Liebenson C., Karpowicz AM, Brown SHM, Howarth SJ, McGill SM. The Active Straight Leg Raise Test and Lumbar Stability. Journal of the American Academy of Physical Medicine and Rehabilitation. Vol. 1, Issue 6. June 2009 pp 530-535.
Those of us that work with patients that have low back complaints will often do the Passive Straight Leg (PSLR) test to see if it reproduces their low back symptoms and/or radicular symptoms. The general thought is that a positive test: between 0-35◦ (we may be thinking extradural involvement), between 35-70◦ (we may be thinking more disc involvement) and between 70-90◦ (we may be thinking more lumbar joint involvement) (1,2). Generally (very generally), if there are any radiating symptoms beyond the low back and into the leg but, above the knee, we often think of this as more of a low back/SI joint problem and lumbar sprain/strain with some possible muscular referral pain. However, if there are radiating symptoms past the knee into the lower leg and/or into the foot we may have a higher suspicion that there is a disc bulge/herniation, spinal stenosis or other space occupying lesion. This can then be further confirmed by a well leg raise test and Braggard’s test. However, as many of us dealing with musculoskeletal complaints and problems day to day know, these tests are often negative and/or inconclusive at best. And so, we’re left with some information but, not the entire story. I would submit that the following study produced some clues that could add an extra layer to your general functional orthopedic evaluation to help delineate if the patient: (1) Is in need of exercise and rehabilitation (2) Requires more diagnostic imaging or procedures or (3) Requires a combination of the two or by doing a PSLR (4) Requires some mobility and mobilization prior to rehabilitation.
This study looked at the utility of the “Active” Straight Leg Raise (ASLR) Test as a screen for lumbar spine stability and abdominal bracing ability. While the study sample was small at 14 participants, it clearly demonstrated that abdominal bracing (AB) reduced lumbar rotation as well as increase lumbar stiffness both of which are very important in reducing the overall stresses/forces on the spines of all our lumbar spine patients during their daily activities. AB has also been shown in prior investigations (3,4) to reduce lumbar spine axial rotation and with this study certainly suggests that it may be a suitable countermeasure for patients whose pain is induced by excessive motion of the lumbar spine or pelvis.
What does this mean to you during your exam? Here’s a very loosely proposed addition to your lumbar spine exam:
· Perform a PSLR
· Perform an ASLR
· Peform an ASLR with AB**
If the PSLR is (+) for radicular pain follow up with Braggard’s test and a well straight leg raise. If they’re positive as well, consider ordering a lumbar MRI. If the PSLR is (-) then perform an ASLR, if the ASLR is (+) for pain or radiating symptoms perform the ASLR with AB and see how the patient’s symptoms change. If the patient’s symptoms improve, then it’s likely they could benefit from some AB/Core stability training. If the patient’s symptoms don’t improve with AB, consider that the patient needs more mobility in their pelvis and thoracic spine in addition to more specific functional testing to delineate whether they have a motor control or tissue extensibility issue and refer accordingly.
**The goal of AB is for the patient to functionally stiffen their spine while maintaining normal respiration. Verbal cues (e.g. stiffen your abdominals or tighten your stomach) can be used to achieve this. Once the patient has attempted to brace you may introduce some perturbations (e.g. small nudges to the spine/pelvis in different directions) while they are encouraged to maintain the locked position.
There is much to be learned from functional testing of the lumbar spine and pelvis and it’s important to serve as a baseline for which therapeutic approaches to consider. The ASLR with and without AB is a simple test to consider with both your acute and chronic lumbar spine patients that will garner some great clinical information for how to proceed therapeutically.
While, I would like to think that we’re moving towards a more decisive diagnostic model as to what combination of therapies would best suit a patient for a particular presentation, in my humble opinion we’re still far from there. Having worked with many primary care physicians and neuromusculoskeletal specialists in different disciplines there is still a wide range of theories and general thoughts of what works when and for which patient. Moving towards a functional assessment model will help move us forward towards eliminating all the guesswork.
1. Cox JM. Low Back Pain: Mechanism, Diagnosis and Treatment. 5th ed. Baltimore: Williams & Wilkins, 1990: 380.
2. Cipriano JJ. Photographic Manual of Regional Orthopedic and Neurologic Tests. 2nd ed. Baltimore: Williams & Wilkins, 1991: 56.
