatomy - Muscles Iliacus –ORIGIN •Iliac fossa within abdomen –INSERTION •Lowermost surface of lesser trochanter of femur –ACTION •Flexes medially rotates hip; acting bilaterally with psoas – flexes the trunk on the femur

Anatomy - Muscles Rectus abdominus –ORIGIN •Pubic crest and symphysis –INSERTION •Costal cartilages of ribs 5-7; xiphoid process –ACTION •Flexes vertebral column

Anatomy - Muscles External obliques –ORIGIN External surfaces of ribs 512, interdigitating with serratus ant’r and lat dorsi –INSERTION •Linea alba, as inguinal ligament, and external lip of ant’r ½ of iliac crest –ACTION •Bilaterally flex vertebral column; unilaterally lateral flexion of column

Anatomy - Muscles Internal obliques –ORIGIN •Inguinal ligament, iliac crest and thoracolumbar fascia –INSERTION •Crest of pubis (with transversus), linea alba and inf’r borders of ribs 10-12 –ACTION •Flexes vertebral column

Anatomy - Muscles Transversus abdominus –ORIGIN •Inner surfaces of ribs 6-12, thoracolumbar fascia, ant’r ¾ of iliac crest and lat’l 1/3 of inguinal lig. –INSERTION •Linea alba, pubic crest and pectin pubis –ACTION •Visceral compression

Anatomy - Muscles Latissimus dorsi –ORIGIN •SP’s T6-12, ribs 8-12, thoracolumbar fascia, post’r 1/3 of iliac crest; a slip from inf’r angle of scapula –INSERTION •Intertubercular groove –ACTION •(with insertion fixed) ass’ts in tilting pelvis anterior/ laterally. Bilaterally, assist with spine hyperextion and anterior pelvic tilt

Anatomy - Muscles Quadratus lumborum –ORIGIN •Iliolumbar lig, iliac crest –INSERTION •Inf’r border of last rib and TP’s of L1-4 –ACTION •Assists in ext’n, lat’l flxn and depresses last rib.

Anatomy - Muscles Erector spinae (iliocostalis) –ORIGIN •Med’l & lat’l crest of sacrum, SP’s of lumbar and T11-12, iliac crest, lower 6 ribs –INSERTION •By tendons into 12 ribs & dorsum of TP of 7th Csp –ACTION •Inc. lordosis; assists with all spinal ext,n, lateral flxn

Anatomy - Muscles Erector spinae (longissimus) –ORIGIN •With iliocostalis lumborum, post’r surfaces of TP’s of lumbar vertebrae, thoracolumbar fascial –INSERTION •By tendons into TP’s of Tsp –ACTION •Increases lordosis; assists with all spinal extension

Anatomy - Muscles Transversospinalis (semispinalis) –ORIGIN •Thoracic TP’s –INSERTION •SP’s of upper 4 thoracic and cervical SP’s 2-7 –ACTION •Extends and laterally flexes spine

Anatomy - Muscles Transversospinalis (multifidi) –ORIGIN •Post’r sacral surface, medial surface of PSIS, TP’s of L5-C4 –INSERTION •Spanning two to four vertebrae, inserting into SP of vertebra above –ACTION •Spinal extension

Anatomy - Muscles Transversospinalis (rotatores) –ORIGIN •TP’s of vertebrae –INSERTION •Lamina of vertebra above –ACTION •Rotates spine

Kinematics ●

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Majority of lumbar movement occurs at L4-5 and L5-S1 ● Center of Gravity passes just anterior to the sacral promontory Therefore, these two segments are most likely to suffer breakdown and degeneration Unstable, excess of motion creating low back pain (ie. spondylolisthesis)

Activity and Percentage Increase in Disc Pressure (at L3) ●

Coughing or straining

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5 to 35%

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Laughing

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40 to 50%

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Walking

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15%

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Lateral flexion

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25%

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Small jump

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40%

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Forward flexion

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150%

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Rotation

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20%

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73%

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Lifting a 20kg wt with back straight and knees bent

Patient History also see handout

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From the intake form, make note of the client's: – – –

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Age Occupation Sex

LODRFICARA-WASPS –

(location, onset, duration, rad./ref., frequency, intensity, character, agg., rel., assoc. s&sx, work demands, activities, systems review, prev. inj., social life)

Observation When observing your client, look for the following four traits: (1) Body type ●

Ectomorphic, mesomorphic, endomorphic

(2) Gait ●

Normal or altered? If altered, is it in the limb or is it in compensation of a problem elsewhere

(3) Attitude ●

Tense? Bored? Lethargic? Appearance? Healthy looking?

(4) Total spinal posture (posture analysis)

Lordotic Spinal Posture Causes of Increased Lordosis 1) Postural deformity 2) Lax (weakened) muscles (especially abdominal) 3) Heavy abdomen 4) Compensatory from a another deformity (ie. Kyphosis) 5) Hip flexion contracture 6) Spondylolisthesis 7) Congenital problems (ie. Hips) 8) Failure of segmentation of the neural arch (ie.

Pathological Lordosis May observe: ● ●

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Sagging shoulders Medial rotation of the legs Anterior head carriage Increased pelvic angle (greater than 30°) Anterior pelvic tilt

All in an attempt to keep the center of gravity where it should be

Tight: Hip flexors, TFL, Erectors Weak: Abdominals

Swayback Deformity Will observe: ●

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*Excessive arching of lumbar spine while thoracic spine exhibits a kyphosis *Increased pelvic angle (greater than 30°)

The spine is sharply bending back at the lumbosacral angle Entire pelvis shifts anteriorly Hips move into extension Tight: Hip extensors, lower (because they have shot forward) lumbar extensors, upper abdominals Thoracic spine flexes on the lumbar spine to maintain center of Weak: Hip flexors, lower gravity abdominals, lower thoracic

extensors

Flatback ●

Decreased lordotic curvature Decreased pelvic inclination to approximately 20° Mobile lumbar spine ●

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Tight: hip musculature (except hip flexors) Weak: erector spinae, hip flexors

Scoliosis

Lateral curvature of the spine (1) Structural Scoliosis – – – – – –

Primarily involves bony deformity (congenital or acquired) May be progressive Wedge vertebra, hemivertebra, failure of segmentation, idiopathic (genetic) Loss of normal flexibility Lateral flexion is asymmetric Curve persists during forward flexing (“rib humping”)

Scoliosis

Lateral curvature of the spine (2) Non-Structural Scoliosis – – – – –

No bony deformity Not progressive Segmental limitation Lateral flexion usually symmetric Disappears on forward flexion

Lumbar Spine Examination & Assessment (1) ROM – Active, Passive, Resisted (2) Special Tests (3) Palpation ✗

Not covered in this class

Lumbar Spine – Active ROM ●

Forward flexion

(40 to 60°)

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Extension

(20 to 30°)

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Lateral flexion (L&R)

(15 to 20°)

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Rotation (L&R)

(3 to 18°)

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Performed standing

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Be on the lookout for limitation of movement

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May apply passive overpressure, but only if ROM is full and pain free – be careful!

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If repetitive motion or combined movements have been reported in the history as causing symptoms, these movements should be performed as well, but only after the patient has completed the basic movements With forward flexion, look to see that the movement is occurring in the lumbar spine and not in the hips or thoracic spine

Lumbar Spine – Passive ROM ●

Forward flexion

(tissue stretch)

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Extension

(tissue stretch)

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Lateral flexion (L&R)

(tissue stretch)

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Rotation (L&R)

(tissue stretch)

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Difficult to perform because of the weight of the body, therefore: ●

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DO NOT PERFORM WHILE CLIENT IS WEIGHTBEARING (STANDING)

Safer to check the end feel of the individual vertebrae during the assessment of joint play movements

Refer to joint play later in lecture

Lumbar Spine – Resisted Isometric ● ●

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Patient is seated Contraction must be resisted and isometric so that no movement occurs “Don't let me move you.” For female therapists, required to buffer your contact with the client through a pillow

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Forward flexion

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Extension

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Lateral flexion (left and right)

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Rotation (left and right)

Special Tests ●

Tests for Neurological Dysfunction Slump test – Straight leg raise test – Bragard's Test – Soto-Hall Test – Valsalva –

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Tests for Joint Dysfunction –

Pheasant test

General Rules to apply:

Always perform bilaterally when possible ● Always perform the unaffected side first ● Must have proper therapist positioning and hand placement; proper client positioning ● Client safety must be ensured ●

Special Tests – Neurological Dysfunction

SLUMP TEST (aka. Sitting Dural Stretch) ● ●

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Series of steps performed sequentially Only progress to the next step if no positive was elicited Perform test: ●

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Start with non-affected side, then repeat on affected side, then repeat with both sides simultaneously

POSITIVE FINDING: –

Reproduction of the symptoms

SLUMP TEST-(aka. Sitting Dural Stretch) 1) Client seated at the edge of table with their hands behind their back 2) Ask client to “slump” the back into flexion 3) Therapist supports client's chin in the neutral position (no head or neck flexion) 4) Therapist applies gentle overpressure across shoulders 5) Ask client to bring their “chin to chest” 6) Therapist again applies overpressure by placing hand over the head 7) With the other hand, therapist dorsiflexes client's foot maximally 8) Client is asked to actively straighten the knee as much as possible 9) If unable to extend knee, release overpressure to neck

SLUMP TEST - (aka. Sitting Dural Stretch)

Special Tests – Neurological Dysfunction STRAIGHT LEG RAISE 1) Client supine; client completely passive 2) Therapist medially rotates hip with some adduction; knee extended 3) Keeping the knee straight, therapist flexes the hip until the client complains of pain or tightness in the back or posterior leg ●

POSITIVE FINDING: –

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Pain; reproduction of symptoms

INDICATION OF: –

Dural, cord and/or nerve root impingement

Special Tests – Neurological Dysfunction STRAIGHT LEG RAISE Caution: -A positive SLR need not imply neurological dysfunction. -Must rule out: (1) Hamstring injury (2) Lumbar facet injury (3) Sacroiliac injury

