There are three general body types (see Figure 15-24): ectomorphic—thin body build, characterized by relative prominence of structures developed from the embryonic ectoderm; mesomorphic—muscular or sturdy body build, characterized by relative prominence of structures developed from the embryonic mesoderm; and endomorphic—heavy (fat) body build, characterized by relative prominence of structures developed from the embryonic endoderm.

The patient should be examined in the habitual relaxed posture (see Chapter 15) that he or she would usually adopt. With acute back pain, the patient presents with some degree of antalgic (painful) posturing. Usually, a loss of lumbar lordosis is present, and there may be a lateral shift or scoliosis. This posturing is involuntary and often cannot be reduced because of the muscle spasm.^72,73

The patient should be observed anteriorly, laterally, and posteriorly (Figure 9-17). During the observation, the examiner should pay particular attention to whether the patient holds the pelvis “in neutral” naturally; if not, is he or she able to achieve the “neutral pelvis” position in standing (normal lordotic curve with the ASISs being slightly lower [one to two finger widths] than the PSISs). Many people with back pain are unable to maintain a neutral pelvis position. Three questions should be considered when looking for a neutral pelvis and whether the pelvis can be stabilized:

These questions will help the examiner determine if the pelvis (and lumbar spine) can be stabilized during different movements or positions so that other muscles originating from the pelvis can function properly. For example, side lying hip abduction should be able to be performed in the frontal plane with the lower limbs, pelvis, trunk and shoulder aligned in the frontal plane (active hip abduction test ) (Figure 9-18).⁷⁴ If the leg wobbles, the pelvis tips, the shoulders or trunk rotate, the hip flexes or the abducted limb medially rotates, it is an indication of lack of movement control and lack of muscle strength and balance.

Anteriorly, the head should be straight on the shoulders, and the nose should be in line with the manubrium, sternum, and xiphisternum or umbilicus. The shoulders and clavicle should be level and equal, although the dominant side may be slightly lower. The waist angles should be equal. Does the patient show a lateral shift or list (Figure 9-19)? Such a shift may be straight lateral movement or it may be a scoliosis (rotation involved). The straight shift is more likely to be caused by mechanical dysfunction and muscle spasm and is likely to disappear on lying down or hanging.^3,75 True scoliosis commonly has compensating curves and does not change with hanging or lying down. The arbitrary “high” points on both iliac crests should be the same height. If they are not, the possibility of unequal leg length should be considered. The difference in height would indicate a functional limb length discrepancy. This discrepancy could be caused by altered bone length, altered mechanics (e.g., pronated foot on one side), or joint dysfunction (Table 9-7). The ASISs should be level. The patellae should point straight ahead. The lower limbs should be straight and not in genu varum or genu valgum. The heads of the fibulae should be level. The medial malleoli should be level, as should be the lateral malleoli. The medial longitudinal arches of the feet should be evident, and the feet should angle out equally. The arms should be an equal distance from the trunk and equally medially or laterally rotated. Any protrusion or depression of the sternum, ribs, or costicartilage, as well as any bowing of bones, should be noted. The bony or soft-tissue contours should be equal on both sides.

From the side, the examiner should look at the head to ensure that the ear lobe is in line with the tip of the shoulder (acromion process) and the arbitrary highpoint of the iliac crest. Each segment of the spine should have a normal curve. Are any of the curves exaggerated or decreased? Is lordosis present? Kyphosis? Do the shoulders droop forward? Normally with a neutral pelvis, the ASISs are slightly lower than the PSISs. Are the knees straight, flexed, or in recurvatum (hyperextended)?

From behind, the examiner should note the level of the shoulders, spines and inferior angles of the scapula, and any deformities (e.g., a Sprengel deformity). Any lateral spinal curve (scoliosis) should be noted (Figure 9-20). If the scoliotic curve is because of a disc herniation, the herniation usually occurs on the convex side of the curve.⁷⁶ The waist angles should be equal from the posterior aspect, as they were from the anterior aspect. The PSISs should be level. The examiner should note whether the PSISs are higher or lower than the ASISs and the patient’s ability to maintain a neutral pelvis. The gluteal folds and knee joints should be level. The Achilles tendons and heels should appear to be straight. The examiner should note whether there is any protrusion of the ribs or bowing of bones. Any deviation in the normal spinal postural alignment should be noted and recorded. The various possible sources of pathology related to posture are discussed in Chapter 15.

