Saddam Kanaan, PT, PhD

Sakher Obeidat, PT
Rwanda Hamdan, PT
1


Functional tests for the trunk

1) Loaded reach test: subject will be asked to stand next to the wall from a standard position
(toes behind a tape mark on the floor). Subjects will hold a weight of 5% of their body weight or
4.5 kg weight with their dominant hand. They will bring their arm to their shoulder level and
reach forward as far as possible. The distance from the start and end points will be measured
in cm. The subjects will complete 3 test trials.

2) Static back extension endurance test (modified Sorensen fatigue test): subjects will be
asked to lie on their stomach. A small pillow will be placed under their lower abdomen. Subjects
will be asked to raise their sternum off the table and hold the position as long as possible. Time
will be recorded in minutes until the subject cannot hold the position (not exceeding a 5-minute
time limit).

3) Lower abdominal test: Subjects will be asked to lie on their back with arms across their
chest. They will be asked to raise their both legs / Knees (at 90 degrees position) and hold this
position as long as possible. Time will be recorded in minutes until the subject cannot hold the
position (not exceeding a 5-minute time limit).

4) Abdominal dynamic endurance test: This is a partial curl up maneuver. Subjects will be
lying on their back on a table with both knees bend and hands to their side. A piece of tape will
be positioned 12 cm distance (for people less than 40 years of age) or 8 cm distance (for
subjects greater than or equal to 40 years of age) from their third finger. Subjects will be asked
to perform partial trunk curl to touch the appropriate line/tape as many times as possible for one
minute. The number of repetitions will be recorded.

5) Upper abdominal isometric test: subjects will be asked to lie on their back with arms to
their side. With their knees bend and feet flat on the table, subjects will be asked to (guided
into) a straight-back sit-up position without flexing their back (thigh-trunk angle to be maintained
at 90 degrees). The subjects will be instructed to stay in the test position as long as possible.
Time will be recorded in minutes until the subject cannot hold the position (not exceeding a 5-
minute time limit).

448 SECTION II Regional Evaluation Techniques
Note: Manual muscle testing of the head and neck is
contraindicated in some instances. Contraindications
include pathology that may result in spinal instability
and pathology of the vertebral artery. In the absence
of contraindications to resisted head and neck move-
ments, resistance is applied with care not to apply too
much resistance for the muscles being tested.
Head and Neck Flexion
Rectus Capitis Anterior, Longus
Capitis, Longus Colli, Scalenus
Anterior, Sternomastoid
Accessory muscles: Scalenus medius, scalenus pos-
terior, suprahyoids, infrahyoids, and rectus capitis
lateralis.
The head and neck exors ( Fig. 9-84 ) are tested
in the against gravity position. The anterior head and
neck exors are tested as a group; followed by isolation of
the sternomastoid muscles.
Start Position. The patient is supine ( Fig. 9-85 ). The arms
are over the head resting on the plinth. The elbows are
exed.
Figure 9-87 Screen position: head and neck flexion. Figure 9-88 Resistance: head and neck flexors.
Stabilization. The trunk is stabilized by the plinth. The
anterior abdominal muscles must be strong enough to
provide anterior xation of the thorax on the pelvis.
36
In
a patient with weak abdominals, stabilization is provided
by downward pressure of the therapists hand on the
thorax ( Fig. 9-86 ).
Movement. The patient exes the head and neck through
partial (grade 2) or full range (grade 3) ( Fig. 9-87 ). The
patient is instructed to keep the chin depressed (i.e.,
tucked in toward the manubrium sternum) as the neck is
exed.
Palpation. Longus capitis, longus colli, and rectus capitis ante-
rior are too deep to palpate. The sternomastoid muscle may
be palpated proximal to the clavicle or sternum. The
muscle is more easily palpated in the isolated test involv-
ing rotation. The scalenus anterior may be palpated above
the clavicle and behind the sternomastoid.
Resistance Location. Applied on the forehead ( Fig. 9-88 ).
Resistance Direction. Head and neck extension.
Figure 9-85 Start position for head and neck flexion. Figure 9-86 Screen position: head and neck flexion with
stabilization.
Form
9-47
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449 CHAPTER 9 Head, Neck, and Trunk
Head and Neck Flexion,
Rotation and Lateral Flexion
Sternomastoid
Start Position. The patient is supine ( Fig. 9-89 ). The
arms are over the head resting on the plinth. The
elbows are exed.
Stabilization. The trunk is stabilized by the plinth. With
abdominal muscle weakness, stabilization of the thorax is
required.
37

Movement. The patient laterally exes on the test side and
rotates the neck to the opposite side ( Fig. 9-90 ). Each side
is tested. The patient laterally exes through partial
(grade 2) or full range (grade 3).
Palpation. Each sternomastoid muscle can be palpated at
any point along the oblique ridge of the muscle from the
mastoid process to the sternum or clavicle.
Resistance Location. The therapists ngers are used to
apply resistance on the temporal region of the head ( Figs.
9-91 and 9-92 ).
Resistance Direction. Oblique posterior direction and ipsi-
lateral rotation.

