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Lab 4: Back and Pelvis
Group 5
Jessi Bradley
Tara Roberto
Corrin Porter
Kathryn Pearson
Matt Verboom
Jimmy Warner
Functional Ability Tests
-Flexion
-Extension
-lateral rotation
-Lateral Flexion
Case Study
• A 45 year old male suffered from a muscular tear to the erector spinae
at level L2 of the spinal column and experienced muscular spasm and
extreme pain due to the lifting motion performed while lifting a case of
beer from the trunk of his car. The patient is 50 lbs overweight. He is
sedentary and has problems adhering to an eating control plan. He has
been treated for muscle spasm with anti inflammatory medication and
muscle relaxants. He has also received physiotherapy treatment to
enable mobility and basic movements only. He now has 60% flexion
range and is 20 degrees from full flexion and is limited in lateral
flexion and rotation. Work related activities include driving a delivery
van and unloading packages up to 100 lbs plus he enjoys golf as a
recreational activity 3 times a week. The client has been referred for
physiotherapy and has been treated for 2 weeks and now requires
range testing, flexibility and strengthening exercises.
The General Scan
• Look for any one of the following conditions:
– Deformations
– Symmetry/Asymmetry
– Swelling
– Skin discolouration/echymosis
– Palpate for scar tissue
– Check for structural deformities
– Pain Scale 1-10
– Mechanism of injury (ie. Lifting the case of beer)
Contraindications and Precautions
for Range of Motion Testing
• Active and passive range of motion are not to be
assessed if any of the following conditions are
present in a client:
– If a dislocation or unhealed fracture is present
– Immediately following surgery only if motion to the
area will not interfere with the healing process
– The presence of myositis ossificans. The client should
be referred to a professional who maintains expertise in
this area.
Contraindications and Precautions
(continued)
The therapist must take great caution when performing AROM and
PROM assesments where motion can irritate a condition further.
• Presence of infections or inflammation
• Patient taking pain medication or muscle relaxants
• Region marked by osteoporosis or where bone fragility is a
factor
• Hypermobility or subluxation at the joint
• Regions with hematoma
• Patients with hemophilia
• Regions with boney ankylosis is suspected
• Regions with newly united fractures
• Prolonged immobilization of a joint.
Functional test #1 Trunk Flexion
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Ask client to tie shoe lace, or
pick up an object off the floor.(90-95 % of full
flexion)
Bend over until client feels mild discomfort or pain
Ask patient to move from standing to sitting and return to
standing position. (Requires 56-66% of full lumbar ROM)
Once trunk is in “critical position” erector spinae muscles
relax and further flexion occurs through hip flexion. (greater
than 70% and often between 80-90%)
Trunk flexion initiated by contraction of abdominals and
vertebral portion of the psoas major m.
– Prime movers of trunk flexion are the
abdominal muscles (rectus abdominus, internal/external
obliques)
– iliopsoas and psoas major are secondary movers
Functional test #2 Extension
• Ask client to bend over and pick up box
• Watch as client extends upward
– Erector spinae(longissimus, iliocostalis,spinalis mm.), multifidus as
well as gluteal muscles allow for extension of the upper torso
– Erector spinae muscles contracts to initiate trunk extension in
standing position.
– When extension is performed against resistance, the erector spinae
muscle contracts to perform the entire movement.
– Ie: when in prone position the trunk is extended to reach for a light
switch located at the head of the bed.
– When lifting objects off the floor from a forward flexed position,
there is no contraction of the erector spinae muscles at the beginning
of the lift. The thoracolumbar fascia, posterior intervertebral
ligaments, and the elastic forces created by the extensor take the load
to extend. Then the erector spinae takes over at the “critical
position.”
– The range of motion during extension is limited by the spinous
processes of the vertebrae.
Functional Test #3 Trunk Lateral
flexion
•Not often used in activities.
Ask client to pick up an object from a low table while facing
perpendicular to that object.
• Ask patient to move from side-lying position to sitting position
• Lateral flexors contract on the ipsolateral side to initiate movement and
contract on the contralateral side to modify movement to upright
position.
• Erector spinae, intertransversarii, and posterolateral fibers of the
external abdominal oblique, qudratus lumborum, and iliopsoas muscles
contribute to lateral flexion of the trunk.
