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
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.
What is clinical efficiency?
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
Supine Hip External Rotation
Bonus: Foam Roller Thoracic Extensions
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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