Introduction

"The doctor of the future will give no medicine, but will interest his patients in the care of

the human spine." Thomas Edison said these words years ago and here we are now, becoming

doctors of the future, with more back problems than ever. Are the "doctors of the future" taking

the health of the human spine into as much consideration as they should? The American

Chiropractic Association found that the single leading cause of disability worldwide is back pain.

The back is a complicated structure of bones, joints, ligaments and muscles1. You can sprain

ligaments, strain muscles, rupture disks and irritate joints, all of which can lead to back pain.

While sports injuries or accidents can cause back pain, sometimes the simplest of movements for

example, picking up a pencil from the floor can have painful results. In addition, arthritis, poor

posture, obesity and psychological stress can cause or complicate back pain. Back pain can also

directly result from disease of the internal organs such as kidney stones, kidney infections, blood

clots or bone loss. In this paper, I would like to address an issue of the lumbar back, in which the

nerves stemming from the spinal cord become entrapped4.

Entrapment refers to the compression or irritation of the nerve. In the case of spinal

nerves, is most likely to be the compression of the nerve root that is causing irritation. Nerve

entrapment is also referred to as compression syndrome or compression neuropathy. All these

names refer to the medical condition which is caused by direct pressure on a single nerve4. It is

known colloquially as a "trapped nerve". For the purposes of this paper, we will refer to this

condition as nerve entrapment20.

Anatomy of the Back

A nerve can become entrapped at any nerve ending stemming from the spinal cord. We

will be analyzing the details of what happens in the human body when a nerve becomes

entrapped in the lumbar back. "Lumbar" is derived from the Latin word "lumbus," meaning lion,

and how the lumbar spine earned its name. It is built for both power and flexibility activities such

as lifting, twisting, and bending. This section of the back starts at spinal disc L1 and runs to L5;

you can also find the lumbar spine by measuring several inches above the iliac crest and ending

in line with the posterior inferior iliac spine7. The lower the vertebra is in the spinal column, the

more weight it must bear. The five vertebrae of the lumbar spine, L1-L5, are the biggest un-fused

vertebrae in the spinal column, enabling them to support the weight of the entire torso2. The

lumbar spine's lowest two spinal segments, L4-L5 and L5-S1, which include the vertebrae and

discs, bear the most weight and are therefore the most prone to degradation and injury. The

lumbar spine meets the sacrum at the lumbosacral joint (L5-S1). This joint allows for

considerable rotation, so that the pelvis and hips may swing when walking and running.

However, there are many variables that can contribute to lumbar nerve roots becoming

entrapped20.

A nerve root is the initial segment of a nerve, where it leaves the central nervous system.

Nerves exiting the area of the lumbar spine provide sensation and motor control to the back,

buttocks and legs and down to the feet. Damage or interference with these nerves can cause

neurological problems such as pain, weakness, abnormal sensations, numbness and changes in

spinal reflexes. Before we can analyze problems of the spine, we have to understand the anatomy

of the back. There are five major regions of the spine, starting with the cervical spine20. The

cervical spine is composed of seven vertebrae in the neck. Cervical vertebrae are the thinnest and

most delicate vertebrae in the spine, but offer great flexibility to the neck. The first cervical

vertebrae, C1, support the skull and are named the "atlas" after the Greek titan who held the

Earth on his shoulders. The skull pivots on the atlas when moving up and down. The second

cervical vertebra, C2, is known as the "axis" because it allows the skull and atlas to rotate to the

left and right7. The next section of the spine is named the thoracic spine and is composed of

twelve vertebrae in the chest region. Thoracic vertebrae are larger and stronger than cervical

discs, but are less flexible. The spinous process of the thoracic vertebrae point inferiority and

help lock the vertebrae together. A unique feature of the thoracic vertebra is that each one forms

joints with a pair of ribs to form the sturdy rib cage that protects the organs and chest. The third

section of the spine is the lumbar spine, and is composed of five vertebrae in the lower back.

Lumbar vertebra is even larger and stronger than thoracic discs, but is more flexible due to the

lack of ribs in the lumbar region. All of the upper body's weight bears down on the lumbar

vertebrae, leading to many back problems in this area, despite the size and strength of the discs.

The fourth section of the spine is called the sacral spine and contains only the sacrum, which is a

single bone in the adult skeleton that is formed by the fusing of five smaller vertebrae during

adolescence. The sacrum is a flat, triangular bone that is found in the lower back and is wedged

between the two hip bones3. The fifth and final segment of the spine is called the coccygeqal

segment and contains only the coccyx, which is a single bone in the adult skeleton that is formed

by the fusion of four small vertebrae during adolescence, much like the sacrum. The coccyx is

often referred to as the human tail bone, as this region is homologous to the tail bones of animals

that have tails. In humans, the coccyx bears out body weight when sitting down and provides

attachment points for muscles of the pelvis and gluteal regions. While most people have a coccyx

comprise of four fused vertebrae, the coccyx could possibly consist of three as few as three or as

many as five fused vertebrae. The length of the coccyx has no effect on human function and

varies upon individual. By understanding the function of each vertebral disc and section of the

spine, we can narrow down are research and study a particular section of the spine, with the

knowledge of the function of the other sections20.

Anatomy of the Lumbar Spine

For the purposes of this paper, we will now go into the anatomy of the lumbar spine, in

depth. The skeletal aspect of the lumbar spine, as stated above is composed of five individual

bones or discs. The muscular body of the lumbar spine is comprised of extensor muscles that are

attached to the posterior part of the spine and enables standing and lifting. These muscles include

the large paired muscles in the lower back, called the erector spine, which help to hold the spine

up5. The lumbar spine is also comprised of gluteal muscles4. The nervous system of the lumbar

spine may appear complicated, but it is important to have a clear understanding of it, if one

wants to find solutions to heal the spinal problems of our world. Nerve endings out of each disc

in the lumbar spine play a role in movement and sensation. We will now reveal those nerve

endings: the nerves emerging from the L1 vertebrae provide nervous system service to the

abdomen and then, as the nerves branch, to the thighs. The nerves emerging from the L2

vertebrae come together to form a bundle of nerves called the cauda equina8. They innervate the

front of the thigh and transmit motor signals that cause the hip to bend. The nerves emerging

from the L3 vertebrae include five different nerves. The first is the femoral nerve which

innervates muscles that allow the leg to bend and straighten. The second nerve is the

genitofemoral nerve, which innervates muscles associated with the reproductive organs. The

third nerve is called the lateral cutaneous nerve of the thigh. This nerve innervates the epidermis

in the mid to upper region of the leg. The fourth nerve is called the obturator and works to

innervate muscles in the pelvis and hip area. Lastly, the fifth muscle that stems from the lumbar

spine is called the quadratus lumbordum. This nerve works to innervate muscles that are

connected to the pelvis and spine. By understanding the nerves that stem from the vertebrae, we

can understand their function to the human body as a whole10.

Lower Back Injury

As you can tell, the anatomy of the spine is extensive and can even be taken into further

depth. With this understanding of the spine, particularly the lumbar spine, we can begin to

uncover how and why people are prone to injury in the lower back18. The problem of

entrapment is one that can happen at any point of the spine, but is more likely to occur in the

lumbar spine because of the functional abilities of this part of the back5. A pinched nerve in the

lower back can be caused my many different mechanisms of injury, including: a herniated disc,

arthritis, bone spurs, or spinal stenosis. There are possible mechanisms of entrapment for the

nerves stemming from the lumbar nerves of L1 - L5. In the L1 disc, the iliohypogastric nerve is

rarely injured in isolation. The most common cause of injury to this nerve is due to surgical

complications. The nerve derived from the L2 disc is called the ilioinguinal nerve and can be

entrapped by the tearing of the lower external oblique aponeurosis. The L3 nerve is called the

genitofemoral nerve; this nerve can become entrapped through its anatomical course through the

body. Injury to this nerve occurs most commonly as a complication of lower back abdominal

