Saddam Kanaan, PT, PhD

Lumbar Spine Examination

Recommended videos: http://morphopedics.wikidot.com/spinal-orthopedic-labs

1. Observation
a. General appearance, affect, visual cues of symptoms
b. Willingness to move, gait, and undressing
c. Body structure and level of fitness
d. Posture

In standing: Lateral tilt, curvature of the spine (Lordosis, flat back, and sway back),
Excessive lumbar lordosis: is when the concave curve of the low back is greater than
normal, and the pelvis is anteriorly tilted.
Flat back: is when the concave curve of the low back is either diminished or completely
flat, and the pelvis is posteriorly tilted.
Sway back: is characterized by increased lordosis due to posterior positioning of the
thoracic spine and the pelvis displacing anteriorly, along with a posterior pelvic tilt.

To determine whether the pelvis is anteriorly or posteriorly tilted, you must bilaterally
palpate the ASIS’s, and PSIS’s. In normal pelvic alignment, the ASIS and PSIS should
be level horizontally, additionally, the ASIS’s should be viewed anteriorly for levelness
from one side to the other. Observing the ASIS positioning in these two different views
will help to identify a variety of alignment concerns. If one ASIS appears higher than the
other, the patient may have a leg-length discrepancy, an innominate upslip, or an
innominate rotation. These conditions may be related to the patient’s lower back
complaints, and thus should be noted in the exam.

In sitting: observing the patient’s adapted sitting posture. Take note of what is
comfortable for them. The adapted sitting posture could be a contributing factor to the
patient’s symptoms, and therefore should be discussed with the patient so they are
educated on how to prevent future lumbar problems.

e. Change in body contour (e.g. swelling, atrophy, and spasm)

2. Functional Examination (e.g. OSwestry Disability Index, Ronald Morris

Questionnaire)

3. Palpation
a. Skin (Temperature, sweating, scratch test, skin rolling)
b. Muscles
i. Tone
ii. Tenderness
iii. Trigger points
iv. Ligaments
c. Bony alignments
i. Tenderness/ stiffness

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 Saddam Kanaan, PT, PhD

ii. Spinous process alignment (depression, protrusion, lateral shift)

iii. Articular process depth

4. Clearing: Clear Thoracic, SIJ, Hip, Knee and Ankle

5. ROM and MMT

6. AROM (pp 94-95)

a. Flexion-OP
b. Extension-OP
c. Side bending-OP (Lt+Rt)-OP
d. Rotation-OP (LT+Rt)- OP: Have the patient seated on a plinth or stable chair,
with feet flat on the floor and arms crossed over the chest. The patient should
rotate to the right and come back to neutral. If there was no pain, have the
patient go through the motion again and this time overpressure must be given
at the end range. Overpressure can be given by placing one hand around the
proximal humerus of each shoulder and pushing posteriorly on the right while
pulling anteriorly on the left for a resultant rotary motion. Repeat these
procedures for left rotation.
e. Quadrant

7. PPIVM’s: Passive Physiological Intervertebral Movements:

A- Flexion/ extension

Patient Position: Patient is in the sidelying position with the hips and knees flexed.

Therapist Position: The therapist stands in a squat stance position in front of the
patient. The therapist reaches with the caudal hand behind and under the patients
flexed knees to grasp anteriorly around the right knee. (The therapist can also grasp
the posterior aspect of the patient’s ankles or if legs are heavy can grasp the top
leg.) The therapist places the cephalad arm over the patient’s lower scapular area
(this will help to prevent thoracic rotation) with the pad of the index finger or middle
finger in the interspinous space of the level to be tested.

Method: Passive movement is produced by rocking the patient’s knees through a 30

degree arc of motion. This movement is produced by side-to-side movement of the
therapist’s pelvis, carrying the patient’s legs.

Indications: Lumbar Spine Objective Examination Sequence. Pre-cursor to stability

testing.