Janda and Jull described a lumbar or pelvic crossed syndrome (Figure 9-21) to show the effect of muscle imbalance on the ability of a patient to hold and maintain a neutral pelvis.⁷⁷ With this syndrome, they hypothesized that there was a combination of weak, long muscles and short, strong muscles, which resulted in an imbalance pattern leading to low back pain.⁷⁸ They felt that only by treating the different groups appropriately could the back pain be relieved. The weak, long inhibited muscles were the abdominals and gluteus maximus, whereas the strong tight (shortened) muscles were the hip flexors (primarily iliopsoas) and the back extensors. The imbalance pattern promotes increased lumbar lordosis because of the forward pelvic tilt and hip flexion contracture and overactivity of the hip flexors compensating for the weak abdominals. The weak gluteals result in increased activity in the hamstrings and erector spinae as compensation to assist hip extension. Interestingly, although the long spinal extensors show increased activity, the short lumbar muscles (e.g., multifidus, rotatores) show weakness. Also, the hamstrings show tightness as they attempt to pull the pelvis backward to compensate for the anterior rotation caused by the tight hip flexors. Weakness of gluteus medius results in increased activity of the quadratus lumborum and tensor fasciae latae on the same side. This syndrome is often seen in conjunction with upper crossed syndrome (see Chapter 3). The two syndromes together are called the layer syndrome.⁷⁷

A “faun’s beard” (tuft of hair) may indicate a spina bifida occulta or diastematomyelia (see Figure 9-20).⁷⁹ Café au lait spots may indicate neurofibromatosis or collagen disease (Figure 9-22). Unusual skin markings or the presence of skin lesions in the midline may lead the examiner to consider the possibility of underlying neural and mesodermal anomalies. Musculoskeletal anomalies tend to form at the same time embryologically. Thus, if the examiner finds one anomaly, he or she must consider the possibility of other anomalies.

A step deformity in the lumbar spine may indicate a spondylolisthesis. The “step” occurs because the spinous process of one vertebra becomes prominent when either the vertebra above (for example, spondylitic spondylolisthesis) or the affected vertebra (for example, spondylolytic spondylolisthesis) slips forward on the one below (Figure 9-23).

Active movements are performed with the patient standing (Figure 9-24). The examiner is looking for differences in ROM and the patient’s willingness to do the movement. The ROM taking place during the active movement is normally the summation of the movements of the entire lumbar spine, not just movement at one level, along with hip movement. The most painful movements are done last. If the problem is mechanical, at least one or more of the movements will be painful.²⁷

While the patient is doing the active movements, the examiner looks for limitation of movement and its possible causes, such as pain, spasm, stiffness, or blocking. As the patient reaches the full range of active movement, passive overpressure may be applied, but only if the active movements appear to be full and pain free. The overpressure must be applied with extreme care, because the upper body weight is already being applied to the lumbar joints by virtue of their position and gravity. If the patient reports that a sustained position increases the symptoms, then the examiner should consider having the patient maintain the position (e.g., flexion) at the end of the ROM for 10 to 20 seconds to see whether symptoms increase. Likewise, 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.

The greatest motion in the lumbar spine occurs between the L4 and L5 vertebrae and between L5 and S1. There is considerable individual variability in the ROM of the lumbar spine (Figure 9-25).^80–84 In reality, little obvious movement occurs in the lumbar spine especially in the individual segments because of the shape of the facet joints, tightness of the ligaments, presence of the intervertebral discs, and size of the vertebral bodies.

For flexion (forward bending), the maximum ROM in the lumbar spine is normally 40° to 60°. The examiner must differentiate the movement occurring in the lumbar spine from that occurring in the hips or thoracic spine. Some patients can touch their toes by flexing the hips, even if no movement occurs in the spine. On forward flexion, the lumbar spine should move from its normal lordotic curvature to at least a straight or slightly flexed curve (Figure 9-26).⁸⁵ If this change in the spine does not occur, there is probably some hypomobility in the lumbar spine resulting from either tight structures or muscle spasm. The degree of injury also has an effect. For example, the more severely a disc is injured (for example, if sequestration has occurred rather than a protrusion), the greater the limitation of movement.⁸⁶ With disc degeneration, intersegmental motion may increase as disc degeneration increases up to a certain point and follows Kirkaldy-Willis’s description of degenerative changes in the disc.⁸⁷ He divided the changes into three stages: dysfunctional, unstable, and stable. During the first two phases, intersegmental motion increases in flexion, rotation, and side flexion⁸⁸ and then decreases in the final stabilization phase. During the unstable phase, it is often possible to see an instability “jog” during one or more movements, especially flexion, returning to neutral from flexion, or side flexion.^89,90 An instability jog is a sudden movement shift or “rippling” of the muscles during active movement, indicating an unstable segment.^85,91 Similarly, muscle twitching during movement or complaints of something “slipping out” during lumbar spine movement may indicate instability.⁹² If the patient bends one or both knees on forward flexion, the examiner should watch for nerve root symptoms or tight hamstrings, especially if spinal flexion is decreased when the knees are straight. If tight hamstrings or nerve root symptoms are suspected, the examiner should perform suitable tests (see “Special Tests” section) to determine if the hamstrings or nerve root restriction (see “Knee Flexion Test”) are the cause of the problem. When returning to the upright posture from forward flexion, the patient with no back pain first rotates the hips and pelvis to about 45° of flexion; during the last 45° of extension, the low back resumes its lordosis. In patients with back pain, commonly, most movement occurs in the hips, accompanied by knee flexion, and sometimes with hand support working up the thighs.⁹³ As with the thoracic spine, the examiner may use a tape measure to determine the increase in spacing of the spinous processes on forward flexion. Normally, the measurement should increase 7 to 8 cm (2.8 to 3.1 inches) if it is taken between the T12 spinous process and S1 (see Figures 9-24, A and B). The examiner should note how far forward the patient is able to bend (i.e., to midthigh, knees, midtibia, or floor) and compare this finding with the results of straight leg raising tests (see “Special Tests” section). Straight leg raising, especially if bilateral, is essentially the same movement done passively, except that it is a movement occurring from below upward instead of from above downward.

During the active movements, especially during flexion or extension, the examiner should watch for a painful arc. The pain seen in a lumbar painful arc tends to be neurologically based (i.e., it is lancinating or lightening-like), but it may also be caused by instability. If it does occur on movement in the lumbar spine, it is likely that a space-occupying lesion (most likely a small herniation of the disc) is pinching the nerve root in part of the range as the nerve root moves with the motion.⁷⁵

Maigne described an active movement flexion maneuver to help confirm lumbar movement and control.⁷² In this happy round maneuver, the patient bends forward and places the hands on a bed or on the back of a chair. The patient then attempts to arch or hunch the back. Most patients with lumbar pathology are unable to sustain the hunched position.

Extension (backward bending) is normally limited to 20° to 35° in the lumbar spine. While performing the movement, the patient is asked to place the hands in the small of the back to help stabilize the back. Bourdillon and Day have advocated doing this movement in the prone lying position to hyperextend the spine.⁹⁴ They called the resulting position the sphinx position. The patient hyperextends the spine by resting on the elbows with the hands holding the chin (Figure 9-27) and allows the abdominal wall to relax. The position is held for 10 to 20 seconds to see if symptoms occur or, if present, become worse.

Side (lateral) flexion or side bending is approximately 15° to 20° in the lumbar spine. The patient is asked to run the hand down the side of the leg and not to bend forward or backward while performing the movement. The examiner can then eyeball the movement and compare it with that of the other side. The distance from the fingertips to the floor on both sides may also be measured, noting any difference. In the spine, the movement of side flexion is a coupled movement with rotation. Because of the position of the facet joints, both side flexion and rotation occur together although the amount of movement and direction of movement may not be the same. Table 9-8 shows how different authors interpret the coupled movement in the spine. As the patient side flexes, the examiner should watch the lumbar curve. Normally, the lumbar curve forms a smooth curve on side flexion, and there should be no obvious sharp angulation at only one level. If angulation does occur, it may indicate hypomobility below the level or hypermobility above the level in the lumbar spine (Figure 9-28). Mulvein and Jull advocated having the patient do a lateral shift (Figure 9-29) in addition to side flexion.⁹⁵ Their viewpoint is that lateral shift in the lumbar spine focuses the movement more in the lower spine (L4–S1) and helps eliminate the compensating movements in the rest of the spine.

Rotation in the lumbar spine is normally 3° to 18° to the left or right, and it is accomplished by a shearing movement of the lumbar vertebrae on each other. Although the patient is usually in the standing position, rotation may be performed while sitting to eliminate pelvic and hip movement. If the patient stands, the examiner must take care to watch for this accessory movement and try to eliminate it by stabilizing the pelvis.

