LUMBAR SPINE PHYSICAL EXAM

Name
I. WTAL SIGNS Brachial B.P: Lt Height / Weight

Date
Rt )_

DOA
Pulse_ Temperature Respirations
Age

2. POSTURALALIGNMENT tr Forward head(lossof lordosis) tr Gothicshoulders/rounded Shoulders tr Thoracicflattening/scapular winging tr Thoracic-lumbar hypertrophy/striations tr Lumbarhyperextension/ Striations tr Glutealhypotrophy/hupertrophy

tr tr

Headtilt R/L Elevated (s) scapula

tr Knee(s)valgus El PesCavus tr I't ray valgus(bunion)R/L tr Knee (s) varus tr Pesplanus tr Rearfootvalgus/varus Quality sham / dull/ pull sharp/dull/pull sham / dull/ oull
sharp/dull/pull

tr ted thoracickyposis tr Pelvicunleveling tr Lossof lumbar lordosis tr Kneeshyperextension

3. ROM (active. active assistedand/or passive)(visual. inclino meter,other: Lumbar Range of Motion Pain McKenzieTests t pain = *1; J pain: -1 (deerees) Location of complnt (0-4 Grade) +2; No Change:0: Centrtlize: -2 Peripheralize= Flexion /6s 0t234 FIS : I R ep:+ 2+ 1, 0, -l -2: l Oreps:+ 2+ 1. 0. -l -2 Extension t30 0 r234 E I S : I R e p :+ 2 + 1 , 0 , - 1 - 2 ; l 0 r e p s :+ 2 + 1 . 0 . - l - 2

L Lat Flex
R Lat Flex

125 /25

0t234 01234

SideGliding: *2,*1,0,-1,-2;LimitedY / N: Blocked Y /N

Side Gliding: +2,+1,0,-1,-2; Limited Y / N: Blocked Y / N

4. OR'I'HOPEDIC E) LAM Gain Scale 0-4; Centralize -l: Lumbar L R Findines Facet: Kemp 0t234 0r234

DoubleSLR
Sacroiliac: Yeoman

0t234 0123 4 0 1234

0r234 0r234
01234
|5

Hibb

ralize: +1); OBJECTIVE: DD Mechanical,BP from Nerve Root Test L R Findines TJ. -/+ Nerve Tension: Chin to chest= LBP 0r234 0 1234 (70\ Supine SLR (A P) 0 r234 t 0 t234 FootDF + SLR 0 1234 0t234 Hip IR + SLR 01234 0t234 Well-leeRaise 0r234 0r234 SittineSLR 0 1 2 34 0t234
D tr n 3. Distraction: * "flip sign" 4. 'RegionalNeurology 5. Exaggeration

Waddell Non-organic LBP signs: Score

tr L Superficial Pain tr 2. SimulationTest: E Axial Cmpr; tr Trunk rotation

Level

5. NEUROLOGICAL EXAMINATION: Red F-lugz Rule out Nerve Root lesion Motor test: [cord level,nerve] Motor xl5 + I Reflex [cord level]
L
R

DTR fWexler)

Sensation

Exam (1.Pin;2.2pt 3.Vib; 4.Semmes-W

L R

Iliopsoas -Hip Flexion lTl2-L3l L2.L4 Quadriceps - Knee Ext. [L3,4 femoral n.] Hip adductors fL24 obturator n.l L4 Tibialis Anterior [L4, deep peroneal n.l L5 Ext Hall Long [L5, deep peroneal n.] Ext Dig Long/Brev [L5, deep peroneal n.] Gluteus Medius [L5, supr.slutn.l S1 Peroneus Lng/Brev [L5,S1 sup.peronealn] Gastrocnemius-soleus ISl, inf. glut. n.i Vestibular: I wnl Cerebellum: [J wnl

Tr2-L3

/5t
/5:
t1,

l5

ts
t5

(Ll,2l Cremasteric Patellar [L2,13,L4]

L PIA

R PIA

Tl2-L3 derm.

Patellar 1L2,13,L41
Hamstring / (semitendinosis) lL4. Ls, Sl,2l Achitles [S1]

t4: l4z _14:' t4|

t4
l4

La-LA dermatome
L4 dermatome L5 dermatome

-Js;
/5:

-ts
t5

14
S1 dermatome l4 Labrinth: E vrnl

I D.Columnsr Ll

wnl

I Cerebrum:

wnl:SOMA

I Babinski (Corticospinal tract) / UMN | Grlp/ Plnc h StreDgth I R l g h rh r o d : ( P r t u i n d u c . d Y / N ) Dor nrrt L/R (Clrcle) k/lbs: 2nd ks/br: | lst
Circumference Upp Ext.: Brach elbow) Low Ext.: Thigh Patella) / /

Pathological -

3rd

S p a s t i c / f l a c c i dP a r a l y s i s L / R I Clonus (L / R elb / | knee) I L e f t h . r d : ( P r t n l n d u c e dY / N ) kr/lbs I lst tslhs: 2nd kcrba: 3d

in. / cm ( iu. / cm (__" " above above AnteBr. Calf / in./cm( in. / cm

UE/LE

kdbs
"belowelbow) below patella)

Chest: Insp_

Exp_

ICS)

Revised l0/03

NAME
6. FUNCTIONAL TEST
Lower Quadrant Test Single leg balance / Trendelenburg's sign Repetitive Squat Repetitive Lunges Thomas Test Hamstring Flexibility / SLR Long sitting ) suPine revealed:

DATE
Exam Findings

(Pe.2 L-spineExam)

Poor balance El Heel raises (tight gastroc/ soleus)

Weak glut. Medius

tr f V lordosis

E Lossoflumbarlordos E e T i g h t R / L p s o a st r T i g h t R i L q u a d t r T i g h t R / L T F L isL.ossofBalanc tr
Psoastightness/ hip ext / 10" Quad tightness/ knee flex _ / 90' TFL tighfness

(90")

tr

LBP

El Radicular Sx

Pelvic tilt coordination

Pass / Fail
Pass / Fail
Pass/ Fail Pass/ Fail

Lower abdominal weakness min / mod / max

Curl-up test
Hip extensionPattern Sorrensen's Test Hip abduction pattern Hin
Normal MM Abduction L / R Adduction

weaknessmin / mod / max Upperabdominal E Lumbarhyperextension / rotation

sec/ 60 sec

tr Overuseof TFL

tr V ed ROM

of QL) EI Overuse ofpsoas E Overuse oflTband tr Hip Hike (overuse

L /R Flexion L /R Extention L /R InternalRotation L/R ExternalRotation L/R

50
Glut nledius

30
Adductor longus

135
Iliopsoas

30 Glut Max

40
Adductor longus. brevis

60
Glut nut obt. exl

Hip Test Fabere Trendelenberg Hibb's Knee

Nomral MM Flex | 135

Exam

Findine Inflammatory hip Glut med weaknesslcontralaterall SI vs. hip

Ext L/R

Test Ober's t
Thomas t Psoas Contracture
IR L/R

Exam

Findins TFL or tibial band contracture Hip flexor contracture Tisht hip flexors
L/R

L/R /

I ER

l0
cannot be isolated

10
cannot be isolated

lsemimemb/tend./biceps lQuad

KneeTest
McMurray Aolev Distraction Aolev Compression Patellar erindine Ankle
Normal MM

Exam

Findins
Posteriormeniscus tear Men scusvs Iieamentouslesion Med al vs. lateral meniscus tear ChondromalaciapatlretropatellarOA
L /R Plantarflexion L/R

Test Varus/Valzus stress AnVpost drawsims

Bounce home Patella Battotement
Inversion L /R

Exam

Findine
latlmed collateral lig Ant/oost cruciate lis Meniscus Edema

Dorsiflexion

Eversion

L/R

20
Tibialis anl EDL, EHL

50
Gastroc. Soleus. Plantaris

35
Tibialis post. FDL. FHL

l5 Peronius.lone. brev. tertius

Ankle Test
AnVoost Drawer Pronation / PesPl.

Exam

Tinel's

Findins Ant/post talofi bular li e (wl wlo metatarsalsiai loss) Ant. Tarsal Tunnel / Deeo Peronealn.

Test
Med/Lat stabilitv t Supination

Exam

Findins Ant talofi bular/calcaneofibular li e Post. Tarsal Tunnel / Tibial n.

Tinel's

Ass$smentt (Chcle:, Mechanical,Nerve root, Pathology);l-disc @ L_ rv/ o ndiation above/ below lmee; Lsprain / strain/ myofascitis/ myositis; arthritis, SIJsprain L / R; Hip - synovitis, bursitis, Other: D D: > I wk; 5. Severe pain ComplicetingFactors: l Abnormal illness behavior; 4. Symptoms 2. Jobdissatisfaction; 3. Past[Ix of>4 episodes; intensity; 6. New condition/ injury relatedto pre-existingstructuralpathologyor skeletalanomaly Goal Settitrg: Short-termGoals: Lotrg-trmGoals: paiE 1- Decrcase %in_days. L Furctionalrestoration. 2. Ilcrease ROM %in_days. 2. InitiateActive/ Homecare. spasmin_days. / Stengthening. 3. Deqease 3, Rehabilitation 4. Retumto work iIl _ days. 4. Education/ "Back school" {_ Plan:
Theranv
Chiro. manipulative therapy Ice/heat Interferential mm. stim.

FrequencY
x/week x weeks: Other l5 minute rotations: on / off / on x 3 (= 1.25 br / sessiou) Acute: 80-100 cps / 10 min.; Chronic: 0-10 cps / 15 nfn.

Remarks

Traction D cerv. longaxis I Lumb.longaxis E Intersegnrental Exercises ! Flexion ! Extension (date) n QFCE _ E Work hardening
MRI / CT / Bone scan

Office: Home:

PoundsI _minutes Pounds/ minutes

Acute: Isometric w/in pain boundaries Subacute: Isotonic, passiveROM to boundary, Initiate proprioception retraining Cluouic: Evaluate functional status (QFCE) Initiate isokinetic. prosressive resistance Lumbar. Thoracic. Cervical: Davis, 5-Series,3-series,2-series

D
f-

X.R
Lab

tr

Restrict activities: I Work I ADL,s

Reeval for RTW Progress reeval Referral to: Disabilitv / impaimreut ratins

BloodTest ; UriueTest: UA, Cultwe, Work: Regular duty Light duty month days,weeks, Total tenmorarv disability:
davs. weeks 1,2,3,a 6, weeks