result from severe pain. While standing, the patient should be observed from the front, back, and sides. Increased and decreased lumbar lordosis, inward curvature of the lower spine, has been seen. Palpation Detection of spondylolisthesis by palpation is most often done by palpating for the spinous process. Each level of the lumbar spine should be palpated. Spinous process palpation by itself is not a definitive method for the detection of spondylolisthesis. Maneuvers Spinal range of motion testing – Range of motion limitations may be seen. Lumbar hyperextension – Extension often elicits pain. This can be assessed by having the patient hyperextend the lumbar spine, provide resistance against back extensions, or undergo repeated lumbar extensions. Sport-specific motion – Patient can be asked to repeat aggravating movements that they experience during their activity. During the movement, ask patient to point to any places with focal pain. Straight leg raise – Maneuver used to assess for hamstring tightness. The straight leg raise has been found to be positive in only 10% of patients with spondylolisthesis. Muscle strength exercises – Lower abdominal, gluteal, and lumbar extensors should be assessed for weakness. Weakness in these muscles can increase lordosis and contribute to sacroiliac instability. Abdominal flexor strength can be assessed with the abdominal flexor endurance test. The test involves the patient lying supine while holding a 45 degree flexed trunk and 90 degree flexed knees for 30 seconds. Gluteal strength can be assessed with a single-leg squat. Lastly, lumbar extension can be assessed with a single-leg bridge. Diagnostic Imaging In adults with non-specific low back pain, strong evidence suggests medical imaging should not be done within the first six weeks. It is also suggested to avoid advanced imaging, such as CT or MRI, for adults without neurological symptoms or "red flags" in the patient's history. General recommendations for initial low back pain treatment is remaining active, avoiding twisting and bending, avoiding activities that worsen pain, avoiding bed rest, and possibly initiating a trial of non-steroidal anti-inflammatory drugs after consulting a physician. Children and adolescents with persistent low back pain may require earlier imaging and should be seen by physician. Once imaging is deemed necessary, a combination of plain radiography, computed tomography, and magnetic resonance imaging may be used. Images are most often taken of the lumbar spine due to spondylolisthesis most commonly involving the lumbar region. Images of the thoracic spine can be taken if