Spinal assessments THE LUMBAR SPINE

Spinal assessments

THE LUMBAR SPINE

Posture

Normal alignment

Posteriorly, the shoulders, waist creases, posterior superior iliac spines, gluteal creases and knee creases should be horizontal. The spine should appear to be vertical. There should be no rotation, side flexion, scoliosis (lateral curvature) or shift (lateral deviation). Laterally, you should observe a normal lordosis in the lumbar spine. Anteriorly, the anterior superior iliac spines should be horizontal.

Common deviations from normal posture

Creases in the posterior aspect of the trunk and, particularly, adjacent to the spine may indicate areas of hypermobility or instability of that motion

segment.

Sway back comprises hyperextension of the hips, an anterior pelvic tilt and anterior displacement of the pelvis.

Flat back consists of a posterior pelvic tilt and a flattening of the lumbar lordosis, extension of the hip joints, flexion of the upper thoracic spine and straightening of the lower thoracic spine.

Kypholordosis consists of a forward-poking chin posture, elevation and protraction of the shoulders, rotation and abduction of the scapulae, an increased thoracic kyphosis, anterior rotation of the pelvis and an increased lumbar lordosis.

Shifted posture (lateral shift) commonly arises from disc herniation or acute irritation of a facet joint. The shift is thought to result from the body finding a position of ease whereby the shoulders are displaced laterally in relation to the pelvis. Most commonly the shift occurs away from the painful side Movements Assess not only the range of movement occurring and the

pain response, but also localised areas of give and restriction occurring at specific motion segments.

Active movements

Flexion

Flexion should result in a smooth curve. Segmental areas of give or restriction appear as hinging (segmental hypermobility). Lack of movement in the lumbar spine may be compensated by flexion at the hips or thoracic

spine flexion. The gross movement may be measured as fingertip-to-floor distance with a tape measure. Note any limitation of movement, lateral deviation and pain response.

Extension

Observe extension in relation to areas of give or restriction. Observe for hinging at specific motion segments indicating areas of hypermobility. This may appear as horizontal lines appearing across the hypermobile segment. Note any limitation of movement and pain response.

Side flexion

Normal movement should be observed as a smooth curve. Areas of give or restriction will be observed as hinging (segments of hypermobility) or plane lines (areas of hypomobility). Compare with the other side for symmetry.

Note any ‘coupling’ of movements, i.e. the trunk may flex or rotate to compensate for restriction of side flexion.

Passive physiological intervertebral movements (PPIVMs)

These can be used to confirm any restriction of motion seen on active movement tests and to detect restriction of movement not discovered by the active movement tests. PPIVMs also detect segmental hypermobility (Magarey 1988; Maitland 2001).

Overpressure

If the plane movements have full range and are pain-free, then overpressure applied slowly and with care can be At the end of the available range the physiotherapist may apply a small oscillatory movement to assess the quality and end-feel of the movement. Also, the range of further movement should be noted, as well as the pain response.

Repeated movements

Repeating movements several times may alter the quality and range of the movement and may give rise to latent pain. McKenzie (1981) advocates the use of repeating flexion and extension in both standing and lying to determine the movement that may centralise the patient’s symptoms. According to Palmer and Epler (1998), progressive worsening of pain on repeated movements indicates a disc derangement – the pain either becoming more intense or spreading more distally. Centralisation of symptoms means that the referred pain becomes more proximal, i.e. pain experienced at the medial aspect of the shin may centralise to the buttock.

Thus, the exercise is believed to be reducing the patient’s symptoms and the disc derangement.

Combined movements

According to Edwards (1992): ‘Although the use of combining

movements is not always necessary – adequate results being obtained by standard examination procedures – there are times when they are helpful. Often, with the more difficult mechanical problems, their use is

essential.’ For example, lumbar spine extension may be performed

and, while maintaining that extension, side flexion may be added. Symptoms are likely to vary with the addition of a second movement and this may indicate whether or not there is a regular or irregular stretch component to the signs and symptoms. For example, if a disc prolapse is aggravated by flexion, it would be reasonable to hypothesise that the addition of contralateral side flexion would also further increase the symptoms because both of the movements are stretching the posterior component of the disc and posterior longitudinal ligament. Combining ipsilateral side flexion to flexion would be expected to lead to a reduction in the patient’s symptoms as the ipsilateral side flexion is reducing the stretch component.

 

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