How I Assess & Treat People With Low Back Pain Part 1: Assessment

I get asked all the time, especially when people find out I’m a physiotherapist, “what can I do for my back pain” or “what exercises can I do for my back?” These are understandable questions as Low Back Pain (LBP) is the leading cause of disability worldwide costing the health care system millions of dollars in assessment, diagnosis and treatment.

When it comes to LBP assessment and treatment we are in a bit of a difficult spot as the vast majority (80-90% of LBP) cases are not attributable to a specific diagnosis such as a disc pressing on a nerve root, a fracture, or a lumbar muscle strain. As such most LBP cases get lumped into the “non-specific LBP” category. While attempts have been made to subgroup LBP patients the validity of most subgroups have been called into question over the last several years.

In terms of treatment the same conundrum exists as many treatment approaches are equally effective for LBP, no form of exercise seems to be better than the other, and the validity of clinical prediction rules has also came under scrutiny over recent years.

This leaves us in a bit of a tough situation – what do we do for people with LBP? Well in my article I will address how I personally assess & manage someone with LBP in the clinic….

Disclaimer 1: This is for professionals and is not intended to be medical advice. If you have any symptoms such as fevers, chills, night sweats, unremitting night pain, unexplained weight loss, sickness or unwellness, tingling/numbness in the groin, changes in bowel/bladder function and/or a loss of sexual function you may have symptoms suggestive of a serious medical pathology and may need to seek medical attention as soon as possible.

Disclaimer 2: The topic of individualized management in LBP is a controversial one so I accept full well that people (you the reader included) may or may not agree on all the points here but I do hope you will give it a read.

Side note: at the time I was working on this article I happened on this paper which is very very similar to my approach (aside from a few subtleties)

FIRST THINGS FIRST – RULE OUT RED FLAGS AND SERIOUS TISSUE PATHOLOGY

The most important reason as to why someone in pain should see a doctor and/or a physical therapist is to make sure, if anything else, that there are no major health concerns that need to be medically managed.

In the research 1-2% of LBP cases are attributable to a serious pathology such as fracture, cancer, infection, inflammatory condition, or cauda equina syndrome among others. I will not go over the symptoms suggestive of these conditions but I suggest updating yourself on these regularly if you are a professional.

AVOID UNNECESSARY IMAGING

Imaging is indicated for LBP patients if they have symptoms suggestive of a red flag or serious tissue pathology and/or if they have a significant neurological deficit (i.e. dermatomal loss of sensation and/or myotomal weakness) that isn’t improving with conservative management. This applies to a small percentage of people with LBP.

Unfortunately medical imaging is overused, particularly in the US. Now I understand that its easy for doctors to feel pressured to send patients for imaging, but a lot of research suggests that people with LBP who don’t have an indication for imaging are actually worse off getting an X-ray or MRI.

Also – its important to keep in mind that 80% of people with LBP have 1+ symptoms suggestive of a red flag condition yet only 1-2% have them. As such its important to have good clinical reasoning to order special tests.

But won’t the X-ray or MRI show me what’s wrong?

The problem is numerous studies have shown that lots of PAINFREE people have degenerated discs, arthritis, and disc lesions among other things. See the chart below for examples.

Patients often freak out about what their MRI findings say while they may be incidental.

WHAT DO I LOOK FOR IN SOMEONE WITH LBP?

I look at pain from a biopsychosocial perspective. Breaking it down

Bio – general health factors (e.g. fitness, comorbidities); aggravating/relieving movements, postures, and loads; sleep;

Side note: a lot of research claims that biomechanical factors don’t correlate with LBP which isn’t necessarily wrong but I do believe biomechanics shouldn’t be ignored. Sometimes people do have pain with specific movements/postures which may be due to overuse of those movements/postures, guarding, kinesiophobia, or other factors.

Psychosocial – factors that can be related to movement, injury and pain such as fear avoidance, catastrophizing, kinesiophobia, other maladaptive beliefs and passive coping; as well as psychosocial factors such as stress, anxiety, work situation, and depression

I also look at what the patient is working towards (in terms of occupational and/or sporting demands) as well as their goals.

Prior to assessment I’ll have each patient fill out the Orebro Questionnaire – a questionnaire designed to detect psychosocial factors & factors that can place someone at an increased likelihood of chronic pain. I’m not as interested in the overall score as I am in the score of individual items.

SUBJECTIVE ASSESSMENT

Peter O’Sullivan taught me to open my assessment with “tell me your story.” I say that, shut up, and let the patient say what they have to say. I find this gives me probably 65-70% of the useful information I need and it gives the patient a chance to get whatever they need to get out there & off their back. Sometimes just talking can be therapeutic.

Examples of specific questions (aside from ones to rule out red flags) that I’ll ask are

-          Any recent life changes in your family, work, hobbies, or financial life? You don’t have to tell me the specifics if you don’t want to.

-          Have you had any X-rays or MRIs recently?

-          Have you gotten any advice from your doctors, friends/family members, or the internet on what is going on and how to address it?

-          What do you think is going on?

-          How have you been doing in managing this?

-          Any stress, anxiety or depression?

-          Any issues with sleep before or after this started?

-          How has this impacted your life?

-          Where do you see yourself in 6 months?

-          What would you like to do that you aren’t already doing?

-          Have you had to stop or modify any activities?

-          What do you think would happen to you if you did <insert activity here>?

Some may disagree with me, but aside from workers comp cases, I don’t ask a lot of questions specifically about pain except for

-          Whether it’s constant or intermittent

-          Type

-          Aggravating/relieving factors

I find the 0-10 pain scale highly subjective plus I don’t like the idea of feeding into a patient who may be ultra pain focused & causing them to ruminate about it even more.

Two papers I recommend for people wanting to learn more about a good biopsychosocial subjective history are the papers “Listening Is Therapy” and Peter O’Sullivan’s recent “Cognitive Functional Therapy” paper.

OBJECTIVE ASSESSMENT

My objective assessment is basically a hybrid of the McKenzie (MDT) assessment as well as the assessment Stu McGill describes in his books Low Back Disorders, Back Mechanic and Gift Of Injury. These assessments guide my exercise, movement & postural recommendations towards what is more tolerable and (temporarily) away from what’s not tolerated in the early going. For the sake of not giving away their work (and keeping this article from getting ridiculously long) I recommend you buy and read those books.

In addition to these I also do a simple neurological assessment (ie dermatomes, myotomes, reflexes & cord signs). As I’ve written about before motion palpation & positional palpation are unreliable so I just quite frankly don’t bother with them.

I also, in a SFMA-ish style, will look at gross function of the surrounding joints (ie hips, shoulders, ankles) to see if a deficit in one of those areas may be causing a client to have to “overdo” painful movements due to a lack of mobility, strength, or motor control at a distal joint. An example of this could be someone who has pain with lumbar flexion but has to flex the lumbar spine everytime they bend over due to a lack of hip mobility.

This isn’t so much of a subgrouping approach but it enables me to pick and choose what is important to the individual’s treatment plan. I’ve had patients with no psychosocial factors and patients with a ton of psychosocial factors involved.

I hope this helps give you an idea of how I assess people with LBP. In Part 2 of this series I get down to the treatment side of things. As always - thanks for reading.