The biomechanical assessment of the
lumbar spine must begin after a scan examination has been
carried out and proven negative (i.e. the therapist has
been unable to make a working diagnosis). The initial
assessment can begin with a biomechanical screening
examination such as position tests, quadrant testing etc.
Or the therapist can dispense with a screening
examination entirely and go straight to passive
physiological intervertebral movement testing (PPIVMs).
In this manual, position testing will be used as a
screening examination from which, the therapist will be
able to move on to a more directed and definitive
biomechanical examination.
Position Tests
The patient is positioned in
extension, flexion and neutral. The therapist then layer
palpates the transverse process. If there is no rotation
of the vertebrae, the transverse processes are usually
non-palpable. But if there is rotation present, the more
posterior transverse process pushes against the overlying
tissue and makes itself available to palpation. The
posterior transverse process may indicate the side
towards which the vertebra is rotated (ipsilateral). To
gain relaxed or passive extension the trunk is propped up
by the elbows sitting on the table or from support by the
up-tilted head end of the table. Flexion is attained by
either having the patient sit flexed in a chair or
positioned in flexed kneeling. Neutral is simply prone
lying.
The posterior transverse process denotes the direction of
rotation of the vertebra. If the rotation is found in
flexion and is determined to be to the left, then the
vertebra is said to be relatively extended (E), rotated
® and side flexed (S) left (L); ERSL. There are a number
of possible reasons for this position to be found, only
one of them being hypomobility. First there is
hypomobility on the left side of the segment so that as
it flexes, the altered axis of rotation through the stiff
zygopophyseal joint causes the vertebra to rotate and
side flex to that side. Secondly, the right side could be
hypermobile permitting increased flexion which would
involve rotation to the left. Thirdly, there may be an
anomaly such as a twisted transverse process. And
finally, the position fault may be due to compensation
and may not be a motion dysfunction at all.
Passive Mobility Tests (PPIVMs
PAIVMs)
The primary and secondary segmental
quadrant tests are essentially overpressure to rotation
at the extreme of flexion/rotation/side flexion or
extension/ rotation/side flexion in order to position the
segments in these extremes, combined movements that
de-rotate the segment are carried.
Flexion/Rotation
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The patient is side laid with
the posterior transverse process towards the bed
and the hips flexed. The upper arm is allowed to
hang in front of the patient. The lower arm is
pulled around the patient's vertical axis
parallel with the bed. If quadrant testing is
being carried out without the patient previously
being positioned tested then the lower arm must
also be pulled somewhat cranially to ensure that
side flexion right is being produced to flex the
left side of the segment. This is not necessary
after position testing because we are not trying
to produce the appropriate coupling but rather we
are trying to de-rotate the segment. In this
case, the side flexion becomes incidental and
insignificant. |
The upper arm can now be taken
back onto the patient's side providing the trunk
is not extended as this is done. The therapist
then slides his/her arm between the patient's to
palpate the spine. The upper leg is then flexed
further until the whole lumbar spine is flexed,
the pelvis is then rotated downwards to complete
the flexion position.
Each segment is now fully flexed on one side,
that is each segment is in its full flexion
quadrant position. |
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The therapist then tests the
end feel of rotation. If it is abnormal, the
joint glide (arthrokinematic) is tested with an
oblique postero-anterior pressure on the inferior
bone. If it is normal, the hypomobility is caused
by extra-articular restrictions if abnormal; the
joint is limiting the motion.
If the primary quadrant test is negative, a
secondary quadrant is carried out to assess for a
flexion hypermobility on the opposite side. This
secondary quadrant test is identical the primary
but the patient lies on the other side. |
Extension/Rotation
The patient is side laid with
the posterior transverse process down towards the
bed and the hips extended the lower hip more so
than the upper. The upper arm is placed behind
the patient and the lower arm is pulled around a
vertical axis but this time towards the ceiling
(almost perpendicular to the bed).
Again if quadrant testing is being carried out
without the patient previously being positioned
tested then the lower arm must also be pulled
somewhat cranially to ensure that side flexion
right is being produced to extend the right side
of the segment. |
The therapist slips his/her
arm between the patient's uppermost arm and
palpates the spine. The lower leg is extended so
as to extend the lumbar spine fully. The pelvis
is rotated towards the floor to complete the
quadrant position. The lumbar spine now has one
side fully extended that is the spine is in its
full extension quadrant.
The therapist then tests the end feel of
rotation. If it is abnormal, the joint glide
(arthrokinematic) is tested with an oblique
postero-anterior pressure on the inferior bone.
If it is normal, the hypomobility is caused by
extra-articular restrictions if abnormal; the
joint is limiting the motion.
If the primary quadrant test is negative, a
secondary quadrant is carried out to assess for
an extension hypermobility on the opposite side.
This secondary quadrant test is identical the
primary but the patient lies on the other side. |
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Interpretation
If the rotation is found in
extension and is again to the left, the vertebra
is said to be relatively flexed (F), rotated (R),
side flexed (S) to the left (L); FRSL. The same
causes apply although now of course they would be
extension hypo or hypermobility.
If the rotation is found in all positions, then,
in the lumbar spine at least, the probability is
that a fixed scoliosis exists. However, it is
quite possible that a transverse subluxation,
such as that hypothesized in the thoracic spine
is present.
Regardless of the provisional interpretation of
the test results, any asymmetry requires passive
movement testing. Symmetrical testing can be
carried out but this has sensitivity problems.
Better are the segmental quadrant tests (PPIVMs).
The patient is position at the extreme of the
hypothesized hypomobile range. If the dysfunction
was ERSL, the patient is laid on the left side
flexed and rotated from the bottom and flexed and
rotated from the top. If an FRSL is found, the
patient is again laid on the left side but this
time extended and rotated from the bottom and
top. The therapist then tests the end feel of
this range by trying to increase rotation. A hard
capsular, muscular or subluxed end feels suggests
segmental hypomobility.
If the primary quadrant PPIVM is abnormal there
is a segmental hypomobility. If this occurs, the
therapist then tests the arthrokinematic end feel
at the extreme range. If the passive accessory
intervertebral movement test is positive
(arthrokinematic test) then an articular
hypomobility either due to pericapsular
restriction of subluxation exists. The
arthrokinematic test is an oblique posterior
anterior pressure in the line of the joint. The
end feel will define which type of articular
hypomobility is present, a hard capsular end feel
comes with a pericapsular restriction and a
pathomechanical (jammed) end feel is associated
with a subluxation. If the PPIVM is positive but
the PAIVM negative, then the problem is
extra-articular, hypertonicity, prolonged muscle
hypomobility, scarring etc.
If the primary quadrant test is negative, then
another cause for the positional asymmetry is
investigated. The secondary hypothesis is that
the positional fault is due to hypermobility on
the opposite side. The patient is turned onto the
other side but otherwise positioned identically
with the primary quadrant test. However, now the
therapist is expecting to find either a soft
capsular end feel or a spasm end feel.
If the secondary quadrant test is positive, then
a hypermobility is present either non-irritable
(soft capsular) or irritable (spasm). In this
case, segmental stability tests are carried out
to determine if the segment is unstable as well
as hypermobile. |
- Disclaimer:
The assessment and treatment techniques depicted
or described in this site are not intended to
replace formal instruction in orthopedic manual
or any other type of physical therapy. They are
intended to review, augment and facilitate the
knowledge and skills previously gained on manual
therapy or other course and to stimulate the
untrained or trainee physical therapist to
increase the bounds of his or her knowledge and
skill base.
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