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A large percentage of the patient population is referred to physical therapy for a spinal dysfunction.  This newsletter will focus on assessing lumbar pathology in patients with back pain.  A thorough assessment is the key to successful treatment for our patients.

Assessment:

  • Positional Assessment (active range of motion and passive segmental testing)
  • Loading/Unloading
  • Neurotension
  • Aggravating Factors

Positional Assessment

During active range of motion we observe the quality of movemant, the quantity of movement, and whether we can reproduce the patient's pain with movement.

For some patients, we can easily reproduce the patient's pain with straight plane movement.  For others, their pain can only be reproduced with combined movements (trunk flexation or extension combined with side-bending and rotation).

Loading/Unloading

During the positional assessment portion of the exam, we notice that a patient's trunk range of motion (ROM) is limited due to reproduced pain.  We will then take the patient to the verge of pain and unload the spine.

If pain relief and improved ROM result, unloading techniques can be incorporated into the patient's treatment program.  By placing the patient in positions that load or unload the spine, we can affect a change in the patients's pain and his or her ability to perform therapeutic exercise.

Neurotension

In addition to a thourough neurological screen (DTRs, sensation, MMT, etc.) testing the mobility of the neuromeningeal tiddue in the lumbo-sacral portion of the spine is of critical importance during our assessment.  This is also an excellent screen for patients who present with hip pain which may be referred from the lumbar spine.

The Slump Test provides greater functional accuracy than the supine Straight Leg Raise Test.  In a sitting or standing position, weightbearing structures are loaded prior to our assessing for neurotension.  If the test is positive (patient's back, hip, or leg symptoms are reproduced), we immediately begin the process of educating our patients on the need to avoid aggravating factors that reproduce neurotension.  Although we may not know what structure or structures are creating neurotension and subsequent pain, we do know that repeated irritations to that tissue will only delay healing.

A detailed patient history, in combination with the aformentioned assessment techniques (positional assessment, loading/unloading, and neurotension screen), will guide our choice of appropriate treatment.

Assessment of Aggravating Factors

The lumbar spine will typically respond well to therapeutic exercise when a correct assessment has been performed.  However, the patient's failure to identify and/or avoid activities of daily living that reproduce or intensify their back pain, will usually result in healing delays.  Here are some examples that we discuss with our patients:

Positive Hypermobility, Avoid:

  • Sitting in a chair without back support/lumbar support
  • Overstretching your back (ie touching your toes)
  • Poor sitting, standing posture
  • Wearing backpack loaded with too many books
  • Using poor body mechanics at work
  • Working at a poorly designed workstation

Positive Neurotension, Avoid

  • Stretching your hamstrings
  • Sitting in a recliner
  • Bending at the waist, without bending your knees

And be careful:

  • Getting in and out of your car, chair, bed, etc.
  • Getting your baby in and out of the car seat
  • With ADLs (washing dishes, laundry, getting dressed)