The Evidence Based Clinical Examination of the Lumbar Spine, Pelvis, & Hip

POSITION PHYSICAL EXAMINATION

Standing Neurologic -Motor: Heel Walk (L4-5) Toe Raise (L5-S1) Squat or Step-up (L3-4)

Observation/Palpation -Lumbar spine Sagittal and Frontal plane (shift or kyphosis) -Iliac Crests -PSIS -ASIS Functional Test -Lumbar/hip differentiation

Special Tests -Stork -Standing Flexion

Range-of-Motion (ROM) -Gross AROM (Flexion, Extension, Sidebending (SB))

-AROM With overpressure: Flexion Extension SB

*Quadrant (special test)

-Measured ROM (bubble goniometer)

Flexion Extension

SB

-Repeated Movements Symptom Behavior (Centralization/peripheralization)

POSITION PHYSICAL EXAMINATION Sitting Neurologic (*predominate root) -Motor: Great Toe Peroneals (L5-S1) Tibialis Posterior (L5-S1) Extension (L5)

-Sensory (area of maximum representation): (L1) inguinal area (L2) anterior mid-thigh (L3) distal anterior thigh and medial knee (L4) medial lower leg (L5) dorsal/medial foot (S1) lateral lower leg and foot (S2) posterior calf, medial/plantar calcaneus

-MSR: Knee Jerk (L4), Ankle Jerk (S1) -UMN: Babinski, Clonus *Observation/Palpation (incorporated with motion testing under Special Tests) Iliac Crests PSIS Special Tests -Provocation: Thoracic rotation FADIR/FABER

Special Tests (cont) -Motion: Seated Flexion Segmental Mobility Curve Assessment

ROM Hip: IR & ER (may defer to supine or prone)

NOTES:

POSITION PHYSICAL EXAMINATION Supine Observation/Palpation Med malleoli Iliac Crests ASIS Inguinal Ligament Pubic Tubercles Neurologic *SLR (ipsi/contralateral) (may also serve as non-neurologic provocative test, often modified or “biased” to reproduce symptoms)

ROM Hip flexion I/E rotation

Special Tests -Provocation Hip Scour Patrick (FABER; w & w/o goniometer)

Special Tests (cont) Gaenslen’s Posterior-shear

Flexibility

Hamstrings (90/90) Piriformis (below 900) Piriformis (above 90)

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POSITION PHYSICAL EXAMINATION Prone ROM Hip: IR ER

Observation/Palpation -Medial Malleoli -Ischial Tuberosity -Iliac crests -PSIS (tenderness), sacral base/ILAs -Paraspinal mms -Spinous processes (fullness, tenderness) (tenderness) Special Tests -Provocation & Motion: Lumbar (& Sacral) springing Central Unilateral Positional

Segmental mobility (assessed during springing, positioning, & translation)

Muscle Flexibility Ilopsoas Rectus Femoris

OTHER Adverse Neural Dynamics -Slump Test (w/wo sensitization)

-SLR Sensitization w/dorsiflexion Sensitization w/plantarflexion

-Femoral Nerve Stretch Internal Abdominal Activation Quadruped Supine Standing

APPENDIX 1: METHODS FOR ASSESSING A PATIENT’S 5. At Least 1 Hip with More than 35 Degrees of Internal STATUS ON EACH CRITERION IN THE SPINAL Rotation Range of Motion Hip range of motion is tested bilaterally with the patient MANIPULATION CLINICAL PREDICTION RULE lying prone and with the cervical spine at the midline. The ex- aminer places the leg opposite that to be measured in approxi- 1. Duration of Current Episode of Symptoms Less than mately 30 degrees of hip abduction to enable the tested hip to be 16 Days freely moved. The lower extremity of the side to be tested is kept Patients are asked to report the number of days since the in line with the body, and the knee on that side is flexed to 90 onset of their current episode of low back pain. degrees. A gravity inclinometer is placed on the distal aspect of 2. Location of Symptoms Not Extending Distal to the the fibula in line with the bone. Internal rotation is measured at Knee the point in which the pelvis first begins to move. Ellison and A body diagram is used to assess the distribution of symp- colleagues (60) reported excellent inter-rater reliability with these toms (19, 50, 51). We categorize the location of symptoms as procedures (intraclass correlation coefficients, 0.95 to 0.97). being in the back, buttock, thigh, or leg (distal to knee) by using the method described by Werneke and colleagues (52), who found high inter-rater reliability (␬ ϭ 0.96). APPENDIX 2: PROCEDURES USED TO PERFORM THE SPINAL MANIPULATION INTERVENTION 3. Score on the FABQ Work Subscale Less than 19 All patients received the same technique. The patient was Points supine. The physical therapist stood opposite the side to be ma- The FABQ (21) is subdivided into 2 subscales, a 5-item nipulated and moved the patient into side-bending toward the physical activity subscale (questions 1 to 5) and a 16-item work side to be manipulated. The patient was asked to interlock the subscale (questions 6 to 16). Decision making using the rule fingers behind the head. The physical therapist then rotated the requires only the FABQ work subscale score. However, all items patient and delivered a quick thrust to the pelvis in a posterior on the questionnaire should be completed since they were in- and inferior direction (Figure 1). The side to be manipulated was cluded when the psychometric properties of the instrument were the more symptomatic side on the basis of the patient’s report. If established. Each item is scored from 0 to 6; however, not all the patient could not specify a side, the physical therapist selected items within each subscale contribute to the score. Four items a side to be manipulated. If a cavitation (that is, a “pop”) oc- (items 2, 3, 4, and 5) are scored for the FABQ physical activity curred, the physical therapist instructed the patient in the range- subscale, and 7 items (items 6, 7, 9, 10, 11, 12, and 15) are of-motion exercise. If no cavitation was produced, the patient scored for the FABQ work subscale. Each scored item within a was repositioned and the manipulation was attempted again. A particular subscale is summed; thus, possible scores range from 0 maximum of 2 attempts per side was permitted. If no cavitation to 42 and 0 to 28 for the FABQ work and FABQ physical was produced after the fourth attempt, the physical therapist activity subscales, respectively. Higher scores represent increased proceeded to instruct the patient in the range-of-motion exercise. fear–avoidance beliefs. Patients were instructed to perform 10 repetitions of the range- of-motion exercise in the clinic and 10 repetitions 3 to 4 times 4. At Least 1 Lumbar Spine Segment Judged To Be daily on the days that they did not attend physical therapy. Be- Hypomobile ginning with the third session, patients in the manipulation Segmental mobility of the lumbar spine is tested with the group completed the same exercise program as patients in the patient prone and the neck in neutral rotation. Testing is per- exercise group. formed over the spinous processes of the vertebrae (53, 54). The examiner stands at the head or side of the table and places the Current Author Addresses: Dr. Childs: 508 Thurber Drive, Schertz, hypothenar eminence of the hand (that is, the pisiform bone) TX 78154. over the spinous process of the segment to be tested. With the Dr. Fritz: Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108. elbow and wrist extended, the examiner applies a gentle but firm, Dr. Flynn: Department of Physical Therapy, Regis University, 3333 anteriorly directed pressure on the spinous process. The stiffness Regis Boulevard, G-4, Denver, CO 80221-1099. at each segment is judged as normal, hypomobile, or hypermo- Drs. Irrgang and Delitto: Department of Physical Therapy, University of bile. The examiner interpreted whether a segment is hypomobile Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260. on the basis of the examiner’s anticipation of what normal mo- Mr. Majkowski: Physical Therapy Service, 3851 Roger Brooke Drive, bility would feel like at that level and compared with the mobility Fort Sam Houston, TX 78234. Mr. Johnson: 2602 Blue Rock Drive, Beavercreek, OH 45434. detected in the segment above and below. Some authors have reported poor inter-rater reliability for judgments of spinal seg- Author Contributions: mental mobility on scales with 7 to 11 levels of judgments (55– Conception and design: J.D. Childs, J.M. Fritz, T.W. Flynn, J.J. Irrgang, A. Delitto. Administrative, technical, or logistic 57). Studies using mobility judgments similar to those in our support: K.K. Johnson, G.R. Majkowski. study have reported adequate inter-rater reliability (␬ ϭ 0.40 to Collection and assembly of data: J.D. Childs, K.K. Johnson, G.R. Maj- 0.68) (58, 59). kowski. www.annals.org 21 December 2004 Annals of Internal Medicine Volume 141 • Number 12 W-165 Stabilization Classification Examination Definitions

Lumbar Spine Range of Motion Measurement Procedures with an Inclinometer 1. To measure total flexion ROM, the spinous process of T12 is identified and marked. The inclinometer is centered over the mark at T12 and zeroed. The patient is instructed to bend forwards as far as possible without bending the knees. The ROM value on the inclinometer is recorded for total flexion. 2. To measure sidebending ROM, the inclinometer is placed just above the mark at T12 parallel to the axis of the spinal column and zeroed. The patient is instructed to lean over to the right or left as far as possible with the fingertips reaching as far down the side of the thigh, and the ROM value on the inclinometer is recorded. 3. To measure pelvic flexion, the measurement of flexion is repeated with the inclinometer placed over the S2 spinous process. The amount of flexion from the lumbar spine is then determined by subtracting the pelvic flexion from the total flexion measurement. 4. To measure extension, the inclinometer is centered over the mark at T12, and the inclinometer is zeroed. The patient is instructed to bend backwards as far as possible without bending his knees, and the ROM value for extension was recorded.

