4. 2nd most common cause for office visit
60-80% of population will have lower back
pain at some time in their lives
Each year, 15-20% will have back pain
Most common cause of disability for persons
< 45 years
1% of US population is disabled
Costs to society: $20-50 billion/year
Back Pain
5. Causes of Low Back Pain:
Lumbar “strain” or “sprain” – 70%
Degenerative changes – 10%
Herniated disk – 4%
Osteoporosis compression fractures – 4%
Spinal stenosis – 3%
Spondylolisthesis – 2%
6. Causes of Low Back Pain:
Spondylolysis, diskogenic low back pain or
other instability – 2%
Traumatic fracture - <1%
Congenital disease - <1%
Cancer – 0.7%
Inflammatory arthritis – 0.3%
Infections – 0.01%
7. Clinicians should conduct a focused
History and physical examination to help place patients with low
back pain into 1 of 3 broad categories:
nonspecific low back pain,
back pain potentially associated with radiculopathy or spinal
stenosis,
back pain potentially associated with another specific spinal
cause.
The history should include assessment of psychosocial risk
factors, which predict risk for chronic disabling back pain
Diagnosis and Treatment of Low Back Pain: A Joint
Clinical Practice Guideline from the American College
of Physicians and the American Pain Society
8. Assessment of LBP
• Rule out serious pathology ‘Red Flags’
• Confirm that the pain:
• Is in the lower back - always assess the hip joint
• Is mechanical — aggravated or relieved by certain movements or
postures.
• Is not inflammatory — that is:
• Not worse in the second half of the night or after waking.
• Not associated with morning stiffness lasting more than
30 minutes.
• Not relieved by activity.
• Not associated with laboratory tests for inflammation
• Exclude specific causes of low back pain
9. Classification of LBP
Conventionally low back pain is categorised
according to its duration as:
Acute (<6 weeks),
Sub-acute (6 weeks - 12 weeks)
Chronic (>12 weeks)
(Spitzer, W. O. and Leblanc, F. E., 1987).
10. Red Flags:
• Red flags for the cauda equina syndrome include:
– Saddle anaesthesia.
– Recent onset of bladder dysfunction or faecal incontinence.
– Major motor weakness.
• Red flags that suggest spinal fracture include:
– Sudden onset of severe central pain in the spine which is relieved
by lying down.
– Major trauma such as a road accident or fall from a height.
– Minor trauma, or even just strenuous lifting, in people with
osteoporosis.
– Structural deformity of the spine.
11. •Red flags that suggest cancer or infection
include:
–Onset in a person over 50 years, or under 20 years, of age.
–History of cancer.
–Constitutional symptoms, such as fever, chills, or unexplained
weight loss.
–Intravenous drug abuse.
–Immune suppression.
–Pain that remains when supine; aching night-time pain
disturbing sleep; and thoracic pain (which also suggests aortic
aneurysm).
12. Yellow Flags
Yellow flags are psychosocial barriers to recovery. They include:
• The belief that pain and activity are harmful.
• Sickness behaviours, such as extended rest.
• Social withdrawal, lack of support.
• Emotional problems such as low or negative mood, depression, anxiety, or
feeling under stress.
• Problems or dissatisfaction at work.
• Problems with claims for compensation or applications for social benefits.
• Prolonged time off work (e.g. more than 6 weeks).
• Overprotective family.
• Inappropriate expectations of treatment, such as low expectations of active
participation in treatment.
14. Investigation:
• Do not offer X-ray of the lumbar spine for the
management of non-specific low back pain.
• MRI for non-specific low back pain should only be
performed within the context of a referral for an
opinion on spinal fusion.
• Consider referral for MRI if sciatica persists > 6
weeks
• ESR/CRP if suspect cancer, infection, Ank Spond
• HLA B27 if suspect AS.
