This is the first of our three part blog on low back pain assessment, stay tuned for parts two and three!
Given that 85% of chronic LBP cases have no exact diagnosis the assessment of the condition needs to cover all potential aspects set out by O’Sullivan (2005).The local mechanical structures must be assessed for their quality of movement as well as their ability to absorb stress. Neurological signs must be fully covered starting with assessment of peripheral neuropathy, to central causes of pain and clearance of lesions to the higher centres. On top of this the therapist must be sensitive to biopsychosocial issues; what is the state of mind of the patient? Are there other factors involved in the maintenance of their symptoms?
The initial stages of an assessment are subjective in nature. The history of an injury, and patient should allow for a reasonable theory of diagnosis to be developed, which can often allow an objective assessment to be more succinct and accurate. It is during the subjective history taking that signs of psychological stress will be first picked up. It is also the point at which the therapist may develop a knowledge of what are known as SIN factors; Severity, Intensity and Nature of the symptoms. This will guide the therapist as to how aggressive any objective assessment may be. Such questions will include, how long have you had the symptoms? How did they start? Is the pain constant? How severe out of 10 is it? Are you having pain at night?
Further special questions must be asked that may give a clue to more serious pathology eg loss of bladder control may be a sign of impingement of the spinal cord that may require emergency surgery. Pain on coughing or sneezing may also be a sign of discogenic injury.
We cannot forget that patients presenting to physiotherapy practises may not be suffering from neuromusculoskeletal problems at all. It is therefore imperative that the therapist has an understanding of when to refer back to a GP or Consultant for medical opinion. This includes an in-depth knowledge of ‘red flags’. A sense of an issue not being neuromusculoskeletal in nature will be picked up at the subjective stage; we cannot try to pigeon-hole all cases into our own understanding of the body. An understanding of medical pathology, or at the very least when a case simply ‘doesn’t fit’ is crucial if we are to provide the best possible care for our patients.
Ferreira M L, Ferreira P H, Latimer J, Herbert R D, Maher C, Refshauge K. Relationship between spinal stiffness and outcome in patients with chronic low back pain. Manual Therapy 2009: 14;61-67
Wand B M, Parkitny L, O’Connell N E, Luomajoki H, McAuley J H, Thacker M, Moseley L. Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. Manual Therapy 2011: 16(1);15-20