Aberrant Movement Tests (positive if at least 1/5 present) While the patient is standing, they are instructed to flex the trunk forward as far as possible and then return to the upright posture. Examiner observes for:

1. A Painful Arc in Flexion is defined as pain only occurring during movement into flexion from the erect standing position. This typically occurs somewhere in the mid-range of the motion during the movement into flexion. Therefore, pain is present at a point (or a through a particular range) during flexion, and not before or after that point.

2. A Painful Arc on Return is defined as pain only occurring during return from flexion to the erect standing position. This typically occurs somewhere in the mid-range of the motion on the return from flexion. Opposite of #1.

3. Gower's Sign is defined as "thigh climbing" or pushing on the thighs (or another surface) with hands for assistance during return from flexion to the upright position.

4. An Instability Catch is defined as any trunk movement outside of the plane of specified motion during that particular motion (i.e. lateral sidebending or trunk rotation during trunk flexion) with sudden acceleration or deceleration.

5. A Reversal of Lumbopelvic Rhythm is defined as the trunk being extended first, followed by extension of the hips and pelvis to bring the body back to upright position. Also may be observed as knee flexion followed by anterior shift of the pelvis before returning to the upright posture.

Segmental Mobility Testing (i.e. Spring testing or Passive Intervertebral Motion Testing): Spring testing of the lumbar spine is tested with the patient prone and the neck in neutral rotation. Testing is performed over the spinous processes of the vertebrae and is both a provocation test and a test of segmental mobility. The examiner stands at the head or side of the table and places the hypothenar eminence of the hand (i.e. pisiform bone) over the spinous process of the segment to be tested. With the elbow and wrist extended, the examiner applies a gentle but firm, anteriorly-directed pressure on the spinous process. SEGMENTAL MOBILITY: The stiffness at each segment is judged as normal, hypomobile, or hypermobile. Interpretation of whether a segment is hypomobile is based on the examiner’s anticipation of what normal mobility would feel like at that level and compared to the mobility detected in the segment above and below. PAIN PROVOCATION: Pain response to the applied force at each segment is judged as painful or not painful and if painful, whether the symptoms are local (i.e. under the examiner’s hand) or referred (away from the examiner’s hand).

Segmental Instability Test (Prone Instability Test): The patient lies prone with the body on the examining table and legs over the edge with feet resting on the floor. While the patient rests in this position, the examiner applies posterior to anterior pressure to the lumbar spine. The patient is asked to report any provocation of pain (Note: If no provocation of pain is reported, the test cannot be performed.) The patient is lifts the legs off the floor (hand-holding to the table may be used to maintain position), and posterior compression is applied again to the lumbar spine at the level at which pain provocation was noted with the legs on the floor. If pain is present in the resting position but subsides in the second position, the test is positive.

Straight Leg Raise: The straight leg raise test is performed with attention to the amount of motion available. The patient is supine with the hips and knees extended. The inclinometer is positioned on the tibial crest just below the tibial tubercle. The inclinometer is zeroed. The examiner then passively lifts the straight leg to the maximum tolerated straight leg raise (not the onset of pain), and the degree of motion is recorded.

Active Straight Leg Raise Test: The active straight leg raise test is performed in a supine position with straight legs and feet 20 cm apart. The test is performed after the instruction: ‘‘Try to raise your legs, one after the other, above the couch for 20 cm without bending the knee.’’ The patient is asked to score impairment on a 6-point scale: not difficult at all = 0; minimally difficult = 1; somewhat difficult = 2; fairly difficult = 3; very difficult = 4; unable to do = 5. The scores of both sides were added, so that the summed score ranged from 0-10. Waddell’s Impairment Index:

Test Cut-off Total Flexion <87 0 Total Extension <18 0 Average Lateral Flexion <24 0 Average SLR ---Female <71 0 ---Male <66 0 Spinal Tenderness Positive Bilateral Active SLR <5 seconds Sit-up <5 seconds

Each item scored 0 or 1, total score = sum of items (range 0-7)

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