15. Disease or condition Patient age (years)
Back strain 20 to 40
disc herniation 30 to 50
Osteoarthritis or spinal
stenosis
>50
Spondylolisthesis Any age
Ankylosing spondylitis 15 to 40
Infection Any age
Malignancy >50
16. Disease or condition Location of pain
Back strain Low back, buttock, posterior thigh
Disc herniation Low back to lower leg
Osteoarthritis or spinal stenosis Low back to lower leg; often bilateral
Spondylolisthesis Back, posterior thigh
Ankylosing spondylitis Sacroiliac joints, lumbar spine
Infection Lumbar spine, sacrum
Malignancy Affected bone(s)
17. Disease or condition Quality of pain
Back strain Ache, spasm
Disc herniation Sharp, shooting or burning pain,
paresthesia in leg
Osteoarthritis or spinal stenosis Ache, shooting pain, "pins and needles"
sensation
Spondylolisthesis Ache
Ankylosing spondylitis Ache
Infection Sharp pain, ache
Malignancy Dull ache, throbbing pain; slowly
progressive
18. Disease or condition Aggravating or relieving
factors
Back strain Increased with activity or bending
Disc herniation Decreased with standing;
increased with bending or sitting
Osteoarthritis or spinal stenosis Increased with walking, especially up
an incline; decreased with sitting
Spondylolisthesis Increased with activity or bending
Ankylosing spondylitis Morning stiffness
Infection Varies
Malignancy Increased with recumbency or cough
19. Disease or condition Signs
Back strain Local tenderness, limited spinal motion
Disc herniation Positive straight leg raise test,
weakness, asymmetric reflexes
Osteoarthritis or spinal stenosis Mild decrease in extension of spine;
may have weakness or asymmetric
reflexes
Spondylolisthesis Exaggeration of the lumbar curve,
palpable "step off" (defect between
spinous processes), tight hamstrings
Ankylosing spondylitis Decreased back motion, tenderness
over sacroiliac joints
Infection Fever, percussive tenderness; may have
neurologic abnormalities or decreased
motion
Malignancy May have localized tenderness,
neurologic signs or fever
20. Clinical Evaluation
Spring Test:
Test Positioning:
Subject is prone
Examiner stands with thumbs or hypothenar eminence
over the spinous process of a lumbar vertebrae
Action:
Apply a downward “springing” force through the
spinous process of each vertebrae to assess anterior-
posterior motion
Positive Finding:
Increases or decreases in motion at one vertebrae
compared to another (hypermobility or hypomobility)
23. Nerve Root Impingement
Tests:
Valsalva Test:
Test Position:
Sitting, examiner standing next to patient
Action:
Subject takes a deep breath and holds while bearing down
as if having a bowel movement
Positive Finding:
Increased spinal or radicular pain due to ↑ intrathecal
pressure
May be secondary to a space-occupying lesion (i.e.
herniated disc, tumor, osteophyte in lumbar canal)
25. Milgram Test:
Test Position:
Patient supine, examiner at feet of the
patient
Action:
Patient performs a bilateral straight
leg raise to the height of 2 to 6 inches
and is asked to hold the position for 30
seconds
26. Milgram Test:
Positive Finding:
Patient unable to hold
position, cannot lift the
leg, or has pain with test
Implications:
Intrathecal or
extrathecal pressure
causing an
intervertebral disc to
place pressure on a
lumbar nerve root
27. Kernig’s Test:
Test Position:
Patient supine, examiner at side of patient
Action:
Patient performs a unilateral active straight leg
raise with the knee extended until pain occurs
After pain occurs, the patient flexes the knee
Positive Finding:
Pain in the spine and possibly radiating into lower
extremity
Pain relieved when patient flexes the knee
Implications:
Nerve root impingement secondary to bulging of
the intervertebral disc or bony entrapment;
irritation of dural sheath; irritation of meninges
28. Patient actively flexes
the cervical spine (lifts
the head)
Hip unilaterally flexed
(no more than 900)
Knee than flexed to no
more than 900
(+) ↑ pain with neck
and hip flexion; pain
relieved when knee is
flexed
Kernig/Brudzinski Test:
29. Test Position:
Patient supine, examiner standing at tested
side with the distal hand around the subject’s
heel and proximal hand on subject’s distal
thigh (anterior) – maintains knee extension
Action:
Examiner slowly raises the leg until
pain/tightness noted or full ROM is obtained
Slowly lower the leg until the pain or tightness
resolves, at which point dorsiflex the ankle and
have subject flex the neck.