surgeries. The L4 nerve is called the lateral femoral cutaneous nerve, and it may become

entrapped due to intrapelvic causes, extrapelvic causes, or mechanical causes. Intrapelvic causes

include pregnancy, abdominal tumors, uterine fibroids, diverticulitis or appendicitis. Injuries

have been described in cases of abdominal aortic aneurysm4. The last nerve, which is derived

from the L5 disc, is called the femoral nerve. This nerve can have several entrapment locations

or causes of injury, including intrapelvic injury or injury to the inguinal region. Diabetic

amytrophy is the most common cause of femoral nerve entrapment. By understanding the

mechanics in which the nerves can become entrapped, we can look for signs and symptoms that

will help us to better narrow down the location of the impingement1.

Symptoms

Symptoms of Lumbar Nerve Entrapment may vary depending on which nerve is

entrapped. If the L1 nerve is entrapped, an individual may have symptoms which include burning

or lancinating pain immediately following the surgical operation. If the L2 nerve is entrapped,

the individual may experience hyperesthesia or hypoesthesia of the skin along with the inguinal

ligament. The sensation here may radiate to the lower abdomen. Pain may be localized to the

median groin, the labia majora or scrotum and to the inner thigh3. The L3 nerve symptoms

include groin pain which is a common presentation of neuralgia from nerve entrapment. The pain

may be worse with internal or external rotation of the hip, prolonged walking or even touch. L4

nerve entrapment symptoms may include anterior and lateral thigh burning, tingling or numbness

that increases with standing, walking or hip extension10. Symptoms may also increase with lying

prone. These symptoms are usually improved with sitting unless compression forces, such as

tight belts or garments are in the way6. Symptoms of L5 entrapment include pain in the inguinal

region that is partially relieved by flexion and external rotation of the hip and dysesthesia over

the anterior thigh and anteriomedial leg. Patients with L5 entrapment complain of difficulty

walking and of knee buckling occurring frequently3. This nerve also gives rise to the saphenous

nerve in the thigh; therefore, numbness in distribution can be present. Anterior knee pain may

also be present because the saphenous nerve supplies the patella. When we understand and can

spot the signs and symptoms that an entrapped nerve can cause to the human body, we can take

steps in educating our patients and finding a solution to the problems they are having16.

Surgical Options

Once it has been determined the cause of the patients nerve entrapment, they will be able

to speak to a doctor about surgery options. These options vary depending on the individual and

their injury. The option of Lumbar Decompression Back Surgery will be made to the patient.

This surgery is done when the cause of the patient’s entrapment is due to a compression of discs

that is crushing the nerve6. Decompression is a surgical procedure that is performed to alleviate

the pain caused by the pinched nerves. During the Lumbar Decompression surgery, a small

portion of the bone over the entrapped nerve root will be removed to give the nerve root more

space and provide a better healing environment. Depending on the surgeon and the needs of the

patient, there are two mechanisms that can be used to decompress the nerve root. The first one is

called a Microdiscectomy, which is typically performed for pain from a herniated disc9. The

surgery is considered to be reliable and the procedure involves removing the central portion of an

inter-vertebral disc, the nucleus pulpus, which causes pain by stressing the spinal cord and nerves

surrounding it7. The second option to performing a decompression of the lumbar spine is called a

lumbar laminectomy10. This procedure is typically performed with patients experiencing spinal

stenosis. The goal of this surgery is to allow more room for the nerve root, thus reducing pain

and any potential leg weakness or other neurological symptoms, and restoring the patient's

ability to participate in everyday life. The procedure to this surgery involves removing a whole

disc from the lumbar spine11. Laminectomy is generally used only when more-conservative

treatments such as medication, physical therapy or injections have failed to relieve symptoms.

Following the Lumbar Decompression Back Surgery, approximately seventy to eighty

percent of all patients will have a significant improvement in their function and reduced levels of

pain and discomfort associated with spinal entrapment11. In certain instances, the success rate of

a decompression for spinal stenosis can be enhanced by also fusing a joint. Fusing the joint

prevents the spinal stenosis for recurring and can help eliminate pain from an unstable segment.

