Lumbar (Orthopedic)

Observation (posture, lumbar list, etc)
Posture during movements like squatting
AROM
Repeated Motions (10x: flexion, extension, lateral flexion, rotation)
P-A and UP-A
Palpation (but not very useful for low back)
Special Tests
-Lumbar radiculopathy: SLR or Slump, 
-Centralization for discogenic (Rules in and rules out. Standing extension and supine knees to chest as not everyone benefits from extension. These are good for interventions, too.)
-Spondylolisthesis (if not had imaging) and lumbar instability: Passive Lumbar Extension Test
-Lumbar Stenosis CPR: bilateral symptoms, leg pain>back pain, pain with walking/standing, pain relieved with sitting, age>48 (0=-LR of 0.19, 4/5 present=+LR of 4.6)
Endurance Testing
Isometric chest raise for extensor musculature (repeated motions or static hold)
Side plank endurance ratio (75% difference unilaterally = imbalance. Extended hips or bent knees)
Flexor-to-extensor endurance ratio (Extensor normally being the stronger. Ratio less than 1.0 is desirable and 0.84 being normal. Biering-Sorensen for extension measure and long sitting with bent knees for flexion measure)
--Biering-Sorensen for extension set-up: on high-low table and two belts anchored around ankles and below glutes with torso hanging off table. Elbows placed on rolling stool. For the test, move the stool and allow them to balance in neutral extension. Normal individuals can balance for 1.5-2 min. If patient starts to creep into flexion, time will stop. Also compare the ratio of extensors to flexors.
--Assess flexion:extension ratio with the the Biering-Sorensen test to the abdominal isometric hold. In hooklying position, hip ankle should be about 30 deg and the head is straight in that position. Compare the two results. Extensors should be stronger. For example, if able to hold extension for 120 sec/2 min, flexion should be held for 100 sec.
Muscle Length Testing
Movement coordination (Picking up object, squatting)
MMT of hip

If hypermobile with P-A, perform stability exercises, if stiff, perform mobilizations/manipulations.

Acute Low Back Pain with Mobility Deficits

Clinical Findings
-Acute low back, buttock, or thigh pain (duration of 1 month or less)
-Restricted lumbar ROM and segmental mobility
-Lower extremity symptoms reproduced with provocation of the involved lower thoracic, lumbar, or SI segments

Subacute Low Back Pain with Mobility Deficits

Clinical Findings
-Subacute unilateral, low back, buttock, or thigh pain
-Symptoms reproduced with end-range spinal motions and provocation of the involved lower thoracic, lumbar, or SI segments
-Presence of thoracic, lumbar, pelvic girdle, or hip active segmental, or accessory mobility deficits.

Acute Low Back Pain with Movement Coordination Impairments

Clinical Findings
-Acute exacerbation of recurring low back pain that is commonly associated with referred lower extremity pain
-Symptoms produced with initial to mid-range spinal movements and provocation of the involved lumbar segment(s)
-Movement coordination impairments of the lumbopelvic region with low back flexion and extension movements

Subacute Low Back Pain with Movement Coordination Impairments

Clinical Findings
-Subacute exacerbation of recurring low back pain that is commonly associated with referred lower extremity pain
-Symptoms produced with mid-range motions that worsen with end-range movements or positions and provocation of the involved lumbar segment(s)
-Lumbar segmental hypermobility may be present
-Mobility deficits of the thorax and pelvic/hip regions may be present
-Diminished trunk or pelvic region muscle strength and endurance
-Movement coordination impairments while performing self-care/home management activities

Chronic Low Back Pain with Movement Coordination Impairments

Clinical Findings
Presence of 1 or more of the following:
-Low back and/or low back–related lower extremity pain that worsens with sustained end-range movements or positions
-Lumbar hypermobility with segmental motion assessment
-Mobility deficits of the thorax and lumbopelvic/hip regions
-Diminished trunk or pelvic region muscle strength and endurance
-Movement coordination impairments while performing community/work-related recreational or occupational activities

