Lumbar Evaluation Form
Patient Name
Physician
Therapist
Eval Date
DOB
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%
2.
Global Score:
3.
5.
Onset of Sx’s   Gradual
6.
Pain Level 
7.
Pain Type   Aching
8.
Pain Location 
9.
What relieves pain/Sxs?
 Dull
 Stage II 20-40%
Wadell Score:
 Sudden
Current pain
 Stage I 40-60%
4.
 Stage III ≤ 20%
FABQ Score:
If sudden, was there a specific event/injury?
____/10
Worst pain _____/10
Tingling
 Stabbing
 Burning
Best pain
 Nauseating
_____/10
Other:
(positions, movements meds, modalities)
10. What makes pain/Sxs worse?
(positions, movements, activities)
11. Pain/Sx’s. Frequency:
 Intermittent
 Constant
14. Symptoms below the knee?
YES
NO
12. Duration of Pain/Sx’s:
13. Pain/Sx’s worse:
 < 16 days
 > 16 days
 In Morning
 At Night
IF YES  PERFORM LOWER QUARTER SCREEN
IF NO  PERFORM SI/PELVIC ASSESSMENT
LOWER QUARTER SCREEN
Sensory Testing
Muscle Testing
Right
Left
L1/L2 (Hip flex)
L3/L4 (Quads)
L4/L5 (Ant Tib)
L5 (EHL)
L5/S1 (Evertors)
(Intact / Diminished /
Absent)
Right
Special Tests
Right
Left
Left
Patellar DTR (L3-4)
(Hypo 1+, Normal 2+, Hyper 3+, Clonus 4+)
Achilles DTR (S1-2)
(Hypo 1+, Normal 2+, Hyper 3+, Clonus 4+)
Babinski (+ or -)
Clonus (If +, # of beats)
SLR (+ or -)
for recreation of “their” pain/sx’s
S1/S2 (PF’ers)
SI/PELVIC ASSESSMENT
Initial SI Test
1. PSIS Levels in Sitting:
+ 2. Standing Forward Flexion:
+ 3. Supine to Sit:
+ 4. Prone Knee Flexion:
+ Total positive:
/4
If 3 / 4 positive
Perform Erhardt & Pubic Manip
Erhardt Manip performed
YES NO
Pubic Manip performed?
YES NO
Audible pop? YES NO
Re-Test 4 SI Tests
SI Re-Test
1. PSIS Levels in Sitting:
+ 2. Standing Forward Flexion:
+ 3. Supine to Sit:
+ 4. Prone Knee Flexion:
+ Total positive:
/4
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
1.
_____ cm
(distance right middle finger to ground in cm)
Left SB’ing
2.
If symmetrical SB’ing (capsular)  Central issue
If asymmetrical SB’ing (non-capsular)  Unilateral issue
_____ cm
(distance right middle finger to ground in cm)
Once you’ve identified capsular vs. non-capsular  Proceed to Repeated Movement Testing
Repeated Movement Testing:
3.
Lateral Shift? R
L None
4.
(pt to SB each dirction at least 10x’s)
Effect on Pain/Sx’s:
Improve
Status Quo
Worsen
 Traction
 Lateral-
Syndrome
Shift Syndrome
Active Pelvic
Translocation
Traction
Flexion
5.
(pt to flex forward at least 10x’s)
Effect on Pain/Sx’s:
Worsen
Improve
Status Quo
 General
 General
(capsular)
(capsular) /
 Specific
(non-capsular)
Mobilization
Syndrome
General –
Passive Pelvic
Translocation &
General Mobs
Specific –
Opening/Closing
Manip/Mob
 Traction
 Flexion
Syndrome
Syndrome
Traction
Active
Flexion
Exercises
 Specific
(non-capsular)
Mobilization
Syndrome
Extension
(pt to extend backward at least 10x’s)
Effect on Pain/Sx’s:
Worsen
Improve
Status Quo
 General
 Traction
Extension
Syndrome
Syndrome
Traction
Active
Extension
Exercises
General Mobs
(capsular)
Specific Mobs
(non-capsular)
(capsular)
 Specific
(non-capsular)
Mobilization
Syndrome
General Mobs
(capsular)
Specific Mobs
(non-capsular)
ROM
Range
Limited By
(Full or % Limited)
(Pain, mm tightness, etc)
Deviations?
Flexion
Extension
R SB’ing
L SB’ing
R Rotation
L Rotation
JT MOBILITY
Level
Central PA
L Unilateral
R Unilateral
(Hypo, N, Hyper)
(Hypo, N, Hyper)
(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)
2. Pain/Sx’s distal to knee (question No. 13)
3. FABQ Score < 19 (question No. 4)
4. > 1 hypomobile lumbar segment (Jt Mobility section)
5. Hip IR of at least one hip > 350
If you answer YES on 4 / 5  Perform Erhardt and pubic manipulation





YES
YES
YES
YES
YES





NO
NO
NO
NO
NO




YES
YES
YES
YES




NO
NO
NO
NO
Indication for Success with Stabilization Training
1. Age <40 years old
2. Average SLR >910
3. Positive prone instability test
4. Aberrant movement (including lumbar catch) during lumbar ROM
If you answer YES on 3 / 4  Perform abdominal and lower back stability exercises