Recovery after a Lumbar Decompression surgery has had early discharge rates, in which the

patient should be able to leave the hospital in about one to four days after the surgery8. Of course

these numbers vary depending on the status and situation of the patient6. The complexity of the

surgery and the patient's level of mobility before operation come into play as well. Most patients

are able to walk unassisted within a day after having the lumbar operation, although more

strenuous activities will need to be avoided for about six weeks, in order for the body to fully

recover and go through its proper healing phases. In between three to twelve months, depending

on the individual, the patient will be able to return to their functional daily activities. With any

surgery, there is a risk that comes with Lumbar Decompression surgery. These risks include, but

are not limited to: infection, blood clots, and further damage to the spine. The effectiveness of

the surgery, on the other hand is very good. Three out of every four patients who have the

Lumbar Decompression back surgery for Lumbar Nerve Entrapment, experience a significant

improvement in pain9. Also, patients who did discover walking difficulties before the surgery

because of leg pain derived from their lumbar back issues found that they were able to walk

further and more easily than before11.

Conservative Treatment

As with any issue that may require surgery, health care professionals first look at

conservative options for treatment. These options have the patient's functionality in mind, and

are focused on reducing the patient's pain and increasing their range of motion. Conservative

Lumbar Entrapment treatment options include different options depending on the lumbar nerve

that is being compressed. If the L1 nerve is being compressed, treatment may include local

injections of anesthetic, oral medications or physical therapy. If the L2 nerve is entrapped,

treatment may also include local injections of anesthetic, oral medications, or physical therapy. If

the L3 nerve is entrapped, the patient may be asked to avoid aggravating activities. Treatment

may include oral anti-seizure medication19. If the L4 nerve root is entrapped, the treatment may

include the injection of local anesthetic agents. Also, a steroid can be used to prolong the effects

of the local anesthetic and reduce inflammation. If the L5 nerve is entrapped, the treatment may

be based on symptoms only, or it may depend on the severity of the injury. Quadriceps weakness

is common among Lumbar Nerve Entrapment and may be treated by a locking knee brace to

prevent instability, or an assistive device that may be used to aid the patient in walking, such as a

cane or walker. While these conservative treatments may not provide a "cure" per say, to the

patent’s entrapped nerve, they will provide temporary relief and mobility17.

A conservative treatment technique for the Entrapped Lumbar nerve is for the patient to

attend physical therapy, in which a physical therapist will assess the needs of the patient and

create a rehabilitation plan to accommodate for the patient10. These rehabilitation plans last as

long as the patient needs and are a conservative yet aggressive approach to relieve pain in the

lumbar spine. In this rehabilitation plan, the therapist will add what is called, therapeutic

exercises, or exercises that work towards strengthening and mobilizing the lumbar spine14. A

patient will typically come to physical therapy twice a week, for an hour to an hour and a half

and work with the therapist. Therapeutic exercises that the therapist may have the patient do are

split up into stretches and strengthening exercises. These exercises all have proper techniques in

which they need to be done, for safety and for optimal advantage. They should also be done in

certain stages of the rehabilitation plan, that the therapist will instruct the patient on. Stretches

that the therapist does with the patient, will all typically be held for twenty to thirty seconds,

unless the patient is experiencing extreme pain. Stretches include, but are not limited to: a Spinal

Twist which is activating the thoracolumbar portion if the spine and is performed in the first and

second stages of rehabilitation. The purpose of this stretch is to work the middle and lower back

and alleviate some pain in that area. The Quadratus Lumbordum Stretch is done to activate the

thoracolumbar spine, and is done in the first and second stages of rehabilitation. The purpose of

this stretch is to stretch the quadratus lumbordum muscle as well as the latissimus dorsi. The

Prolonged Side Bend Stretch is done to activate the lumbar spine directly and should be done in

the first and second stages of rehabilitation. This stretch works to benefit the lateral trunk area.

