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of the Trunk and
Pelvic Floor TRUNK EXTENSION
42 Chapter 4 | Testing the Muscles of the Trunk and Peie Floor TRUNK EXTENSION
Table 41 TRUNK EXTENSION
8 Wocosiolsneracs Ribs 12 up to 7 (onal) Bes 6 up to 1 (angles)
(C7 vertebra (Hansverse:
proces)
co] Mocostalis lumborum Tendon of erector spinae (anterior surface) Ribs 6-12 (angles)
Thoracolumbocr fence
‘Sacrum (posterior surface)
a Longissimus thoracis Tendon of erector spinae T1112 vertebrae
Thoracolumbar fascia (transverse
LL vertebrae (transverse processes) processes)
mee 212 between
angles and
tubercles)
92 ‘Spinalis thoracis (often Common tendon of erector spinae TI-14 vertebrae (or to
indistinct) TH42 vertebrae (spinous processes) 18, spinous processes)
Blend win semen
‘hoes
oy Semispinalis thoracis Te-T10 vertebrae (transverse processes) (C614 vertebrae
(spinous processes)
9 Mi Socrum (postion Seinous processes of
Erector spinae (aponeurosis) higher vertebra (may.
urn (PSIS) and crest span 2-4 vertebrae
Sacrotiac ligaments before inserting)
L1-L5 vertebrae (mamillary processes)
TI-112 vertebroe (transverse processes)
CAC) Vertbrae(oticulor processes)
95,96 — Rotatores thoracis and Thoracic and lumbar vertebroe (transverse Next highest vertebra:
jumborum (11 pairs) Processes: variabie in lumbar area) Seaport
97,98 _Interspinales thoracis _Thoracis: (3 pais) between spinous processes, See origin
‘and lumborum ‘of contiguous vertebrae (11-12: 12-13; 111-112)
Lumborum: (4 pois) le between the § lumbar
‘vertebrae; 1un between spinous processes
99 Infetronsversori Thorocis: @ pois) between transverse See arign
thoracis and ‘process of coniiguous veriebroe TIO-T12
himborum endl
Lumborum: medio! muscles: accessory process
‘of superior vertebra to mamilary process of
vertebra below
Lateral muscles: fil space between transverse
‘processes of adjacent vertebrae
100 Quodatuslumborum lum (crest and inne ip) 12th tb Gower borde)
liolumbor ligament U4 vertebroe
(ransverse
processes)
112 vertebra (body)
Other
182 Gluleus maximus
(provides stable base:
for trunk extension By
stablizing pelvis)
(Chapter 4 | Testing the Muscles ofthe Trunk and Pelvic Floor 43 TRUNK EXTENSION
Grade 5 (Normal) and Grade 4 (Good)
Note: The Grades 5 and 4 tests for spine extension are
different for the lumbar and thoracic spines. Beginning
at Grade 3, the tests for both spinal levels are
combined.
Position of Patient: Prone with hands clasped behind
head.
Position of Therapist: Standing so as to stabilize the
lower extremities just above the ankles ifthe patient has
Grade 5 hip extensor strength (Figure 4-3).
Alternate Position: Therapist. stabilizes the lower
extremities using body weight and both arms placed
across the pelvis if the patient has hip extension weakness.
It is very difficult to stabilize the pelvis adequately in the
presence of significant hip weakness (Figure 4-4),
‘Test: Patient extends the lumbar spine until the entire
trunk is raised from the table (clears umbilicus).
Instructions to Patient: “Raise your head, shoulders,
and chest off the table. Come up as high as you can.”
Grading
Grade 5 (Normal) and Grade 4 (Good): The therapist
distinguishes between Grade 5 and Grade 4 muscles by
the nature of the response (sce Figures 4-3 and 4-4). The
Grade § muscle holds like a lock; the Grade 4 muscle
yields slightly because of an elastic quality at the end
point. The patient with Grade 5 back extensor muscles
‘can quickly come to the end position and hold that posi-
tion without evidence of significant effort. The patient
with Grade 4 back extensors can come to the end posi-
tion but may waver or display some signs of effort.
44° Chapter
‘Testing the Muscles of the Trunk and Pelvic Floor Alternative Grade 5 Sorensen Lumbar
Spine Extension Test
‘The Biering-Sorensen test or Sorensen test is, 2 global
measure of back extension endurance capacity.”
