Spinal (Lumbar) Range of Motion Worker's name: DOI: WCD #: Use this form to describe range of motion of the spine. Indicate the active range of motion measured in degrees with an inclinometer. Bulletin No. 239 describes the criteria for measuring spinal range of motion using a single fluid-filled inclinometer. A videotape illustrating the use of a single fluid-filled inclinometer is available from the Department of Consumer and Business Services. The values in parentheses under each movement are the norms established by the Department of Consumer and Business Services. PLEASE COMPLETE AND RETURN WITH YOUR REPORT Movement Description Measurements (minimum of three) 1 Lumbar flexion (60�) Lumbar extension (25�) Passive straightleg raising right a. Degrees of flexion at T12.................................................. b. Degrees of flexion at midsacrum.......................................... c. True lumbar flexion angle (a minus b ).................................. d. Are measurements within +/- 10% or 5� (whichever is greater)?............. e. Maximum true lumbar flexion angle..................................... a. Degrees of extension at T12............................................... b. Degrees of extension at midsacrum....................................... c. True lumbar extension angle (a minus b )............................... d. Are measurements within +/- 10% or 5� (whichever is greater)?............. e. Maximum true lumbar extension angle.................................. a. Right straight-leg raising (SLR) angle.................................... b. Are measurements within +/- 10% or 5� (whichever is greater)?............. c. Maximum straight-leg raising right....................................... d. Left straight-leg raising (SLR) angle..................................... e. Are measurements within +/- 10% or 5� (whichever is greater)?............. f. Maximum straight-leg raising left......................................... g. Total motion at midsacrum (1b + 2b).................................... h. Maximum midsacral motion.............................................. i. Tightest SLR equal to or within 10� of maximum midsacral motion (3h)?.. a. Degrees of right lateral flexion at T12................................... b. Degrees of right lateral midsacral flexion................................ c. Right lateral flexion angle (a minus b)................................... d. Are measurements within +/- 10% or 5� (whichever is greater)?............. e. Maximum lumbar right lateral flexion angle............................ a. Degrees of left lateral flexion at T12..................................... b. Degrees of left lateral midsacral flexion.................................. c. Left lateral flexion angle (a minus b).................................... d. Are measurements within +/- 10% or 5� (whichever is greater)?............. e. Maximum lumbar left lateral flexion angle.............................. Yes No 2 Yes No Yes No 3 Passive straightleg raising left Straight-leg raising validity check Yes No Yes No 4 Lumbar right lateral flexion (25�) Lumbar left lateral flexion (25�) Yes No 5 Yes No Examining physician name and title (print or type): Signature: 440-2278L(6/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Date of examination: