Having digested the information supplied by the referring doctor, extracted as much relevant information as possible from the patient, and checked the radiologist’s report, we may proceed to the examination proper.
If the patient is able to do so, we should make him sit on a straight backed chair while taking his history. During this lime he will reveal the true nature of his sitting posture. When the patient rises to undress after the interrogation we should observe the way he rises from sitting, his gait, the way he moves, and any deformity that may be obvious.
We will record the following:
I. POSTURE SITTING
If the patient has been sitting during history taking, we already have a good impression of his posture. We now ask him to sit on the edge of the examination table with his back unsupported. In the majority of cases the patient will sit slouched with a flexed lumbar spine. Some patients are more aware of the relationship between their posture and pain. They have discovered that they can control their sitting pain by sitting upright and may sit very well on first observation. Unfortunately, these patients are few and far between.
Fig. Relaxed sitting posture.
II. POSTURE STANDING
We examine in particular the following features:
1. Reduced or accentuated lordosis
The most common postural fault to be observed in the standing position is the flattened lumbar spine or reduced lordosis. Some patients have a deformity in kyphosis.
Another common deformity or departure from the ‘norm’ is the patient exhibiting an accentuated lumbar lordosis. Though much less common than the flattened spine this is clearly a separate category and should be treated accordingly.
Fig. a. – Reduced lumbar lordosis. b. – Accentuated lumbar lordosis. c – Lateral shift to the right.
2. Lateral shift
A departure from the midline causing a lumbar scoliosis or lateral shift is evident in about fifty-two percent of patients. There are many reasons for the lumbar spine to depart even slightly from the midline: the anatomical configuration of the joint surfaces may dictate this; a congenital anomaly may be present; there may be some remote mechanical cause; and an alteration in the position of the disc nucleus may be responsible.
The lateral shift is sometimes barely discernable, and great care must be taken to ensure that the deformity is not overlooked. This is important because some movements, especially extension, produce pain when performed in the presence of a lateral shift, whereas if there was no shift they would be painfree. We must never fail to recognise a minor lateral shift and its possible role in the production of symptoms.
I have chosen to describe a right lateral shift — or a lateral shift to the right — as the situation which exists, when the vetebra above has rotated and laterally flexed to the right in relation to the vertebra below, carrying the trunk with it. Thus the top half of the patient’s body has moved to his right in relation to the bottom half.
3. Leg length discrepancy
If a leg length discrepancy is encountered, we must investigate the relevance of the discrepancy to the patient’s symptoms. When in the history there is no record of pain being enhanced by standing and walking, the difference in leg length is not likely to be relevant. But when pain is produced by standing or walking, we should increase the length of the short leg to bring about symmetry and await the effect of this on the patient’s symptoms. When relevant, leg length adjustment causes a fairly rapid change in the symptoms experienced during standing and walking. This change should become apparent within a few days at the most.
There are various methods of measuring the leg length, but the only truly reliable way to detect minor differences in leg lengths is by taking an x-ray of the pelvis and both full legs with the patient in standing. However, it is doubtful that minor leg length discrepancies cause significant low back pain.
At this stage, with the patient still standing, it may be advisable to quickly test the integrity of the conduction of the lower lumbar and upper sacral nerve roots. Therefore we ask the patient to walk on his toes and then on his heels. In case of difficulty or when in doubt about the outcome a more detailed neurological examination must be performed.
III. EXAMINATION OF MOVEMENT
Here we are interested in observing the quality of the movement itself — that is, the range of movement and the movement pathway. We will determine if there is a movement loss and if deviation from the normal movement path takes place. The word ‘pain’ should not be mentioned until we are ready to assess the effects of the movements on pain.
The patient should be standing with his feet about thirty centimeters apart and only one movement will be performed in the direction to be evaluated. We examine:
This is the first movement to be examined, because in patients with dysfunction or derangement the flexion movement provides us with the most relevant information regarding the nature and the degree of the disturbance. The standing patient is asked to run the hands down the front of both legs, moving as far as possible into flexed standing, followed immediately by returning to neutral standing.
Fig. Examination of movement — flexion.
Any loss of flexion should be noted. Loss of flexion manifests itself in one of two ways: either the end range of flexion is limited, or a deviation from the normal pathway of flexion has developed. In some patients with a severe loss of flexion end range, the lumbar lordosis is still present after the patient has bent forward as far as possible, in others the lumbar spine merely remains flat. Any asymmetrical impediment to flexion may cause the spine to take the path of least resistance, resulting in a deviation from the sagittal pathway. By far the majority of patients with a flexion loss divert from the sagittal plane during flexion and deviate to one side or the other of the midline. This may occur in an arc-type of movement, the flexion commencing and ending in midline positions; or, once movement is commenced, it may divert from the midline and increase its departure for as long as flexion is continued.
Deviation in Flexion
In my experience there are three clearly defined and separate causes for deviation in flexion. The mechanism is different in each case and the treatment must be varied accordingly. Thus deviation in flexion may be due to:
- (a) Derangement within the vertebral joint. In this situation the altered position of the fluid nucleus compels a deviant flexion pathway. Generally, the deviation in flexion occurs away from the painful side as long as there is no sciatic nerve root irritation. In some patients the deviation is variable and will occur one day to the left and the next day to the right.
- (b) Dysfunction within the vertebral joint. This develops following repair of damage after derangement. In this situation the consequent scarring by fibrous connective tissue prevents flexion in the sagittal plane and the deviation may take place towards or away from the painful side, but is never variable.
- (c) Dysfunction external to the vertebral joint. This exists in the presence of an entrapped or adherent sciatic nerve root. In this situation the root is no longer able to lengthen adequately and allow flexion to occur in the sagittal plane. It will now act as an anchor and pull the patient during flexion towards the side of root adherence. The deviation in flexion may become very severe and always take place towards the painful side.
The standing patient is asked to place his hands in the small of the back and bend backwards as far as possible, followed immediately by returning to neutral standing.
The loss of some degree of extension is very common after the age of thirty. Any limitation of extension evident in the lumbar spine should be recorded as well as the presence of a deviation in the extension pathway which is occasionally encountered. Major disc bulging will cause a deviation in extension away from the side of the pain and enhancement of sciatica will occur. However, facet apposition in full extension usually prevents significant deviation.
3. Side gliding
Having considered over the past twenty-five years the relevance of the information obtained by assessing the movements of rotation and side bending separately, I have come to the conclusion that it is better to combine the two movements in the one movement of side gliding.
In order to examine side gliding the standing patient is asked to move his shoulders and pelvis simultaneously in opposite directions while keeping the shoulders parallel to the ground. As some patients have difficulty in performing this movement, it may be necessary to assist the patient by guiding the movement with a hand placed on one of his shoulders and the other hand on his oppositic iliac crest.
Fig. Examination of movement — extension. Examination of movement — side gliding.
The side gliding movement is frequently unilaterally impaired. When the patient has a lateral shift, there is always some unilateral loss of side gliding. In this situation the movement is restricted or completely blocked in the direction opposite to the lateral shift.
IV. MOVEMENTS IN RELATION TO PAIN
After examining the lumbar spine in relation to function, we must now investigate the effects of various movements on the pain. Let us assume that pain is produced by mechanical deformation as described by Wyke. As discussed before, stresses applied to soft tissues will under certain circumstances be productive of pain. Any attempt to force normal movement (application of abnormal stress) in a joint with a visibly impaired function (abnormal tissue), must result in the production or enhancement of pain.
In order to stress the joints in a controlled manner and avoid exacerbation I have devised a sequence of test movements, the mechanics of which are relatively well understood and the effects of which can be controlled. By applying the test movements during the examination we will enhance pain under some circumstances and reduce it in others. Information gained by deliberately stressing the joints is vital and enables us to select and categorise patients into three groups — that is, patients with pain arising from postural, dysfunctional or derangemental causes.
The test movements are first performed in standing and then in lying. When performed in lying they must be done in such a way that the effect on the lumbar spine is a passive stretch, and any form of active movement produced by the muscles surrounding the lumbar spine should be avoided. In this way we can achieve a better end range stress than with active movements.