Position of Patient: Prone with the trunk flexed off the
end of the table at a level between the anterior superior
iliac spine (ASIS) and umbilicus. The arms are folded
across the chest. The pelvis, hips, and legs are stabilized
‘on the table (Figure 4-5),
Position of Therapist: Kneeling above patient so as 10
stabilize the lower limbs and pelvis at the ankles.
nt lifts the tnank to the horizontal and main
as long as possible, The therapist uses
a stopwatch to time the effort, activating it at the “begin”
command and stopping it’ when the patient shows
“obvious signs of fatigue and begins to falter."
n, aise your
head, chest, and trunk from the table and hoid the posi
tion 3s long as you can. T will be timing you. Let me
snow if you have any back pain.”
Chapter 4
TRUNK EXTENSION
oe ine
+ Low levels of endurance of back muscles, are
reported as cause and effect of low back pain?
‘+ The Sorensen test has been validated 3s a differen-
tial diagnostic test for low back pain.”* Individuals
with low back pain have significantiy lower hold
times than those without low back pain. In subjects
with low back pain, the mean endurance time
ranges from 39.55 to 54.5 seconds in mixed-
gender groups (compared with 80 to 194 seconds
for -men and 146 to 227 seconds for women
‘without pain)
‘+ The mean endurance time for all subjects (with and
without low back pain) in one study way 113 £46
seconds Men had higher mean endurance than.
‘women.
+ Because average endurance times have not been
«established for older individuals, caution should be
exercised when testing individuals aged 60 years
and older.
‘+ Assignificant difference was found in the endurance
time across the age groups indicating that a
decrease in endurance time should be expected
‘with increasing age. Some age-based norms are
listed in Table 4-2
‘+ More recent data ‘suggest that normative values
vary by specific populations and by specific anthro-
pomorphic characteristics such as body mass index
and torso length*
“+ The multifidus demonstrates more electromyo-
‘gram (EMG) activity and faster fatigue cates than
the iiocostais lumborum.*
“Testing the Muscles of the Trunk and Pelvic Floor 45 TRUNK EXTENSION
‘Number in porenthosos ror to standard dovision (SD). The standard deviaton & ontyavatbo for some o9e groups.
°Dad trom £08 subjects win ond winou# back pon that Comprised equa group of ve ond white color mate and female subjects. Modtied
Sorensen test pertorned (ams af 300)
‘Data tom S61 heathy. nonsmoling subjects n Nigeria without ow back pain. performing a mode Sorensen tet (cms too)
THORACIC SPINE
Grade 5 (Normal) and Grade 4 (Good)
Position of Patient: Prone with head and upper trunk
extending off the table from about the nipple line (Figure
46).
Position of Therapist: Standing so as to stabilize the
lower limbs at the ankle.
‘Test: Patient extends thoracic spine to the horizontal.
Instructions to Patient: “Raise your head, shoulders,
and chest to table level.”
Grading
Grade 5 (Normal): Paticnt is able to raise the upper
trunk quickly from its forward flexed position to the
horizontal (or beyond) with ease and no sign of exertion
(Figure 4-7).
Grade 4 (Good): Patient is able to raise the trunk to the
horizontal level but does it somewhat laboriously LUMBAR AND THORACIC SPINE
Grade 3 (Fair)
Position of Patient: Prone with arms at sides,
Position of Therapist: Standing at side of table. Lower
‘extremities are stabilized just above the ankles.
‘Test: Patient extends spine, raising body from the table
so that the umbilicus clears the table (Figure 4-8).
Instructions to Patient: “Raise your head, arms, and
‘chest from the table as high as you can.”
Grading
Grade 3 (Fair): Paticnt completes the range of motion,
TRUNK EXTENSION
Grade 2 (Poor), Grade 1 (Trace), and
Grade 0 (Zero)
‘These tests are identical to the Grade 3 test except that
the therapist must palpate the lumbar and thoracic spine
extensor muscle masses adjacent to both sides of the
spine. The individual muscles cannot be isolated (Figures
49 and 4-10).
Grading
Grade 2 (Poor): Patient completes partial range of
motion.
Grade 1 (Trace): Contractile activity is detectable but
no movement.