Unilateral Straight Leg Raise Test
(Lasegue Test):
30. Positive Findings:
Leg and/or low back
pain occurring with DF
and or neck flexion is
indicative of dural
involvement and/or
sciatic nerve irritation
Lack of pain
reproduction with DF
and/or neck flexion is
indicative of hamstring
tightness or SI pathology
Straight Leg Raise Test:
31. Test Position:
Patient standing with feet shoulder width
apart
Examiner stands behind the patient, grasping
the patient’s shoulders
Action:
Patient extends the spine as far as possible,
than sidebends and rotates to affected side
Examiner provides overpressure through the
shoulders, supporting the patient as needed
Quadrant Test:
33. Positive Findings:
Reproduction of patient’s symptoms
Implications:
Radicular pain indicates compression of the
intervertebral foramina that impinges on the
lumbar nerve roots
Local pain (not radiating) indicates facet joint
pathology
Symptoms isolated to the area of the PSIS
may indicate SI joint dysfunction
Quadrant Test:
34. Test Position:
Patient sits over edge of table; examiner is at
side of patient
Action:
(1) Patient slumps forward along
thoracolumbar spine, rounding the shoulders
while keeping cervical spine neutral
(2) Patient flexes cervical spine; Clinician
holds patient in this position
(3) Knee is actively extended
(4) Ankle is actively dorsiflexed
(5) Repeat on opposite side
Slump Test:
35. Positive Findings:
Sciatic pain or
reproduction of
other neurological
symptoms
Implications:
Impingement of
the dural lining,
spinal cord, or
nerve roots
Slump Test:
36. Hoover Test:
Test Position:
Patient supine
Examiner at feet of patient with hands cupping the
calcaneous of each leg
Action:
Patient attempts to actively straight leg raise on the
involved side
Positive Findings:
Patient does not attempt to lift the leg and examiner
does NOT sense pressure from the uninvolved leg
pressing down on the hand
Patient is not attempting to perform the test
Test for Patient Malingering:
37. Hoover Test:
Test Note: Examiner should be standing at feet of patient with
their hands cupping the heels of each leg
38. Test Position: Athlete supine
Athletic Trainer Position: At the foot of the
athlete holding a blunt tool (reflex hammer)
Procedure: Rub the tool up bottom of
athlete’s foot starting at the calcaneus and
ending at the great toe.
Positive test: Great toe extends while other
toes splay.
Implications: Lesion of upper motor
neurons, may be caused by trauma to the
brain
Comments: This reflex occurs naturally in
newborns. However, this reflex should cease
quickly after birth.