Figure 9-89 Start position: sternomastoid. Figure 9-90 Screen position: sternomastoid.
Figure 9-91 Resistance: sternomastoid. Figure 9-92 Sternomastoid.
Form
9-48
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450 SECTION II Regional Evaluation Techniques
Head and Neck Extension
The head and neck extensors are tested as a group
in the against gravity position. The muscles include
semispinalis capitis, rectus capitis posterior (major
and minor), obliquus capitis (inferior and superior),
splenius capitis, semispinalis cervicis, longissimus capitis
and cervicis, splenius cervicis, spinalis capitis and cervi-
cis, and iliocostalis cervicis.
The strength of upper trapezius is tested as an elevator
of the scapula.
Start Position. The patient is prone ( Fig. 9-93 ). The arms
are over the head resting on the side of the plinth. The
elbows are exed.
Stabilization. The patient grasps the end of the plinth for
stabilization. The therapist may stabilize the upper tho-
racic region to prevent trunk extension.
Movement. The patient extends and rotates the head and
neck ( Fig. 9-94 ).
Palpation. The extensor muscles ( Fig. 9-96 ) are palpated as
a group paravertebrally.
Resistance Location. Applied on the head just proximal
to the occiput ( Fig. 9-95 ).
Resistance Direction. Head and neck exion and rotation.
Figure 9-93 Start position: head and neck extensors. Figure 9-94 Screen position: right head and neck extensors.
Figure 9-95 Resistance: right head and neck extensors.
10
10
11
1
2
3 5
4
7
6
8
10
9
10
11
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Semispinalis capitis
Rectus capitis posterior minor
Rectus capitis posterior major
Obliquus capitis inferior
Obliquus capitis superior
Splenius capitis
Semispinalis cervicis
Longissimus capitis
Splenius cervicis
Longissimus cervicis
Iliocostalis cervicis
Figure 9-96 Head and neck extensors.
Form
9-49
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474 SECTION II Regional Evaluation Techniques
Substitute Movement. Hip exors (lumbar lordosis).
36

Palpation. Lateral to the midline on the anterior abdomi-
nal wall midway between the sternum and the pubis.
Grading
Grade 0: No movement, and no palpable contraction is
evident.
Grade 1: No movement is possible but a icker of a
muscle contraction may be palpated. When testing for
grade 1, the patient may also be asked to cough while
the therapist observes and palpates for the presence of
muscle contraction ( Fig. 9-140 ).
Grade 2 ( Fig. 9-141 ): With the arms held outstretched
in front of the trunk, the patient lifts the head and
cervical spine off the plinth. The scapulae remain on
the plinth.
Grade 3 ( Fig. 9-142 ): With the arms held outstretched
in front of the trunk, the patient lifts the inferior angles
of the scapulae clear of the plinth.
Resistance. Resistance is not applied manually by the
therapist but is provided through positioning of the arms.
The resistance of the head, trunk, and upper limbs
increases as the upper limbs are moved toward the head.
Accordingly, the arms are positioned across the chest ( Fig.
9-143 ) or at above shoulder level with the hands beside
the ears ( Fig. 9-144 ) throughout the movement, for
grades of 4 and 5, respectively. Note: For grade 5 testing,
the hands are positioned beside the ears, rather than
behind the head, to prevent stress being placed on the
cervical spine inadvertently during testing.
Grading
Grade 4 ( Fig. 9-143 ): With the arms positioned across
the chest, the patient lifts the inferior angles of the
scapulae clear of the plinth.
Grade 5 ( Fig. 9-144 ): With the hands positioned beside
the ears, the patient lifts the inferior angles of the scap-
ulae clear of the plinth.
Trunk Flexion
The strength of the neck and hip exors should be tested
before testing the strength of the abdominal muscles.
36
If
the neck exors are weak, the head will have to be sup-
ported during the testing.
A half curl-up is performed to assess abdominal mus-
cle strength. The movement begins from a supine posi-
tion with the feet unsupported. The patient initially tilts
the pelvis posteriorly to ex the lumbar spine, exes the
cervical spine, and then exes the thoracic spine to lift
the head and scapulae off the plinth.
Using the curl-up movement with the feet unsup-
ported is more effective in activating the rectus abdomi-
nus muscle than performing the full sit-up from the
supine position with the feet supported.
49
The rst phase
of the curl-up, start position to 45 , is primarily performed
by the rectus abdominis, whereas the second phase, from
45 to the sitting position, is primarily performed by the
iliacus muscle.
50
Therefore, a half curl-up is used to test
abdominal muscle strength.
Rectus Abdominis
Accessory muscles: iliopsoas, rectus femoris, inter-
nal abdominal oblique, and external abdominal
oblique.
The rectus abdominis muscle ( Fig. 9-145 ) is
tested in the against gravity position for all grades.
Start Position. The patient is supine.
Stabilization. Flexion of the cervical spine serves to x the
thorax and when combined with a posterior pelvic tilt
provides the optimal posture for decreasing the lumbar
lordosis, reducing the stress on the low back, and activat-
ing the abdominal muscles
51
in performing the curl-up. If
the patient is unable to perform a posterior pelvic tilt and
maintain the lumbar spine in a exed position when
being tested for abdominal muscle strength, the test is
discontinued.
To prevent contraction of the iliopsoas muscle and
greater hyperextension of the lumbar spine, the therapist
should not stabilize the feet.
52

