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Lumbar Evaluation Form

Patient Name




Eval Date




Physician




DOB




Therapist




Next MD visit







PERSONAL DATA


1. Temperature >100° ? YES NO

2. BP (sitting):

_________/__________



3. Heart Rate:

__________bpm



4. Resp. Rate

______ per min



Pt History of Pain/Symptoms

  1. Modified Oswestry Score: ______%  ≥ 75%  Stage I 40-60%  Stage II 20-40%  Stage III ≤ 20%

  1. Global Score:

  1. Wadell Score:

  1. FABQ Score:

5. Onset of Sx’s   Gradual Sudden If sudden, was there a specific event/injury?

6. Pain Level  Current pain ____/10 Worst pain _____/10 Best pain _____/10

7. Pain Type   Aching Dull Tingling Stabbing Burning Nauseating Other:

8. Pain Location 

9. What relieves pain/Sxs?

(positions, movements meds, modalities)

10. What makes pain/Sxs worse?

(positions, movements, activities)

11. Pain/Sx’s. Frequency:

Intermittent Constant



  1. Duration of Pain/Sx’s:

< 16 days > 16 days

  1. Pain/Sx’s worse:

In MorningAt Night

  1. Symptoms below the knee?

YES NO

IF YES  PERFORM LOWER QUARTER SCREEN

IF NO  PERFORM SI/PELVIC ASSESSMENT





Muscle Testing

Sensory Testing

(Intact / Diminished / Absent)

Special Tests

Right

Left

Right

Left

Right

Left

L1/L2 (Hip flex)













Patellar DTR (L3-4)

(Hypo 1+, Normal 2+, Hyper 3+, Clonus 4+)







L3/L4 (Quads)













Achilles DTR (S1-2)

(Hypo 1+, Normal 2+, Hyper 3+, Clonus 4+)







L4/L5 (Ant Tib)













Babinski (+ or -)







L5 (EHL)













Clonus (If +, # of beats)







L5/S1 (Evertors)













SLR (+ or -)

for recreation of “their” pain/sx’s









S1/S2 (PF’ers)















LOWER QUARTER SCREEN

SI/PELVIC ASSESSMENT

Initial SI Test




SI Re-Test

1. PSIS Levels in Sitting: + -




Erhardt Manip performed




1. PSIS Levels in Sitting: + -

2. Standing Forward Flexion: + -




YES NO




2. Standing Forward Flexion: + -

3. Supine to Sit: + -




Pubic Manip performed?




3. Supine to Sit: + -

4. Prone Knee Flexion: + -




YES NO




4. Prone Knee Flexion: + -

Total positive: /4




Audible pop? YES NO




Total positive: /4

If 3 / 4 positive

Perform Erhardt & Pubic Manip




Re-Test 4 SI Tests




Document results and proceed to Lumbar Assessment


LUMBAR ASSESSMENT

For single movement and repeated movement testing, use the following definitions

Worsen (peripheralizes): Parasthesia is produced or pt’s pain/parasthesia moves distally from lumbar spine once movements stop(not only during movements)

Improves (centralizes): Parasthesia or pain is abolished or moves from periphery toward lumbar spine once movements stop (not only during movements)

Status Quo: Patient’s symptoms may increase or decrease in intensity but do not centralize or peripheralize
Single Movement Testing:

  1. Right SB’ing

(distance right middle finger to ground in cm)

_____ cm

If symmetrical SB’ing (capsular)  Central issue

If asymmetrical SB’ing (non-capsular)  Unilateral issue



  1. Left SB’ing

(distance right middle finger to ground in cm)

_____ cm

Once you’ve identified capsular vs. non-capsular  Proceed to Repeated Movement Testing


Repeated Movement Testing:

  1. Lateral Shift? R L None

(pt to SB each dirction at least 10x’s)

  1. Flexion

(pt to flex forward at least 10x’s)

  1. Extension

(pt to extend backward at least 10x’s)

Effect on Pain/Sx’s:

Effect on Pain/Sx’s:

Effect on Pain/Sx’s:

Worsen

Improve

Status Quo

Worsen

Improve

Status Quo

Worsen

Improve

Status Quo

 Traction Syndrome

Lateral-Shift Syndrome

 General (capsular)

 Traction Syndrome

Flexion Syndrome

 General (capsular) /

 Traction Syndrome

Extension Syndrome

 General (capsular)

Specific

(non-capsular) Mobilization Syndrome

 Specific

(non-capsular) Mobilization Syndrome

 Specific

(non-capsular) Mobilization Syndrome

Traction

Active Pelvic Translocation

General

Passive Pelvic Translocation & General Mobs



Traction

Active Flexion

Exercises



General Mobs (capsular)

Traction

Active Extension Exercises

General Mobs (capsular)

Specific – Opening/Closing Manip/Mob

Specific Mobs (non-capsular)

Specific Mobs (non-capsular)


ROM




Range

(Full or % Limited)

Limited By

(Pain, mm tightness, etc)

Deviations?




Flexion










Extension










R SB’ing










L SB’ing










R Rotation










L Rotation











JT MOBILITY

Level

Central PA

(Hypo, N, Hyper)

L Unilateral

(Hypo, N, Hyper)

R Unilateral

(Hypo, N, Hyper)

Pain w/ assessment?

Does it recreate “their” pain?

T12
















L1
















L2
















L3
















L4
















L5

















Indication for Lumbar Manipulation (besides (+) 3/4 SI Tests)

  1. Duration of current episode of low back pain is < 16 days in duration (question No. 11)

YES NO

  1. Pain/Sx’s distal to knee (question No. 13)

YES NO

  1. FABQ Score < 19 (question No. 4)

YES NO

  1. > 1 hypomobile lumbar segment (Jt Mobility section)

YES NO

  1. Hip IR of at least one hip > 350

YES NO

If you answer YES on 4 / 5  Perform Erhardt and pubic manipulation


Indication for Success with Stabilization Training

  1. Age <40 years old

YES NO

  1. Average SLR >910

YES NO

  1. Positive prone instability test

YES NO

  1. Aberrant movement (including lumbar catch) during lumbar ROM

YES NO

If you answer YES on 3 / 4  Perform abdominal and lower back stability exercises


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