When the test movements are performed in standing a normal stress is applied to normal or abnormal tissue; in the former case no pain will be produced; in the latter case pain will be produced or increased if the test movements enhance the mechanical deformation, but pain will be decreased or abolished if the test movements reduce the mechanical deformation. When the test movements are performed in lying a passive stress is added by the patient and an abnormal stress is applied to normal or abnormal tissue; in the former case no pain should result, because the stress is not excessive and is only applied momentarily; in the latter case pain will be produced or increased if the test movements enhance the mechanical deformation, but pain will be decreased or abolished if the test movements reduce the mechanical deformation.
If we are to relate movements to pain, the test movements must be performed in such a way that they produce a change in the patient’s symptoms. This change may be brought about in various ways: if prior to movement pain is present, the test movement may increase or reduce its intensity; it may alter the site of the pain by centralisation or by abolishing one pain and introducing another one. If prior to movement no pain is present, the test movement may produce the pain complained of.
If there is no change in the patient’s symptoms during or immediately following the test movements, the joints have not been stressed adequately and the process should be repeated more vigorously. It may also be that the pain is not of mechanical origin, because mechanical pain must be and always is affected by movement or position. Or, alternatively, the lumbar spine is not causing the problems and other areas should be investigated.
When assessing the results of the test movements it is important to examine the effects of repeating them. Repeated movements are vital in the examination of spinal segments when disc pathology is suspected and it is necessary to determine if a derangement situation exists. It is my belief that with movement of the vertebral column the nucleus can alter its shape, and with sustained positions or repeated movements it will eventually alter its position. Clinically this manifests itself in the derangement syndrome by a change in intensity or site of the symptoms. A decrease or centralisation of pain is absolutely reliable in indicating which movement should be chosen to reduce mechanical deformation. I have learnt to rely implicitly on centralisation as the most important clinical guide to establish the correct direction of movement which will reduce derangement. An increase or peripheralisation of pain is just as reliable in indicating which movement should be avoided because it enhances mechanical deformation. If there is an increase or peripheralisation of pain when performing any technique or movement, a worsening of the condition of the patient is likely. There is one exception to this rule: the patient with an adherent nerve root in chronic sciatica. There are special tests which easily identify this condition, and these will be discussed later.
In derangement the performance of repeated movements in the direction which increases accumulation of nuclear material will result in a progressively increasing derangement and increasing or peripheralising pain. The performance of repeated movements in the opposite direction will result in a reduction of the derangement and reduction or centralisation of pain. Thus, repeated movements are diagnostic in derangement pathologies.
In dysfunction the performance of repeated movements in the direction which stretches adaptively shortened structures will produce pain at the end range of movement, but repetition does not make the patient progressively worse. When he returns to the neutral position the pain will disappear. Thus, repeated movements are diagnostic in dysfunction as well.
Patients with the postural syndrome will not experience pain with any of the test movements or their repetition. These patients must be positioned in order to have their pain reproduced.
Apart from exposing the derangement and dysfunction syndromes, repeated movements are essential in determining whether the timing is appropriate to commence stretching procedures following trauma and derangement. When repeated movements, applied to painful structures, produce less and less pain with each repetition these structures should be exercised. On the other hand, when more and more pain is experienced with each repetition exercising is not indicated and more time should be allowed for the condition to heal. This fundamental response of pain sensitive structures to stress must be applied to soft tissue lesions throughout the musculoskeletal system in order to determine whether a passive or an active treatment approach should be developed.
The movements that I have chosen as test movements are the ones of flexion, extension and side gliding. In my experience these movements will induce or reduce mechanical deformation in the lumbar spine quicker and more effectively than any other movement. Generally speaking, the movements that produce the greatest amount of mechanical deformation and therefore pain can, when reversed or modified, be used to have the greatest effect on the reduction of that mechanical deformation and pain. For example, rotation is rarely complained of as producing significant pain and therefore neither enhances nor reduces mechanical deformation significantly. On the other hand, flexion and extension are commonly stated to be the most painful movements and are potentially the most useful movements for treatment purposes.
Different effects are produced when the tests movements are performed in standing compared with lying. This requires further discussion for both flexion and extension.
