Physical Therapy Continuing Education – How to Assess for Lumbar Spine Dysfunctions
Many hours, both in Physical Therapy school and Physical Therapy Continuing Education courses, are dedicated to learning how to access patients. We recently interviewed one of the leading rehab experts in regards to how he assesses the lumbar spine. Here are some of the questions and answers.
Interviewer: If we switch gears here to more assessment, can you describe how you assess lumbar spine patients?
Spine Rehab Expert: Yes. It’s probably not what people would expect a standard fare. If I’m really needing to sort out a back it will take me about three hours and it begins with an interview. I ask the patient about their pain patterns. What they perceive is causing the pain, in terms of activities, and motions, postures, and loads. What can they do without getting pain? When they roll over in bed, for example, do they get sharp pains? That would be an indication of unloaded spine instability, for example. So, we have a set of questions like that, probing them to try to understand the nature of their pain. Also other things, like what do they currently do for their back? What therapies have they tried in the past that haven’t worked, and this kind of thing.
Then we watch their movement habits, and this is huge. We watch from the very second they enter the waiting room. How are they’re sitting for example. Patients often sit in a way that causes their back pain. It’s almost paradoxical. If someone is flexion intolerant, they sit in flexion. If they’re extension intolerant they almost always sit in extension. So, that’s a huge clue. Simply watching them get out of the chair. If you know the signs you’ll see if they have gluteal deficiency and are hamstring dominant, for example, which is a very common pattern of those who’ve had chronic pain.
Then we watch them walk. Then if they are say an electrician, we might be watching them bend over, get down to the floor, get back up again, all this kind of thing. If they’re a sportsman or an athlete we will ask them to perform some of the athletic moves that are both painless and painful. So, these are signature movement patterns or habits that quite often, if they are not changed, will thwart the recovery of the patient.
Spine Rehab Expert: So, now we’ve understood what causes their pain and we’ve got some good ideas on taking it away. We now prove it with provocative testing. We try to provoke their pain. Does this make you worse? If they say, “yes” now we’re starting to fine tune it and hone in on levels, specific levels of their tolerance and capacity.
All of this is now used to guide the design of corrective and therapeutic exercise. Correct the patterns, the habitual patterns that are causing their pain and within their tolerance, and then design a progression; a therapeutic exercise starting off with corrective exercises. Stabilize those elements that need stabilizing. Mobilize those elements that are too stiff perhaps.
Then move into endurance training which has to found all strength. Adding more strength to a painful back is usually problematic in that strength, in the literature, doesn’t prevent future back troubles. The reason, as we’ve discovered, is you can take a strong person and they can do three or four perfect repetitions of a strength move and they are protected. On the sixth rep they’re starting to fatigue and they break form a little bit. That’s the time that they get their bad back. So, if you’re going to give repetitions of strength the patient or athlete absolutely has to have the endurance underneath to ensure perfect form.
Then once that is achieved we can move onto the real performance variable such as power and speed and that kind of thing. So, that’s a synopsis of the assessment and the progression through exercise.