Active Movement Screening: Lumbar Spine, Hip Contribution, and Functional Tests

Purpose and Concept: What This Screen Tells You

This chapter outlines a quick, lumbar-focused active movement screen that helps you: (1) identify which directions and functional tasks are symptom-provoking, (2) observe whether motion appears to come primarily from the lumbar spine or the hips, and (3) decide when to stop and shift to neurological testing. The goal is not to “diagnose” a structure, but to map symptom behavior (what movements change symptoms) and movement strategy (how the person moves) so you can triage and plan next steps.

A key idea is lumbar–hip contribution: many tasks that look like “low back motion” are actually a mix of lumbar spine movement and hip movement. If the hips are stiff or poorly controlled, the lumbar spine often moves more (or earlier) to compensate, which can amplify symptoms. Conversely, hip pain can be mistaken for lumbar pain if you don’t watch hip motion and symptom location carefully.

1) Setup and Safety: Baseline, Irritability, and Positioning

Baseline pain rating and symptom map

• Ask for a baseline pain rating (0–10) at rest/standing.
• Clarify symptom location: midline low back, unilateral low back, buttock, groin, lateral hip, thigh, below knee, foot.
• Ask whether symptoms are constant or movement-dependent, and whether there is any leg symptom (tingling, numbness, burning, weakness).

Irritability check (how cautious to be)

Use a brief “irritability” check to decide how many reps and how far to move:

• High irritability: pain spikes quickly, lingers after movement, or symptoms spread distally (toward the leg/foot). Use small ranges, 1–2 reps, and stop early.
• Low–moderate irritability: symptoms change predictably and settle quickly. You can use 3–5 reps and explore end-range more safely.

General setup

• Use a clear start position: standing, feet hip-width, knees unlocked, arms relaxed.
• Explain: “We’ll do a few movements. Tell me what you feel and where you feel it. We stop if symptoms worsen or move down the leg.”
• Consider a support option (hands on a counter/wall) for balance during side-bending/rotation or squat/hinge.

2) Movement Sequence: Lumbar Motions + Functional Tests

Keep the sequence consistent so you can compare sessions. A practical order is: flexion → extension → side-glide/side-bending → rotation (if appropriate) → functional movements (sit-to-stand, squat/hinge).

A. Lumbar flexion (standing)

Instruction: “Slowly bend forward as if reaching toward your shins. Don’t force it. Then return to standing.”

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• Perform 1–5 reps depending on irritability.
• Option: pause briefly at the bottom to note symptom change, then return.

What to record: range (to knees/mid-shin/ankles), pain location, and whether symptoms centralize (move toward the back) or peripheralize (move toward the leg/foot).

B. Lumbar extension (standing)

Instruction: “Place hands on your hips or low back and gently lean backward. Keep knees straight but not locked. Return to neutral.”

• Use small range first; add range only if tolerated.
• Note whether extension is limited by pain, stiffness, fear, or balance.

C. Side-glide / side-bending (standing)

Choose one method based on what you can observe best.

Option 1: Side-bending — “Slide your hand down the outside of your thigh toward your knee, then come back up.” Do both sides.

Option 2: Side-glide (translation) — “Keep shoulders level and gently shift your pelvis to the right, then to the left, without leaning your trunk.” This can be useful when you suspect a lateral shift pattern.

• Compare left vs right: range, symptom response, and movement quality.

D. Rotation (as appropriate)

Rotation is optional if symptoms are irritable or if flexion/extension already strongly provokes leg symptoms. If used:

Instruction: “Cross your arms over your chest and gently rotate your trunk to the right, then left, keeping hips facing forward.”

• Keep it small and slow; avoid forcing end-range.

E. Functional movement 1: Sit-to-stand

Setup: Standard chair height, feet under knees, arms crossed if safe (or hands on thighs if needed).

Instruction: “Stand up and sit down at a comfortable pace.”

• Do 3 reps if tolerated.
• Note pain on the way up vs down, and whether symptoms change after repetition.