Acute Low Back Pain with Referred LE Pain

Clinical Findings
-Low back pain, commonly associated with referred buttock, thigh, or leg pain, that worsens with flexion activities and sitting
-Low back and lower extremity pain that can be centralized and diminished with positioning, manual procedures, and/ or repeated movements
-Lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility, and clinical findings associated with the subacute or chronic low back pain with movement coordination impairments category are commonly present

Acute Low Back Pain with Radiating Pain

Clinical Findings
-Acute low back pain with associated radiating pain in the involved lower extremity
-Lower extremity paresthesia, numbness, and weakness may be reported
-Symptoms are reproduced or aggravated with initial to mid-range spinal mobility, lower limb tension/straight leg raising, and/or slump tests
-Signs of nerve root involvement (sensory, strength, or reflex deficits) may be present

*It is common for the symptoms and impairments of body function in patients who have acute low back pain with radiating pain to also be present in patients who have acute low back pain with related (referred) lower extremity pain. 

Subacute Low Back Pain with Radiating Pain

Clinical Findings
-Subacute, recurring, mid-back and/or low back pain with associated radiating pain and potential sensory, strength, or reflex deficits in the involved lower extremity
-Symptoms are reproduced or aggravated with mid-range and worsen with end-range lower-limb nerve tension/ straight leg raising and/or slump tests

Chronic Low Back Pain with Radiating Pain

Clinical Findings
-Chronic, recurring, mid-back and/or low back pain with associated radiating pain and potential sensory, strength, or reflex deficits in the involved lower extremity
-Symptoms are reproduced or aggravated with sustained end-range lower-limb nerve tension/straight leg raise and/ or slump tests

Outcome Measures
-Short-Form-36 (SF-36)
-Oswestry Disability Index (minimally important change is 10 points (out of 100) or 30% from baseline score)
-Roland-Morris Disability Questionnaire (minimally important change of 5 points (out of 24) or 30% from baseline score)

Physical Impairment Measures

Lumbar Active ROM
Thoracolumbar flexion and extension with inclinometer placed at thoracolumbar junction and other at sacrum. No normal values from notes.
Thoracolumbar lateral flexion using inclinometer in frontal plane at thoracolumbar junction or goniometer. 35 deg is normal.

Segmental Mobility Assessment
Patient prone and providing P-A mobility assessment to spinous process or transverse process of lower thoracic and lumbar spine. 
Assessing of mobility as well as pain.

Centralization and Peripheralization
Patient flexes, extends, and/or lateral flexion and it is noted which movements cause centralization.

Prone Instability Test
Patient lies prone over table with LE's flexed and feet on floor. While patient resting in this position, examiner provides P-A pressure to spinous process of the lower portion of lumbar spine. Pain is noted. The patient will then lift legs off the floor and the patient can hold table to maintain position and P-A pressure is applied. Positive is pain in resting position that is reduced in extended position. Negative is pain during both positions or no pain in either position. 

Aberrant Movement
Painful arc with flexion or return from flexion. This is pain during movement but not at end ranges of motion.
Instability "catch" is positive when patient deviates from straight plane sagittal movement during flexion and extension.
Gower sign is positive if the patient needs to utilize “thigh climbing” on return from flexion, specifically, the hands push against the anterior thighs in a sequential distal to proximal manner to diminish the load on the low back when returning to the upright position from a forward bent position.
Reversal of lumbopelvic rhythm is positive if the patient, upon return from a forward bent position, suddenly bends his/her knees to extend the hips, shifting pelvis anteriorly, as he/she returns to the standing position.

Straight Leg Raise
The patient is supine and the therapist passively raises the lower extremity, flexing the hip with an extended knee. A positive test is obtained with reproduction of lower extremity radiating/radicular pain at nerve root, usually L5-S1, or herniation of nucleus pulposus.

Slump Test
The patient is asked to sit in a slumped position with knees flexed over table. Cervical flexion, knee extension, and ankle dorsiflexion are sequentially added up to the onset of patient lower extremity symptoms. Judgments are made with regard to a reproduction of symptoms in this position, and relief of symptoms when the cervical spine component is extended or nerve tension is relieved from 1 or more of the lower-limb components, such as ankle plantar flexion or knee flexion. Positive is indicative of neural tension or herniation of nucleus pulposus.

Trunk Muscle Power and Endurance
Trunk Flexors: The patient is positioned in supine; the examiner elevates both of the patient’s fully extended legs to the point at which the sacrum begins to rise off the table. The patient is instructed to maintain contact of the low back with the table while slowly lowering extended legs to the table without assistance. The examiner observes and measures when the lower back loses contact with the tabletop due to anterior pelvic tilt.
Trunk Extensors: The patient is positioned in prone, with hands behind the back or by the sides. The patient is instructed to extend at the lumbar spine and raise the chest off the table to approximately 30° and hold the position. The test is timed until the patient can no longer hold the position.
Lateral Abdominals: The patient is positioned in sidelying with hips in neutral, knees flexed to 90°, and resting the upper body on the elbow. The patient is asked to lift the pelvis off the table and to straighten the curve of the spine without rolling forward or backward. The position is held and timed until the patient can no longer maintain the position.
Transversus Abdominis: The patient is positioned in prone over a pressure biofeedback unit that is inflated to 70 mmHg. The patient is instructed to draw in the abdominal wall for 10 seconds without inducing pelvic motion while breathing normally. The maximal decrease in pressure is recorded.
Hip Abductors: The patient is positioned in sidelying with both legs fully extended, in neutral rotation and a relaxed arm position, with the top upper extremity resting on the ribcage and hand on abdomen. The patient is instructed to keep the leg extended and raise the top thigh and leg toward the ceiling, keeping the limb in line with the body. Patients are graded on quality of movement.
Hip Extensors: The patient is positioned in supine with knees flexed to 90° and the soles of the feet on the table. The patient is instructed to raise the pelvis off the table to a point where the shoulders, hips, and knees are in a straight line. The position is held and timed until the position can no longer be maintained.

Passive Hip Internal Rotation, External Rotation, Flexion, and Extension
Hip External and Internal Rotation: The patient is positioned prone with feet over the edge of the treatment table. The hip measured is placed in 0° of abduction, and the contralateral hip is placed in about 30° of abduction. The reference knee is flexed to 90°, and the leg is passively moved to produce hip rotation. Manual stabilization is applied to the pelvis to prevent pelvic movement and also at the tibiofemoral joint to prevent motion (rotation or abduction/adduction), which could be construed as hip rotation. The motion is stopped when the extremity achieves its end of passive joint range of motion or when pelvic movement is necessary for additional movement of the leg. The inclinometer is aligned along the shaft of the tibia, just proximal to the medial malleolus, for both medial and lateral rotation range-of-motion measurements.
Hip Flexion: With the patient supine, the examiner passively flexes the hip to 90° and zeroes an inclinometer at the apex of the knee. The hip is then flexed until the opposite thigh begins to rise off the table.
Hip Extension: With the patient supine at the edge of a plinth with the lower legs hanging free off the end of the plinth, the examiner flexes both hips and knees so that the patient’s lumbar region is flat against the tabletop. One limb is held in this position, maintaining the knee and hip in flexion, the pelvis in approximately 10° of posterior tilt, and the lumbar region flush against the tabletop, while the ipsilateral thigh and leg are lowered toward the table in a manner to keep the hip in 0° of hip abduction and adduction. The patient is instructed to relax and allow gravity to lower the leg and thigh toward the floor. The angle of the femur of this lowered leg to the line of the trunk (and tabletop) is measured. The amount of knee flexion is also monitored to assess the relative flexibility of the rectus femoris muscle.

Interventions
-Clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain. Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain. (A)
-Lumbar coordination, strengthening, and endurance exercises are another commonly utilized treatment for patients with low back pain. These exercises are also described in the literature as motor control exercises, transversus abdominis training, lumbar multifidus training, and dynamic lumbar stabilization exercises. In addition, these exercises are commonly prescribed for patients who have received the medical diagnosis of spinal instability.
Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments and in patients post–lumbar microdiscectomy. (A)
Refer to your book regarding multifidus stabilization and transversus abdominis.
-Clinicians should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. (A)
-For stenosis, clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain. (C)
-Clinicians should consider utilizing lower-quarter nerve mobilization procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain. (C)
-There is conflicting evidence for the efficacy of intermittent lumbar traction for patients with low back pain. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise will benefit from intermittent lumbar traction in the prone position. There is moderate evidence that clinicians should not utilize intermittent or static lumbar traction for reducing symptoms in patients with acute or subacute, nonradicular low back pain or in patients with chronic low back pain. (D)
-Clinicians should consider (1) moderate- to high intensity exercise for patients with chronic low back pain without generalized pain, and (2) incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain. (A)

Low Back Pain with Radiating Pain due to Disc

Interventions
-Also, refer to picture above that states: acute LBP with related (referred) lower extremity pain. Lumbago due to displacement of intervertebral disc
-They may present with a flat back because of the pain moving into lordosis. They may present with a lateral shift. You can use these as interventions educating the patient that initially it will be painful with extension, but we are attempting to reposition the disc bulge. (I believe the shift will be away from the bulge considering most disc herniations are L4-L5.
-If lack of hip hinge, improve biomechanics with bending and lifting.
-Supine traction. Patient is hooklying and pull back on their knees while sitting at their feet for a gentler lumbar traction. Good for patients with flared herniated disc.
-Specific Sidelying Traction. Good for lumbar radicular problem. Good for treating disc problem. Let the leg hang off the table. It creates a very aggressive opening on the lateral portion of the lumbar spine. For example, if the patient is sidelying on their left side, you would be treating their R side disc problem creating an aggressive opening on top side (R) segments. (I assume you would tract the side that has the pain or the side the leg pain is on, but I could be wrong).
-*"Physical therapists may use exercise training interventions, including trunk muscle strengthening and endurance and specific trunk muscle activation, to reduce pain and disability in patients with acute LBP with leg pain." "B"
-----Dead bug with bracing would be appropriate here.
-----Quadruped exercises
-Education regarding lumbar support while seated and driving if there is pain while seated.
-Progress to interventions consistent with the Subacute or Chronic LBP with Movement Coordination Impairments intervention strategies.

Lumbar Microdisectomy 

Usually outpatient procedure and therapy starts 1-week after surgery. Usually immediate reduction in radicular symptoms following. Note that prior to surgery, dural tissue was likely compromised chronically or many months and mobility issues will need to addressed. Surgery will not correct prior compensatory movement patterns, postural faults and muscle weakness. Primary healing structures: wound, ligamentum flavum, bone, and disc. The edge of the disc that was trimmed will need to scar over during recovery. Because of the nature of the procedure with minimal trauma, recovery is shortened. Success rate is 90-95% with elimination of radicular symptoms and reduction in pain.

Week 1-3 (Inflammatory/Protective Phase)
Posture, body mechanics, and safe ADLs. Patient should avoid long term flexed positions. Twisting should be avoided. Sitting tolerance should slowly increase until they can tolerate 20 minutes at a time. Incorporate progressive ambulation until they can tolerate 30 minutes of walking.
Since lumbar disc was involved, teaching a self sciatic nerve mobilization is indicated. This can be done in supine with hand behind knee, for example. Depending on irritability patient can perform gliders or tensioners. 
Lumbar mobilization can be performed for pain relief (probably grade 1). 
Driving should be avoided for 2 weeks due to the flexed posture sitting in the car and sitting should be be under 20 minutes. Lower extremity weakness can cause hazards to driving until regained.
B/c intradiscal pressure is increased with flexion in standing or sitting, lumbar flexion under load and standing ROM should be avoided during this phase. Education regarding reduced flexing at the waist during ADLs should be avoided during this phase. 
End range movements and hip strength testing should be deferred until week 5 as the muscles attach to the surgical area. Slump testing should be deferred until later.