Movement. The patient initially tilts the pelvis posteri-
orly to ex the lumbar spine, exes the cervical spine
lifting the head off the plinth, and then exes the tho-
racic spine to perform a curl-up. The movement is per-
formed slowly.
Form
9-67
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475 CHAPTER 9 Head, Neck, and Trunk
Figure 9-140 Test position: rectus abdominis, grade 0 or 1. The
therapist asks the patient to cough while palpating for muscle
contraction.
Figure 9-141 Test position: rectus abdominis, grade 2.
Figure 9-142 Screen position: rectus abdominis, grade 3. Figure 9-143 Test position: rectus abdominis, grade 4.
Figure 9-144 Test position: rectus abdominis, grade 5.
Figure 9-145 Rectus abdominis.
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476 SECTION II Regional Evaluation Techniques
Trunk Flexion and Rotation
Against Gravity: External Abdominal
Oblique, Internal Abdominal Oblique
Accessory muscles: rectus abdominus, semispinalis
thoracis, multidus, rotatores, and latissimus dorsi.
Start Position. The patient is supine.
Stabilization. None.
Movement. The patient exes and rotates the trunk to
perform a half curl-up with rotation ( Fig. 9-146 ). The
patient performs the movement slowly.
Palpation. External abdominal oblique: at the lower edge of
the rib cage. Internal abdominal oblique: medial to and
above the anterior superior iliac spine.
When trunk rotation is performed toward the patients
right side, the left external abdominal oblique and right
internal abdominal oblique muscles are palpated. When
trunk rotation is performed toward the patients left side,
the right external abdominal oblique and left internal
abdominal oblique muscles are palpated.
Substitute Movement. None.
Resistance. Resistance is provided through positioning of
the arms
37
and increases as the arms are moved cranially.
The arms are positioned across the chest ( Fig. 9-147 ) or
with the hands beside the ears ( Fig. 9-148 ) throughout
the movement, for grades of 4 and 5, respectively.
Grading
Grade 3 ( Fig. 9-146 ): With the arms held outstretched
in front of the trunk, the patient exes and rotates the
trunk to lift the inferior angles of the scapulae clear of
the plinth.
Grade 4 ( Fig. 9-147 ): With the arms positioned across
the chest, the patient exes and rotates the trunk to lift
the inferior angles of the scapulae clear of the plinth.
Grade 5 ( Fig. 9-148 ): With the hands positioned beside
the ears, the patient exes and rotates the trunk to lift
the inferior angles of the scapulae clear of the plinth.
Form
9-68
Figure 9-146 Screen position: right external abdominal oblique
and left internal abdominal oblique, grade 3.
Figure 9-147 Test position: right external abdominal oblique and
left internal abdominal oblique, grade 4.
Figure 9-148 Test position: right external abdominal oblique and
left internal abdominal oblique, grade 5.
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477 CHAPTER 9 Head, Neck, and Trunk
Gravity Eliminated: External Abdominal
Oblique, Internal Abdominal Oblique
Start Position. The patient is sitting with the hands off the
plinth and the feet supported ( Fig. 9-149 ).
Stabilization. The pelvis is stabilized by the patients body
weight.
End Position. The patient rotates the thorax with slight
exion ( Figs. 9-150 and 9-151 ).
Substitute Movement. None.
Deviation of the umbilicus
36
: With marked weakness
of the abdominal muscles deviation of the umbilicus can
occur during testing. The umbilicus will be pulled toward
the stronger muscle(s) and away from the weaker
muscle(s). The umbilicus may also be pulled by and devi-
ated toward a muscle that is shortened and being
stretched. Palpation of the muscles can be used to con-
rm the presence of deviation of the umbilicus due to
muscle imbalance.
Figure 9-149 Start position: external abdominal
oblique, internal abdominal oblique.
Figure 9-150 End position: left external abdominal oblique,
right internal abdominal oblique, grade 2.
Figure 9-151 Left external abdominal oblique, right internal
abdominal oblique.
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478 SECTION II Regional Evaluation Techniques
Double Straight
Leg Lowering
53

