BACK PAIN Assessment for Drs
Acute Low Back Pain Assessment and Management
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RED FLAGS : Red flags” include a history of trauma, fever, incontinence, unexplained weight loss, a cancer history, long-term steroid use, parenteral drug abuse, and intense localized pain and an inability to get into a comfortable position.
POTENTIALLY SERIOUS SPINAL CONDITIONS
Spinal tumor, infection, fracture and the cauda equina syndrome are potentially serious causes of acute low back pain. These conditions are suggested by characteristic findings from the history and physical examination
NONSPECIFIC BACK SYMPTOMS
Some patients have symptoms primarily in the back that suggest neither nerve root compromise nor a serious underlying condition. Mechanical low back pain is in this category. These patients also usually improve with conservative treatment.
With this clinical classification, the unique care physiotherapists can use the history and physical findings to specify the type of back pain affecting the patient and properly treat patients who have potentially serious spinal conditions
History
The diagnosis of low back pain requires a careful history to determine whether the causes are mechanical, or secondary and more threatening. Mechanical causes of acute low back pain include dysfunction of the musculoskeletal and ligamentous structures. Pain can originate from the disc, annulus, facet joints and muscle fibers. Mechanical low back pain generally has a favorable outcome, but back pain with a secondary cause requires treatment for the underlying condition.
Fortunately, secondary causes of low back pain are much less frequent than mechanical causes. An important consideration in the patient's history is age. Patients older than 50 and younger than 20 are more likely to have secondary causes.
Less common secondary causes of acute low back pain include metabolic diseases, inflammatory rheumatologic disorders, referred pain from other sources, Paget's disease, fibromyalgia and psychogenic pain
The physical examination is not as important as the history in identifying secondary causes of acute low back pain. Nevertheless, certain aspects of the physical examination are considered important.
GAIT AND POSTURE
Observation of the patient's walk and overall posture is suggested for all patients with low back pain. Scoliosis may be functional and may indicate underlying muscle spasm or neurogenic involvement.
ROM
The examiner should record the patient's forward flexion, extension, lateral flexion and lateral rotation of the upper torso. Pain with forward flexion is the most common response and usually reflects mechanical causes. If pain is induced by back extension, spinal stenosis should be considered. Unfortunately, the evaluation of spinal range of motion has limited diagnostic use,10 although it may be helpful in planning and monitoring treatment.
PALPATION OR PERCUSSION OF THE SPINE
Point tenderness over the spine with palpation or percussion may indicate fracture or an infection involving the spine. Palpating the paraspinous region may help delineate tender areas or muscle spasm.
HEEL-TOE WALK AND SQUAT AND RISE
A patient unable to walk heel to toe, and squat and rise may have severe cauda equina syndrome or neurologic compromise.
PALPATION OF THE SCIATIC NOTCH
Tenderness over the sciatic notch with radiation to the leg often indicates irritation of the sciatic nerve or nerve roots.
STRAIGHT LEG RAISING TEST
With the patient in the supine position, each leg is raised separately until pain occurs. The angle between the bed and the leg should be recorded. Pain occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root irritation . Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it (popliteal compression test). If placing the knee back in full extension during straight leg raising and dorsiflexing the ankle also increase the pain (Lasègue's sign), nerve root and sciatic nerve irritation is likely.
The result of straight leg raising is positive in 95 percent of patients with a proven herniated disc at surgery, but it is also positive in 80 to 90 percent of patients without any form of disc protrusion at surgery. In contrast, crossed straight leg raising is less sensitive but much more specific for disc herniation. In the crossed straight leg raising test, the contralateral, uninvolved leg is raised. The test result is positive when pain is produced.
REFLEXES AND MOTOR AND SENSORY TESTING
Testing knee and ankle reflexes in patients with radicular symptoms often helps determine the level of spinal cord compromise. An altered knee or ankle reflex alone does not suggest the need for invasive management because this finding is generally transient and fully reversible
Weakness with dorsiflexion of the great toes and ankle may indicate L5 and some L4 root dysfunction. Sensory testing of the medial (L4), dorsal (L5) and lateral (S1) aspects of the foot may also detect nerve root dysfunction
LIMITED NEUROLOGIC TESTING
In the primary care of patients with low back pain and leg symptoms, the neurologic examination can be limited to just a few tests. These include the testing of dorsiflexion strength of the ankle and great toe, ankle reflexes and light touch over aspects of the foot, as well as the straight leg raising test. This abbreviated neurologic examination of the lower extremities allows the detection of most clinically important radiculopathy related to lumbar disc herniation. If patients with abnormal findings on these tests do not show improvement by one month, further diagnostic work-up or referral to a specialist is necessary.8 Those with progressive symptoms should undergo further evaluation without delay.
Laboratory Tests
Laboratory tests generally are not necessary in the initial evaluation of acute low back pain. If tumor or infection is suspected, a complete blood cell count and erythrocyte sedimentation rate should be obtained.1 Other blood studies, such as testing for HLA-B27 antigen (present in ankylosing spondylitis) and serum protein electrophoresis (results abnormal in multiple myeloma), are not recommended unless clinically warranted. Additional laboratory tests, such as urinalysis, should be tailored to the possible diagnoses suggested by the history and physical findings.