Flexion in standing compared with flexion in lying
In the test movements flexion of the lumbar spine is examined in two ways: in standing by bending the trunk forwards; and in supine lying by using the hands to passively bend the knees onto the chest. Apart from the obvious difference achieved by removal of gravitational stress in flexion in lying, there are two major points to note:
In flexion in lying the flexion takes place from below upwards, the L5-S1 joint moving first followed by flexion in turn of each successively higher segment. On the other hand, in flexion in standing the flexion occurs from above downwards.
A better flexion stretch is obtained, especially at L5-S1, by the passively performed flexion in lying, and patients with flexion dysfunction describe a stretch pain in flexion in lying which they may not experience in flexion in standing. Frequently in flexion in lying, pain is produced immediately when the movement commences and the pain increases as the degree of flexion increases. Thus, in flexion in lying pain is produced as soon as the L5-S1 segment (and perhaps L4-L5) is placed under full stretch which occurs immediately flexion is initiated. In flexion in standing the pain will only be experienced at the end of the movement, because only when flexion in standing is almost full are the L4-L5-S1 segments stretched to the full.
The effects on the sciatic nerve roots are different in flexion in standing and flexion in lying. In flexion in standing the sciatic nerve is fully lengthened and placed on full stretch, producing effects identical to those obtained in straight-leg-raising tests. Flexion in lying, when performed with simultaneous hip and knee flexion as described, has no such effect and root adherance or root tension can not be identified in this manner.
The production or enhancement of sciatic pain by flexion in standing may be caused by a bulging disc or an adherent root. However, production or enhancement of sciatic pain by flexion in lying can only be caused by a bulging disc. We have now at our disposal a simple test to differentiate between disc bulging and root adherence. No one should persist with the performance of flexion in lying in the presence of increasing referred pain. Such perserverance can be rewarded by the production of a severe disc lesion.
Extension in standing compared with extension in lying
In the test movements extension of the lumbar spine is examined in two ways: in standing by bending the trunk backwards; and in prone lying by passively raising the trunk, using the arms instead of the back muscles and at the same time keeping the pelvis down. Both manoeuvres cause extension of the lumbar spine from above downwards. There are two major points to note:
The gravitational forces applied to the joints are different in extension in lying and extension in standing. In extension in lying the weight of pelvis and abdomen causes an increase of extension range in the joints of the low back. The force exerted is almost perpendicular to the plane of the body and has a maximal mechanical effect. In extension in standing the gravitational forces act on the joints of the low back at an angle of up to forty five degrees from perpendicular and are therefore less efficient. The greatest extension stretch that a person can apply to his own back is by performing extension in lying. The extension range and stretch are never as complete in extension in standing.
In extension in standing the compressive forces appear sometimes sufficient to prevent full end range movement. This would indicate that some derangements are too large to be reduced in the presence of compressive forces in standing. However, reduction of the same derangements becomes possible in the prone lying position, when the vertical compressive forces are removed.
I believe that there must be other factors, unexplained as yet, which contribute to the purely mechanical effects of exercises performed in lying and in standing. Gravitational or compressive forces alone do not account for the nature of the differences which can be observed clinically.
THE TEST MOVEMENTS
All patients should perform the test movements except when they are in such severe pain that it is intolerable to do so. This only occurs in major derangement situations, and it may be necessary to place such patients on bed rest in order to facilitate reduction of the derangement by removing gravitational stresses. After a period of twenty-four to forty-eight hours in bed, positioned so that reduction may be enhanced, re-assessment should follow.
Flexion in standing
The patient, standing with his feet about thirty centimeters apart, is asked to run his hands down the front of both legs as far as range and pain allow. He then immediately returns to neutral standing. With the hands actually placed on the legs the more acute or insecure patients will feel safer in performing flexion. Flexion in standing is performed once and its effects on the pain are recorded. The movement should then be repeated up to ten times and the effects of repetition recorded. We must ensure that maximum possible stretch is obtained during the last few movements.
- Flexion in standing — produces (R) buttock pain at end range.
- Repealed flexion in standing — worsens (R) buttock pain and produces (R) calf pain.
Fig. Test movements — flexion in standing. Test movements — extension in standing.