The Lumbar Rock is a stretch done to activate the lumbar spine and should be done in stage two

of rehabilitation, or later9. This will stretch the lower back and hips. The Knee to Chest stretch

will work to activate the lumbar spine, and should be done in the first and second stages of

rehabilitation. This stretch will also stretch out the lower back and hips. The Lateral Trunk

Stretch is done to activate the lumbar spine and is done in the second stage of rehabilitation, or

later. This stretch works to alleviate pain in the lateral lumbar spine14.

Strengthening exercises that the therapist will do with the patient are also be very

technique specific and should be done in order of what stage of rehabilitation they are

appropriate for11. They include, but are not limited to: The Posterior Pelvic Tilt, which should

be performed in the second stage of rehabilitation. The purpose of this stretch is to strengthen

gluteal and abdominal muscles and encourage a more natural and unforced posterior pelvic tilt.

The Abdominal Curl may be performed in the second and third stages of rehabilitation and

serves to strengthen the rectus abdominis and oblique’s. The Abdominal Crunch is a more

intense version of the abdominal curl, and is done in the second and third stages of rehabilitation.

The purpose of this exercise is to strengthen the rectus abdominals and oblique’s12. The Oblique

Abdominal Curl is an exercise that is done in the second and third stages of rehabilitation and is

done to strengthen the internal and external oblique muscles. The Supine Leg exercise is done in

the second and third stages of rehabilitation and is done to strengthen the lower rectus abdominal

muscles and facilitate neutral pelvic positioning. The Self Bridge is an exercise that is done in

the second and third stages of rehabilitation and is done to strengthen the oblique’s and quadratus

lumbordum. Bridging is an exercise that is done in the second stage of rehabilitation and is done

to strengthen the trunk extensors and emphasize stabilization. The Side-Lying Sit Up is another

exercise, which is done in the third stage of rehabilitation and to strengthen the quadratus

lumbordum. Lateral trunk rotations are done in the third stage of rehabilitation and are done to

strengthen the oblique’s and quadratus lumbordum. Lunges are another exercise, which are done

in the third stage of rehabilitation and serve to strengthen the abdominal muscles, thighs, gluteal

muscles and facilitate trunk stability. The Prone Leg Lift is an exercise done in the third stage of

rehabilitation and is done to strengthen trunk extensors and gluteal muscles. The Lateral Pull

Down is an exercise that is also done in the third stage of rehabilitation and is done to strengthen

the latissimus dorsi14.

Physical Therapy Evaluation

Before a patient can engage in these exercises, a clinician will evaluate their situation and

make notes of the patient's status before starting a rehabilitation program. An evaluation can be

done by any physical therapist, but will look differently if it is done in an inpatient setting versus

an outpatient setting. When a therapist does an evaluation in an outpatient setting, an evaluation

will include the therapist writing subjective notes about the patients overall health and medical

history. When a patient with Lumbar Nerve Entrapment is going through the subjective part of

an evaluation, the therapist will ask the patient to describe their symptoms and when they are the

worst, their pain levels during different times of the day, their home living situation, what kind of

work they do, how they spend their time and how active they are. Then a therapist will fill out an

objective part of the evaluation, where the therapist will write down things that they observe with

the patient13. For example, a therapist writing notes for a patient with Lumbar Nerve Entrapment

may observe swelling in the lower back, uneven gait and apprehension when lifting weights and

so on15. The observation process for the therapist starts when the patient walks through the

clinic doors. The third part of the evaluation is the assessment aspect. In the assessment, the

therapist will measure the rang of motion of the patient's joint, perform and grade manual muscle

tests, perform an upper and lower nerve test, perform functional tests, may do a gait analysis, and

special tests according to what the therapist thinks the problem is. For a patient that is suspected

to have Lumbar Nerve Entrapment, their trunk range of motion may be limited from zero to

twenty degrees in extension, from zero to fifty degrees in flexion, from zero to forty degrees in

rotation. Measurements can be done with a tape measurer, or an inclinometer14. Muscles that the

therapist is likely to test, when doing manual muscles tests include the rectus abdominis, gluteus

maximus, gluteus medius, hop adductor, hip rotators, hamstrings, and the iliopsoas. Muscle

testing can be graded on a scale of trace signs of strength from poor, to weak, to partially week,

to strong. Upper and lower nerve tests is important to perform as well. The upper and lower

nerve testing, check to see how well the patient’s stimulation is, in all quadrants of their body15.

