Lumbar Rotation
Lumbar Rotation as a Key
Factor in Low Back Pain:
Anatomy
Kinesiology
Role in degenerative disc disease
Clinical and Research Evidence
Shirley Sahrmann, PT, PhD, FAPTA
Nancy Bloom, PT, DPT, MSOT
Barbara J Norton, PT, PhD, FAPTA
Presented by Shirley Sahrmann, PT,
PhD, FAPTA
Key Concepts for Diagnostic Categories
Lumbar Rotation
Syndromes
– Accelerated by the following 2 factors
Presented by:
Nancy Bloom, PT, DPT, MSOT
Importance of 2 Factors to Development
of LBP
(repeated movements & prolonged postures)
• Results in adoption of movement & alignment
strategies in lumbar spine in a specific direction(s)
•
the most flexible segment moves
• More frequently
• Through greater range of motion than optimal
• Can compensate for the restricted range of adjoining
segments
Copyright: S. Sahrmann & Associates
LBP is a mechanical disorder associated with the
progressive characteristics of degenerative joint
disease (the march to stenosis
stenosis))
Repeated movements of the spine in specific
direction(s)
Overt trunk movements, e.g., forward bending & return
Induced movements via limbs, e.g,
e.g, lumbopelvic rotation with hip
rotation
Prolonged postures of the spine associated
with specific direction(s)
Importance of 2 Factors to Development
of LBP
(repeated movements & prolonged postures)
• Strategies are generalized across person’s
everyday activities
• Continued use of strategies contributes to changes
in movement system elements
e.g., changes in muscle length &/or stiffness
e.g., changes in motor recruitment patterns
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Low Back Movement System
Impairment Diagnoses
Primary Test & Secondary Test
Trunk Movement
Named for movement direction or alignment
most consistently causing symptoms
– Flexion, Extension, Rotation, Flexion
Flexion--rotation;
Extension--rotation
Extension
Treatment
– prevent movement in the painful direction
– Correct the tissue adaptations that are
contributing to the segments’ directional
susceptibility to movement (interrupt the vicious
cycle)
Patient-Preferred Movement
Modified Movement
Symptoms Monitored & Compared
Primary & Secondary Test
Trunk Alignment
Patient-Preferred Alignment
Primary: Patient Preferred
Secondary: Modified
Support above iliac crest
Modified Alignment
Symptoms Monitored & Compared
+ Pain
- Pain
5 Syndromes
Lumbar Rotation*
Lumbar Rotation with Extension*
Lumbar Rotation with Flexion
Lumbar Extension*
Lumbar Flexion
Lumbar Rotation Syndrome
* Most prevalent in sample of people with primarily
subacute/chronic,
subacute
/chronic, recurrent LBP
(Van Dillen et al., 2003)
Judgment based on consistency of responses across
examination
(Norton et al, 2004)
Copyright: S. Sahrmann & Associates
2
Key Examination Findings
Signs
Key Examination Findings
– Lumbar rotation impairments across several
positions
Rotation
= rotation; side bending; lateral shift
– Impairments
Alignment
of the lumbar spine, e.g., asymmetry
in standing or quadruped
Movement of the lumbar spine
– e.g., asymmetric side bending
– e.g., lumbopelvic rotation with hip rotation
Alignment:
Iliac Crest High on Right (SB)
Symptoms
– sxs often associated with lumbar rotation
signs, particularly if in weight bearing
position
e.g., side bending – asymmetric & sxs
– sxs may also with both flexion and
extension movements of the lumbar spine
e.g., sitting in flexion & sitting in extension
e.g., forward bending & return
Lumbar Rotation Syndrome - Example
Demographics:
24 year old P.T.
student
Female
Prolonged
posture:
• Carrying tray
with left hand
Complaint:
• LBP with
sitting
• Specifically –
class
• Sitting in
class leaning
to R>L
Occupation:
• Student fulltime
• Waitress parttime
RotationRotation
-Related Movement Impairment
Repeated
movement:
Repeated
shifting in class
Student with Low Back Pain, Unable to Sit in Class
Asymmetric side bending
Pelvic shift to left; Trunk shift to right
Trunk shift to left
Copyright: S. Sahrmann & Associates
3
2 Types of Rotation
Classification
1 Month Later
Primary Rotation
Secondary Rotation
No Pain
Able to Sit in Class
Has to be Careful
Primary Rotation
Primary Rotation
Acute Pain (often)
– The rotation is causing the symptoms
– Pt presents with a shift
Most often has pain at rest, particularly when
weight bearing
Has notable asymmetry in lumbar region
May have symptoms as rest or on verge of sxs
Symptoms with sidebending and rotation in
standing
– Correction of the rotation reduces the
symptoms
– Dx:
Dx: typically FlexionFlexion-Rotation
Rotation-Related Alignment Impairment
Primary
Rotation Classifications:
Primary
Quadruped: rocking back, the rotation in the
lumbar spine increases
– Has symptoms as lumbar region goes from
flexion toward neutral (extension)
– Decreases in flexion and Sxs as repeats the
rocking backward. (slight manual correction)
Asymmetry corrected with repeated rocking
Remain susceptible to recurrent episodes of
rotation of offending joints (rotation(rotation-ext/flex)
LBP in standing.
Lumbar side bend to right with shift of trunk to left.
Copyright: S. Sahrmann & Associates
4
Flexion--rotation during
Flexion
rocking backward
Improved lumbopelvic alignment
Hips stiffer than lumbar spine
Acute Episode of LBP –
Primary Rotation
Treatment Effect
Before
Day 1
After quadruped rocking
Day 5
Copyright: S. Sahrmann & Associates
Day 1
Day 5
5
Lumbar rotation (clockwise/L side prominent)
with Rocking Back in Quadruped
Natural standing
Left foot resting on phonebook
Rotation Classification
Secondary
Correction for Treatment
Day 13 – taped
Rotation-Related Alignment Impairment
Asymmetry of thoracolumbar regions
No symptoms at rest even in weight bearing
The rotated region/joints prevent motion at
these joints resulting in excessive motion at the
joints below the rotated regions
– Disc degeneration in joints with excessive motion
The rotated joints do not cause pain
Asymmetry of lumbar spine region
Copyright: S. Sahrmann & Associates
6
Rotation-Related Alignment Impairment
Rotation-Related Movement Impairment
Asymmetry of lumbar spine region
Asymmetric rotation
Asymmetrical Lateral Lumbar Flexion
Unable to side bend to left
because spine rotated left
vertebrae cannot rotate right
Stiffness of left hypertrophied
left paraspinal muscles limit
side bending to right
Primary & Secondary Test
Limb Movement
Copyright: S. Sahrmann & Associates
Induced Spinal Movement via
Limb Movement
Hip abduction/LR induces lumbar rotation
Lumbar rotation - Hip
abd/add
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Key Examination Findings
Standing
– Asymmetry in lumbar spine region
– Asymmetric side bending; movement at 1 or a few
segments of lumbar spine
Lumbar Rotation with
Extension Syndrome
Sitting
– Lumbar rotation with knee extension (asymmetric)
– Sxs with knee extension; Modified knee extension sxs
Side lying
– Sxs
Lumbar Rotation with Extension Syndrome - Example
Demographics:
62 y/o female
5’ 1/2” tall
Complaints:
LBP with sitting at
work
Occupation:
Administrative
assistant
Prolonged
posture:
• Sits on edge of
chair in lumbar
extension
& thoracic flexion
Repeated
movements:
• Arm flexion at
desk
in side lying (asymmetric); Modified side lying sxs
Patient-Preferred Movement - Forward Bend
Thoracic
flexion
Lumbar
spine
straight
Hip flexion
80 degrees
• Rotates to the
right
Patient-Preferred Movement
Modified Movement
Lordosis & kyphosis
with arm movement
Less lordosis & kyphosis
with arm movement
Copyright: S. Sahrmann & Associates
8
Key Examination Findings
Prone position
– Sxs ; Modified prone - sxs
Knee flexion in prone
– Anterior tilt &/or lumbopelvic rotation (asymmetric)
– Sxs with 1 extremity; Modified knee flexion - sxs
Key Examination Findings
Quadruped
– Asymmetry in lumbar region
– Extended in lumbar region
– Sxs with quadruped
– Modified quadruped sxs
Hip rotation in prone
– Lumbopelvic rotation (asymmetric)
– Sxs with 1 extremity; Modified hip rotation – sxs
Patient-Preferred Alignment - Quadruped
Thoracic
flexion
Patient-Preferred Alignment - Quadruped
Lumbar
rotation to
the right
Straight
lumbar spine
Decreased
hip flexion
(45 degrees)
Modified Alignment - Quadruped
Decreased
thoracic
kyphosis
Flat
lumbar
spine
without
rotation
Lumbar Rotation with
Flexion
90
degrees of
hip flexion
Copyright: S. Sahrmann & Associates
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Key Examination Findings
Standing
–
–
–
Standing Alignment: Note
Asymmetries (mild scoliosis)
Asymmetry lumbar region
Lumbar flexion > hip flexion with forward bend
Forward bend – sxs ; Modified forward bend – sxs
Sitting
–
–
–
Sitting in flexion – sxs ; Modified sitting – sxs
Knee extension – flexion & rotation of lumbar spine
(asymmetric)
Knee extension – sxs ; Modified knee extension sxs
Primary Test & Secondary Test
Trunk Movement
Sitting Knee Extension
–
–
–
–
Relative stiffness of hamstrings vs lumbar spine
Is hamstring shortness the real problem?
Will stretching the hamstrings resolve impairment?
Secondary Test:
Note decrease in knee extension ROM
What muscles does she have to use to do this?
Preferred Test
Patient-Preferred Movement
Secondary Test
Modified Movement
Symptoms Monitored & Compared
Hip Flexor Length Test
– Relative flexibility/stiffness of hip flexors vs lumbar
spine
– Asymmetry between (R) and (L) sides in TFL
TFL--ITB
stiffness & shortness
– Contributes to rotation impairment
Copyright: S. Sahrmann & Associates
Unilateral Hip & Knee Flexion: Passive
– Relative flexibility/stiffness of gluteus
maximus vs lumbar spine
– No true shortness of gluteus maximus
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Unilateral Hip & Knee Flexion: Active
– Lumbo
Lumbo--pelvic rotation during initiation of movement
– Size of legs in relation to trunk
– Secondary test: note difficulty of stabilization –
symptoms decrease
Key Examination Findings
Sidelying
Hip Abduction With Lateral Rotation
– Lumbopelvic rotation in 1st half of ROM
– Secondary test: symptoms decrease
– Again, note difficulty of stabilizing pelvis
Hip Abduction/Lateral Rotation
– Lumbopelvic rotation during 1st half of motion
– Secondary test
– Sxs in side lying (asymmetric); Modified side
lying – sxs
– Lumbopelvic rotation with hip LR
– Lateral flexion with hip abd
abd/add
/add
Prone
– Lumbopelvic rotation (asymmetric) during
knee flexion and hip rotation
– Sxs (asymmetric); Modified test:
sxs
Hip Abduction/Adduction
– Lateral flexion of trunk during 1st half of
motion
– Secondary test – stabilizing with lateral
abdominals
Copyright: S. Sahrmann & Associates
Prone Knee Flexion: Passive & Active
– Relative flexibility/stiffness of 2 joint hip
flexors (primarily TFLTFL-ITB) vs lumbar spine
– Secondary test: using abdominals to stabilize
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Prone Hip Rotation
– Asymmetry of medial vs lateral rotation
– Lumbo
Lumbo--pelvic rotation
– Craig test: normal = 14
14--190 ; (R) = 270
Quadruped With Rocking Backward
No influence of hamstring length
Stiffness of Rectus Abdominus
Abdominus!!
Note difficulty with correction
Key Examination Findings
Quadruped
Rocking back in quadruped
– Asymmetry in lumbar region
– Flexion in lumbar region
– Sxs in quadruped; Modified quadruped –
sxs
– Flexion and rotation in lumbar region
– Sxs rocking back; Modified rocking – sxs
Treatment Guidelines
Modify daily work, leisure, and self care
activities.
– Change direction
direction--specific movement &
alignment strategies during regular activities.
Change
regular stimulus that is proposed to
be related to LBP & adaptations contributing
to LBP.
– Decreased stress on tissue (short
(short--term effects)
– Changes stimulus contributing to passive or
active adaptations (long(long-term effects)
Treatment Guidelines
Prescribe exercise/positioning to
address contributing factors (changes
in movement system elements).
– Motor control
Retrain
in appropriate movement strategy
– Redistribute motion
Clinical Research Supporting
Rotation Syndromes
Presented by:
Barbara J Norton, PT, PhD, FAPTA
Decreasing
Increasing
movement in lumbar spine
movement in other segments
Copyright: S. Sahrmann & Associates
12
Case Presentation: Part 1&2
Clinical Examination for
Rotation Syndromes
Several Slides and videos of the
examination of a 58 year old male with
Secondary Rotation Syndrome
Presented by:
Nancy Bloom, PT, DPT, MSOT
Clinical and Laboratory
Research of the Role of
Lower Extremity Motions in
Producing Lumbopelvic
Rotation
Presented by:
Shirley Sahrmann, PT, PhD, FAPTA
Trunk Motion and Rotation
Presented by:
Barbara J Norton, PT, PhD, FAPTA
Treatment Considerations
Presented by:
Shirley Sahrmann, PT, PhD, FAPTA
Copyright: S. Sahrmann & Associates
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