If a movement such as side flexion toward the painful side increases the symptoms, the lesion is probably intra-articular, because the muscles and ligaments on that side are relaxed. If a disc protrusion is present and lateral to the nerve root, side flexion to the painful side increases the pain and radicular symptoms on that side. If a movement (such as, side flexion away from the painful side) alters the symptoms, the lesion may be articular or muscular in origin, or it may be a disc protrusion medial to the nerve root (Figure 9-30).

McKenzie advocated repeating the active movements, especially flexion and extension, ten times to see whether the movement increases or decreases the symptoms.³⁹ He also advocated, like Mulvein and Jull,⁹⁵ a side gliding movement in which the head and feet remain in position and the patient shifts the pelvis to the left and to the right.

If the examiner finds that side flexion and rotation have been equally limited and extension has been limited to a lesser extent, a capsular pattern may be suspected. A capsular pattern in one lumbar segment, however, is difficult to detect.

Because back injuries rarely occur during a “pure” movement (such as, flexion, extension, side flexion, or rotation), it has been advocated that combined movements of the spine should be included in the examination.^96,97 The examiner may want to test the following more habitual combined movements: lateral flexion in flexion, lateral flexion in extension, flexion and rotation, and extension and rotation. These combined movements (Figure 9-31) may cause signs and symptoms different from those produced by single plane movements and are definitely indicated if the patient has shown that a combined movement is what causes the symptoms. For example, if the patient is suffering from a facet syndrome, combined extension and rotation is the movement most likely to exacerbate symptoms.⁹⁸ Other symptoms that would indicate facet involvement include absence of radicular signs or neurological deficit, hip and buttock pain, and sometimes leg pain above the knee, no paresthesia, and low back stiffness.^99,100

While the patient is standing, the examiner may perform a quick test of the lower peripheral joints (Figure 9-32), provided the examiner feels the patient has the ability to do the test. The patient squats down as far as possible, bounces two or three times, and returns to the standing position. This action quickly tests the ankles, knees, and hips as well as the sacrum for any pathological condition. If the patient can fully squat and bounce without any signs and symptoms, these joints are probably free of pathology related to the complaint. However, this test should be used only with caution and should 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.

The patient is then asked to balance on one leg and to go up and down on the toes four or five times. This is, in effect, a modified Trendelenberg test. While the patient does this, the examiner watches for Trendelenburg sign (Figure 9-33). A positive Trendelenburg sign is shown by the nonstance side ilium dropping down instead of elevating as it normally would when standing on the leg. A weak gluteus medius muscle or a coxa vara (abnormal shaft-neck angle of the femur) on the stance leg side may produce a positive sign. If the patient is unable to complete the movement by going up and down on the toes, the examiner should suspect an S1 nerve root lesion. Both legs are tested.

McKenzie advocated doing flexion movements with the patient in the supine lying position as well.³⁹ In the standing position, flexion in the spine takes place from above downward, so pain at the end of the ROM indicates that L5–S1 is affected. When the patient is in the supine lying position with the knees being lifted to the chest, flexion takes place from below upward so that pain at the beginning of movement indicates that L5–S1 is affected. Remember that greater stretch is placed on L5–S1 when the patient is in the lying position.

During the observation stage of the assessment, the examiner will have noted any changes in functional limb length (see Table 9-7). Wallace developed a method for measuring functional leg length.¹⁰¹ The patient is first assessed in a relaxed stance. In this position, the examiner palpates the ASISs and the PSISs, noting any asymmetry. The examiner then places the patient in a symmetric stance, ensuring that the subtalar joint is in the neutral position (see Chapter 13), the toes are straight ahead, and the knees are extended. The ASISs and PSISs are again assessed for asymmetry. If differences are still noted, the examiner should check for structural leg length differences (see Chapters 10 and 11), sacroiliac joint dysfunction, or weak gluteus medius or quadratus lumborum (Figure 9-34). The pelvis may also be leveled with the use of calibrated blocks or cards so that the functional length difference can be recorded.

Resisted isometric muscle strength of the lumbar spine is first tested in the neutral position. The patient is seated. The contraction must be resisted and isometric so that no movement occurs (Figure 9-35). Because of the strength of the trunk muscles, the examiner should say, “Don’t let me move you,” so that movement is minimized. The examiner tests flexion, extension, side flexion, and rotation. Figure 9-36 shows the axes of movement of the lumbar spine. The lumbar spine should be in a neutral position, and the painful movements should be done last. The examiner should keep in mind that strong abdominal muscles help to reduce the load on the lumbar spine by approximately 30% and on the thoracic spine by approximately 50%, as a result of the increased intrathoracic and intra-abdominal pressures caused by the contraction of these muscles. Table 9-9 lists the muscles acting on the lumbar vertebrae.

