Static and dynamic postural assessment are important components of my physical examination. Static postural assessment cues me into what dynamic postures I want to evaluate. The most common spinal postural deviations I see clinically are lumbar lordosis, kypholordotic, swayback, and flatback postures. Of those four, increased lumbar lordosis is the most common postural problem in my outpatient population. In this post, I will break analyze the lordotic posture and give a few assessment suggestions.
Background & Biomechanics
Individuals with lumbar lordosis will have relatively tight hip flexors, rectus femoris, erector spinae, tensor fascia latae, and plantarflexors. This line of muscles running from posterior to anterior is generally thought to be strong and facilitated. On the contrary, the rectus abdominus, transversus abdominus, obliques, gluteus maximus and gluteus medius are all relatively lengthened and inhibited. In addition to muscle changes, there is increased pressure on the anterior lumbar vertebral bodies, adaptive shortening of the posterior lumbar ligaments, and relative narrowing of the intervertebral foramen. Patients will often have the greatest stress placed across L4-S1 segments. It is important to note that understanding the biomechanics is only as important as understanding the movement dysfunction, patient's pain science, and how to appropriately prescribe corrective exercise.
Assessment & Treatment
Due to the increased lumbar lordosis, patients will generally have difficulty maintaining a neutral core during functional movements. Additionally, they will have difficulty isolating their glut muscles due to over facilitation of the lumbar paraspinals or hamstrings. Based on the patient's occupation and daily requirements, it is important to look at both the upper and lower extremities when treating spinal dysfunctions. A few quick clinical tests you can perform to assess for abdominal control are as follows:
1) Standing Hip Extension test: Have the patient perform hip extension from a standing position. If the patient is unable to move into hip extension without excessive lumbar movement, they lack lumbopelvic rhythm. Individuals with lumbar lordosis will generally initiate hip extension from the lumbar spine. Turn this test into a treatment by performing the same movement with specific cueing.
2) 180 degree shoulder flexion test: Have the patient raise their arms overhead fully and see how the core responds to the movement. Generally, the patient will over-extend their lumbar spine creating a hinge point in the low back.
3) Straight leg raise : Have the patient raise 1 leg into the air and assess for core stability. The patient will often hyperextend their low back secondary to core insufficiency.
These 3 assessments are only a few of the many assessment and treatment tools we teach in the OPTIM COMT and Fellowship programs. Don't forget to check out TSPT Insider Access Page for exclusive information!