Modification to SLR Test ●

If for any reason you cannot perform a SLR with the client supine, you can instead conduct the test in the side-lying position

(1) Client side lying with hip and knee flexed to 90° (2) Passively extend the knee

Special Tests – Neurological Dysfunction BRAGARD'S TEST ●

Same procedure as for SLR except the addition of the following: At the degree of hip flexion that elicits a positive finding, therapist gently lowers the leg until the symptoms disappear – Therapist then maximally dorsiflexes the foot –

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POSITIVE FINDING: –

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Pain; reproduction of symptoms

INDICATION OF: –

Dural, cord and/or nerve root impingement

Special Tests – Neurological Dysfunction SOTO-HALL TEST ●

Same procedure as for SLR except the addition of the following: At the degree of hip flexion that elicits a positive finding, therapist gently lowers the leg until the symptoms disappear – Client flexes chin to chest (actively or passively) –

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POSITIVE FINDING: –

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Pain; reproduction of symptoms

INDICATION OF: –

Dural, cord and/or nerve root impingement

Special Tests – Neurological Dysfunction VALSALVA 1) Client seated 2) Ask client to take a deep breath in, hold it, and then bear down ●

POSITIVE FINDING: –

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Pain; reproduction of symptoms

INDICATION OF:

Special Tests – Joint Dysfunction PHEASANT TEST 1) Client prone 2) With one hand, the therapist applies gentle pressure to posterior aspect of lumbar spine 3) With the other hand, the examiner passively flexes the patient's knees until the heels touch the buttocks ●

POSITIVE FINDING: –

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Pain

INDICATION OF: –

Unstable spinal segment; facet jamming

Test shown above is Ely's test. Pheasant's is exactly the same except gently pressure is applied to the lumbar spine with one hand.

Special Tests – Joint Dysfunction QUADRANT TEST 1) Client stands with therapist behind 2) Client extends spine; therapist supports 3) Therapist applies overpressure while client side flexes and rotates to side 4) Continued until limit of range is reached or symptoms are produced ●

POSITIVE FINDING: –

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Pain; reproduction of symptoms

INDICATION OF: –

Facet joint stress; maximum narrowing of IVF

JOINT PLAY MOVEMENTS ●

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USED TO DETERMINE END FEEL OF JOINT MOVEMENT Replaces passive movements Note any decreased ROM, pain, or differences in end feel

Joint play movements of the lumbar spine: ●

Flexion

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Extension

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Side flexion

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PA central vertebral pressure (spinous process) PA unilateral vertebral pressure (lamina or transverse process) Transverse vertebral pressure (spinous process)

FLEXION ● ●

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Client side lying; therapist standing in front Therapist flexes both hips toward the chest with the knees bent Palpating between SPs, passively flex and release client's hips (use body weight to create movement) Feeling for a “gapping” between the spinous processes

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Excessive gapping: hypermobile

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Decreased gapping: hypomobile

Extension ● ●

Client side lying; therapist standing in front Therapist extends both hips with the knees bent (use body weight)

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Palpate between spinous processes

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Feeling for a “closing” of the space

Side Flexion ● ●

Client side lying Therapist grasps client's uppermost leg and rotates upward Will cause side flexion in the lumbar spine ● Must rule out hip pathology in advance Palpate SPs for lateral flexion ●

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PA Central Vertebral Pressure ● ●

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Client prone; move from L5 to L1 Bilateral contact with thumbs on SP and fingers spread laterally Apply downward pressure – Vertebrae is being pushed anteriorly Apply pressure slowly and cautiously

Unilateral Central Vertebral Pressure ● ●

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Client prone; move from L5 to L1 Bilateral contact with thumbs on lamina or TVP Apply downward pressure – Vertebrae is being pushed anteriorly

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Apply pressure slowly and cautiously

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Feel for “springing”

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May repeat more than once

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Perform bilaterally

Transverse Vertebral Pressure ●

Client prone; move from L5 to L1

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Bilateral contact with thumbs on side of SP

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Apply lateral pressure First from one side, then the other Apply pressure slowly and cautiously ●

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Feel for “springing”

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May repeat more than once

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Perform bilaterally

Length & Strength Testing Muscles Testing and Function Kendall, McCreary & Provance

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Abdominal Strength

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Back Strength

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Hip Extensor Strength

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Oblique Trunk Flexor Strength

Length & Strength Testing Muscles Testing and Function Kendall, McCreary & Provance

Abdominal Strength ●Supine; bilateral SLR ●Back held flat: Strong ●Back hyperextends: Weak

Length & Strength Testing Muscles Testing and Function Kendall, McCreary & Provance

Back & Hip Extensor Strength ●Prone; Extend spine ●Hands behind head; legs stabilized ●If can raise trunk into extension: Strong ●If cannot extend at all or can only hyperextend at the lumbar spine: Weak

Length & Strength Testing Muscles Testing and Function Kendall, McCreary & Provance

Oblique Trunk Flexor Strength ●Supine ●Stabilize legs (held straight) ●Client clasps hands and is put into position of trunk rotation and flexion and is told to hold pos'n