Week 4-6 (Reparative/Functional Recovery Phase)
At this point complete wound healing should have occurred. Scar mobilization may be necessary. Neural tension should be negative. Functional activity should be near normal. 
-Reinforcing neutral spine principles.
-Progressing CV conditioning. High impact aerobic exercise should be avoided.
-Improving core strength, motor control, and endurance. Example: dead bug, functional exercises that mimic sports or work. All exercises should avoid end range spinal positions and should reinforce functional neutral spine. Non-thrust spinal mobilization may be indicated if there are stiff or immobile segments. Loaded lumbar flexion should be avoided. Lumbar ROM can be assessed with caution if they are progressing well.
-Maintain nerve root mobility. 
-Develop LE strength and flexibility.

Week 7-11 (Remodeling/Resistive Training Phase)
Focus is independence with self care and ADLs and return to previous level of function.
-Prolonged positioning. Patient should be able to tolerate prolonged positioning in sitting and standing.
-Loaded spinal movements may be incorporated. Education regarding lifting techniques with appropriate hip hinge.
-End range spinal movement and Slump test can be assessed.
-Higher level specific work/sport specific movements should be incorporated. This should include rotational and diagonal patterns, overhead activities, and proprioception and balance.
-If segmental mobility or pain, utilize soft tissue and mobilization.
-Running not recommended until after 12 weeks b/c of increased axial loads.

Lumbar Fusion

Indicated for severe degenerative pathology, instability like spondylolisthesis, failed discectomy, recurrent herniation, or multi-level disc herniation, neurological injury from cancer or other medical conditions that can compromise the spinal cord. Can be performed anteriorly or posteriorly. Significantly more trauma than microdiscectomy. Involves laminectomy and cleaning up bone spurs. Bone graft from iliac crest or donor is used at surgically removed majority of disc. Pedicle screws and rods are implanted at transverse process and bone graft along fixation creating a fusion. Prolonged rehab process. Usually smoking is ceased prior to surgery due to long healing time. Hypermobility at adjacent segments can result from fusion overtime. If this isn't addressed in rehab, additional surgical procedure may be required. Rehab is typically similar to discectomy but more drawn out. Stricter precautions. Typically, in hospital for 3-5 days, and referred to outpatient PT up to 6 weeks. In hospital and up to 6 weeks: brace, no lumbar ROM, no hip flexor strength testing (due to psoas attachment to spine), no driving, no lifting, no bending, no twisting, and avoid prolonged sitting. 

Week 6-10 (Reparative Phase)
Continue avoiding end-range lumbar ROM. 
-Restrictions: no lifting more than 10 lbs. and no overhead lifting
-Exercise: work up to 30 mins/day for 5 days/week, light weight training, avoid loading the lumbar spine, spinal stabilization, and aerobic activity (walking endurance)
-Body mechanics/posture education

Week 11-1 Year (Remodeling Phase)
If pain, no mobilization to fused segments and care to the adjacent segments since risk for hypermobility. Soft tissue is appropriate. After 20 weeks, focus can be to return patient to pre-injury status. Can take up to 1 year for bone to remodel and adapt.
-Functional activities: work and sports
-Resistance training: more strenuous stabilization exercises
-Avoid: end range rotation, flexion, and extension
-Pain: soft tissue mobilization or grade 1 for adjacent joints.

Interventions Based on Impairment

Manual Therapy to Improve Lumbar ROM and/or Segmental Mobility
-Lumbar gapping mobilization and/or manipulation while sidelying

Lumbar ROM Limitations
-Open book stretch (sustained hold and/or AROM)
-Cat/cow stretch
-LTR 
-Seated trunk rotation (progress with TheraBand)
-Seated flexion stability ball (SB) walks on table 
-Seated forward flexion towards floor (also can alternate L and R)
-Lumbar extension with belt (to improve extension ROM)

Manual Therapy to Improve Hip ROM and/or Joint Mobility
-To improve hip extension, perform prone anterior glide
-To improve hip flexion, perform supine posterior glide
-To improve hip ROM, perform lateral distraction while supine (with or without belt)
-To improve hip ROM, perform long-axis distraction while supine 
-To improve hip ROM, perform caudal glide while supine (with or without belt)

Protocols: https://wexnermedical.osu.edu/neurological-institute/clinical-centers/ohio-state-spine-care/spine-rehabilitation-guidelines