Provided neutral isometric testing is normal or only causes a small amount of pain, the examiner can go on to other tests, which will place greater stress on the muscles. These tests are often dynamic and provide both concentric and eccentric work for the muscles supporting the spine. With all of the following tests, the examiner should ensure that the patient can hold a neutral pelvis. If there is excessive movement of the ASIS (supine) or PSIS (prone) when doing the test, the patient should not be allowed to do them. In normal individuals, the ASIS or PSIS should not move when doing the tests. Motivation may also affect the results.¹⁰²

Dynamic Abdominal Endurance Test.103,104

This test checks the endurance of the abdominals. The patient is in supine with the hips at 45° and knees at 90° and hands at sides. A line is drawn 8 cm (for patients over 40 years of age) or 12 cm (for patients under 40 years of age) distal to the fingers. The patient tucks in the chin and curls the trunk to touch the line with the fingers (Figure 9-37) and repeats as many curls as possible using a cadence of twenty-five repetitions per minute. The number of repetitions possible before cheating (holding breath, altered mechanics) or fatigue occurs is recorded as the score. The test may also be done as an isometric test (Figure 9-38) by assuming the end position and holding it. The grading for this isometric abdominal test would be as follows^105–107:

• Normal (5) = Hands behind neck, until scapulae clear table (20 to 30 second hold)

• Good (4) = Arms crossed over chest, until scapulae clear table (15 to 20 second hold)

• Fair (3) = Arms straight, until scapulae clear table (10 to 15 second hold)

• Poor (2) = Arms extended, toward knees, until top of scapulae lift from table (1 to 10 second hold)

• Trace (1) = Unable to raise more than head off table

McGill¹⁰⁸ advocated doing the isometric test by starting with the patient resting against a back rest angled at 60^o from the horizontal with the hips and knees flexed to 90^o and the arms folded across the chest and the hands on opposite shoulders (Figure 9-39). The patient’s feet are held securely and the back rest is lowered away from the patient’s back while the patient maintains the 60^o position as long as possible.

Dynamic Extensor Endurance Test.103,109,110

This test is designed to test the strength of iliocostalis lumborum (erector spinae) and multifidus. The patient is placed in prone lying with the hips and iliac crests resting on the end of the examining table and the hips and pelvis stabilized with straps (Figure 9-40). Initially, the patient’s hands support the upper body in 30° flexion on a chair or bench (see Figure 9-40, A). Keeping the spine straight, the examiner instructs the patient to extend the trunk to neutral and then lower the head to the start position. During the exercise, the patient’s arms are crossed at the chest. The cadence is twenty-five repetitions per minute. The number of repetitions possible before cheating (holding breath, altered mechanics) or fatigue occurs is recorded as the score. The test may also be done isometrically, and the examiner times how long the patient can hold the contraction without pelvic or spinal movement. This test may also be done with the patient beginning in prone lying and extending the spine if the preceding test is too hard.^111,112 In this case, the patient can start with the hands by the side, moving the hands in the small of the back, and finally moving the hands behind the head for increasing difficulty. The test, if done isometrically (isometric extensor test) (Figure 9-41), would be graded as follows^105–107:

• Normal (5) = With hands clasped behind the head, extends the lumbar spine, lifting the head, chest, and ribs from the floor (20 to 30 second hold)

• Good (4) = With hands at the side, extends the lumbar spine, lifting the head, chest, and ribs from the floor (15 to 20 second hold)

• Fair (3) = With hands at the side, extends the lumbar spine, lifting the sternum off the floor (10 to 15 second hold)

• Poor (2) = With hands at the side, extends the lumbar spine, lifting the head off the floor (1 to 10 second hold)

• Trace (1) = Only slight contraction of the muscle with no movement

Biering and Sorensen described a similar test (Biering-Sorensen fatigue test) in which the subject had arms by the side, and the time the patient was able to hold the straight position before fatigue was recorded (i.e., the patient could not hold the position).^113,114 The start position is the same as for the dynamic test.

