Assessing the Back

Most patients with back pain come to see their health professional because: They are in pain and they want it to stop. They are frightened and they want reassurance.

90% of low back diagnoses include Intervertebral disc degeneration Intervertebral disc herniation Spinal stenosis Facet joint osteoarthritis Paraspinal muscle sprain/strain Idiopathic/non-specific is just a description And over half of these are

There is another way “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Quebec Task Force 1987

They are called syndromes and they begin with the history

What is mechanical pain? Pain related to movement Pain related to position Pain related to a physical structure “You have a sore thing in your back”

The most important question in the mechanical pain history is: Where do you hurt? Where is your pain the worst? Where does your pain go? How are you feeling? What brought you here today? The correct answer is B, where is your pain the worst.

The most important question in the mechanical pain history is: Where do you hurt? Is it back or leg dominant? Where does your pain go? How are you feeling? What brought you here today? The correct answer is B, where is your pain the worst.

The other most important question in the mechanical pain history is: Is your pain constant or intermittent?

Part A Is there ever a time when you are in your best position or at the best time of your day when your pain stopsand I know it comes right back but is there a moment or two when the pain is gone?

Part A Is there ever a time when you are in your best position or at the best time of your day when your pain stopsand I know it comes right back but is there a moment or two when the pain is gone?

Part B When your pain stops does it stop completely? Is it all gone? Are you completely without your pain?

When the pain is constant consider: Malignancy Systemic conditions Pain disorder Constant mechanical pain

Aggravating movement/position Where is your pain the worst? Is your pain constant or intermittent? Aggravating movement/position

Relieving movement/position Where is your pain the worst? Is your pain constant or intermittent? Aggravating movement/position Relieving movement/position

Have you had this same pain before? Where is your pain the worst? Is your pain constant or intermittent? Aggravating movement/position Relieving movement/position Have you had this same pain before?

Have you had treatment before? Where is your pain the worst? Is your pain constant or intermittent? Aggravating movement/position Relieving movement/position Have you had this same pain before? Have you had treatment before?

What can’t you do now that you could do before you got the pain? Where is your pain the worst? Is your pain constant or intermittent? Aggravating movement/position Relieving movement/position Have you had this same pain before? Have you had treatment before? What can’t you do now that you could do before you got the pain?

History takes precedence over physical examination but the physical examination must support the history

Physical Examination Observation

Physical Examination Observation Movement Flexion Extension

Physical Examination Nerve root irritation tests Observation Movement Straight leg raising Femoral stretch test

Straight leg raising Reproduction of typical leg pain Back pain is not relevant At any degree of leg elevation

Physical Examination Nerve root conduction tests Observation Movement Nerve root irritation tests Nerve root conduction tests L5 S1 Hip abduction Ankle dorsiflexion Great toe extension Hip extension Ankle plantar flexion Ankle reflex

Physical Examination Plantar reflex Observation Movement Nerve root irritation tests Nerve root conduction tests Plantar reflex upper motor response

Physical Examination Saddle sensation Observation Movement Nerve root irritation tests Nerve root conduction tests Plantar reflex Saddle sensation lower sacral nerve root response

Physical Examination Plantar reflex Saddle sensation High low tests Observation Movement Nerve root irritation tests Nerve root conduction tests Plantar reflex Saddle sensation High low tests

History takes precedent over physical examination. Leg pain takes precedent over back pain. Mechanical pain takes precedent over non-organic pain.

There are 4 mechanical patterns

Pattern 1

History Back dominant pain Pattern 1 Back Buttock Greater trochanter Groin Pattern 1

History Back dominant pain Worse with flexion Pattern 1

History Back dominant pain Worse with flexion Constant or Intermittent Pattern 1

Pattern 1 Fast Responder Physical Examination Back dominant pain Worse on flexion Better or no change with extension Pattern 1 Fast Responder Pattern 1

Pattern 1 Slow Responder Physical Examination Back dominant pain Worse on flexion Worse with extension Pattern 1 Slow Responder Pattern 1

Physical Examination Back dominant pain Worse on flexion Neurological examination normal or non-contributory Pattern 1

Pattern 2

History Back Dominant pain Worse with extension Never worse with flexion Always intermittent Pattern 2

Physical Examination Back dominant pain Worse with extension No effect or better with flexion Neurological exam is normal or non-contributory Pattern 2

Pattern 3

History Leg dominant pain below the gluteal fold Pattern 3

History Leg dominant pain Affected by back movement/position Constant Pattern 3

Physical Examination Leg dominant pain Leg pain affected by back movement Positive irritative test and/or conduction loss Pattern 3

Pattern 4

History Leg dominant pain Worse with activity Better with rest and posture change Always intermittent Pattern 4

Physical Examination Negative irritative tests Possible conduction loss Pattern 4

The mechanical syndrome (Pattern) is supported on three legs That’s all there is The mechanical syndrome (Pattern) is supported on three legs Concordant Physical Examination Anticipated Treatment Response Unequivocal History