•The range of motion is limited by the inferior aspect of the ribs
contacting the iliac crest.
PASSIVE RANGE OF MOTION
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Passive movement when used as an assessment method is called passive range
of motion or PROM, and muscle length assessment
The therapist uses PROM to determine the ROM at a joint, end feel, and the
length of muscles
Normal range of motion for lumbar spine flexion is 0-80 degrees
PROM: Flexion
Test for Flexion in the Thoracolumbar Spine
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Start Position: The patient is standing with feet shoulder width apart
End Position: The patient flexes the trunk forward to the limit of motion for
thoracolumbar flexion
Measurement: A tape measurer is used to measure the distance between the
spinous processes of C7 and S2. A measure is taken in the start position and at
the limit of motion. The difference between the two measures is the
thoracolumbar spinal flexion range of motion (about 10 cm)
Substitution/Trick Movement: None
PROM: Flexion
Test for Flexion in the Lumbar Spine
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Start Position: The patient is standing with feet shoulder width apart
End Position: The patient flexes the trunk forward to the limit of motion
Measurement: A tape measurer is used to measure a distance and make a point
10cm about the spinous process of S2. A measure is taken in the start position
and at the limit of motion. The difference between the two measures is the
lumbar spinal flexion range of motion. The method of measurement is referred
to as the modified Schober Test
Substitution/Trick Movements: None
Ligaments for Flexion of the Trunk
Anterior Longitudinal Ligament
• a thick band of fibrous tissue that runs along the anterior surfaces of vertebral
bodies. It extends from the anterior tubercle of the atlas bone inferiorly down
the full length of the spinal column to fuse with the upper, pelvic surface of the
sacrum. It guards against hyperextension of the spine
Supraspinal Ligament
• The supraspinal ligament (supraspinous ligament) is a strong fibrous cord,
which connects together the apices of the spinous processes from the seventh
cervical vertebra to the sacrum; at the points of attachment to the tips of the
spinous processes fibro cartilage is developed in the ligament. It is thicker and
broader in the lumbar than in the thoracic region
Interspinal Ligament
• The interspinal ligaments (interspinous ligaments), thin and membranous,
connect adjoining spinous processes and extend from the root to the apex of
each process. They meet the ligamenta flava in front and the supraspinal
ligament behind. They are narrow and elongated in the thoracic region;
broader, thicker, and quadrilateral in form in the lumbar region; and only
slightly developed in the neck
Ligamentum Flavum
• The ligamenta flava connect the laminæ of adjacent vertebræ, from the axis to
the first segment of the sacrum. They are best seen from the interior of the
vertebral canal; when looked at from the outer surface they appear short, being
overlapped by the laminæ. Each ligament consists of two lateral portions
which commence one on either side of the roots of the articular processes, and
extend backward to the point where the laminæ meet to form the spinous
process; the posterior margins of the two portions are in contact and to a
certain extent united, slight intervals being left for the passage of small vessels
Posterior Longitudinal Ligament
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The posterior longitudinal ligament is situated within the vertebral canal, and
extends along the posterior surfaces of the bodies of the vertebræ, from the
body of the axis, where it is continuous with the membrana tectoria, to the
sacrum.
It is broader above than below, and thicker in the thoracic than in the cervical
and lumbar regions.
Muscles for Flexion of the Trunk
Rectus Abdominus
• Muscle Origin: crest and superior ramus of pubis; ligaments covering the
anterior surface of the symphysis pubis
• Muscle Insertion: 5th, 6th, 7th costal cartilages
External Abdominal Oblique
• Muscle Origin: 8 digitations from the external and inferior surfaces of the
lower 8 ribs
• Muscle Insertion: anterior half of the outer lip of iliac crest; as the inguinal
ligament into the anterior superior iliac spine and pubic tubercle
Internal Abdominal Oblique
• Muscle Origin: lateral 2/3rds of the inguinal ligament; anterior 2/3rds of the
iliac crest; the thoracolumbar fascia
• Muscle Insertion: inferior borders of the ¾ lower ribs; pubic crest and medial
aspect of the pecten pubis
PROM: Extension
Trunk Extension in the Erector Spinae
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Start Position: patient lying in prone position with feet over end of bed and
pillow under abdomen
Stabilization: strap can be placed over pelvis to isolate lumbar extensors or can
use hand on lower back. Therapist places other hand proximal to ankles to
stabilize legs.