Double Straight Leg Lowering Test.111,112,115

(Note: This test checks the abdominals. It should only be performed if the patient receives a “normal” grade in the dynamic abdominal endurance test or the abdominal isometric test.) This is an abdominal eccentric test that can place a great deal of stress on the spine so the examiner must ensure the patient is able to hold a neutral pelvis before doing the exercise. It also causes greater abdominal activation than curlups.¹¹⁶ The patient lies supine and flexes the hips to 90° (Figure 9-42, A) and then straightens the knees (Figure 9-42, B). The patient then positions the pelvis in neutral (i.e., the PSISs are slightly superior to the ASISs) by doing a posterior pelvic tilt and holding the spinous processes tightly against the examining table. The straight legs are eccentrically lowered (Figure 9-42, C). As soon as the ASISs start to rotate forward, the test is stopped, the angle measured (plinth to thigh angle), and the knees bent. The test must be done slowly, and the patient must not hold his or her breath. The grading of the test is as follows¹⁰⁶:

• Normal (5) = Able to reach 0° to 15° from table before pelvis tilts

• Good (4) = Able to reach 16° to 45° from table before pelvis tilts

• Fair (3) = Able to reach 46° to 75° from table before pelvis tilts

• Poor (2) = Able to reach 75° to 90° from table before pelvis tilts

• Trace (1) = Unable to hold pelvis in neutral at all

Internal/External Abdominal Obliques Test.111,112

This test checks the combined action of the internal oblique muscle of one side and the external oblique muscle on the opposite side. The patient is in supine lying with hands by the side. The patient is asked to lift the head and shoulder on one side and reach over and touch the fingernails of the other hand (Figure 9-43, A). The examiner counts the number of repetitions the patient performs. The patient’s feet should not be supported and the patient should breathe normally. The test can be made more difficult by asking the patient to put the hands on the opposite shoulders across the chest (Figure 9-43, B) and do the test by taking the elbow toward where the fingers would have rested beside the body or, more difficult still, by putting the hands behind the head and taking the elbows toward the position where the fingernails would have rested beside the body (Figure 9-43, C). The grading of the test, if done isometrically (isometric internal/external abdominal oblique test), would be as follows¹⁰⁶:

• Normal (5) = Flexes and rotates the lumbar spine fully with hands behind head (20 to 30 second hold)

• Good (4) = Flexes and rotates the lumbar spine fully with hands across chest (15 to 20 second hold)

• Fair (3) = Flexes and rotates the lumbar spine fully with arms reaching forward (10 to 15 second hold)

• Poor (2) = Unable to flex and rotate fully

• Trace (1) = Only slight contraction of the muscle with no movement

• (0) = No contraction of the muscle

Dynamic Horizontal Side Support (Side Bridge) Test.117

This movement tests the quadratus lumborum muscle. The patient is in a side lying position resting the upper body on his or her elbow (Figure 9-44, A). To begin, the patient side lies with the knees flexed to 90°. The examiner asks the patient to lift the pelvis off the examining table (Figure 9-44, B) and straighten the spine. The patient should not roll forward or backward when doing the test. The patient repeats the movement as many times as possible in a dynamic test or holds for as long as possible in an isometric test. In younger, more fit patients, the test can be made more difficult by having the legs straight and asking the patient to lift the knees and pelvis off the examining table with the feet as the base so the whole body is straight (Figure 9-44, C). As an isometric test, the test would be graded as follows:

• Normal (5) = Able to lift pelvis off examining table and hold spine straight (10 to 20 second hold)

• Good (4) = Able to lift pelvis off examining table but has difficulty holding spine straight (5 to 10 second hold)

• Fair (3) = Able to lift pelvis off examining table and cannot hold spine straight (less than 5 second hold)

• Poor (2) = Unable to lift pelvis off examining table

McGill reported that the side bridge should be able to be held 65% of the extensor time for men and 39% for women and 99% of the flexor time for men and 79% for women.¹¹⁸

Back Rotators/Multifidus Test.

This test checks the ability of the lumbar rotators and multifidus to stabilize the trunk during dynamic extremity movement. The patient assumes the quadriped position (Figure 9-45, A) and is asked to hold the “neutral pelvis” position and breathe normally. The patient is then asked to do the following movements (Figure 9-45, B–D):

1. Single straight arm lift and hold

2. Single straight leg lift and hold

3. Contralateral straight arm and straight leg lift and hold

The scoring for the test would be as follows:

• Normal (5) = Able to do contralateral arm and leg, both sides while maintaining neutral pelvis (20 to 30 second hold)

• Good (4) = Able to maintain neutral pelvis while doing single leg lift but not able to hold neutral pelvis when doing contralateral arm and leg (20 second hold)

• Fair (3) = Able to do single arm lift and maintain neutral pelvis (20 second hold)

