Clinical Reasoning for functional stability of the lumbar spine

• Body Chart - one or more areas of pain

• Past History - misuse (incorrect technique), abuse (trauma), overuse (prolonged activity), disuse (atrophy due to 'fear-avoidance' behaviour) leading to deconditioning and hence reduced loading tolerance increasing the susceptibility to recurrences even with minor loading activity

• Current History - onset similar to past history, may be becoming progressively more frequent and more severe in nature, may be taking longer to settle than usual

• Aggravating Factors - unguarded movements e.g. cough/sneeze, twist/turn; can move into every position but don't like to stay in any one position for too long, and have trouble moving out of that position

• Special Questions - ask for X rays if you suspect spondylolisthesis due to Spina Bifida (patch of hair on back), or pars interarticularis fractures; question steroid use, prostate cancer, blood anomalies,  infections, major weight loss, cauda equina/cord compression symptoms, osteoporosis, etc 

• Physical Examination

Special Tests

• stork test
• walking + stair walking
• (dys)functional leg length discrepancy
• peripheral muscle length test on pelvic tilt (posterior tilt for rectus femoris, posterior tilt for hamstrings, and Thomas test) 
• timing of peripheral muscle activation e.g. Gluteals vs. Hamstrings vs. Quadriceps
• Transverse Abdominal/Internal Oblique activation with leg and arm movements
• effect of changes in Latissimus Dorsi length on lumbar stability
• position of the Belly Button
• active straight leg raise for symphasis pubis instability/oblique abdominal muscle insufficiency
• multifidus activity and lumbar stability in 
• prone lying hip extension (legs over end of bed)
• 4 point kneeling crossed extension
• rocking side to side and forward/backward, as well as alternating arm movements at   90 degrees flexion
• clunk test' in side lying
• after PPIVM's the movement pattern of restriction or excessive mobility may change dramatically
• spasm during PAIVM's
• Pressure Cuff biofeedback (inability to maintain the neutral zone)
• Transverse/Internal Oblique and Multifidus with EMG testing (no onset, late onset, or prolonged onset?)