1. Assessing the Back

2. 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.

3. 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

4. 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

5. They are called syndromes and they begin with the history

6. 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”

7. 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.

8. 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.

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

10. 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?

11. 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?

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

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

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

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

16. 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?

17. 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?

18. 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?

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

20. Physical Examination
Observation

21. Physical Examination
Observation
Movement
Flexion
Extension

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

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

24. 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

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

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

27. 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

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

29. There are 4 mechanical patterns

30. Pattern 1

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

32. History
Back dominant pain
Worse with flexion
Pattern 1

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

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

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

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

37. Pattern 2

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

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

40. Pattern 3

41. History
Leg dominant pain
below the gluteal fold
Pattern 3

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

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

44. Pattern 4

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

46. Physical Examination Negative irritative tests
Possible conduction loss
Pattern 4

47. 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