This is a key test to determining which nerve is causing the problem in a patient with lumbar

entrapment15. The upper body nerve test will be done if it is suspected that one of the nerves that

branch to the upper body is entrapped. Because all lumbar nerves run to the lower body, a

therapist performing a nerve test for a lumbar nerve patient is likely to only perform lower body

nerve evaluation 9.

Part of the assessment that a clinician will do includes performs tests which are referred

to as "special tests". These tests isolate certain nerves and help the clinician narrow down the

cause of the patient’s pain and therefore, create a better rehabilitation plan. There are five special

tests that are all specific to certain body parts and nerves. The first special tests is called a

"Spring Test", in which the patient lies prone and the examiner stands with their thumbs, or

hypothenar eminence over the spinous process' of the lumbar spine20. The clinician will apply a

downward "springing" force through the spinous process of each vertebra to assess the anterior-

posterior motion of the spinal discs. A positive result of the spring test would be if the patient

experiences pain or tingling down their back when the pressure is applied. The second special

test is called the "Valsalva Test"16. This test is performed while the patient is seated and with the

examiner standing next to the patient. The patient is asked to take a deep breath and hold it for

ten seconds while using force to bear down, as if having a bowel movement. The test is positive

if the patient experiences pain in increase in spinal or radicular pain. The third special test is

called the "Milgram Test" and is done with the patient laying supine and the examiner at the feet

of the patient. The patient will be asked to perform a bilateral straight leg raise test, lifting their

legs about three inches from the surface they are laying on, and asked to hold that position for

thirty seconds. The test will be positive if the patient fails to hold the position, or if becomes

painful15. The fourth special test is called the "Kernig's Test" and is performed with the patient

laying supine and the examiner at the side of the patient. The patient will perform a unilateral

active straight leg raise, with their knees extended16. When the patient feels pain, they will be

asked to flex their knees. The test will be positive if the patient's pain is relieved when the flex

their knees2. The fifth test is called the "Quadrant Test" and is performed with the patient

standing with their feet shoulder width apart and the examiner standing behind the patient,

grasping the patient’s shoulders to provide stability. The patient will be asked to expend their

spine as far back as possible and then side bends and rotates their upper body to the affected side.

The examiner will provide pressure through the patient, and support the patient as needed. The

test will be positive if the patient has a reproduction of their pain and if they are not able to

maintain their balance very well. Performing special tests allows the clinician to see what

movements are causing the patients pain and to address those issues first20.

Next, a therapist will continue on with the assessment, by performing a special test. The

therapist may perform one of the special tests that have been listen previously in this paper,

including the Spring Test, Valsalva Test, Milgram's Test, Kernig's Test and the Quadrant Test. I

would like to go into further detail regarding the Lumbar Quadrant test, which is also called

Kemp's Test. This test is very reliable when assessing the function of the Lumbar spine. The

lumbar quadrant or Kemp’s test is a test to assess the lumbar spine facet joints. It is a provocative

test to detect pain, which can be local, referred or radicular. The facet joints or zygapophyseal

joints play an important role in load transmission17. The purpose of facet joints these are to

stabilize the motion segment in flexion, extension and also restricting axial rotation. They also

provide a posterior load-bearing helper13. The lumbar facet joints are paired, true synovial joint

that comprise the poster lateral articulation between vertebral levels. The orientation of the facet

joints in a transverse plane varies from the upper level of the lumbar spine to the lower one.