3. Vera-Garcia FJ, Elvira JL, Brown SH, McGill SM. Effects of abdominal stabilization maneuvers on the control of spine motion and stability against sudden trunk perturbations. J Electromyogr Kinesiol 2007;17:556-557. Epub 2006 Sep 22.
4. Grenier SG, McGill SM. Quantification of lumbar stability using two different abdominal activation strategies. Arch Phys Med Rehabil 2007; 88:54-62.
In every facet of being a healthcare provider, we are challenged daily to solve problems for our patients. Perhaps we need to order another test or change their medication to stabilize their condition or maybe we need advanced imaging to confirm our suspicions. Whatever the case may be, I, like most have fully embraced that we will always be “practicing” or in practice because we will always be at the mercy of the every changing complexity of the human body. This is especially the case when it comes to the musculoskeletal system. When we’ve done every orthopedic and neurological test under the Sun and we’ve ordered every imaging study there is to order and these tests are negative and the patient is still in pain or not improving towards gaining full function again, then we are forced to consider that the patient may be malingering or that there is an inherent bio-psychosocial component to their condition.
While I feel this consideration should be on the list of things on our minds, we should continue to search out other methods and techniques that may help us better help our patients or ensure we’re not “missing” anything.
One of these methods or tools that I’ve found that has been tremendously helpful when it comes to evaluating the musculoskeletal system is looking at movement patterns. By looking at movement patterns, we can visualize how a patient’s muscles and joints move through a given plane of motion and either how synchronous or how aberrant that motion is. Thereby, we can visualize imbalances and instabilities side to side. This approach is very different than simply looking at one joint or one muscle at a time. A joint may have full range of motion however, if that joint does not move synchronously in a functional pattern with the rest of the body, than one can argue that dysfunction exists and the potential for injury is present.
While, this method isn’t new per se, as it has been written about and championed by most of the founders of modern conservative musculoskeletal medicine (Vladamir Janda, MD, James Cyriax, MD, Janet Travell, MD, Robin McKenzie, PT, Shirley Sharmann, PT, etc.), it has been systematized in a very logical set of procedures by Gray Cook, MSPT who has lectured extensively and written about it in his book Movement. The diagnostic approach to looking at movement patterns is called the Selective Functional Movement Assessment (SFMA), which is designed for clinicians while the prognostic approach to looking at movement patterns is the Functional Movement Screen (FMS) is designed for not only clinicians but also, trainers and fitness professionals. And while, to break down the SFMA in detail is not only way beyond the scope of this blog post but also, it certainly would not do it justice as it would be quite honestly be limited by my understanding of it as I am trained in the SFMA but, still a rookie in my opinion. However, it consists of 7 fundamental movements (based in fetal development) and subsequent breakouts to delineate exactly what might be the cause of a patient’s dysfunction whether it’s a structural issue or a joint mobility/tissue extensibility problem or simply a motor control challenge. And by working off of this baseline, we have a much better understanding of what the patient needs (i.e. Chiropractic? Physical Therapy? Massage Therapy? Dry Needling? Exercise Therapy?).
While I’ve only been utilizing this method in my own practice a short time, it has yielded very encouraging results. It has assisted me in being more precise with not only my evaluations but also, with my treatment and has certainly helped me be a much better Chiropractic Physician. I feel that it is an extremely valuable tool for any Physician who routinely evaluates and treats musculoskeletal injuries.
In future posts, I will be writing a little bit more about the details of the SFMA.
Giles A, Dorgo S. Preventing Lumbar Injuries in Rotational Striking Athletes. Strength and Conditioning Journal. Vol. 35 No. 2. April 2013. Pg 55-61.
Sports like golf, tennis, baseball and hockey are very popular with our patients, and athletes of all levels (from weekend warrior to professions) often come to us with specific training and strength and conditioning needs. The nature of these activities lend themselves to higher rotational forces through the lumbar spine and a higher likelihood of injury. This article did a great job summarizing not only the basic mechanics of the lumbar spine including types and causes of lumbar injuries in rotational athletes but also, practical training progressions to assist athletes in preventing these types of injuries. Highlights:
- Between 21-84% of athletes in rotational sports have experienced a lower back injury as a result of participation in their sport.
