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
-
Modified Oswestry Score: ______% ≥ 75% Stage I 40-60% Stage II 20-40% Stage III ≤ 20%
| -
Global Score:
| -
Wadell Score:
| -
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
| -
Duration of Pain/Sx’s:
< 16 days > 16 days
| -
Pain/Sx’s worse:
In Morning At Night
| -
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:
-
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
| -
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:
-
Lateral Shift? R L None
(pt to SB each dirction at least 10x’s)
| -
Flexion
(pt to flex forward at least 10x’s)
| -
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)
-
Duration of current episode of low back pain is < 16 days in duration (question No. 11)
|
YES NO
| -
Pain/Sx’s distal to knee (question No. 13)
|
YES NO
| -
FABQ Score < 19 (question No. 4)
|
YES NO
| -
> 1 hypomobile lumbar segment (Jt Mobility section)
|
YES NO
| -
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
-
Age <40 years old
|
YES NO
| -
Average SLR >910
|
YES NO
| -
Positive prone instability test
|
YES NO
| -
Aberrant movement (including lumbar catch) during lumbar ROM
|
YES NO
|
If you answer YES on 3 / 4 Perform abdominal and lower back stability exercises
| 40> |