Lumbar facet joints contain hyaline cartilage, synovial membrane, fibrous capsule, and a joint

space with a potential capacity of one to two milliliters. The existence of menisci in the lumbar

facet joints has been emphasized in numerous publications. The purpose of this test is to assess

the lumbar spine facet joints. Lumbar quadrant test uses the patient’s trunk both as a lever to

induce tension and as a compressive force. This test is used in differentiation and diagnosis of a

lumbar posterior facet syndrome, though it is nonspecific. The Lumbar quadrant test is a

provocation test to detect pain. Local pain suggest a facet cause, while radiating pain into the leg

is more suggestive of nerve root irritation, especially if the pain is below the knee. The lumbar

quadrant test may be performed with the patient either in the seated or standing position. In the

standing position, the patient is standing before the therapist. The therapist fixes the opposite

ilium from the side being tested with one hand. The other hand grabs the shoulder from the

patient and leads the patient to extension, ipsilateral side bending and ipsilateral rotation (3D

extension movement). The patient will be asked to hold this position for three seconds. In the

sitting position, the patient seated with arms crossed over the chest. One hand of the therapist

stabilizes the patient’s lumbosacral region on the side to be tested. The other arm controls the

patient’s upper body movement. The patient is passively directed into flexion, rotation, lateral

flexion, and finally extension15. Depending on the patient’s response, axial compression may be

applied in the fully extended and rotated position to increase stress on the posterior joints. The

test is positive when the patient reports pain, numbness or tingling in the area of the back or

lower extremities. The pain is located on the side being tested. Local pain suggests a facet cause,

while radiating pain into the leg is more suggestive of nerve root irritation, especially if the pain

is below the knee. The seated position is more preferable because the therapist has more control

over the patient’s positioning and there is less muscle activation. Results showed for Lumbar

Quadrant Test in following article: Relationship of Physical Examination findings and Self-

reported symptom severity and physical function in patients with degenerative lumbar

conditions. The purpose of this study was to examine the relationships of symptom provocation

during physical examination procedures and self-report of symptom severity and function in

patients with degenerative lumbar conditions, which showed that the quadrant test was the

strongest predictor of symptom severity. The quadrant test distinguished those subjects with

clinically meaningful low back symptom severity but was not predictive of impaired function.

The quadrant test was the most common test that reproduced the patient’s symptoms. Patients

who reported symptoms during the quadrant test had higher self-reported Lumbar Spinal

Stenosis symptom severity scores compared with those who did not report symptoms during the

quadrant test. The clinician will mark down all results from the assessments that they do and will

then move on to the next step of the evaluation20.

The next process that the physical therapist will complete in the evaluation is to create a

plan for the patient. In this section, the therapist will create a therapeutic exercise plan for the

patient, using the therapeutic stretches and exercises that were stated previously in this paper.

The clinician will also create a home exercise plan for the patient to follow on the days that they

do not come into the clinic. This plan will be a detailed outline of what the therapist expects to

do with the patient and what they expect the patient to do at home. It concludes short term and

long term goals for the patient and can be adjusted when those goals are met. The plan includes

what exercise that patient will be doing and how many, as well as how many weights the patient

will be using and how long of a break they will have in between exercises. All things put into the

plan, can be adjusted by the therapist, according the needs of the patient. This evaluation is

followed up by notes that the therapist will type to record the progress of the patient at each

session that they attend. These notes are also very detailed and contain information about how

the patient is responding to the therapy.

Conclusion

As you can see from the depth of this paper, the human spine is complicated and

necessary for health care professionals to understand if they aim at treating back issues correctly.

Lumbar Nerve Entrapment is a problem that has solutions, but there is always room for growth,

as there is not prevention to this issue. I believe that the purpose of medicine goes much farther

than treatment, but prevention as well. The steps to prevention start with research and

application. Lumbar nerve entrapment is a back problem that, in my opinion could possibly be

prevented as health care professionals learn to work inter-professionally, more effectively so that

prevention of lumbar nerve entrapment can begin early. It is also necessary for health care

professionals to educate their patients on the importance of things like proper posture and lifting

techniques in hopes of keeping their backs healthy as long as possible. It is in this education

where I see the words of Thomas Jefferson come alive: that the doctor of the future will give no

medicine, but will interest his patients in the care of the human spine.