Movement: Grade 1-2: hands by side and raise off bed as high as is
comfortable
Grade 3-4: hands behind back and lift
Grade 5: hands behind head and lift
Substitution/trick Movement: None
Resistance: Not applied manually because the it is provided through arm
positioning . The resistance is increased as the upper extremities are moved
towards the head.
Muscles for Extension of the Trunk
Primary Muscles:
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Erector Spinae
Iliocostalis thoracis/ lumborum
Longissimus thoracis
Spinalis thoracis
Semispilalis thoracis
Multifidus
Accessory Muscles:
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Interspinales
Quadratus lumborum
Latissimus dorsi
PROM: Lateral Flexion
 Start Position: The patient is standing with the feet
shoulder width apart
 Stabilization: None
 End Position: The patient laterally flexes the trunk to the
limit of motion
 Measurement: A tape measure is used to measure the
distance between the tip of the third digit and the floor
 Substitution/Trick Movement: Trunk flexion, trunk
extension, ipsilateral hip and knee flexion, and raising the
contralateral or ipsilateral foot from the floor
Muscles of Lateral Flexion
Lateral Flexion
 Erector spinae
 Intertransversarii
 Posterolateral fibers of the:
-External abdominal oblique
-Quadratus lumborum
-Iliopsoas
PROM: Lateral Rotation
 Start Position: The patient is sitting with the feet supported
on a stool and the arms crossed in front of the chest
 Stabilization: The therapist stabilizes the pelvis
 End Position: The patient rotates the trunk to the limit of
motion. The therapist visually estimates the trunk rotation
ROM (45 degrees).
 Substitution/Trick Movement: Trunk flexion, trunk
extension, and shoulder horizontal abduction in the
direction of trunk rotation.
Muscles of Lateral Rotation
Lateral Rotation
 Erector spinae
 Multifidus
 Trunk rotatores
 Internal and external abdominal oblique’s
Soft Tissue Involved in Lateral Flexion
& Rotation
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Saggital plane; Frontal Axis
- anterior longitudinal ligament
- anterior atlantoaxial ligament
- anterior fibres of annulus
- anterior neck muscles
Frontal plane; Saggital axis
- spinal ligaments
- fibres of the annulus
Horozontal plane; Vertical axis
- costovertebral ligaments
- annulus fibrosus of the Intervertebral discs
Active Range of Motion
 Active range of motion or AROM is when the therapist
moves the patient into the desired range of motion until the
point of discomfort or pain.
 The same movements as done for passive range of motion
are then performed actively with the therapists assistance.
 The therapist much careful not to move the patient into the
end of range too quickly because may reproduce pain and
therefore must inform the patient when the movement has
gone far enough, if the therapist is not before met with
great resistance.
Active Range of Motion Movements
 Flexion: Standing to the side of the patient place one hand on their
thoracic spine and other on their lower and slowly bring them into
forward flexion. Have them relax their hands down towards their toes
and go as far as they will allow.
 Extension: Have the patient lying in the prone position and get them
to move their arms appropriately through each test grade (1-5) until
they can no longer life their chest from the table.
 Lateral Flexion: Patient stands with feet shoulder width
apart. Therapist presses on opposite side of the hand they
wish to reach down towards the knees (ie: apply pressure
on right should, therefore bending towards left knee).
 Lateral Rotation: Can be done sitting or standing. Patient
crosses arms over chest and therapist moves them in to
lateral rotation. Therapist applies pressure on right
shoulder to have them turn right and holds left hip so they
are just moving from lumbar spine, not the hips.
Exercise Prescription Factors
• It is extremely important to take caution with the spine when
prescribing exercise. The therapist must take into consideration the
patient’s ROM and make note of any substitutions or trick movements
that might be present. For example with trunk flexion the hip flexors
can come into play if the rectus abdominis m. is weak. Our patient’s
trunk flexion at the moment is limited to 60% which causes the rectus
abdominus muscles to activate flexion to this point while the hip
flexors come into play during the last 30-40% of the hip flexion.
Therefore following the recovery phase focus will have to be put on
strengthening and developing stabilization in the hip flexor muscles.
Furthermore, because of the presence of slight scarred tissue of the
erector spinae around L2 the client will need to strengthen the lower
back muscles once soft tissue recovery has completed.