Lumbar Evaluation and Initial Interventions

If you are a new graduate, treating acute low back pain can be frightening. Often times, a patient arrives in agonizing pain with a limited ability to do any movement. In these moments, your standard examination is dismantled. The natural default mode is to start performing every lumbar spine test and measure you learned in Physical Therapy school.  In these moments, you gather information without considering ‘why’ you chose to perform the test and 'how' the outcome would impact your overall plan of care. It is in these moments that you realize that the special tests are not very special. So what happens next!? The answer is a better, more efficient evaluation from the start! 

Key Lumbar Examination Points

1. Minimal positional changes for the patient. It is inefficient to have the patient constantly rolling over, standing, and sitting. A patient in high levels of pain will not be able to tolerate multiple positional changes.
2. Perform pain provocation testing last in each position. For example, if a patient states that bending forward increases their symptoms, perform lumbar flexion active range of motion last. Pain will cloud the results of your physical exam.
3. Examiner must assess regional joints, muscles, and nervous system tissue. The body is a single kinetic chain. Movement at one joint increases the demands on local tissue. For example, when someone performs shoulder flexion, movement occurs in the thoracic spine, rib cage, acromioclavicular joint and more. If one of those areas is dysfunctional, it can be the source of pain. Each examination needs to evaluate each source of a patient’s symptoms. 

​Lumbar Examination: Efficiency and Reliability

A good clinician ​will follow the same general steps when performing any Physical Therapy Evaluation. These tests and measures are performed in a systematic, reproducible manner.  While the clinician may add or remove testing as needed, the general framework for formulating their diagnosis is consistent.  This consistency allows for efficiency and reproducibility. For example, in the lumbar evaluation the examiner assesses the function of the core muscles in supine; however this should only be completed after a thorough examination of the functional testing of the core in standing. It would not be an efficient use of time to take an acute low back pain patient from standing, to supine, back to standing, to prone. The entire session would be disrupted with positional changes. Additionally, the goal of any physical therapy session is to maximize the patient's functional ability so we must assess function first. 

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What is clinical efficiency?

AT IT'S CORE, CLINICAL EFFICIENCY IS ARRIVING AT THE CORRECT PHYSICAL THERAPY DIAGNOSIS AND DETERMINING THE APPROPRIATE PLAN OF CARE WITHOUT PERFORMING UNNECESSARY TESTS AND MEASURES.

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Lumbar Examination Sequence

​Lumbar Interventions: Typical Day 1 Treatment and More

Similar to my shoulder evaluation post, my Day 1 lumbar interventions heavily focus on desensitizing the painful tissue through graded tissue exposure. Additionally, I spend a significant amount of time educating the patient on pain science. 

Below are 3 common exercises I give patients on the first day

Hand Heel Rocks

General Cues

• Position yourself so that your hands are directly under your shoulders and knees are directly under your hips
• Rock backwards as far as you can before your lower back starts to round
• Make sure that your head does not start to look up or drop down and that your lower back does not round during the exercise

​I like to use a foam roller or dowel along the lower back to ensure the neutral position.

Supine Hip External Rotation

General Cues

• From a hooklying position, bring one leg over the top of the other 
• Use your hands to press your thigh further into hip rotation
• Engage the lower abdominals to minimize movement from the low back (this movement is not bad, but just not the purpose of this exercise)

Prone Press-ups

General Cues

• From your stomach, use your hands to press up into back extension
• Relax your glutes and low back to sink further into the movement

Bonus: Foam Roller Thoracic Extensions

General Cues

• Place the foam roller across your middle back
• Arch over the foam roller while keeping the core engaged (this minimizes the movement across the low back-- important if they are in pain)

There are no single set of exercises for every patient. Their individualized pain triggers and tolerance to exercise will heavily dictate what they can do! 

Jim Heafner PT, DPT, OCS

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