Extension in standing
The patient, standing with the hands in the small of the back to act as a fulcrum, is asked to bend backwards as far as possible. He then immediately returns to netural standing. The test movement is performed once and its effects on the pain are recorded. The movement should then be repeated up to ten times and the effects of repetition recorded. We must ensure that maximum possible stretch is obtained during the last few movements.
- Extension in standing — produces central back pain.
- Repeated extenstion in standing — reduces central back pain.
If extension in standing increases or peripheralises the pain, we must consider the possibility of the presence of a lateral shift. If a lateral shift is present and is relevant to the patient’s symptoms, the performance of any of the test movements with the shift uncorrected will always increase mechanical deformation and thus enhance pain. Extension in standing following shift correction will reduce the derangement and thus decrease the pain.
Side gliding in standing
This is done to determine whether side gliding increases or decreases mechanical deformation and, in the presence of a lateral shift, to test the relevance of the shift to the patient’s symptoms.
Fig. Test movements — side gliding in standing with operator-assistance.
As some patients find it difficult to perform side gliding in standing the examiner may initially have to assist this movement. The patient stands in front of the examiner, who places one hand on one of the patient’s shoulders and the other hand on the patient’s opposite iliac crest. The examiner presses both hands towards the midline, causing a major movement of the top half of the patient’s body in relation to the bottom half. Instead of applying the pressure on the patient’s shoulder, it may under certain circumstances be preferable to press against the side of his rib cage. In all instances both shoulders of the patient should remain parallel to the ground. Side gliding must be tested first in the one and then in the other direction, before the sequence is repeated. The effects of the test movements on the pain should be recorded.
- (L) side gliding — increases (R) buttock pain and produces (R) calf pain.
- (R) side gliding — reduced (R) buttock and calf pain.
- Repeated (L) side gliding — not indicated as it is likely to worsen the symptoms.
- Repeated (R) side gliding — reduces (R) buttock pain, abolishes (R) calf pain.
When side gliding is found to be painful and blocked usually a lateral shift is present and in the treatment therapist assistance may be required.
When side gliding is found to be painful but not blocked, a lateral shift is unlikely to be present and in the treatment, therapist assistance is usually unnecessary.
When assessing the relevance of a lateral shift, we must determine whether the shift results from the same mechanical distrubance which has produced the patient’s pain. The shift is considered to be relevant when the movement of side gliding alters the site or intensity of the pain. If no pain change occurs during the performance of side gliding to the one side or the other, the scoliosis cannot be considered part of the mechanical problem causing pain.
Flexion in lying
The patient, lying supine with the knees flexed and the feet flat on the couch, is asked to bend the knees onto the chest. Clasping the knees with his hands he applies a firm pressure to produce maximum possible lumbar flexion.
The legs are then lowered to the starting position. The effects of the first test movement on the pain are recorded. The movement should then be repeated up to ten times, ensuring that the maximum possible stretch is obtained during the last few movements. The effects of repetition are recorded.
- Flexion in lying — increases pain (R) L5.
- Repeated flexion in lying — worsens pain (R) L5 and produces (R) buttock pain.
Fig. Test movements — flexion in lying.
Extension in lying
The patient, lying prone with the hands directly under the shoulders as in the traditional press-up position, is asked to raise the top half of his body by straightening the arms, at the same time keeping the thighs and legs on the couch (Fig. 7:10). If the pelvis lifts from the couch as the arms are straightened, we must make sure that the low back is allowed to sag as much as possible. The patient then returns to the starting position. The effects of this movement on the pain are recorded. The movement should then be repeated up to ten times, ensuring that the maximum possible stretch is obtained during the last few movements. Again, the effects of repetition are recorded.
- Extension in lying — reduces (L) buttock pain.
- Repeated extension in lying — abolishes (L) buttock pain and produces central low back pain.
Fig. Test movements — extension in lying.
The test movements should be performed in a certain sequence. The examiner should not deviate from this method, unless it is obvious that to persist will inflict unnecessary pain on the patient.
In abbreviated form the sequence of test movements is as follows:
- FIS (flexion in standing)
- Rep FIS (repeated flexion in standing)
- EIS (extension in standing)
- Rep EIS (repeated extension in standing)
- SGIS (right and left side gliding in standing)
- Rep SGIS (repeated right and left side gliding in standing)
- FIL (flexion in lying)
- Rep FIL (repeated flexion in lying)
- EIL (extension in lying)
- Rep EIL (repeated extension in lying)
V. OTHER EXAMINATION PROCEDURES
At this stage it is appropriate to test the mobility of the hip joints and the integrity of the sacro-iliac joints, if these are thought to contribute to the problems of the patient. Should passive stretching of the various structures about the hip reproduce the symptoms complained of, this joint must be considered a possible source of the pain. The sacro-iliac joints, although not commonly the cause of low back pain, turn out to be involved often enough to make a fool of those failing to check them. In my opinion the tests described by Cyriax are adequate to determine if the symptoms are arising from these joints. (Testing of sacro-iliac structures by using bony prominences as land marks and attributing pain to asymmetries so located is dishonest.)
A more detailed neurological examination may be required, if there is the slightest suggestion of nerve root or spinal cord signs. In these cases the patient’s symptoms will be felt in the lower limb. Further neurological examination should include testing of reflexes, muscle strength and sensation.
The correlation of information from history, examination and test movements will indicate whether the patient is suffering from the postural, derangemental or dysfunctional syndrome. This differentiation is essential, as it indicates which principle of treatment should be used.
In the postural syndrome postural correction is the only treatment required.
The extension principle
In posterior derangement the extension principle should be applied when extension reduces mechanical deformation. Thus in the treatment we are making use of those movements which centralised, decreased or stopped the pain during the examination. The patient should receive mechanical therapy based on the principle of extension. This includes: passive extension, extension mobilisation, extension manipulation, extension in standing, extension in lying, and sustained extension.
Patients with an acute lumbar scoliosis or a lateral shift are placed in the extension principle category once correction of the lateral deformity has been achieved.
In dysfunction, however, the extension principle should be applied when extension produces mechanical deformation. Thus in the treatment we are making use of those movements which actually produced the pain during the examination. For treatment of dysfunction to be successful it is imperative that some pain be experienced, especially in the initial stages when adaptively shortened tissues must be stretched enough to assist them to regain their original length and elasticity. Pain thus produced during treatment of extension dysfunction must always be across the back and near the midline, and significant buttock pain should not occur. The treatment procedures are based on the principle of extension (see above).
The flexion principle
In anterior derangement the flexion principle should be applied when flexion reduces mechanical deformation. Again, in the treatment we are making use of those movements which centralised, decreased or stopped the pain during the examination. The treatment consists of procedures based on the principle of flexion. This includes: flexion mobilisation, flexion manipulation, flexion in lying, and flexion in standing.
In dysfunction, however, the flexion principle should be applied when flexion produces mechanical deformation, and in the treatment we use those movements which actually produced the pain during the examination. Some pain must be experienced in treatment of flexion dysfunction to be effective and treatment consists of procedures utilising flexion (see above).
in the treatment of derangement we must choose the movement that relieves the pain, as this movement decreases the mechanical deformation by reducing the derangement.
in the treatment of dysfunction we must always choose the movement that produces the pain, as this movement will gradually stretch and lengthen contracted soft tissues, eventually reducing mechanical deformation.
About seventy-five to eighty percent of all the patients with low back pain will respond to the extension and flexion programmes. These patients have a very good chance of becoming independent of therapists. They will be able to perform exercises to relieve themselves of pain without requiring techniques performed by specialist therapists. The remaining twenty to twenty-five percent of patients will require special techniques and manipulative procedures. The experienced practitioner will be able to identify these patients with a trial of test procedures carried out over a twenty-four hour period.
Hopefully at this stage we will be able to categorise patients into the appropriate syndrome and adopt a principle of treatment. We are now ready to teach the patient how to correct the posture, restore lost function and, where possible, reduce derangement himself.
I will proceed with a discussion of the procedures which may be used in treatment, as these will be frequently referred to in chapters to follow. Then I will consider the three syndromes and their respective treatment approaches individually.