Low Back Pain Assessment – 2

The objective assessment will aim to test the hypotheses developed during the subjective assessment. As stated, for low back pain it is often difficult to narrow down a particular structure at fault due to the complexity of the region. Therefore a full neuromusculoskeletal assessment is performed regardless:

Mechanical 

The most basic way to begin any assessment is to look at the posture of the patient. Often in cases of back pain a patient may stand in a shifted position, which may indicate a lesion or ‘bulging’ of an intervertebral disc, or severe muscle spasm on one side. General observation of posture and gait may reveal muscle imbalances that are often associated with mechanical causes of low back pain. Classic examples are tightness of the calves and hamstrings. Muscle length and strength testing are important aspects of any mechanical assessment.

Also crucial is the assessment of the integrity of active movements. In the low back this comprises flexion, extension, side flexion and rotation left and right. Is there full, pain-free movement and if not why? Is there limitation of movement due to a musculotendinous lesion, or is the issue more arthrogenic in nature? Passive movements of the joints (PPIVM’s) will alert the therapist to arthrogenic issues, whereas palpation and resisted movements will reveal lesions within the contractile tissues.

Imaging

If indicated, patients may be sent for imaging. In the case of non-specific back pain there is little indication for scanning the back. In-fact patients who do receive scans in these situations often perform more poorly in the long-term. Scanning, usually with MRI is indicated if the patient is likely to require a surgical opinion, or if medical pathology is suspected that may require an onward referral to a specialist. Occasionally scans may be used to give a patient piece of mind if the symptoms are persisting due to psychological stress.

References:

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

O’Sullivcan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy 2005: 10;242-255

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