People with LBP should have a detailed history taken to identify those at higher likelihood of red flag and other relevant conditions, and identify personal factors, which may include:
Bardin, L.D., King, P. and Maher, C.G., 2017. Diagnostic triage for low back pain: a practical approach for primary care. The Medical Journal of Australia, 206(6), pp.268-273.
NSW Agency for Clinical Innovation. (2016) Management of people with low back pain. Available from: https://www.aci.health.nsw.gov.au/resources/musculoskeletal/management-of-people-with-acute-low-back-pain/albp-model/albp-moc
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther 2016;39:1-22
Thorough history and evidence-informed examination procedures are critical components of chiropractic clinical management. These procedures provide the clinical rationale for appropriate diagnosis and subsequent treatment planning.
Assessment should include but is not limited to the following:
• Health history (eg, pain characteristics, red flags, review of systems, risk factors for chronicity)
• Specific causes of LBP (eg, aortic aneurysm, inflammatory disorders)
• Examination (eg, reflexes, dermatomes, myotomes, orthopedic tests)
• Diagnostic testing (indications) for red flags (e.g., imaging and laboratory tests)
Spinal Range of Motion Assessment
Range of motion testing may be used as a part of the physical examination to assess for regional mobility, although evidence does not support its reliability in determining functional status.
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
The first qualified practitioner with the ability to do a full assessment (i.e., history, physical and neurological red flags, and psychosocial yellow flags) should assess the patient and undertake diagnostic triage (see Appendix E for summary of red and yellow flags, and the companion documents Clinical Assessment for Psychosocial Yellow Flags and Management of Psychosocial Yellow Flags – see complete list of companion materials). If serious spinal pathology is excluded, manage as non-specific low back pain
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
A detailed history, taken in temporal proximity to the time of injury, should primarily guide evaluation and treatment.
Physical Examination: Should include accepted tests and exam techniques applicable to the area being examined, including:
i. General inspection, including stance and gait;
ii. Visual inspection;
iv. Lumbar range of motion -preferably measured or quantified range of motion, quality of motion, and presence of muscle spasm. Motion evaluation of specific joints may be indicated;
v. Examination of cervical, thoracic and lumbar spine; pelvis, and lower extremities;
vi. Nerve tension testing; Both the straight leg raising test and the slump test can be used to reproduce symptoms and are highly reproducible and correlated. Symptoms usually occur at around 50 degrees of flexion and are exacerbated by ankle dorsiflexion. The slump test is a straight leg raise performed with the patient in a seated slumped forward posture, neck flexed and arms behind the back. A positive contralateral straight leg raising is quite specific, although less sensitively for disc herniation.
vii. Motor and sensory examination of the lower extremities with specific nerve root focus;
viii. Deep tendon reflexes with or without Babinski’s;
ix. Assessment of gait, rapid walking, and balance;
x. For providers trained in the technique, repeated end range testing to establish the presence of a directional preference;
xi. A combination of multiple physical exam test results is preferred as none are independently diagnostic;
xii. If applicable to injury, anal sphincter tone and/or perianal sensation; and
xiii. If applicable, abdominal examination, vascular examination, circumferential lower extremity measurements, or evaluation of hip or other lower extremity abnormalities;
xiv. If applicable, Waddell’s signs, which include five categories of clinical signs: (1) tenderness: superficial and non-anatomic, (2) pain with simulation: axial loading and rotation, (3) regional findings: sensory and motor, inconsistent with nerve root patterns (4) distraction/inconsistency in straight leg raising findings, and (5) over-reaction to physical examination maneuvers. Significance may be attached to positive findings in three out of five of these categories, but not to isolated findings. Waddell advocates considering Waddell’s signs prior to recommending a surgical procedure. These signs should be measured routinely to identify patients requiring further assessment (i.e., biopsychosocial) prior to undergoing back surgery.