External Abdominal Oblique, Internal
Abdominal Oblique, Rectus Abdominis
Start Position. The patient is lying supine. The
therapist raises the legs to a position of 90 hip
exion ( Fig. 9-152 ). The patient posteriorly tilts the
pelvis to ex the lumbar spine and atten the small
of the back onto the plinth.
Stabilization. None.
Movement. The therapist places one hand touching the
posterolateral aspect of the ilium to ensure the posterior
pelvic tilt is maintained while the patient slowly lowers
the legs to the plinth.
Movement is stopped when the patient can no longer
maintain the posterior pelvic tilt. When the therapist
feels that the pelvis begins to rotate anteriorly, the thera-
pist supports the legs and notes the angle between the
legs and the plinth before lowering the legs to the plinth.
Measurement. The OB Myrin goniometer may be used
to measure the angle of hip exion at the limit of motion.
This measurement procedure allows the therapist to eas-
ily assess the angle of hip exion without assistance. The
strap is placed around the distal thigh and the dial is
placed on the lateral aspect of the thigh ( Fig. 9-154 ).
Grading.
36
Angles of hip exion are translated into grades
as follows:
Grade 3: 90 to 75
Grade 3 + : 74 to 60 ( Fig. 9-153 )
Grade 4 : 59 to 45
Grade 4: 44 to 30
Grade 4 + : 29 to 15 ( Fig. 9-154 )
Grade 5: 14 to 0 .
Palpation. External abdominal oblique: at the lower edge of
the rib cage. Internal abdominal oblique: medial to and
above the anterior superior iliac spine. Rectus abdominus:
lateral to the midline on the anterior abdominal wall
midway between the sternum and the pubis.
Substitute Movement. Increased lumbar lordosis due to
anterior tilting of the pelvis.
Resistance. Resistance is not applied manually by the
therapist but is provided through the increased torque
created by the lower extremities as the limbs are moved
from 90 hip exion to the surface of the plinth.
Form
9-69
Figure 9-152 Start position: double
straight leg lowering.
Figure 9-153 Test position: hip flexion 60 , grade 3 + .
OB Myrin
goniometer
Figure 9-154 Test position: hip flexion 20 , grade
4.
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479 CHAPTER 9 Head, Neck, and Trunk
Trunk Extension
Erector Spinae: Iliocostalis Thoracis
and Lumborum, Longissimus Thoracis,
Spinalis Thoracis, Semispinalis
Thoracis, and Multifidus
Accessory muscles: interspinales, quadratus lumbo-
rum, and latissimus dorsi.
The strength of the neck and hip extensors
should be tested before testing the strength of the
trunk extensor muscles.
37
If the neck extensors are weak,
the head will have to be supported during testing. If the
hip extensors are weak or paralyzed, the pelvis cannot be
adequately xed in an extended position on the thigh as
the patient attempts trunk extension and the patient will
be unable to extend the trunk.
36

The trunk extensors are tested as a group in the against
gravity position.
Start Position. The patient is prone-lying with the feet
over the end of the plinth and a pillow under the abdo-
men ( Fig. 9-155 ).
Stabilization. A strap is placed over the pelvis to isolate the
lumbar extensor muscles
54
and the therapist stabilizes the
legs proximal to the ankles.
Form
9-70
Substitute Movement. None.
Palpation. The trunk extensor muscles ( Fig. 9-160 ) are
palpated as a group paravertebral to the lumbar or tho-
racic spines.
Grading
Grade 0: No movement, and no palpable contraction is
evident.
Grade 1: No movement is possible but a icker of a
muscle contraction can be palpated or observed as the
patient attempts to lift the head.
Grade 2 : With the arms at the sides, the patient lifts the
head and upper portion of the sternum off the plinth
( Fig. 9-156 ).
Grade 3: With the hands held behind the low back, the
patient extends the trunk through partial ROM ( Fig.
9-157 ).
Resistance. Resistance is not applied manually by the
therapist. Resistance is provided through positioning of
the arms and increases as the upper limbs are positioned
toward the head. The hands are positioned behind the
low back ( Fig. 9-158 ) or behind the head ( Fig. 9-159 ) to
test for grades 4 and 5, respectively.
37

