Lumbal spine assesment

The primary goal of a physiotherapeutic examination for a patient presenting with low back pain is to classify them according to the diagnostic triad recommended by international guidelines for back pain management¹. Although serious conditions such as fractures, cancer, infections, ankylosing spondylitis, or specific causes of back pain with neurological deficits (e.g., radiculopathy or cauda equina syndrome) are rare², it is crucial to screen for these pathologies¹³. Serious underlying conditions account for only 1–2% of individuals presenting with back pain⁴. In approximately 5–10% of cases, the pain is associated with radicular symptoms⁴. Once serious and specific causes are excluded, patients are classified as having nonspecific (mechanical) low back pain.

Nonspecific Low Back Pain

Nonspecific low back pain represents over 90% of patients presenting to primary healthcare settings⁵⁶ and constitutes the majority of individuals referred to physiotherapy.

The physiotherapeutic evaluation aims to identify contributing factors that influence pain onset or persistence. These include:

• Biological factors: muscular weakness or stiffness.

• Psychological factors: depression, fear of movement, or catastrophizing.

• Social factors: occupational environment and lifestyle⁷.

Unlike peripheral joints (e.g., the knee), physiotherapy assessment does not focus on identifying specific anatomical structures as the source of pain (e.g., intervertebral disc)⁷. Evidence and international guidelines suggest that identifying a specific tissue source is neither necessary nor possible for the effective management of mechanical back pain¹³⁸.

Structure of the Assessment

Subjective Examination

Patient history forms the foundation of the clinical assessment and assists in generating hypotheses regarding pain mechanisms and origin.

Objective Examination

Clinical testing is then used to confirm or refute these hypotheses established during the interview phase.

Subjective Examination in Detail

The subjective evaluation is one of the most valuable tools a clinician has when examining and treating patients with low back pain. The questions asked in this process help increase the clinician’s confidence in identifying serious pathologies requiring referral and allow recognition of yellow flags that may influence rehabilitation strategies.

A detailed patient history serves not only as a record of past and current symptoms but also as a foundation for planning treatment, prevention, and prognosis.

Patient Information and Reporting

• Present Complaint (PC) – Description of current pain or dysfunction.

• History of Present Complaint (HPC) – How the symptoms developed and progressed.

• Past Medical History (PMH) – Previous conditions or injuries that may be relevant.

• Drug History (DH) – Current and previous medication use.

• Social History (SH) – Lifestyle factors, occupation, and psychosocial background.

Region-Specific Questions

General Information

• What is the patient’s age and occupation?

• What was the mechanism of injury or pain onset?

• How long has the condition persisted?

Pain Characteristics

• Where is the pain located and how far does it spread?

• Is the pain centralizing or peripheralizing?

• Describe the pain: deep, superficial, burning, aching, or shooting.

• Has the pain improved, worsened, or remained unchanged?

Pain Provocation and Relief

• Does coughing, sneezing, or deep breathing increase pain?

• Are there specific postures or movements that aggravate or relieve symptoms?

• Is the pain worse in the morning or evening, or does it fluctuate throughout the day?

Neurological Symptoms

• Does the patient experience tingling (paresthesia) or numbness (anesthesia)?

• Any weakness, especially in the legs during walking or stair climbing?

Lifestyle and Activities

• Which activities aggravate or alleviate symptoms?

• Are there lifestyle habits contributing to the pain?

Sleep and Daily Function

• What is the patient’s sleeping position?

• Are there sleep disturbances or difficulties performing daily tasks?

Red Flags

• History of cancer, unexplained weight loss, immune suppression, infection, fever, or bilateral leg weakness.

• Recent trauma, use of corticosteroids, or progressive neurological deficits.

Special Questions

Although uncommon, serious spinal pathologies can present as low back pain in about 5% of patients seeking primary care⁹. These include:

• Cauda Equina Syndrome

• Malignancy

• Ankylosing Spondylitis

• Lumbar Spinal Stenosis

• Lumbar Disc Herniation

• Vertebral Fracture

• Spinal Infection

• Abdominal Aortic Aneurysm

Clinicians must remain vigilant for red flags, as these may coexist with mechanical low back pain¹⁰.

Identified Red Flags

According to Koes et al.¹¹, key red flags include:

• Onset before age 20 or after age 55.

• Non-mechanical pain (not related to time or activity).

