Have the patient relaxed, lying prone, with the head to one side and the arms by the sides. The levels of the spinous processes are identified by standing behind the patient and using your hands to identify L4 and L5 in relation to the top of the iliac crests. Mark the important reference points. Palpation, which is performed with the tips of the thumbs opposed, can commence at the spinous process of L1 and then systematically proceed distally to L5 and then over the sacrum and coccyx. Include the interspinous spaces as well as the spinous processes. When the thumbs (or other part of the hand such as the pisiforms) are applied to the spinous processes, a firm pressure is transmitted to the vertebrae by a rocking movement for three or four 'springs'. Significant reproduction of pain is noted.

Palpation occurs at three main sites:

• centrally (spinous processes to coccyx)

• unilateral—right and left sides (1.5 cm from midline)

• transverse pressure to the sides of the spinous processes (R and L)

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