Figure 9-155 Test position: trunk extensors, grade 0 or 1. Figure 9-156 Test position: trunk extensors, grade 2.
LWBK979-C09-p400-492.indd 479 17/11/11 9:57 PM
480 SECTION II Regional Evaluation Techniques
6
2
3
4
5
1
7
6
2
3
4
5
1
7
1.
2.
3.
4.
5.
6.
7.
Iliocostalis
thoracis
Iliocostalis
lumborum
Longissimus
thoracis
Spinalis
thoracis
Semispinalis
thoracis
Multifundus
Erector
spinae
Figure 9-160 Trunk extensors.
Figure 9-159 Test position: trunk extensors, grade 5.
Figure 9-157 Screen position: trunk extensors, grade 3.
Figure 9-158 Test position: trunk extensors, grade 4.
Grading
Grade 4: With the hands held behind the back, the
patient extends the trunk through the full ROM, that
is, lifts the head and upper portion of the sternum, so
that the xiphoid process is off the plinth ( Fig. 9-158 ).
Grade 5: With the hands held behind the head, the
patient extends the trunk through the full ROM and
lifts the head and the sternum, so that the xiphoid pro-
cess is off the plinth ( Fig. 9-159 ).

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481 CHAPTER 9 Head, Neck, and Trunk
Pelvic Elevation
Gravity Eliminated:
Quadratus Lumborum
Accessory muscles: latissimus dorsi, contralateral
hip abductors, internal abdominal oblique, exter-
nal abdominal oblique, and erector spinae.
The quadratus lumborum muscle is tested in the
gravity eliminated position.
Start Position. The patient lies supine or prone ( Fig.
9-161 ) with the feet off the end of the plinth, the hip in
abduction, and slight extension.
Stabilization. The weight of the trunk; the patient holds
the edges of the plinth.
Palpation. Above the crest of the ilium, lateral to the para-
vertebral extensor muscle mass, although quadratus lum-
borum is difcult to palpate.
Substitute Movement. Lateral bers of the external abdom-
inal oblique and internal abdominal oblique, latissimus
dorsi, and erector spinae.
Figure 9-161 Start position: quadratus lumborum.
Figure 9-162 End position: quadratus lumborum.
Grading
Grade 0: No movement, and no palpable contraction is
evident.
Grade 1: No movement but a icker of a muscle con-
traction may be palpated (see note under palpation
above) as the patient attempts to elevate the iliac crest
toward the ribs.
Grade 2: The patient elevates the iliac crest toward the
ribs through the full ROM ( Fig. 9-162 ).
Resisted Gravity Eliminated:
Quadratus Lumborum
Start Position. The patient lies supine or prone ( Fig.
9-161 ) with the feet off the end of the plinth, with the
hip in abduction and slight extension.
Stabilization. The weight of the trunk; the patient holds
the edges of the plinth.
Movement. The patient elevates the iliac crest toward the
ribs through the full ROM.
Form
9-71
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482 SECTION II Regional Evaluation Techniques
Resistance Location. Anterior aspect of the distal end of
the femur ( Fig. 9-163 ). Alternatively, resistance can be
applied on the posterolateral aspect of the iliac crest if hip
pathology is present ( Fig. 9-164 ).
Resistance Direction. A traction force equal to the weight
of the leg is applied to the femur when performing a
screen test and additional resistance is applied for grades
4 and 5.
Grading
Grade 3: The patient elevates the iliac crest toward the
ribs through the full ROM against resistance equal to
the weight of the lower extremity ( Fig. 9-163 ).
Grade 4: The patient elevates the iliac crest toward the
ribs through the full ROM against resistance equal to
the weight of the lower extremity and moderate resis-
tance.
Grade 5: The patient elevates the iliac crest toward the
ribs through the full ROM against resistance equal to
the weight of the lower extremity and maximal resis-
tance.
Alternatively, quadratus lumborum may be tested
against gravity in standing. The therapist must ensure the
contralateral hip abductors do not contract to depress the
ipsilateral pelvis and elevate the iliac crest on the test side
for quadratus lumborum.
37

Figure 9-163 Resistance: quadratus lumborum.
Figure 9-164 Quadratus lumborum .
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