WORKBOOK
PHYSICAL THERAPY OF THE
MUSCULOSKELETAL SYSTEM:
LUMBAR SPINE
Marta Martínez López
Ariadna Aguilella Pérez
3º A
Group: 3
Rafael Torres Cueco
PHYSICAL EXPLORATION: ASSESSMENT
A) INSPECTION:
● Observe the morphology of the spine in statics and dynamics and whether the patient
adopts an antalgic posture or some abnormal gait pattern.
1. Anterior view: shoulder antepulsion, the shape of the thorax
2. Posterior view: anatomical prominences, height of shoulders, winged scapula.
3. Lateral view: position of shoulders, head and sternum. Moreover, notice the
axis deviations: hyperkyphosis, disappearance of physiological kyphosis (flat
back) or scoliosis
● Observe any anomaly in the lumbar area
B) PALPATION of all spinous processes to look for any kind of pain and knock gently to see if
there is fracture
C) MOBILITY ARCS: active and passive movements to assess range of motion and whether
there are instability or limitations. Pay attention to the patterns of pain to identify the kind of pain
● Flexion
Add pressure
● Extension fotos
Add pressure
● Rotations
Add pressure
● Side bendings
Add pressure
D) NEUROLOGICAL EXAMINATION
● Dermatomes: comparing with the contralateral side
L1: Oblique band superior and anterior portion of the thigh
L2: Oblique band mid-thigh
L3: Oblique band above the kneecap
L4: internal part of the leg and foot
L5: external part of the leg and plantar face of the foot
S1: External part of the foot
● Myotomes: is important to compare both sides
L2: iliopsoas
The patient in a sitting position
Insertar foto
Patient performs hip flexion against load
The physiotherapist: the hand performing the
force is placed on the patient's distal part of
the thigh
L3: quadriceps femoris
The patient in a sitting position
Insertar foto
Patient performs knee extension against load
The physiotherapist: the hand performing the
force is placed on the patient's distal part of
the leg
L4: Tibialis Anterior
Patient performs a walk with the heels foto
The patient is in a supine position foto
Patient performs ankle inversion and
dorsiflexion against resistance
L5: Extensor hallucis longus and extensor digitorum longus
The patient in in a sitting position
Patient performs a big toe extension against
load
The physiotherapist: The hand performing the
force is placed in the anterior aspect of the big
toe (hallucis longus) and the other toes
(digitorum longus)
S1: Lateral peroneus and gastrocnemius
The patient does a walking tiptoe for the foto
gastrocnemius
The patient in a supine position
Patient performs a plantar flexion and eversion foto
against load
The physiotherapist: The hand performing the
force is placed in the anterior (for plantar
flexion) and lateral (for eversion) aspect of the
feet
● Reflexes
L4: Patellar reflex
The patient is in a sitting position, straight back foto
with the legs off the stretcher
The physiotherapist uses the reflex hammer to
hit the patellar tendon. He takes the patient's
posterior aspect of the knee with one arm and
with the other hits the tendon.
S1: Achilles reflex
The patient is in prone position with the feet off foto
of the bench
The physiotherapist uses the reflex hammer to
hit the achilles tendon. He puts the patient's
feet on his thigh to feel the movement.
E) NEURODYNAMIC TESTS
If the patient shows radicular symptoms, we can do some neurodynamic tests to assess neural
mechanosensitivity
● Straight leg raise:
The patient is in a supine position
The physiotherapist has their distal hand
around the achilles tendon, and the
proximal hand is distal to the quadriceps.
The physiotherapist flexes the hip (with an
extension of the knee) of the patient.
Both sides are compared.
The test is positive when they have
symptoms of radicular pain in the involved
side. It appears, usually, around 45
degrees.
The sensitization for the lower limb is
made with a dorsiflexion of the ankle and
for the upper limb is made with an internal
rotation and adduction of the hip or doing
both at the same time.
Treatment: When the physiotherapist,
passively, extends the hip the patient has
to flex their neck.
● Passive knee flexion: This is for testing the femoral nerve.
The patient is in a prone position.
The physiotherapist, passively, flexes the
knee to stretch the femoral nerve, then
holds that position for a few seconds.
The test is positive when pain appears in
the anterior part of the thigh or before 90
degrees of knee flexion.
➔ If the patient cannot flex well the knee:
The patient is in a prone position
The physiotherapist grasps with one hand
the distal part of the quadriceps and, with
the other, they fix the hip.
The physiotherapist does a flexion of the
knee with a passive extension of the hip.
➔ For young patients:
Patient is in a sitting position on the edge
of the stretcher with their legs hanging.
One knee is grasped by the patient, while
they are lying slightly on their backs, the
other leg is pressed down by the
physiotherapist.
● Slump test:
The patient is sitting on the edge of the
stretcher.
First stage: The physiotherapist asks
their patient to hold the hands behind the
back, and slump into lumbar and thoracic
flexion while maintaining the head erect,
then flex his neck towards the chest. The
physiotherapist gently applies pressure
over the neck or the shoulders, but just to
keep the position. If the patient has pain
in the lower limb, they stop the neck
flexion.
Second stage: The physiotherapist asks
their patient to extend their knee and,
passively, make a dorsiflexion of the
ankle to increase tension. Both sides are
compared.
If the patient has pain in the lower limb,
they stop the knee extension.
Third stage: The physiotherapist does
both stages at the same time.
In this test, the physiotherapist asks in all stages for symptoms.
CLINICAL CONDITIONS and PHYSICAL IMPAIRMENTS
A) LOW BACK PAIN. Can be caused by:
● Discogenic pain: is the degeneration of the intervertebral discs. Specially in the acute
phase when the patient does a side bending movement, extension or flexion. This kind of
pain is diffuse
● Facet joint pain: The facet syndrome has a degenerative evolution, and it starts in young
adult patients, where repetitive trauma will lead to degenerative changes, where in turn, it
can cause joint instability and stiffness. It is a localized pain, unilateral given at the end of
range in extension or the combined movement of extension, side bending and ipsilateral
rotation. There is an improvement in pain with the supine position and flexion because the
posterior joint surfaces move away. The treatment of this impairment is focused on pain
management and if there are components of functional instability, motor control exercises
as functional exercises and daily life activities. Furthermore, it is important to reduce
inflammation and pain.
Combined movements to provoke pain:
The patient in a standing position
The therapist presses every vertebra with one hand,
evaluating each level
The other hand grabs the patient’s shoulder from the
side being tested
-The hand which is on the shoulder leads the patient to
extension, ipsilateral side bending and ipsilateral
rotation. Hold this position for three seconds
-It can also be performed with flexion, side bending and
rotation
To assess the upper back: we do the same as before, but with the physiotherapist’s hands
on the higher vertebrae of the patient
● Instability. There can be a minor instability: hypomobility (loss of control of joint mobility,
responsible for pain and active/passive dysfunction) or hypermobility: major instability
(when we have a fracture, spondylolysis or ligament strain) we have:
For the treatment of hypomobility:
Patient in a prone position
Physiotherapist's proximal hand on the buttock Foto
and the distal one on the contralateral iliac
crest.
The physiotherapist, with both hands,
performs gentle and dynamics mobilizations to
one side and the other, trying to focus on the
movement of the lumbar spine
To assess instability:
Lumbar Mobilization Posterior to Anterior: Central PA
The physiotherapist contacts the spinous process with his Foto de la mano
pisiform and the other hand is going to be over the first one,
keeping the elbows straight and avoid hyperextension of the
distal phalanges
Body weight should be used to create the force
It can also be performed with the double-thumb technique
The stretcher has to be low for a good performance of the test
The examiner uses a posterior to anterior directed force in a Foto de la técnica
sustained or oscillatory way directly over the spinous
processes
This test is considered positive if the patient reports
reproduction of pain. The mobility of the segment should be
assessed as normal, hypermobile, or hypomobile.
Test should be repeated for each lumbar segment
Lumbar Mobilization Posterior to Anterior: Unilateral PA
The physiotherapist contacts the unilateral zygapophyseal Foto de la mano
joint with one thumb over the other thumb, keeping the elbows
straight
Body weight should be used to create forces
The stretcher has to be low for a good performance of the test
The examiner uses a posterior to anterior directed force in a Foto de la tecnica
sustained or oscillatory way directly over the facet joints
This test is considered positive if the patient reports
reproduction of pain. The mobility of the segment should be
assessed as normal, hypermobile, or hypomobile.
Test should be repeated for each lumbar segment
● Sacroiliac pain
● Spondylolysis: is a bone defect at the level of the pars interarticularis of a vertebra. It
usually presents bilaterally, affecting predominantly L5. It is the most frequent anatomical
injury in young athletes with lumbar pain. Repetitive flexion, extension, rotation, and
weight bearing gestures more frequently can develop pain in the gluteal region and
sometimes in the thighs.
B) LOWER LIMB PAIN can be caused by:
● Herniated disc radiculopathy. If the patient performs a hip flexion, it can be disc herniation.
The treatment consists in manual therapy for pain, neurodynamic, epidural infiltration,
conservative treatment, nucleolysis, percutaneous nucleotomy and surgical discectomy
● Lateral canal stenosis: If the patient performs a hip extension, it can be lateral canal
stenosis
● Central canal stenosis: To diagnose it we have to find a neurogenic claudication,
aggravated by extension and relieved by lumbar kyphosis. Also, it is important to rule out
any peripheral neurological injury and herniated disc. Physiotherapy consists in manual
therapy and neurodynamic (but careful with increasing pain)
All of these can compromise the nerves.
OTHER PHYSICAL IMPAIRMENTS
• Thoracic myelopathy
• Cauda equines syndrome
• Disc protrusion
• Complete prolapse
• Lumbar fracture: the main objectives are:
o Early stabilization
o Reincorporation of the patient to his daily
activities
o Avoid painful or functional sequelae
o Preservation of physiological curves
o Protection of nervous structures
o Prevent deformity
• There are three kinds of fracture:
o Type A: pure compression injury.
o Type B: compression-distraction injury
o Type C: rotational injury.
STRENGTHENING / ACTIVATING MUSCLES
A) TRANSVERSE ABDOMINAL MUSCLE
The main function of this muscle is to give stability to the lumbar spine when maintaining good
posture. In addition, the activation of this muscle is very important in coughing, sneezing and in
defecation
The patient is in a supine position
The physiotherapist has to feel the transverse
abdominal muscle. To feel it, they have to
locate the anterior- superior iliac spine, with
their index and middle finger. In that position
move two fingers toward the midline and two
fingers down.
The patient has to collocate his finger in the
same place to feel the activation too.
The patient has to draw his belly button into his
spine to feel the activation or contraction of the
muscle.
It can be completed by some exercises (while
performing them this muscle has to be
activated with a good breathing):
1. Flexion and extension of the knee
2. With both knees flexed, alternately lift the
heels off the table
3. Raise the arms alternately
B) MULTIFIDUS MUSCLE:
The patient is in a sitting position on the edge
of the stretcher with their feet in the ground.
They should have their back straight.
The patient has to feel the multifidus muscle
with their thumb. To palpate it, he has to put
their thumbs in every side next to the spine,
just where this muscle is
The patient has to move forward without
bending their back.
The patient is in a prone position.
The patient has to palpate the muscle with one
hand and the contralateral arm has to flex the
shoulder, trying not to rotate the trunk
