LUMBAR SPINE AND HIPS
Integrative Diagnosis (ID) is a complete system for diagnosis and conservative treatment of musculoskeletal disorders. Lumbar and Hip assessment and treatment is the best entry point into the ID system. These regions represent the human core and are among the most common reasons for patients seeking health care services. Lumbar and Hip disorders make up approximately 33% of a typical practice.
All clinical encounters begin with a thorough history. The history is used to develop a hypothesis as to what tissues are dysfunctional and what load factors are present for each individual patient. Everything else happens in the context of the data collected during the history.As you progress through the Lumbar and Hip material keep in mind we don’t have a history or a specific patient. The assessment taught here is an outline and a technical starting point. The patient history and diagnosis will change the interpretation of these tests. See the Advanced Diagnosis section for history taking details.
PERFORM THE TESTS:
The ID Lumbar and Hip assessment consists of five core tests. These should be performed on all patients with lumbar or hip symptoms and/or dysfunction. The beginning of this section is similar to the Intro to Integrative Diagnosis section. However, there is a lot more depth as you progress through the material.
Performing these tests properly is the most fundamental skill in the entire ID system. Perform and measure all five tests.
Why these five tests?
At this point you have established the functional health and capacity of the lumbar spine and hips. However, most patients have several positive tests… you can’t fix all of them at once. Right? This is another very important ID concept: Establishing Priority. You need to fix the number one problem and leave the rest of the problems alone.
Which is the worst (most restricted) test and therefore our highest priority? To answer this question we have to do some math. To compare the 5 tests we convert the test measurements into a percent of function number.
- SLR: Divide the range measurement by 90 (full range). Example: 75 degrees divided by 90 degrees is 83%. This patient has 83% of their SLR function.
- SHF: Thigh touching the ribs is 100%. Each 1 inch decrease is -10% function. Each finger width is about 3/4 inch. Four finger (3″) decrease is 70% hip flexion function.
- QLF: See the video above for measuring and converting into percent function. Example: two flexed segments, two flat and one extended = 60% lumbar flexion function.
- KHE: Divide the range measurement by 12 (full range). Example: 9″ divided by 12″ is 75%. This patient has 75% of their hip extension function.
- SLPF: This is an estimate. Touching the floor is 100%, mid shin is 75% and touching the knees is 50%. Example: a little past mid shin = 80%
In this example comparing the five test percentages QLF has the lowest at 60%. This is the priority test, we need to fix this first.
|SLR||Measurement ÷ 90||75÷90=83||83|
|SHF||-10% each inch less than full (or -7.5% each finger width)||4 Fingers: 100-30||70|
|QLF||0,1, 2 for each segment: total x 10||2+2+1+1+0=6×10=60||60||#1|
|KHE||Measurement ÷ 12||9÷12=75||75|
|SLPF||Estimate: to knees 50%, mid shin 75%, touching floor 100%||past mid shin||80|
FIX THE PRIORITY TEST:
Your job is to improve the test that is the #1 priority. Only work on this one test. Focus and priority are core principles of the ID system. Doing more results in worse outcomes.
Each test and related treatments are explained in greater detail below. Follow the detailed steps and use the related charts.
Starter Content >> Body Regions >> Lumbar Spine & Hips >> Standing Lumbopelvic Flexion (SLPF)STANDING LUMBOPELVIC FLEXION (SLPF)Instruction and Performance: Demonstrate and verbalize the following for the patient. Say: Do: Stand like this....
Starter Content >> Body Regions >> Lumbar Spine & Hips >> Kneeling Hip ExtensionKNEELING HIP EXTENSION 1. Patient is in split kneeling position with both knees at 90 degrees.2. Keeping torso upright, slide pelvis forward and down.3. Go as...
Starter Content >> Body Regions >> Lumbar Spine & Hips >> Quadruped Lumbar Flexion (QLF)QUADRUPED LUMBAR FLEXION (QLF) Performance Checklist and Testing: Patient Setup and SymptomsPatient on table, on hands and knees, knees under hips,...
Starter Content >> Body Regions >> Lumbar Spine & Hips >> Supine Hip Flexion (SHF)SUPINE HIP FLEXION (SHF) 1. Place the patient supine2. Stand on same side as hip being tested3. Place your inferior hand in the poplitealfossa, flex the knee...
Starter Content >> Body Regions >> Lumbar Spine & Hips >> Straight Leg RaiseSTRAIGHT LEG RAISE Patient is supine. Stand on the same side as the leg being tested. Place your superior hand on the distal quadriceps slightly above the knee. Place...
FUNDAMENTAL INTEGRATIVE DIAGNOSIS CONCEPTS
Combining Data Points:
Utilizing multiple data points increases the accuracy and confidence of your findings. If you are not sure of one assessment you can rely on the other cross referenced assessments for back up. Cross referencing multiple data points is a core principle of the Integrative Diagnosis System. Don’t draw conclusions from one part of one test (this is where many traditional orthopedic tests fail).
There are two basic reasons why a motion can be limited:
1. The tissues that are required to lengthen are unable to do so; the tissue has reached it’s maximal length before normal range is completed. The most common reason for this is adhesion.
A. Adhesion is an abnormal area of dense collagen fibers.
B. Trauma (tear or crush) and hypoxia (sustained or repeated contraction) cause adhesion.
C. Adhesion is highly reversible with proper treatment.
D. Adhesion is identified via palpation as a focal area of reduced compressibility.
2. Muscles that need to relax are staying contracted preventing full motion. This is called protective tension. The nervous system will not allow the muscles to relax and complete the motion if doing so would create potentially dangerous loads on tissue with decreased capacity. Example: disc inflammation at L5-S1, flexion loads injury, body protects with contraction of “erectors” to prevent flexion. Identified by increased tension through an entire muscle or group of muscles. The muscles are contracted with a uniform increased tension and normal texture. A great example of this is severely limited SLPF and relatively normal QLF. The disc is being protected by the erectors in the weight bearing position.
After adhesion has been located and treated, an immediate reduction in adhesion and a corresponding increase in function (range of motion) should result. To determine the impact of treatment repeated the test post treatment.
An immediate improvement in gross range, segmental range and tissue tension/compressibility should be noted. If this has not happened the tissue was either treated ineffectively or was not responsible for the limited range. In this case start at the beginning and try to determine if anything was missed.
Positive functional changes fall into two categories: sustainable changes and reflex changes. A sustainable change is the result of an actual reduction in adhesion. The post treatment improvement will be largely maintained at the beginning of the next visit, days or weeks later. A reflex change causes the tissues to temporarily relax. With reflex changes the observed function will revert to baseline in minutes to hours. Reflex changes are not the result of a real reduction in pathology and therefore are of very limited clinical value.
It is often unavoidable to get both reflex and sustainable changes post treatment. A patient may have gross SLPF6 inches from the floor pre treatment, improve to touching the floor post treatment then revert to 3 inches from the floor 1 day later. This is normal. Just applying pressure to muscles will cause a reflex relaxation. As long as there is some sustainable change treatment was successful.