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Lumbar Spine Passive Mobility Tests

The biomechanical assessment of the lumbar spine must begin after a scan examination has been
carried out and proven negative (i.e. the therapist has been unable to make a working diagnosis).
The initial assessment can begin with a biomechanical screening examination such as position
tests, quadrant testing etc. Or the therapist can dispense with a screening examination entirely
and go straight to passive physiological intervertebral movement testing (PPIVMs). In this
manual, position testing will be used as a screening examination from which, the therapist will
be able to move on to a more directed and definitive biomechanical examination.
Technique
Position Tests
The patient is positioned in extension, flexion and neutral. The therapist then layer palpates the
transverse process. If there is no rotation of the vertebrae, the transverse processes are usually
non-palpable. But if there is rotation present, the more posterior transverse process pushes
against the overlying tissue and makes itself available to palpation. The posterior transverse
process may indicate the side towards which the vertebra is rotated (ipsilateral). To gain relaxed
or passive extension the trunk is propped up by the elbows sitting on the table or from support by
the up-tilted head end of the table. Flexion is attained by either having the patient sit flexed in a
chair or positioned in flexed kneeling. Neutral is simply prone lying.
The posterior transverse process denotes the direction of rotation of the vertebra. If the rotation is
found in flexion and is determined to be to the left, then the vertebra is said to be relatively
extended (E), rotated and side flexed (S) left (L); ERSL. There are a number of possible
reasons for this position to be found, only one of them being hypomobility. First there is
hypomobility on the left side of the segment so that as it flexes, the altered axis of rotation
through the stiff zygopophyseal joint causes the vertebra to rotate and side flex to that side.
Secondly, the right side could be hypermobile permitting increased flexion which would involve
rotation to the left. Thirdly, there may be an anomaly such as a twisted transverse process. And
finally, the position fault may be due to compensation and may not be a motion dysfunction at
all.
Passive Mobility Tests (PPIVMs PAIVMs)
The primary and secondary segmental quadrant tests are essentially overpressure to rotation at
the extreme of flexion/rotation/side flexion or extension/ rotation/side flexion in order to position
the segments in these extremes, combined movements that de-rotate the segment are carried.
Flexion/Rotation

The patient is side laid with the posterior transverse
process towards the bed and the hips flexed. The upper
arm is allowed to hang in front of the patient. The lower
arm is pulled around the patient's vertical axis parallel
with the bed. If quadrant testing is being carried out
without the patient previously being positioned tested
then the lower arm must also be pulled somewhat
cranially to ensure that side flexion right is being
produced to flex the left side of the segment. This is not
necessary after position testing because we are not
trying to produce the appropriate coupling but rather we
are trying to de-rotate the segment. In this case, the side
flexion becomes incidental and insignificant.

The upper arm can now be taken back onto the patient's
side providing the trunk is not extended as this is done.
The therapist then slides his/her arm between the
patient's to palpate the spine. The upper leg is then
flexed further until the whole lumbar spine is flexed, the
pelvis is then rotated downwards to complete the
flexion position.
Each segment is now fully flexed on one side, that is
each segment is in its full flexion quadrant position.

The therapist then tests the end feel of rotation. If it is
abnormal, the joint glide (arthrokinematic) is tested with
an oblique postero-anterior pressure on the inferior
bone. If it is normal, the hypomobility is caused by
extra-articular restrictions if abnormal; the joint is
limiting the motion.
If the primary quadrant test is negative, a secondary
quadrant is carried out to assess for a flexion
hypermobility on the opposite side. This secondary
quadrant test is identical the primary but the patient lies
on the other side.
Extension/Rotation

The patient is side laid with the posterior transverse
process down towards the bed and the hips extended the
lower hip more so than the upper. The upper arm is
placed behind the patient and the lower arm is pulled
around a vertical axis but this time towards the ceiling
(almost perpendicular to the bed).
Again if quadrant testing is being carried out without
the patient previously being positioned tested then the
lower arm must also be pulled somewhat cranially to
ensure that side flexion right is being produced to
extend the right side of the segment.

The therapist slips his/her arm between the patient's
uppermost arm and palpates the spine. The lower leg is
extended so as to extend the lumbar spine fully. The
pelvis is rotated towards the floor to complete the
quadrant position. The lumbar spine now has one side
fully extended that is the spine is in its full extension
quadrant. The therapist then tests the end feel of
rotation. If it is abnormal, the joint glide
(arthrokinematic) is tested with an oblique postero-
anterior pressure on the inferior bone. If it is normal, the
hypomobility is caused by extra-articular restrictions if
abnormal; the joint is limiting the motion.
If the primary quadrant test is negative, a secondary
quadrant is carried out to assess for an extension
hypermobility on the opposite side. This secondary
quadrant test is identical the primary but the patient lies
on the other side.
Interpretation
If the rotation is found in extension and is again to the left, the vertebra is said to be relatively
flexed (F), rotated (R), side flexed (S) to the left (L); FRSL. The same causes apply although
now of course they would be extension hypo or hypermobility.
If the rotation is found in all positions, then, in the lumbar spine at least, the probability is that a
fixed scoliosis exists. However, it is quite possible that a transverse subluxation, such as that
hypothesized in the thoracic spine is present.
Regardless of the provisional interpretation of the test results, any asymmetry requires passive
movement testing. Symmetrical testing can be carried out but this has sensitivity problems.
Better are the segmental quadrant tests (PPIVMs). The patient is position at the extreme of the
hypothesized hypomobile range. If the dysfunction was ERSL, the patient is laid on the left side
flexed and rotated from the bottom and flexed and rotated from the top. If an FRSL is found, the
patient is again laid on the left side but this time extended and rotated from the bottom and top.
The therapist then tests the end feel of this range by trying to increase rotation. A hard capsular,
muscular or subluxed end feels suggests segmental hypomobility.
If the primary quadrant PPIVM is abnormal there is a segmental hypomobility. If this occurs, the
therapist then tests the arthrokinematic end feel at the extreme range. If the passive accessory
intervertebral movement test is positive (arthrokinematic test) then an articular hypomobility
either due to pericapsular restriction of subluxation exists. The arthrokinematic test is an oblique
posterior anterior pressure in the line of the joint. The end feel will define which type of articular
hypomobility is present, a hard capsular end feel comes with a pericapsular restriction and a
pathomechanical (jammed) end feel is associated with a subluxation. If the PPIVM is positive
but the PAIVM negative, then the problem is extra-articular, hypertonicity, prolonged muscle
hypomobility, scarring etc.
If the primary quadrant test is negative, then another cause for the positional asymmetry is
investigated. The secondary hypothesis is that the positional fault is due to hypermobility on the
opposite side. The patient is turned onto the other side but otherwise positioned identically with
the primary quadrant test. However, now the therapist is expecting to find either a soft capsular
end feel or a spasm end feel.
If the secondary quadrant test is positive, then a hypermobility is present either non-irritable (soft
capsular) or irritable (spasm). In this case, segmental stability tests are carried out to determine if
the segment is unstable as well as hypermobile.