B- Side bending

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 Saddam Kanaan, PT, PhD

C-Rotation

8. PAIVM’s: Passive Accessory Intervertebral Movements

Quality of movement, Range of movement, Pain response, Resistance, End feel,
Provocation of muscle spasms

a. Central PA’s Grade (I, II), III, IV (PP 96)

b. Unilateral PA Grade I, II, III, IV (pp97)

c. Transverse glide

Note: for unilateral technique it is

preferred to start working on the
painless side to avoid pain and
irritability

d. Rotation (pp 98)

Patient is lying on the painless side
Grade I, II
Grade III, IV

I recommend this technique for different cases including impingement, facet joints, and
unilateral pain

e. Traction (pp 99)

I recommend this technique for assessment and general management of back

condition

9. Special test:

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 Saddam Kanaan, PT, PhD

A- Prone Instability Test

The patient lies prone with the body on the examining table and legs over the edge and
feet resting on the floor. While the patient rests in this position with the trunk muscles
relaxed, the examiner applies posterior to anterior pressure to an individual spinous
process of the lumbar spine. Any provocation of pain is reported. Then the patient lifts
the legs off the floor (the patient may hold table to maintain position) and posterior to
anterior compression is applied again to the lumbar spine while the trunk musculature is
contracted.

The test is considered positive if pain is present in the resting position but subsides in
the second position, suggesting lumbo-pelvic instability. The muscle activation is
capable of stabilizing the spinal segment.

B- Neurodynamic testing

I. Straight Leg Raise (SLR)

Recommended Video: https://www.youtube.com/watch?v=KziCDXXfC-4

Basic Principles of Straight Leg Raise Test

Standardize your patient’s position (pillow or no pillow)
1. Perform on uninvolved side first
2. Explain to the patient what you are going to do
3. Get baseline symptoms
4. Perform test passively, the patient should not assist!
5. Add components to sensitize the test
6. Added components may be distally or proximally according to the area we need
to stress most
7. Remember that over 70° the pain may be coming from hamstring, SIJ, and
lumbar spine.
8. Reassess frequently

Added components:
Dorsiflexion: tibial nerve
Hip adduction
Medial rotation: lumbosacral plexus

Option:
Passive neck flexion
Bilateral straight leg raise

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II. Slump Test

Recommended video: http://www.youtube.com/watch?v=6ohO2CHy8NE

A- Initial set up:

a. Sit with your knees all the way back to the table and as close together as
possible
b. Look forward
c. Place your hands behind your back

B- Ask patient to slump (control the neck)

C- Overpressure in attempt to ‘bow’ the spine
D- Take your chin to your chest
E- Overpressure to cervical flexion (gentle)
F- Extend knee
G- Dorsiflexion
H- (Release neck flexion)

Option:
Bilateral knee extension
Hip adduction/medial rotation

C- Special tests: Segmental Neuro Exam

A. Myotomes

– L2: Hip Flexion—Psoas; resisted above knee with both hands

– L3: Knee Extension—Quads; resist at ankle, stabilize at ASIS of hip
– L4: DF/ Inv—Anterior Tibialis; resist medial aspect of feet, directing force down and
out
– L5: Toe Extension—EHL and EDL; resist distal phalanges
– S1: Ankle PF – Gastroc/soleus OR Eversion—Peroneus longus and brevis; direct
force down and in
– S2: FDL; have pt. curl toes around finger and have resist unrolling toes

B. Reflexes
– L3, L4—Knee Jerk (can perform in sitting position if unable to elicit in supine
position)
– L5—Hamstring Jerk (can perform in prone position if unable to elicit in supine
position)
– S1—Ankle Jerk (can perform in prone position if unable to elicit in supine position)

C. Sensation

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– L1—groin
– L2—anterior proximal thigh
– L3—medial aspect of distal thigh and knee
– L4—lateral aspect of knee and medial distal leg
– L5—Dorsum of foot
– S1—lateral foot
– S2—medial aspect of heel