• Thoracic pain.

• History of cancer, corticosteroid use, or HIV infection.

• Poor general health or unexplained weight loss.

• Widespread neurological symptoms.

• Structural deformities of the spine.

Additional “Flag” Categories

• Yellow Flags: Psychological factors such as fear-avoidance, catastrophizing, or activity avoidance that may affect treatment and prognosis.

• Orange Flags: Mental health conditions such as major depression or anxiety disorders.

• Blue Flags: Work-related or social factors, e.g., dissatisfaction with work or occupational strain.

• Black Flags: External barriers such as financial issues or lack of employer support that hinder recovery.

  
  

Standardized Measurement Tools

Bruken av spørreskjemaer for pasienter med ryggsmerter er en verdifull måte å kartlegge pasientens fremgang, behov for behandling og målområder. Selv om mye informasjon kan samlUsing validated questionnaires for patients with low back pain is a valuable method to assess progress, treatment needs, and therapeutic goals. While much information is collected during the subjective examination, standardized questionnaires provide a more objective approach to understanding patient function. They can uncover details that may not emerge during the interview or physical examination and also serve as documentation of treatment effectiveness — useful for communication with other stakeholders such as insurance companies or employers¹⁰.

Recommended Questionnaires

Oswestry Disability Index (ODI)

One of the most widely used tools to measure functional disability in patients with low back pain. It quantifies limitations in daily activities and provides a reliable baseline for tracking progress.

Fear Avoidance Belief Questionnaire (FABQ)

Assesses a patient’s beliefs and fears about movement and activity, both physical and occupational. High scores may predict slower recovery due to fear-avoidance behaviors.

STarT Back Screening Tool

A brief screening instrument that helps classify patients according to their risk of developing chronic back pain. It guides treatment decisions and facilitates early intervention.

Acute Low Back Pain Screening Form

Designed for patients with newly developed low back pain, focusing on identifying risk factors and immediate treatment needs.

Quebec Back Pain Disability Scale

Evaluates the degree of disability and changes in functional capacity over time, particularly in patients with chronic pain.

Hendler 10-Minute Screening Test

A quick screening method for identifying complex or chronic low back pain conditions.

Roland-Morris Disability Questionnaire

Measures daily functional ability and limitations caused by back pain; particularly useful for mild to moderate disability levels.

Optimal Screening for Prediction of Referral and Outcome (OSPRO)

A comprehensive instrument that predicts the need for referral and potential treatment outcomes by combining psychosocial and physical domains.

Functional Pain Management Society’s Intake Questionnaire

Evaluates pain intensity, functional capacity, and psychological contributors related to chronic pain management.

Previous Examinations

When assessing a patient, it is essential to determine whether other investigations have been performed:

• Radiology: X-ray, MRI, CT, or ultrasound to assess structural or pathological changes.

• Blood Tests: To identify or rule out inflammatory, systemic, or metabolic disorders.

Clinical Relevance:Prior test results provide valuable insights into the patient’s condition and should always be reviewed before planning further evaluation or treatment strategies.

Objective Examination

The objective assessment aims to confirm or refute hypotheses developed during the subjective examination. This phase involves a systematic evaluation of the Severity, Irritability, Nature, Stage, and Stability (SINSS) of symptoms.

Before Testing

• Severity: Determined by the intensity of symptoms and perceived functional limitation.

• Irritability: Evaluates how little activity provokes symptoms, the intensity of symptoms produced, and the time required for them to subside.

  • Example: If a minor movement triggers sharp pain that takes several minutes to resolve, irritability is considered high.

• Nature: Refers to the type of disorder (mechanical, inflammatory, neural, psychosocial) and includes red and yellow flag considerations.

Note: Lumbar symptoms often radiate to the lower extremities. It is therefore important to screen for referred pain and rule out pathology originating from the lumbar spine when evaluating lower-limb complaints without clear traumatic origin.

Examination Protocol

Sequence: The assessment should progress in a standardized order: standing → sitting → supine/prone.Tests likely to provoke pain are reserved for the end of the session.

Asterisk (Comparable Signs): After completing the examination, clinicians identify a key clinical sign that can be measured, reproduced, and reassessed — such as range of motion, pain score, or functional task. This serves as a benchmark for monitoring improvement.

Observation

Movement Patterns:

• Observe how the patient enters the room — note any flexion deformity, lateral pelvic tilt, or antalgic gait.

• Observe how they sit down — do they brace their trunk or avoid spinal motion?

• Observe how they rise — patients with low back pain may stabilize their spine excessively to avoid discomfort.

Posture:

• Scoliosis: Static, sciatica-related, or idiopathic.

• Lordosis: Excessive or flattened curvature.

• Kyphosis: Typically thoracic, may appear exaggerated in chronic cases.

Other Observations:

• Body Type: Somatotype can influence movement and load distribution.

• Facial Expression and Posture: Indicators of pain or anxiety.

• Skin and Hair: Color, texture, or hair growth changes may indicate vascular or neurological issues.

• Leg Length Discrepancy: Evaluate both structural and functional differences.

  
  

Functional Testing

Demonstration of Pain-Provoking Movements:Ask the patient to perform movements that typically trigger their symptoms. This helps identify patterns, sensitivities, and potential pain generators.

Squat Test:Used to screen for pathology in the lower extremities.

• Contraindicated: In elderly, pregnant, or arthritic patients with mobility limitations.

• Interpretation: A negative result typically eliminates the need for additional peripheral joint testing in a lying position¹².

Movement Testing

Active Range of Motion (AROM):

• Flexion: 40–60°

• Extension: 20–35°

• Side-bending: 15–20°

Observe:

• Willingness to move

• Quality of motion (smooth or jerky)

• Origin and location of movement

• Pain pattern (including arcs or deviations)

Overpressure: Applied at the end of pain-free AROM to evaluate end-feel, which should normally be tissue stretch.

Additional Tests:

• Sustained Postures: Used when indicated by patient history.

• Combined Movements: Helpful for identifying specific movement dysfunctions.

• Repeated Movements: Used to detect centralization or directional preference patterns.

Muscle Strength Testing

Isometric Resistance Tests: Evaluate strength in flexion, extension, lateral flexion, and rotation.

Core Stability and Functional Strength Tests: Assess the ability to maintain lumbopelvic control during movement.

Movement Control Tests

Purpose: To evaluate the patient’s ability to control lumbopelvic movement. Poor motor control is strongly associated with recurrent low back pain¹³¹⁴¹⁶.

Reliability: A standardized set of six movement control tests has been shown to provide reliable assessment of lumbopelvic stability¹³.

Examples:

• Assessing lumbopelvic coordination.

• Identifying faulty movement patterns that contribute to pain.

For detailed test procedures, refer to specialized lumbar assessment resources¹⁵.

Neurological Assessment – Lumbar Spine

A neurological examination is essential when neurological deficits are suspected or when the patient reports symptoms below the gluteal fold. This assessment helps identify nerve root involvement, distinguish between radicular and referred pain, and guide further diagnostic or therapeutic decisions.

Myotomes

Myotome testing evaluates the muscle groups innervated by specific spinal nerve roots. Weakness in any of these muscles may indicate nerve root compression or irritation. Testing should be performed isometrically and compared bilaterally.

Level	Muscle Function
L2	Hip flexion
L3	Knee extension
L4	Ankle dorsiflexion
L5	Great toe extension
S1	Ankle plantarflexion, ankle eversion, hip extension
S2	Knee flexion

Dermatomes

Dermatome testing assesses sensory regions supplied by specific spinal nerve roots. Light touch and pinprick (sharp-dull) discrimination are commonly used.

Level	Sensory Area
L2	Anterior upper thigh
L3	Lower thigh and medial knee
L4	Medial leg and ankle
L5	Lateral leg and dorsum of foot, including great toe
S1	Heel and lateral foot
S2	Posterior calf and thigh

Interpretation: Altered sensation such as numbness, tingling, or hypersensitivity may indicate nerve root irritation or compression.

Reflexes

Reflex testing evaluates the integrity of spinal reflex arcs and assists in localizing potential neurological lesions.

Reflex	Spinal Level	Clinical Use
Patellar Reflex	L3–L4	Commonly tested; absence may indicate femoral nerve or L3–L4 root involvement
Medial Hamstring Reflex	L5–S1	Rarely used; may detect subtle lumbosacral deficits
Lateral Hamstring Reflex	S1–S2	Rarely used
Posterior Tibial Reflex	L4–L5	Occasionally used for lower lumbar evaluation
Achilles Reflex	S1–S2	Common in practice; often reduced in S1 radiculopathy

Clinical Note: Both hypo- and hyperreflexia should be noted, as exaggerated reflexes may suggest upper motor neuron involvement.

Refleks	Nivå	Klinisk Bruk
Patellar	L3–L4	Vanlig i praksis
Medial Hamstring	L5–S1	Sjeldent brukt
Lateral Hamstring	S1–S2	Sjeldent brukt
Posterior Tibial	L4–L5	Sjeldent brukt
Achilles	S1–S2	Vanlig i praksis

Neurodynamic Testing

Neurodynamic tests assess the mobility and mechanosensitivity of neural tissue along the spine and lower limbs. They help determine whether neural irritation contributes to the patient’s symptoms.

Test	Purpose
Slump Test	Evaluates tension and irritability of the entire neural axis from cervical to lumbar spine. Positive when neural symptoms are reproduced and relieved by neck extension.
Straight Leg Raise (SLR)	Assesses neural mobility of L4–S2 nerve roots. Pain radiating below the knee between 30–70° hip flexion suggests nerve involvement.
Prone Knee Bend (Femoral Nerve Stretch Test)	Evaluates upper lumbar roots (L2–L4). Reproduction of anterior thigh pain may indicate femoral nerve tension.

Modified Tests: Adjustments can be made depending on symptom irritability and patient tolerance.

Circulatory Assessment

When vascular disorders are suspected, a hemodynamic evaluation is necessary.This includes:

• Palpation of peripheral pulses

• Measurement of blood pressure

• Assessment of capillary refill and skin temperature

These tests help rule out vascular claudication or other circulatory causes of lower limb pain.

Palpation

Palpation of the lumbar spinous processes is an important component in diagnosing low back pain.Both central and unilateral posterior–anterior pressures are used, especially when applying Maitland’s techniques¹⁷.

Purpose:

• Identify tenderness, stiffness, or abnormal mobility between vertebral segments

• Correlate findings with the patient’s reported pain location

Reliability of Palpation

Study / Source	Findings
Snider et al.	Using anatomical landmarks for identifying lumbar spinous processes can be more accurate than previously assumed. Accuracy depends on examiner experience, anatomy, and body composition¹⁹.
Phillips et al.	Combining manual palpation with verbal patient feedback improves reliability when identifying symptomatic lumbar segments²⁰.
Influencing Factors	High BMI and abnormal 12th rib morphology can reduce palpation accuracy, especially between L1–L4²¹²².

Screening of Adjacent Joints

A full lumbar assessment requires examination of adjacent joints to rule out referred symptoms or compensatory dysfunctions.

Thoracic Spine

Seated Rotation with Combined Movements and Overpressure: The patient rotates the trunk while the therapist applies gentle overpressure. Pain reproduction or stiffness indicates thoracic contribution to lumbar pain.

Sacroiliac Joint (SIJ)

A combination of mobility and provocation tests helps identify SIJ dysfunction:

• Gillet Test: Evaluates ilium motion relative to the sacrum during hip flexion.

• Sacral Clearing Test: Palpation of sacrum to detect tenderness or restriction.

• Cluster Tests: Includes FABER and Thigh Thrust tests to increase diagnostic precision.

Hips

Passive Range of Motion (PROM) with Overpressure:

Assesses hip mobility and detects pain that may influence lumbar mechanics. Hip stiffness often contributes to compensatory lumbar motion.

Knees and Ankles

Mobility Assessment:

Evaluate both joints for range of motion restrictions that could alter gait or load transfer. Limited dorsiflexion or knee extension can increase lumbar strain.

Neurological Dysfunction and Lumbar Instability Tests

A neurological examination of the lumbar spine aims to identify neural tension, nerve root compression, or spinal instability that contributes to low back pain. These tests also help classify mechanical versus neurogenic pain patterns and guide targeted interventions.

Tests for Neurological Dysfunction

Centralization and Peripheralization

Used to identify pain behavior in response to specific movements.

• Centralization: Pain moves proximally toward the spine, suggesting improvement.

• Peripheralization: Pain radiates distally, indicating nerve irritation or worsening condition.

Crossed Straight Leg Raise Test

Assesses radicular pain elicited when lifting the contralateral leg.A positive test reproduces pain on the affected side, suggesting a disc herniation with nerve root irritation.

Femoral Nerve Traction Test

Evaluates tension or compression of the femoral nerve.Pain in the anterior thigh during passive hip extension and knee flexion indicates upper lumbar (L2–L4) involvement.

Prone Knee Bend Test

Also known as the Femoral Nerve Stretch Test.Performed in prone position to assess femoral nerve and upper lumbar root irritability. A positive test reproduces anterior thigh pain.

Slump Test (Variant)

Tests the entire neural axis from the head to the feet.Sequential flexion of the spine, knee extension, and ankle dorsiflexion provoke neural tension. Pain reduction with cervical extension confirms neural origin.

Straight Leg Raise Test (SLR)

Assesses lower lumbar nerve root irritation (L4–S2).Pain between 30°–70° of hip flexion radiating below the knee suggests radiculopathy or sciatic nerve tension.

Tests for Lumbar Instability

1. Lumbar instability occurs when passive stabilizing structures fail to maintain neutral spinal alignment during movement. The following tests evaluate both segmental and functional stability.

Test	Purpose
H and I Test	Functional test assessing lumbar control through combined flexion, extension, and lateral movements. Instability is indicated by inconsistent movement or pain during one direction but not the other.
Passive Lumbar Extension Test	Detects lumbar instability by elevating both lower limbs approximately 30 cm while observing for a sense of “heaviness” or pain reproduction¹²⁴.
Prone Segmental Instability Test	Identifies painful hypermobility at a specific lumbar segment. Pain decreases when the patient activates spinal extensors.
Specific Lumbar Torsion Test	Evaluates rotational instability in the lumbar region.
Anterior–Posterior Instability Tests	Determines the direction of instability based on the provoked movement or pain pattern.

Tests for Joint Dysfunction

Test	Purpose
Bilateral Straight Leg Raise Test	Detects dysfunction in the lumbosacral joints by lifting both legs simultaneously. Increased lumbar pain suggests segmental stress.
One-Leg Standing (Stork Standing) Lumbar Extension Test	Evaluates lumbar pain and stability during single-leg weight bearing. Useful for identifying spondylolysis or pars interarticularis stress.
Quadrant Test	Combines extension, rotation, and side bending to localize pain from facet joints or intervertebral discs.

Tests for Muscle Tightness

Assessing muscle flexibility is essential to identify movement restrictions contributing to lumbar dysfunction.

Test	Target Muscle / Structure	Purpose
90–90 Straight Leg Raise Test	Hamstrings	Measures hamstring tightness by assessing knee extension angle from 90° hip flexion.
Ober’s Test	Iliotibial band	Evaluates IT band flexibility and lateral hip tension.
Rectus Femoris Test	Rectus femoris	Determines quadriceps flexibility; tightness may cause anterior pelvic tilt.
Thomas Test	Hip flexors	Identifies hip flexor tightness; positive if the thigh fails to reach the table during passive hip extension.

Other Clinical Tests

Sign of the Buttock

Used to detect serious underlying pathology.If passive hip flexion produces pain and additional movements (e.g., knee flexion) do not increase range, it may indicate abscess, tumor, or SIJ dysfunction.

Lumbopelvic Disorders and Classification

Lumbopelvic disorders encompass a variety of conditions affecting the lumbar spine and pelvis.Research suggests that classification-based approaches enhance treatment outcomes by tailoring interventions to specific movement patterns and symptom clusters²⁵²⁶.

Purpose of Classification Systems:

• Identify key signs and symptoms

• Avoid unnecessary focus on structural diagnosis

• Guide evidence-based, targeted interventions

• Improve communication between clinicians

Psychosocial Assessment

Psychosocial factors play a crucial role in the onset, maintenance, and prognosis of lumbopelvic pain. A comprehensive evaluation of these aspects ensures a biopsychosocial approach to patient care.

Flag System

The flag system provides a structured way to identify psychological and social barriers to recovery.

Flag	Meaning	Description
Yellow Flags	Psychological	Fear of movement, catastrophizing, or avoidance behavior that hinders rehabilitation.
Orange Flags	Mental Health	Indications of severe depression, anxiety, or psychiatric conditions requiring specialist referral.
Blue Flags	Work-Related	Job dissatisfaction or perceived overwork affecting motivation and recovery.
Black Flags	Socioeconomic	External barriers such as financial hardship or lack of employer support.

Recommended Tools

Tool	Purpose
STarT Back Screening Tool	Combines biological and psychological factors to assess risk for persistent low back pain.
Örebro Screening Tool	Evaluates psychosocial contributors to pain and disability, including patient motivation and recovery beliefs.

Summary

A comprehensive neurological and functional examination of the lumbar spine combines mechanical, neural, and psychosocial evaluation.This multidimensional approach helps the clinician determine whether pain arises from neural irritation, joint dysfunction, muscle imbalance, or behavioral barriers — leading to individualized, evidence-based treatment planning.

Sources

1.        Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075–94

2.        Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2009 Oct;60(10):3072-80.

3.        Van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A, COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. European guidelines for the management of acute nonspecific low back pain in primary care. European spine journal. 2006 Mar;15(Suppl 2):s169.

4.        O'Sullivan, P. and Lin, I. Acute low back pain Beyond drug therapies. Pain Management Today, 2014, 1(1):8-14

5.        Koes BW, Van Tulder M, Thomas S. Diagnosis and treatment of low back pain. Bmj. 2006 Jun 15;332(7555):1430-4.

6.        Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017 Nov 13;189(45):E1386-E1395.

7.        M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118

8.        Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European Spine Journal. 2007 Oct 1;16(10):1539-50.

9.        Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?. Jama. 1992 Aug 12;268(6):760-5.

10.   Rainey N. Considerations for Lumbar Assessment Course. Plus, 2023.

11.   Koes BW, Van Tulder M, Thomas S. Diagnosis and treatment of low back pain. Bmj. 2006 Jun 15;332(7555):1430-4.

12.   Magee, D. Lumbar Spine. Chapter 9 In: Orthopedic Physical Assessment. Elsevier, 2014

13.   Meier R, Emch C, Gross-Wolf C, Pfeiffer F, Meichtry A, Schmid A, Luomajoki H. Sensorimotor and body perception assessments of nonspecific chronic low back pain: a cross-sectional study. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-0.

14.   Tsunoda Del Antonio T, José Jassi F, Cristina Chaves T. Intrarater and interrater agreement of a 6-item movement control test battery and the resulting diagnosis in patients with nonspecific chronic low back pain. Physiotherapy Theory and Practice. 2022 Mar 4:1-1.

15.   Adelt E, Schöttker-Königer T, Luedtke K, Hall T, Schäfer A. Dataset for the performance of 15 lumbar movement control tests in nonspecific chronic low back pain. Data in brief. 2022 Jun 1;42:108063.

16.   Khodadad B, Letafatkar A, Hadadnezhad M, Shojaedin S. Comparing the effectiveness of cognitive functional treatment and lumbar stabilization treatment on pain and movement control in patients with low back pain. Sports Health. 2020 May;12(3):289-95.

17.   tsudpt11's channel. Maitland Lumbar PAIVM (skeletal model). Available from: http://www.youtube.com/watch?v=t0OCzavA6SY[last accessed 19/08/15]

18.   McKenzie AM, Taylor NF. Can physiotherapists locate lumbar spinal levels by palpation?. Physiotherapy. 1997 May 1;83(5):235-9.

19.   Snider KT, Snider EJ, Degenhardt BF, Johnson JC, Kribs JW. Palpatory accuracy of lumbar spinous processes using multiple bony landmarks. Journal of manipulative and physiological therapeutics. 2011 Jun 1;34(5):306-13.

20.   Phillips DR, Twomey LT. A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure. Manual therapy. 1996 Mar 1;1(2):82-7.

21.   Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. The American journal of emergency medicine. 2007 Mar 1;25(3):291-6.

22.   Snider KT, Snider EJ, Degenhardt BF, Johnson JC, Kribs JW. Palpatory accuracy of lumbar spinous processes using multiple bony landmarks. Journal of manipulative and physiological therapeutics. 2011 Jun 1;34(5):306-13.

23.   Physical Therapy Nation. Lumbar and SIJ Examination. Available from: http://www.youtube.com/watch?v=EL5tXj81Q8M[last accessed 19/08/15]

24.   PTY621 H and I test Available from: https://www.youtube.com/watch?v=P_N_Sg07XR0 (last accessed 26.11.2019)

25.   Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine. 2006 Mar 15;31(6):623-31.

26.   Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of internal medicine. 2004 Dec 21;141(12):920-8.