- While there’s approximately 5-7◦ of collective rotation in the lumbar spine, this can be increased in coupled motion (combined rotation; flexion, extension or lateral flexion) in spinal flexion by 13.8% and spinal extension by 23.8%.
- The muscles of the spine stiffen at ball contact to properly transition the force from the legs to the arms through to the club, racket, bat or stick. If the athlete is unable to maintain this posture at ball contact, they are more susceptible to injury.
- The more common injuries in athletes are facet injuries in tennis and baseball pitching and disc injuries in hockey, baseball (hitting) and golf.
- The research is inconclusive as to which deficiencies in particular trunk and deep lumbar muscles are more responsible for spine stability. However, the erector spinae group appears to contribute more of an influence.
- Focusing on one particular muscle or group of muscles in training/rehab is likely not sufficient as the nature and forces of the motion in each sport are very specific (i.e. coordination and timing are crucial) and movement inefficiencies are likely more influential.
- A training program that elicits a reflexive contraction of both the anterior and posterior lumbar musculature is important to an injury prevention program.
- A proposed progression in phases of training may be: (1) neuromuscular facilitation phase (2) dynamic stability/endurance phase (3) strength phase (4) power phase and an optional (5) sport-specific phase.
Being a Seattle Chiropractor and Rehabilitation/Strength and Conditioning Specialist for over 10 years, I have a unique perspective on rotational injuries. I have seen numerous rotational injuries from rotational sports and occupational activities, and while I agree the author’s suggested approach is logical and sound, I would humbly add an additional approach for your consideration and hope you find them useful when working with your clients.
I feel that it’s important to train the core by implementing both static and dynamic stability strategies however, when it comes to rotational sports I feel it’s equally important to ensure that you have the requisite mobility to layer on good static and dynamic stability prior to progressing to loading/strength strategies. What do I mean by this? I’m referring to a joint-by-joint approach that both Mike Boyle and Gray Cook first brought to my attention. If you were to look at the body as a whole from bottom to top, certain joints are designed for either mobility or stability. Generally speaking: Ankles (mobile), Knee (stable), Hip (mobile), Lumbar spine (stable), Thoracic spine (mobile), Cervical spine (stable).
Deficiencies in any of these areas will tend to cause more stress and strain above and below. For example, if you had an ankle sprain that wasn’t properly rehabbed or retrained in addition to an ankle mobility issue, the knee on that same side will have to pick up the slack. It must move more, which in turn can subject the knee to more wear and tear and cause a potential injury over time. In this example with rotational sports (doesn’t matter if it’s golf, tennis or lacrosse), power generation starts at the feet and lower body, so we should ensure that our client or patient’s ankle mobility is clear. (This can mean foam rolling their gastrocs and running them through an ankle mobility protocol.)
Next, I propose clearing the hip and thoracic spine of any mobility issues before addressing the core. I’m a firm believer in what Gray Cook said about taking all mobility issues off the table before progressing towards stability. Layering on stability over poor mobility simply re-enforces the poor mobility. In principle, it’s easy to understand with weight training (i.e. why would you have someone trying to do shoulder presses when they don’t have full range of motion in their shoulders?). However, when it comes to a much more complex movement pattern, like a golf swing, mobility sometimes gets lost in the shuffle.
While every client or patient is unique, generally speaking I’d focus on 4 key areas even prior to addressing the core specifically (which is a whole other discussion unto itself!).
Train and/or ensure:
1. Adequate and equal mobility at the ankle joint bilaterally
2. Adequate and equal mobility at the hips bilaterally
3. Adequate strength and stability in both hips in different planes of motion
4. Adequate thoracic spine mobility
Each of these 4 key areas can be broken down further and discussed in the context of flexibility, mobility and motor control, however I feel that addressing all 4 areas is crucial to develop a more holistic preventative strategy when it comes to rotational injuries and the lumbar spine.
Seahawk trainers using FMS.
In training and in rehab we are often able to visualize a client’s effort and garner reasonable information as to where and how to progress them. One of the challenges we all run up against is when a client hits a plateau. This is especially the case when we’ve tried to vary their routine and change as many variables we can think of, and they’re still hitting a wall. What then?
When we reach these hurdles, I feel it’s always important to question our own techniques and ask our colleagues for a second opinion but also, it’s equally important to continually learn and seek out different methods. One tool I’ve come upon that has helped me immensely when it comes to getting past these hurdles is the Functional Movement Screen (FMS). Founded by physical therapist Gray Cook and athletic trainer Lee Burton, it is a standardized objective method of measuring a client or patient’s imbalances, core function and mobility and stability. It consists of 7 fundamental movements (movements based in fetal development) which are graded. Your client’s performance on this screen will give you clues to pinpoint where they’re imbalanced or deficient, and more importantly, it’ll give you more direction for what they truly need in order to get past their hurdle. The FMS is a phenomenal tool to get everyone (trainers, strength and conditioning specialists, chiropractors, physical therapists, athletic trainers) involved speaking the same language when assessing and treating athletes or injured patients. In fact, many of the elite professional sports and military organizations have utilized the FMS as a baseline to help assess their athletes and personnel. If you haven’t heard about it, I highly recommend learning about it and utilizing it with your clients as another layer of service you can provide to get results for them.
Seahawks players & trainers using the FMS.
Over the past 3 years, I’ve made it a personal mission to really push my learning and clinical expertise to provide you with the very best in conservative musculoskeletal care. I’ve pursued specialty certifications in Chiropractic Rehabilitation, Strength and Conditioning, Functional Movement, and Whiplash and Brain Trauma rehabilitation. If you haven’t been in for an appointment for some time, an appointment at our office may look quite different than what you remember. Now in addition to soft tissue work and Chiropractic adjustments, I have new tools at my disposal such as precise corrective exercises with the goal to help you move better and be more durable whether it’s for your job or your recreational activities. And so, along with your regular treatment, I’ll have you doing everything from body weight mobility exercises, dynamic stretching and using resistance bands or kettlebells.
My favorite tool to get a baseline of how you move and look at imbalances in your body is the Functional Movement Screen (FMS).
What is it? It consists of 7 functional movements designed from a developmental movement perspective (i.e. movements we should all be all be able to complete from infancy and childhood) and it is predictive in nature (i.e., if you score poorly, it gives us an idea that you are at a greater risk for injury). From these 7 tests, we can get a baseline of how a person moves (much like taking blood pressure to assess heart function). And based on what we find we can then prescribe exercises that will help balance out any weaknesses or deficiencies you might have. Most importantly, if we find the “correct” exercises for your condition, you will often start to notice a change in just 1 session! For that reason, I’ve made it a major focal point for corrective exercise and rehabilitation for my patients. Furthermore, the FMS is used in many professional and amateur sports and military organizations. Even our Seattle Seahawks use it!
And so, it doesn't matter if your main concern is fall or injury prevention or sport-specific performance enhancement and durability, the FMS will help discern what precisely your body needs. If you're interested in getting an evaluation, call Robin to schedule a complimentary screening.
Everyone knows that one of the most important things you can do for your health is to not only watch what you eat but more importantly, watch the quality and quantity of what you eat. I’ve never been a huge fan of particular diets because everyone is different. Depending upon your activity level, your metabolism and even your genetics, what’s right for one person may not be right for another. However, what I have always been a huge advocate of is eating more fruits and vegetables.
Typically, we should be getting at least 8-12 servings of fruits and vegetables a day. And while, that’s ideal, in reality it’s quite difficult to do. Much like anything, it takes some planning and good ‘ol discipline to get the 8-12 servings. However, you can certainly cheat and get several servings at once just by juicing!
While the benefits of juicing have long been documented, a recent award winning film by Joe Cross – “Fat, Sick and Nearly Dead”
is an eye-opening account of what juicing can do for one’s health. I had been thinking of diving into juicing myself for some time, the film definitely inspired me to take the leap. And you know what? It’s AWESOME! It still takes some planning and discipline but, depending on what your goals are a serving of fresh juice (of 4-8 fruits and vegetables) can act as nice snack or even a meal replacement. I highly highly recommend it and I promise you’ll feel GREAT!If you’re serious about looking into juicing there’s definitely no shortage of resources but, here are a few books I’d recommend:The Juicing Bible
by Pat CrockerThe Big Book of Juices
by Natalie SavonaThe Healthy Juicer's Bible
by Farnoosh Brock
And definitely check out these sites:www.fatsickandnearlydead.com/www.rebootwithjoe.com/
Lastly, check with your Medical Doctor, Naturopathic Doctor, Nutritionist or Dietician to ensure you have no problems to juicing as a supplement to your diet.