Works Cited

Abdulla, A. (1984). Lumbar nerve root compression by synovial cysts of the ligamentum flavum

Report of four cases. Journal of Neuroscience, 60(3), 617-620.

Rijn, J. (2006). Observer variation in the evaluation of lumbar herniated discs and root

compression: Spiral CT compared with MRI. British Journal of Radiology, 79(941), 372-377.

Huang, P. (2014). How Fast Pain, Numbness, and Paresthesia Resolves After Lumbar Nerve

Root Decompression: A Retrospective Study of Patient's Self-reported Computerized Pain

Drawing. Spine, 39(8), 529-536.

Ahuja, S. (2014). Reviewer’s comment concerning “Is NICE guidance for identifying lumbar

nerve root compression misguided?”. European Spine Journal, 23(1), 25-25.

Murray, M. (2014). Ahuja, S. (2014). Reviewer’s comment concerning “Is NICE guidance for

identifying lumbar nerve root compression misguided?”. European Spine Journal, 23(1), 25-25.

The Encyclopedia of Computational Neuroscience, 46(14), 16-18.

Gillard, D., Corenman, D., & Dornan, G. (2013). Failed less invasive lumbar spine surgery as a

predictor of subsequent fusion outcomes. International Orthopaedics, 811-815.

Shapiro, I. (n.d.). Introduction to the Structure, Function, and Comparative Anatomy of the

Vertebrae and the Intervertebral Disc. The Intervertebral Disc, 3-15.

Miertz, R. (2014). Lumbar motion changes in chronic low back pain patients: A secondary

analysis of data from a randomized clinical trial. The Spine Journal, 14(11), 2618-2627.

Jung, J. (2014). Early Surgical Decompression Restores Neurovascular Blood Flow and Ischemic

Parameters in an in Vivo Animal Model of Nerve Compression Injury. The Journal of Bone and

Joint Surgery, 11(3), 897-906.

Yoshiyasu MD, PhD, A. (2014). A Prospective Comparative Study of 2 Minimally Invasive

Decompression Procedures for Lumbar Spinal Canal Stenosis: Unilateral Laminotomy for

Bilateral Decompression (ULBD) Versus Muscle-Preserving Interlaminar Decompression

(MILD). The Spine Journal, 39(4), 332–340-332–340.

Rojas, J., Syre, P., & Welch, W. (2013). Regional anesthesia versus general anesthesia for

surgery on the lumbar spine: A review of the modern literature. Clinical Neurology and

Neurosurgery, 119(1), 39-43.

Wang, J. (2014). Pneumocephalus After Epidural Anesthesia in an Adult who has Undergone

Lumbar Laminectomy. Journal of Neurosurgical Anesthesiology, 26(3), 261-263.

Martin, H. (2014). Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal

region. Knee Surgery, Sports Traumatology, Arthroscopy, 22(4), 882-888.

Richardson, C., Jull, G., Hodges, P., & Hides, J. Therapeutic Exercise for Spinal Segmental

Stabilization in Low Back Pain: Scientific Basis and Clinical Approach.

Thomas, S. (2003). Spinal stenosis: History and physical examination. Physical Medicine and

Rehabilitation Clinics of North America, 14(1), 29-39.

Zylbergold, R. S., and M. C. Piper. "Lumbar disc disease: comparative analysis of physical

therapy treatments." Archives of physical medicine and rehabilitation 62.4 (1981): 176-179.

Li, Linda C., and Claire Bombardier. "Physical therapy management of low back pain: an

exploratory survey of therapist approaches." Physical therapy 81.4 (2001): 1018-1028.

Adams, Michael A., et al. "Effects of backward bending on lumbar intervertebral discs:

relevance to physical therapy treatments for low back pain." Spine 25.4 (2000): 431-438.

Kirkaldy-Willis, W. H., et al. "Pathology and pathogenesis of lumbar spondylosis and stenosis."

Spine 3.4 (1978): 319-328.

Arnoldi, C. C., et al. "Lumbar spinal stenosis and nerve root entrapment syndromes." Clinical

orthopaedics and related research 115 (1976): 4-5.