Grade 0 (Zero): No contractile activity
FIGURE 4-8
FIGURE 4-9
Chapter 4
FIGURE 4-10
‘Testing the Muscles of the Trunk and Pelvic Floor 47 TRUNK EXTENSION
Helpful Hints
‘+ Tests for hip extension and neck extension should
precede tests for trunk extension,
‘+ When the spine extensors are weak and the hip
extensors are strong, the patient will be unable 10
raise the upper trunk from the table. Instead, the
pelvis will tlt posteriorly while the lumbar spine
‘moves into flexion (low back flattens).
‘+ Ifthe hip extensor muscles are Grade 4 or better, it
be helpful to use belts to anchor hips to the
fan caste ce pee mero se
ger than the testing therapist.
+ When the back extensors are strong and the hip
extensors are weak, the patient can hyperextend the
ow back (increased lordosis) but will be unable to
raise the trunk without very strong stabilization of
the pelvis by the therapist.
+ If the neck extensors are weak, the therapist may
need to support the head as the patient raises the
trunk,
48° Chapter 4
‘+ The position of the arms in external rotation and
fingertips lightly touching the side of the head pro-
vides added resistance for Grades 5 and 4; the weight
of the head and arms essentially substitutes for
‘manual resistance by the therapist.
+ If the patient is unable to provide stabilization
through the weight of the legs and pelvis (such as in
paraplegia or amputee), the test should be done on
mat table. Position the subject with both legs and
pelvis off the mat. This allows the pelvis and limbs
to contribute to stabilization, and the therapist
holding the lower trunk has a chance to provide the
necessary support. (Ifa mat table is not available, an
assistant will be required, and the lower body may
rest on a chair.)
‘+ The Modified Sorensen testis the Sorensen test but
performed with arms at the patient's sides.
Testing the Muscles of the Trunk and Peie Floor ELEVATION OF THE PELVIS
FIGURE 4-11
Table 43 ELEVATION OF THE PELVIS
1D. ‘Muscle Origin Insertion
100 Quodratuslumborum ium (crest and inner ip) Rb 12 (ower border)
lilumbar igoment U-L4 vertebros
Processes. apex)
TB vertebra (body:
occasionally)
no Obiiquas extemus Ribs 5-12 (interdigitating hac crest (outer borden)
‘abdomins ‘on extemal and infenor Aponeuross from 9th
surtaces) costal cartlage to ASIS:
both sides meet at
midline to form linea
iba
Pubic symphysis (unper
border)
m Obliquus internus ioc crest (anterior 2/3 of Ribs 9-12 (inferior border
‘abdominis intermediate ine) ‘and cartilages by
Tnoracolumbar fascia igitations that appecr
Inguinal ligament (ateral_ continuous with intemal
2183 of upper aspect) intercostals)
Ribs 7.9 (cartilages)
Aponeuross to linea iba
Others
130 Lttssimus dorsi (arms fixed)
90 Wocostals lumborum
(Chapter 4 | ‘Testing the Muscles ofthe Trunk and Pelvic Floor 49) ELEVATION OF THE PELVIS
Grade 5 (Normal) and Grade 4 (Good)
Position of Patient: Supine or prone with hip and
lumbar spine in extension. The patient grasps edges of
the table to provide stabilization during resistance (not
illustrated).
Position of Therapist: Standing at foot of table facing
patient. Therapist grasps test limb with both hands just
above the ankle and pulls caudally with a smooth, even
pull (Figure 4-13). Resistance is given as in traction.
Test: Patient hikes the pelvis on one side, thereby
approximating the pelvic rim to the inferior margin of
the rib cage.
Instructions to Patient: “Hike your pelvis to bring it
up to your ribs, Hold it, Don’t let me pull your leg,
down.”
Grading
Grade 5 (Normal): This motion, certainly not attsib-
uted solely to the quadratus lumborum, is one that toler-
ates 2 huge amount of resistance that is not readily
bbroken when the muscles involved are Grade 5.
Grade 4 (Good): Patent wlerates very strong resistance
‘Testing this movement requires more than a bit of clini
cal judgment.
FIGURE 4-13
Grade 3 (Fair) and Grade 2 (Poor)
Position of Patient: Supine or prone. Hip in extension;
lumbar spine neutral or extended.
Position of Therapist: Standing at foot of table facing,
patient, One hand supports the leg.just above the ankle;
the other is under the knee so the limb is slightly off the
table to decrease friction (Figure 4-14)
Test: Patient hikes the pelvis unilaterally to bring the
rim of the pelvis closer to the inferior ribs.
Instructions to Patient: “Bring your pelvis up to your
ribs.”
Grading
Grade 3 (Fair): Patient completes available range of
motion,
Grade 2 (Poor): Patient completes partial range of
URE 4-14
50 Chapter 4 | Testing the Muscles of the Trunk and Pehic Floor Grade 1 (Trace) and Grade 0 (Zero)
‘These grades should be avoided to ensure clinical accu
racy. The principal muscle involved in pelvic elevation,
the quadratus lumborum, lics deep to the paraspinal
muscle mass and can rarely be palpated. In people who
have extensive truncal atrophy, paraspinal muscle activity
may be palpated, and possibly, but not necessarily con:
vincingly, the quadratus lumborum can be palpated.
Ste
‘The patient may attempt to substitute with trunk
lateral flexion, primarily using the abdominal muscles.
‘The spinal extensors may be used without the qua:
dratus lumborum. In neither case can manual testing,
detect an inactive quadratus lumborum.
Chapter 4
ELEVATION OF THE
ivis
See
+ The quadratus lumborum hikes the ipsilateral hip
when the spine is fixed.
+ It should be noted that the quadratus lumborum
may have functions other than hip hiking, such as
maintaining upright posture, though these func-
tions have been less well studied. Quadratus lum-
borum strength has also been linked to low back
pain and thus may deserve closer analysis.
Testing the Muscles of the Trunk and Pelvic Floor 51 TRUNK LATERAL ENDURANCE
Side Bridge Endurance Test
Quadratus lumboru
clicited without ge
the lumbar spine.
que and transverse muscles are
ig large compression forces on
Position of Patient: Side-lying with legs extended,
resting on the lower forearm with the elbow flexed to
90°. Upper arm is crossed over chest.
Position of Therapist: Standing or sitting in front of
patient holding a stopwatch. Patient is given feedback
regarding posture; the hips and trunk should be level
throughout the test (Figure 4-15).
Test: Patient lifts hip off the table, holding the elevated
position in a straight line with the body on a flexed
mn is maintained until the patient loses
form, fatigues, or complains of pain. The thera
1s the effort
Instructions to the Patient: “When I say “go!” lift your
hip off the table, keeping it in a straight line with your
body for as long as you can. 1 will be timing you.”
FIGURE 4-15
Helpful Hint
Despite the high reliability of the side bridge test, sig-
nificant changes in hold times must be observed to
confidently assess a true change in strength. Therefore,
the patient’s rating of perceived exertion (RPE) would.
help inform clinical decision making.” Mean hold times
52. Chapter 4
range from 20 to 203 seconds (mean 104.8 seconds)
for the right side bridge test and from 19 to 2:
seconds (mean of 103.0 seconds) forthe left side bridge
test.” Males demonstrated longer endurance times than
females.
‘Testing the Muscles of the Trunk and Pelvic Floor AEAEzEz-=—=——=———_——————__=_=——-—-~~"7!
TRUNK FLEXION
Ss
} Te
| 7
| 8
| w [re
| Rectus abdominus
i no f trite
! m
{ ne
' st
i
s
ume 4.17
0" 10.8"
noua 4-16
Table 44 TRUNK FLEXION
1D. Muscle Origin Tneerion
113 -Rectus abdomins—Pubis Ribs 5-7 (costal cartioges)
(Gored muscle) Lateral fers (ubercle on crest —_Stemum (ohold Igoments)
‘and pecten pubis)
Medial fers (igamentous
‘covering of symphysis attaches
to contralateral muscle)
110 Oblquusextemus Ribs 5-12 (interdigitating on ioe crest (outer border)
‘abdorinis ‘extemal and inferior surfaces) Aponeuross from 9th costal cartilage to
'ASIS: both sides meet at midline fo form
linea alba
111 Obliquusintemus —_tlac crest (anterior 2/3 of Ribs 9-12 (inferior border and cartilages by
‘abdominis intermediate ine)