Babinkski’s Test:
39. Common low back pathology
MOI:
History of heavy or repetitive
lifting
Signs/Symptoms:
Aching back
Pain ↑ with passive and active
flexion, resisted extension
Neurological Evaluation:
Negative results
Erector Spinae Muscle Strain:
40. Pathology of facet joints: 40% of all chronic low back pain
Vague signs/symptoms:
Often resemble other low back pathologies (i.e. strain/spasm
of paraspinal muscles, nerve root impingement, disc
degeneration)
Involvement:
Dislocation/sublocation of facet:
Tends to “lock” the involved spinal segment (hypomobile
vertebrae)
Facet joint syndrome: (inflammation)
Causes: repetitive stress through movement or loading
Degeneration: (arthritis)
Causes: undefined history
↓ intervertebral foramen size (nerve root impingement)
Facet Joint Dysfunction:
41. History:
Onset: Insidious
Pain characteristics: Localized
MOI: Extension, rotation, lateral bending of vertebrae
Predisposing conditions: Repeated motions of spinal
extension, rotation, lateral bending
Inspection:
Patient may assume posture that ↓ pressure on affected facets
Palpation:
Possible local muscle spasm (paravertebral muscles)
Facet Joint Dysfunction:
42. Ligamentous Tests:
Spring Test – pain, ↓ motion
Neurological Tests:
Not applicable unless secondary
nerve root impingement occurs
Special Tests:
Quadrant Test (+)ve
Intervertebral disc lesions (-)ve
Facet Joint Dysfunction:
43. History:
Onset of pain:
Insidious; pain begins as an ache, ↑ to constant pain
Characteristics:
Lumbar pain, radiating into buttocks and upper
posterolateral thigh
MOI:
Repetitive stress (extension)
Predisposing conditions:
Muscular imbalances
Repetitive hyperextension activities
Inspection:
↑ lordotic curve
Altered GAIT
Spondylolysis and Spondylolisthesis:
44. Palpation:
Step-off deformity may be felt
Spasm of paraspinal muscles
Functional Tests:
AROM:
Flexion – restricted, pain free
Extension – pain
Rotation and bending - pain
PROM:
Hip flexion – hamstring tightness
RROM:
Weakness of spinal erectors
Spondylolysis and Spondylolisthesis
45. Special Tests:
Pain with Spring test
SL stance test; straight leg
raises may produce pain
Spondylolysis and Spondylolisthesis:
47. Inspection:
Levels of iliac crests, ASIS, PSIS
Palpation:
Pain over SI joints and PSIS
Functional tests:
Trunk flexion (with knees extended) will cause movement of
the sacrum on the ilia (pain)
Neurological testing:
Lower quarter screen
Special tests:
Long sit; SI compression and distraction; straight leg
raising; fabre; gaenslen’s; quadrant
Sacroiliac Joint Dysfunction:
48. Test position:
Subject supine; examiner stands next to subject and with
arms crossed, places heel of both hands on the subject’s
ASISs
Action:
Examiner applies outward and downward pressure with
the heels of both hands
Positive finding:
Unilateral pain at SI joint or in gluteal/leg region is
indicative of anterior SI ligament sprain
Sacroiliac Joint Stress Test:
49. Test position:
Subject side-lying; examiner
stands next to patient and places
both hands (one on top of the
other) directly over the subject’s
iliac crest
Action:
Apply downward pressure
Positive finding:
Increased pain indicative of SI
pathology (possible involvement of
posterior SI ligament)
Sacroiliac Joint Stress Test:
50. Test position:
Subject lying supine; examiner places
both hands on lateral aspect of
subject’s iliac crests
Action:
Apply inward and downward
pressure
Positive finding:
Increased pain indicative of SI
pathology (possibly involving
posterior SI ligaments)
Sacroiliac Joint Stress Test:
51. Test position:
Subject lying prone; examiner places both
hands (one on top of the other) over subject’s
sacrum
Action:
Apply downward pressure on sacrum
Positive finding:
Increased pain indicative of SI pathology
Sacroiliac Joint Stress Test:
52. Test position: Subject supine
Action:
Examiner passively flexes, abducts, and
externally rotates the involved leg until
the foot rests on the top of the knee of
uninvolved lower extremity; examiner
slowly abducts the involved lower
extremity towards the table
Positive test:
Involved lower extremity does not
abduct below level of uninvolved side
SI pathology, iliopsoas tightness
Patrick or FABER Test:
53. Test position:
Subject supine, lying close to edge of
table; examiner stands at side
Action:
Slide patient to edge of table; patient
pulls far knee up to the chest; near leg
allowed to hang over edge of table
Examiner applies downward pressure on
near leg, forcing it into hyperextension
Positive finding:
Pain in SI region indicating SI joint
dysfunction
Gaenslen’s Test:
