Research Review: Lumbar Instability

low back plank

How to assess lumbar instability clinically, Specific levels? Validity and issues with these procedures, Review available evidence both favorable and unfavorable, Goldthwaith’s test, Lumbar instability prone test.

· Connection between lumbar extension ability and low back pain when it comes to the area of lumbar instability

· Instability is the loss of stiffness in the spine and this allows increased motion to occur at each vertebral segment leading to aberrant movement

· Hypermobility: Quantitative measure of instability

· Various body systems lead to stability: structural (passive system), muscular (active system) and the neural control system

· Loss of the osseoligamentous integrity would result in lack of stability if other systems could not compensate

Mechanical Instability

· Disruption of passive stabilizers, and decreased structural integrity

· Use of X-Ray MRI to assess the degrees of degeneration

· The degree of disc and facet joint degeneration has a positive association with excessive translational motion

Functional Instability

· Lack of neuromuscular control of the joint during activities

· Individuals with low back pain who met stabilization criteria demonstrated aberrant motion in the sagittal plane during lumbar extension

· Related to decreases in neuromuscular control of the lumbar vertebral segments during function

Signs and Symptoms

· Subjective: history of painful locking or catching during spinal motion, pain on return from forward bending, pain during transitional activities, worsening in sustained position

· Objective findings: Muscle dysfunction, motor control abnormalities, strength losses

· Flexion extension radiographs

· Increased lumbar range of motion (>53 degrees) shown to be predictive of segmental instability

Assessment Tests

Aberrant Motion

· Assessed standing and asking patient to bend foreword as far as possible and then return to standing

· Aberrant motion is present if any one of the following identified: Instability catch, painful arc of motion in flexion, painful arc on return from flexion, thigh climbing (Gower’s sign) or reversal of lumbopelvic rhythm

· Reliability is moderate

SLR

· Patient is supine while the examiner raises one leg to the maximum tolerated height indicated by the patient

· Individual's with a straight leg raise greater then 91 degrees is consistent with chronic lumbar instability

· Reliability is excellent

PA Glide

· Measure of individual segmental stiffness, good agreement for identifying most mobile segment

· Individual's who are hypermobile with PA glide or have lumbar flexion range greater than 53 degrees were 5 time more likely to have radiographic instability

Prone Instability Test

· Patient lies prone on table with feet on the floor and the pelvis off the table

· Clinician puts hand on segment which elicited pain during PA mobility testing. Patient lifts feet off floor

· As patient lifts feet off floor clinician applies PA force through vertebra. If this is less painful than initial PA test it is a positive prone instability test

· Sensitivity = .72 - LR = .48

· Specificity = .58 + LR = 1.7

Goldthwaith's

· Patient is placed supine and the examiner places one hand under the lumbar spine with each finger pressed firmly against the interspinous spaces

· Other hand of the examiner is used to slowly conduct an SLR test. If pain occurs or is aggravated before the lumbar processes open 1º- 30º, a sacroiliac lesion should be suspected

· Pain occurred while the processes were opening at 30º-60º, a lumbosacral lesion was suggested Pain occurring at 60º-90º, an L1–L4 disc lesion

· When pain is brought on before the lumbar spine begins to move, a lesion, either arthritic or a sprain involving the sacroiliac joint is suspected

· If pain does not arise until after the lumbar spine begins to move, the disorder is likely to be in the lumbosacral area or less commonly in the sacroiliac area

· The test should be repeated with the unaffected limb

· A positive sign of a lumbosacral lesion is elicited if pain occurs at about the same height as it did with the first limb. When the unaffected limb can be raised higher than the affected limb it is thought to be sacroiliac of the affected side

References

· Beazell, J. R., Mullins, M., & Grindstaff, T. L. (2010). Lumbar instability: an evolving and challenging concept. The Journal of Manual & Manipulative Therapy, 18(1), 9–14.

Demoulin C, Distrée V, Tomasella M, Crielaard JM, Vanderthommen M. Lumbar functional instability: a critical appraisal of the literature. Ann Readapt Med Phys. 2007

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Chiropractor, Sports Sciences Resident RCCSS(C)

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