F. Functional movement 2: Squat vs hip hinge pattern

Use this to observe lumbar vs hip strategy under load-like conditions.

Squat screen (general): “Squat down as if sitting back, then stand.”

Hip hinge screen (lumbar-sparing): “Place hands on your hips, soften knees slightly, and push your hips back like closing a car door with your butt. Keep your spine long. Return.”

• Choose the hinge first if flexion is provocative; choose squat first if extension is provocative (squat often biases hip flexion and can reduce lumbar extension demand).
• Use a dowel along the spine (head–mid-back–sacrum contact) if you want a simple cue for neutral spine control.

3) What to Observe: Lumbar Curve, Pelvis, and Pain Behaviors

Reversal of lumbar curve and segmental control

• Flexion: Does the lumbar spine reverse smoothly into flexion, or does it stay rigid while the person “hinges” mostly at hips? Either extreme can matter: excessive lumbar flexion early may irritate flexion-sensitive backs; a rigid lumbar strategy may indicate guarding.
• Extension: Is extension distributed through the lumbar spine or concentrated at one segment (a visible “hinge point”)? Segmental hinging can correlate with localized pain provocation.
• Return from flexion: Watch for a painful “catch,” a sudden shift, or using hands on thighs (Gower-like support) suggesting poor tolerance or protective behavior.

Pelvic motion and hip contribution

• In forward bending, does the pelvis rotate (hip flexion) or does the lumbar spine do most of the motion?
• In squat/hinge, does the pelvis move back with relatively stable lumbar posture (hip-driven), or does the lumbar spine round early (lumbar-driven)?
• Look for asymmetry: pelvic hike, trunk shift, or unequal depth side-to-side.

Pain behaviors and movement quality

• Speed changes (sudden slowing), breath-holding, facial grimacing, guarding, or “en bloc” movement (whole trunk moves as one unit).
• Repeated small adjustments, shaking, or needing hand support.
• Symptom report consistency: same movement reliably reproduces symptoms vs unpredictable responses.

4) Symptom Behavior: Mechanical Low Back Patterns vs Leg Symptom Provocation

Patterns more consistent with mechanical low back pain

• Symptoms primarily in the low back/buttock, with predictable changes based on direction (e.g., worse with flexion tasks, better with extension tasks, or vice versa).
• Symptoms that ease quickly when returning to neutral or changing posture.
• Local stiffness or ache without progressive distal spread.

Patterns that raise concern for nerve involvement (during this movement screen)

• Leg symptom provocation (tingling, numbness, burning) that appears or intensifies with lumbar movements, especially if it travels below the knee.
• Peripheralization: symptoms move farther down the leg with repeated movements or end-range loading.
• New weakness reported during tasks (e.g., giving way on sit-to-stand) or visible foot drop/slap.

When leg symptoms are provoked, your immediate task is to document: what movement caused it, where it went (buttock → thigh → calf → foot), how intense it became, and whether it settles when you stop. This information guides whether you proceed, modify range, or switch to neurological testing.

5) Quick Hip Screen Elements (to Avoid Misattribution)

You are not doing a full hip exam here. You are checking whether hip motion limits or hip pain patterns could be driving what looks like “lumbar” pain.

A. Observe hip flexion strategy during functional movement

• During squat/hinge: Is depth limited by early lumbar rounding because hips don’t flex well? Does the person shift weight to one side to avoid a hip?
• During sit-to-stand: Do knees collapse inward, or does the trunk lean excessively forward to compensate for hip weakness/pain?

B. Quick hip rotation observation (standing or seated)

Standing rotation bias check: Ask the person to rotate the trunk while you watch whether the pelvis rotates with it. Excess pelvic rotation may indicate they are using hip rotation rather than lumbar rotation (or avoiding lumbar rotation).

Seated hip rotation glance (if time and tolerated): Seated with hips and knees at 90°, ask for gentle internal and external rotation of each hip (feet move out/in). Note large side-to-side differences or reproduction of groin/lateral hip pain. If hip rotation is clearly limited or painful, interpret lumbar movement findings cautiously.