Radiographic Evaluation
Plain radiographs are not recommended for the routine evaluation of acute low back pain within the first month unless a finding from the history and clinical examination raises concern. If red flags suggest cauda equina syndrome or progressive major motor weakness, the prompt use of computed tomography (CT), magnetic resonance imaging, myelography or combined CT and myelography is recommended. In the absence of red flags after one month of symptoms, it is reasonable to obtain an imaging study if surgery is being considered.
Causes of Low Back Pain
| CONDITION | CLINICAL CLUES |
| Nonspecific back pain (mechanical back pain, facet joint pain, osteoarthritis, muscle sprains, spasms) | No nerve root compromise, localized pain over lumbosacral area |
| Sciatica (herniated disc) | Back-related lower extremity symptoms and spasm in radicular pattern, positive straight leg raising test |
| Spine fracture (compression fracture) | History of trauma, osteoporosis, localized pain over spine |
| Spondylolysis | Affects young athletes (gymnastics, football, weight lifting); pain with spine extension; oblique radiographs show defect of pars interarticularis |
| Malignant disease (multiple myeloma), metastatic disease | Unexplained weight loss, fever, abnormal serum protein electrophoresis pattern, history of malignant disease |
| Connective tissue disease (systemic lupus erythematosus) | Fever, increased erythrocyte sedimentation rate, positive for antinuclear antibodies, scleroderma, rheumatoid arthritis |
| Infection (disc space, spinal tuberculosis) | Fever, parenteral drug abuse, history of tuberculosis or positive tuberculin test |
| Abdominal aortic aneurysm | Inability to find position of comfort, back pain not relieved by rest, pulsatile mass in abdomen |
| Cauda equina syndrome (spinal stenosis) | Urinary retention, bladder or bowel incontinence, saddle anesthesia, severe and progressive weakness of lower extremities |
| Hyperparathyroidism | Mostly men in their early 20s, positive for HLA-B27 antigen, positive family history, increased erythrocyte sedimentation rate |
| Nephrolithiasis | Colicky flank pain radiating to groin, hematuria, inability to find position of comfort |
| Differential Diagnosis of Low Back Pain | |
| Primary mechanical derangements | Ligamentous strain |
| Muscle strain or spasm | |
| Facet joint disruption or degeneration | |
| Intervertebral disc degeneration or herniation | |
| Vertebral compression fracture | |
| Vertebral end-plate microfractures | |
| Spondylolisthesis | |
| Spinal stenosis | |
| Diffuse idiopathic skeletal hyperostosis | |
| Scheuermann's disease (vertebral epiphyseal aseptic necrosis) | |
| Infection | Epidural abscess |
| Vertebral osteomyelitis | |
| Septic discitis | |
| Pott's disease (tuberculosis) | |
| Nonspecific manifestation of systemic illness | |
| Bacterial endocarditis | |
| Influenza | |
| Neoplasia | Epidural or vertebral carcinomatous metastases |
| Multiple myeloma, lymphoma | |
| Primary epidural or intradural tumors | |
| Metabolic disease | Osteoporosis |
| Osteomalacia | |
| Hemochromatosis | |
| Ochronosis | |
| Inflammatory rheumatologic disorders | Ankylosing spondylitis |
| Reactive spondyloarthropathies (including Reiter's syndrome) | |
| Psoriatic arthropathy | |
| Polymyalgia rheumatica | |
| Referred pain | Abdominal or retroperitoneal visceral process |
| Retroperitoneal vascular process | |
| Retroperitoneal malignancy | |
| Herpes zoster | |
| Paget's disease of bone | |
| Primary fibromyalgia | |
| Psychogenic pain | |
Treatment
Most patients require only symptomatic treatment for acute low back pain. In fact, about 60 percent of patients with low back pain report improvement in seven days with conservative therapy, and most note improvement within four weeks. Patients should be instructed to watch for worsening symptoms such as an increasing loss of motor or sensory functions, increasing pain and the loss of bladder or bowel function. Should any of these occur, the patient should undergo further evaluation and treatment immediately, with weekly follow-up.
Patients should gradually return to their normal activities, as tolerated. Continuing ordinary activities within the limits permitted by pain leads to a more rapid recovery than either bed rest or back-mobilizing exercises
Patients with acute low back problems benefit from exercise programs, if started early and if the exercises cause minimal mechanical stress on the back. The goal of an exercise program is, first, to prevent debilitation related to inactivity and, second, to improve activity tolerance and return patients to their highest level of functioning as soon as possible
Spinal manipulation IFT, trigger-point release are helpful in the management of low back pain. Patients with red flags noted at the initial evaluation may be candidates for immediate non conservative management.
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Dr.Nakkiran.PT. B.P.T., M.Sc., M.I.A.P., C.P.C (US) India, P.G.D.I.P.L
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