Low Back Pain - JOSPT

Measurement method
(continued)
Nature of variable Continuous, ordinal
Low Back Pain: Clinical Practice Guidelines
Trunk Muscle Power and Endurance (continued)
Trunk Extensors
The patient is positioned in prone, with hands behind the back or by the sides. The patient is instructed to extend at the lumbar spine
and raise the chest off the table to approximately 30° and hold the position. The test is timed until the patient can no longer hold the
position.
Lateral Abdominals
The patient is positioned in sidelying with hips in neutral, knees flexed to 90°, and resting the upper body on the elbow. The patient is
asked to lift the pelvis off the table and to straighten the curve of the spine without rolling forward or backward. The position is held
and timed until the patient can no longer maintain the position.
Transversus Abdominis
The patient is positioned in prone over a pressure biofeedback unit that is inflated to 70 mmHg. The patient is instructed to draw in
the abdominal wall for 10 seconds without inducing pelvic motion while breathing normally. The maximal decrease in pressure is
recorded.
Hip Abductors
The patient is positioned in sidelying with both legs fully extended, in neutral rotation and a relaxed arm position, with the top upper
extremity resting on the ribcage and hand on abdomen. 226 The patient is instructed to keep the leg extended and raise the top thigh
and leg toward the ceiling, keeping the limb in line with the body. Patients are graded on quality of movement.
Hip Extensors
The patient is positioned in supine with knees flexed to 90° and the soles of the feet on the table. The patient is instructed to raise
the pelvis off the table to a point where the shoulders, hips, and knees are in a straight line. The position is held and timed until the
position can no longer be maintained.
Units of measurement Seconds to hold position, muscle performance assessment, change in mmHg using a pressure biofeedback device
Measurement properties The double-leg lowering assessment for trunk flexor strength has demonstrated discriminative properties in identifying patients with
chronic low back pain. 128,187 If patients demonstrate anterior pelvic tilt with hip flexion greater than 50° in males and 60° in females,
they are more likely to have chronic low back pain. 327 The assessment of trunk extensor strength has been highly correlated with the
development and persistence of low back pain. 9,167,219 Males who are unable to maintain an isometric hold of 31 seconds (33 seconds
for females) are significantly more likely to experience low back pain (+LR = 4.05-6.5; –LR = 0.24-0.02) with good reliability (ICC =
0.89-0.90). 9 Lateral abdominal strength has been measured in healthy controls and found reliable (ICC = 0.97). 95,212 Performance of
the transversus abdominis has been evaluated in prone and found to be reliable (ICC = 0.58; 95% CI: 0.28, 0.78). 69,164,284 A 4-mmHg
decrease in pressure is established as normal, whereas the inability to decrease the pressure biofeedback device measure by 2 mmHg
is associated with incidence of low back pain. 164,174,255 The hip abduction test has demonstrated discriminative ability to predict patients
who will develop pain with standing (+LR = 2.68-4.59). 226,227 Endurance assessment of the bridge position to assess gluteus maximus
strength has demonstrated good reliability (ICC = 0.84). 266 Mean duration of hold for patients with low back pain is 76.7 seconds
compared to 172.9 seconds in persons without low back pain. 266
Instrument variations There are numerous alternate test positions for all described muscle groups. For trunk flexion, test variations include bent doubleleg
lowering and sit-up tasks. For trunk extension, numerous variations have been described, including the Sorensen test and prone
double straight leg raise. 9,167,219 The Sorensen test and modified versions of this test have been the subject of extensive research, and
strong diagnostic utility values for the test make it a viable alternative to the previously described back extensor test. 219 Transversus
abdominis performance has been described by a palpatory method. 69 Hip abduction and hip extension strength can both be assessed
with manual muscle testing. 179 Clinician’s selection of test may be dependent on patient’s level of conditioning and symptom behavior.
Passive Hip Internal Rotation, External Rotation, Flexion, and Extension
ICF category Measurement of impairment of body function – mobility of a single joint
Description The amount of passive hip rotation, flexion, and extension
Measurement method Hip External and Internal Rotation
The patient is positioned prone with feet over the edge of the treatment table. The hip measured is placed in 0° of abduction, and the
contralateral hip is placed in about 30° of abduction. The reference knee is flexed to 90°, and the leg is passively moved to produce hip
rotation. Manual stabilization is applied to the pelvis to prevent pelvic movement and also at the tibiofemoral joint to prevent motion
(rotation or abduction/adduction), which could be construed as hip rotation. The motion is stopped when the extremity achieves
its end of passive joint range of motion or when pelvic movement is necessary for additional movement of the leg. The inclinometer
is aligned along the shaft of the tibia, just proximal to the medial malleolus, for both medial and lateral rotation range-of-motion
measurements.
Hip Flexion
With the patient supine, the examiner passively flexes the hip to 90° and zeroes an inclinometer at the apex of the knee. The hip is then
flexed until the opposite thigh begins to rise off the table.
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a26 | april 2012 | volume 42 | number 4 | journal of orthopaedic & sports physical therapy