C. Symptom location clues

• Groin/anterior hip pain during squat/hinge often points you toward hip contribution.
• Lateral hip pain may reflect hip region sensitivity; confirm whether lumbar motions reproduce it or whether it is more load/stance related.
• Back-dominant pain that changes with repeated lumbar flexion/extension is more consistent with lumbar contribution.

6) Stop Rules and When to Prioritize Neurological Testing

Stop the movement screen (or significantly scale it back) and prioritize neurological testing and/or urgent referral pathways when any of the following appear:

• New or worsening leg weakness (e.g., repeated knee buckling, new foot drop, inability to heel/toe walk if you check informally).
• Progressive numbness or rapidly spreading sensory changes down the leg.
• Saddle symptoms (numbness in saddle region) or new bladder/bowel changes reported during the session.
• Severe unremitting pain that does not ease with position change, or pain that escalates sharply with minimal movement and does not settle.
• Marked peripheralization with repeated movements (symptoms moving farther down the leg and persisting).

If symptoms are moderate but clearly nerve-like, you can still document which direction provokes/relieves, but avoid repeated end-range loading and transition to a focused neurological screen.

Practical Documentation Template (Fast and Repeatable)

Short Case Examples (How to Apply the Screen)

Case 1: Acute low back strain (movement-sensitive, no leg symptoms)

Presentation: Sudden onset after lifting; localized low back pain; baseline 5/10; no numbness/tingling.

Screen findings:

• Flexion: limited to knees; guarded; pain 5→7/10, settles quickly when upright.
• Extension: small range tolerated; pain 5→6/10, settles.
• Side-bending: mildly limited both sides; local ache only.
• Sit-to-stand: slow, uses hands; pain mainly on initiation.
• Hinge: with cueing, can shift motion to hips and reduce pain to 4/10.

Interpretation: Mechanical, irritable local pain with protective guarding. Hip-dominant strategy reduces symptoms, suggesting lumbar tissues are sensitive to early rounding and load. Keep ranges small, emphasize symptom-guided movement, and monitor for any new leg symptoms.

Case 2: Extension-intolerant pain (standing/walking worse)

Presentation: Low back pain increases with standing and walking; relief with sitting; baseline 2/10 sitting, 5/10 standing.

Screen findings:

• Extension: reproduces pain quickly (2→6/10) and lingers.
• Flexion: reduces symptoms (standing flexion 5→3/10) and feels relieving.
• Squat: tolerable and often relieving (hip flexion bias).
• Hinge: if performed with excessive lumbar extension (“arched back”), symptoms increase; with neutral spine and hip flexion, symptoms are better.

Interpretation: Directional sensitivity toward extension. Functional coaching should avoid sustained lumbar extension and emphasize hip flexion strategies and positions that reduce symptoms. Watch carefully for any leg symptom provocation during extension—if present or progressive, prioritize neurological testing.

Case 3: Flexion-intolerant pain (sitting/bending worse)

Presentation: Pain with sitting and bending forward; difficulty putting on socks; baseline 3/10 standing, 6/10 after sitting.

Screen findings:

• Flexion: reproduces pain and may refer into buttock (3→7/10); repeated flexion worsens and lingers.
• Extension: small range reduces pain (3→2/10) and feels like “pressure relief.”
• Hinge vs lumbar rounding: when asked to reach toward the floor, early lumbar rounding increases pain; when coached to hinge at hips with a long spine, pain decreases and reach improves.
• Quick hip check: hip flexion appears limited; compensatory lumbar flexion occurs early.

Interpretation: Flexion sensitivity with possible hip contribution (limited hip flexion leading to lumbar overuse). Prioritize hip-driven strategies for daily tasks, limit repeated end-range lumbar flexion early on, and monitor for any distal symptom spread. If buttock symptoms progress below the knee or numbness appears, shift to neurological testing.