My spinal assessment:
The first stage of the spinal assessment is observation, it is important to look for swelling, scarring, deformity and changes in spinal curvature (Been & Kalichman, 2014; Weiss et al., 2016). I observed the patient in both sitting and standing, mainly focusing on their sitting position as they experience pain in the lumbar spine when seated; when seated the lordosis of the lumbar spine is decreased (Diana, De Carvalho, David, Ross, & Callaghan, 2010; Mörl & Bradl, 2013), and the spine is in a flexed position. It is important to assess the spine in the position that causes the pain, to achieve a valid observation. I then asked the patient to lie supine and measured their leg length to check that they were not suffering from true or apparent leg length discrepancy. I first measured their apparent leg length by seeing if their pelvis was level and then measuring from their naval to their medial malleolus (Sabharwal & Kumar, 2008), apparent leg length discrepancy can be caused by tightening of tissues around the hip and knee. They were suffering from apparent leg length discrepancy so I progressed onto checking their true leg length by measuring from their anterior superior iliac spine (ASIS) to their medial malleolus (Jamaluddin et al., 2011), which was equal on both legs, indicating no true leg length discrepancy. Leg length discrepancy (LLD) can cause lateral tilt of the pelvis and lumbar spine, leading to asymmetrical weight-bearing and thereby causing back pain (Kendall, Bird, & Azari, 2014).
The next stage of the spinal assessment is palpation, during palpation I felt for swelling and changes in temperature which could indicate underlying trauma. I palpated the spinous and transverse processes to check for any vertebral fractures, I also palpated the interspinous ligament which connect adjoining spinous process (Biel, 2014). I then palpated the iliac cress and the PSIS before palpating the spinal muscles including the erector spinae, quadratus lumborum, Piriformis, Psoas major and thoraco-lumbar fascia. When palpating the muscles, I felt for any tightness which could be caused by muscle spasm or muscle guarding which can occur in the presence of pain (O’Sullivan & Ivan, 2014).
I asked the patient to actively perform the lumbar movements of flexion, extension and side bending and I applied overpressure at their end range to check end feel (Magee, 2014). A soft end feel is normal in both flexion and side flexion while a hard end-feel indicates an underlying issue, however, a hard end-feel in extension is not a cause for concern unless it is accompanied by pain and reduced ROM. The patient was suffering from pain and reduced ROM in flexion and side flexion. This highlights the importance of checking end feel, as these symptoms accompanied by a soft end feel is often a sign of muscle tightness (which can be improved by stretching). In contrast, a hard end-feel with pain and reduced ROM is a sign of facet joint problem. However, the two are not mutually exclusive and it is common to experience the two together.
I asked the patient to point to the area of pain which was around L3-L4, therefore I began palpation on this spinous process. I performed passive accessory intervertebral movements at the end range of L3 spinous process and asked the patient if they felt any pain. They did not experience pain therefore I moved onto the transverse process of this vertebrae and performed a deep mobilisation, which showed no symptoms. I checked the transverse process on the opposite side before moving to the vertebrae below (L4), the patient reported pain during the deep mobilisation of the transverse process, so I continued to treat this vertebra using Maitland mobilisations at a grade 3(Saini, 2012; Samir, Zak, & Soliman, 2016). Grade 3 and 4 are effective at increasing ROM (Saini, 2012)as they reach the end range, whereas grade 1 and 2 only reduce pain; the first two grades are only used if the patient has high irritability and therefore cannot cope with deeper pressure. It is essential to check that the patient is not suffering from a discogenic problem before proceeding with mobilisations. In contrast, if the patient was suffering from a discogenic problem the physical therapy technique called McKenzie approach can be used to centralise the pain (Donelson, Silva, & Murphy, 1990). This technique involves the patient repeatedly performing a lumbar movement to see if it improves their symptoms (Holdom, 1996), if it does, this movement is used as the treatment plan, if it does not then another movement is tried.