• Poor (2) = Unable to maintain neutral pelvis while doing single arm lift

If tested isokinetically, the back extensors are stronger than the flexors. Men produce a force equal to approximately 65% of body weight in flexion, whereas women produce approximately 65% to 70% of their body weight in flexion. In extension, men produce approximately 90% to 95% of their body weight, and women produce 80% to 95% of their body weight, depending on the speed tested. In rotation, men produce approximately 55% to 65% of their body weight, whereas women produce approximately 40% to 55% of their body weight, depending on the speed tested.¹¹⁹

After the resisted isometric movements of the lumbar spine have been completed, if the examiner did not use the quick test to test the peripheral joints or is unsure of the findings or whether the peripheral joints are involved, the peripheral joints should be quickly scanned to rule out obvious pathology in the extremities. Any deviation from normal should lead the examiner to do a detailed examination of that joint. The following joints are scanned.120

Sacroiliac Joints

With the patient standing, the examiner palpates the PSIS on one side with one thumb and one of the sacral spines with the other thumb. The patient then fully flexes the hip on that side, and the examiner notes whether the PSIS drops as it normally should or whether it elevates, indicating fixation of the sacroiliac joint on that side (Figure 9-46). The examiner then compares the other side. The examiner next places one thumb on one of the patient’s ischial tuberosities and one thumb on the sacral apex. The patient is then asked to flex the hip on that side again. If the movement is normal, the thumb on the ischial tuberosity moves laterally. If the sacroiliac joint on that side is fixed, the thumb moves up. The other side is then tested for comparison. This test has also been called Gillet’s or the sacral fixation test (see Chapter 10).

Having completed the scanning examination of the peripheral joints, the examiner next tests the patient’s muscle power for possible neurological weakness (Table 9-10).¹²⁰ With the patient lying supine, the myotomes are assessed individually (Figure 9-47). When testing myotomes (Table 9-11), the examiner should place the test joint or joints in a neutral or resting position and then apply a resisted isometric pressure. The contraction should be held for at least 5 seconds to show any weakness. If feasible, the examiner should test the two sides simultaneously to provide a comparison. The simultaneous bilateral comparison is not possible for movements involving the hip and knee joints because of the weight of the limbs and stress to the low back, so both sides must be done individually. The examiner should not apply pressure over the joints, because this action may mask symptoms.

Remember that the examiner has previously tested the S1 myotome with the patient standing and has tested for a positive Trendelenburg sign (modified Trendelenburg test); these movements are repeated here only if the examiner is unsure of the result and wants to test again. The ankle movements should be tested with the knee flexed approximately 30°, especially if the patient complains of sciatic pain, because full dorsiflexion is considered a provocative maneuver for stretching of neurological tissue. Likewise, the extended knee increases the stretch on the sciatic nerve and may result in false signs, such as weakness that results from pain rather than from pressure on the nerve root. Rainville, et al.¹²¹ have recommended testing the L3 and L4 nerve roots at the same time by doing a single leg sit-to-stand test to check for unilateral quadriceps weakness (Figure 9-48). Note that the patient can hold the examiner’s hands for balance.

If the patient is in extreme pain, all tests with the patient in the supine position should be completed before the patient is tested in prone. This reduces the amount of movement the patient must do, decreasing the patient’s discomfort. Ideally, all tests in the standing position should be performed first, followed by tests in the sitting, supine, side lying, and prone positions. This procedure is shown in the précis at the end of the chapter.

To test hip flexion (L2 myotome), the examiner flexes the patient’s hip to 30° to 40°. The examiner then applies a resisted force into extension proximal to the knee while ensuring that the heel of the patient’s foot is not resting on the examining table (see Figure 9-47, A). The other side is then tested for comparison. To prevent excessive stress on the lumbar spine, the examiner must ensure that the patient does not increase the lumbar lordosis while doing the test and that only one leg at a time is tested.

To test knee extension or the L3 myotome, the examiner flexes the patient’s knee to 25° to 35° and then applies a resisted flexion force at the midshaft of the tibia ensuring the heel is not resting on the examining table (see Figure 9-47, B). The other side is tested for comparison.

To test ankle dorsiflexion (L4 myotome), the examiner asks the patient to place the feet at 90° relative to the leg (plantigrade position). The examiner applies a resisted force to the dorsum of each foot and compares the two sides (see Figure 9-47, C). Ankle plantar flexion (S1 myotome) is compared in a similar fashion, but the resistance is applied to the sole of the foot. Because of the strength of the plantar flexor muscles, it is better to test this myotome with the patient standing. The patient slowly moves up and down on the toes of each foot (for at least 5 seconds) in turn (modified Trendelenburg test), and the examiner compares the differences as previously described. Ankle eversion (S1 myotome) is tested with the patient in the supine lying position, and the examiner applies a force to move the foot into inversion (see Figure 9-47, D).

Toe extension (L5 myotome) is tested with the patient holding both big toes in a neutral position. The examiner applies resistance to the nails of both toes and compares the two sides (see Figure 9-47, E). It is imperative that the resistance be isometric, so the amount of force in this case is less than that applied during knee extension, for example.

Hip extension (S1 myotome) is tested with the patient lying prone. This test needs to be done only if the patient is unable to do plantar flexion testing in standing or ankle eversion. The knee is flexed to 90°. The examiner then lifts the patient’s thigh slightly off the examining table while stabilizing the leg. A downward force is applied to the patient’s posterior thigh with one hand while the other hand ensures that the patient’s thigh is not resting on the table (see Figure 9-47, F).

Knee flexion (S1–S2 myotomes) is tested in the same position (prone) with the knee flexed to 90°. An extension isometric force is applied just above the ankle (see Figure 9-47, G). Although it is possible to test both knee flexors at the same time, it is not advisable to do this because the stress on the lumbar spine is too great.

Injury to the lumbar spine can greatly affect the patient’s ability to function. Activities such as standing, walking, bending, lifting, traveling, socializing, dressing, and sexual intercourse can be affected. Numerical scoring tables may be used to determine the degree of pain caused by lumbar spine pathology or disability. Care must be taken when selecting one of these scales to ensure that it measures the disability from the patient’s perspective.122–125 Examples are the Oswestry Disability Index^126–128 (Figure 9-49), the Quebec Back Pain Disability Scale^129,130 (Figure 9-50), and the Hendler 10-Minute Screening Test for Chronic Back Pain Patients (Figure 9-51).^124,127,131 It has been reported that the Hendler test helps to differentiate organic from functional low back pain.¹³² The Oswestry Disability Index is a good functional scale because it deals with ADLs and therefore is based on the patient’s response and concerns affecting daily life. It is the most commonly used functional back scale. The disability index is calculated by dividing the total score (each section is worth from 1 to 6 points) by the number of sections answered and multiplying by 100. The Roland-Morris Disability Questionnaire is short and simple, and it is suitable for following up on progress in clinical settings and for combining with other measures of function (e.g., work disability) (Figure 9-52).^133,134 Other numerical back pain scales include the Functional Rating Index,^135,136 the Dallas Pain Questionnaire,¹³⁷ the Million Index,¹³⁸ the Japanese Orthopedic Association Scale,¹³⁹ the Iowa Low Back Rating Scale,¹⁴⁰ the Bournemouth Questionnaire,^141,142 the Scoliosis Research Society form (SRS-22 for those with spinal deformity),^143–145 the Lumbar Spinal Stenosis Questionnaire,¹⁴⁶ and the Aberdeen Back Pain Scale.¹⁴⁷ Thomas provide a good review of these and other scales.¹²⁴ Lehman and colleagues developed a rating scale for lumbar dysfunction (Figure 9-53) that includes assessment criteria, physician criteria, and, perhaps more importantly, patient criteria for determining the degree of dysfunction.¹⁴⁰ These criteria can be evaluated during the normal assessment for the patient.

Waddell and colleagues developed a series of tests to differentiate between organic and nonorganic back pain.¹⁴⁸ Each test counts +1 if positive or 0 if negative:

Positive findings of +3 or more should be investigated for nonorganic cause; these patients may also have social and psychological components to their complaint.^3,149,150

Waddell also described a simple clinical functional capacity evaluation (Figure 9-54),³ which examiners may find useful for testing patients.¹⁵¹

Simmonds, et al.¹⁵² came up with several functional tests or physical performance measures that they felt would be useful and discriminate between individuals with and without low back pain:

Special tests should always be considered as an integral part of a much larger examination process.154 They should never be used in isolation.¹⁵⁵ Many of the special tests in the lumbar spine are purported to have poor diagnostic value.¹⁵⁶ Because these are clinical tests and commonly depend on the skill of the examiner, many of them show low reliability and validity or have not been studied at all.^157–161 Thus, the icons are graded primarily on clinical experience.

For the reader who would like to review them, the reliability, validity, specificity, sensitivity, and odds ratios of some of the special tests used in the lumbar spine are available on the Evolve website.