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Low Back Pain Care Pathway

Date of last update: November, 2024

7. Physical Examination

 

Overview: A comprehensive physical examination considers the biopsychosocial aspects of a patient’s condition, cultural sensitivity, informed consent, and the patient’s overall comfort. The selection and scope of assessments should be tailored to the individual clinical encounter, with a focus on increasing confidence in primary diagnostic considerations and refining differential diagnoses. This section provides an inventory of assessments rather than a prescriptive algorithm, allowing clinicians to choose appropriate measures based on the unique presentation and needs of each patient.

Additional Details for Selected Components:

 

Neurological Examination: Record clinical findings for each:

  • Motor strength testing: E.g., L5: Extensor hallucis longus (EHL) strength: L5: EHL – L3/5, R5/5.

  • Strength testing: E.g., "Patient reports that they perceive the same for sharp, light, and vibration for L3, L4, L5, and S1." "Patient reports a loss of perception of sharp and light for S1 on the right with all other sensations intact."

  • Reflex testing: E.g., L5: R 2/4, L 3+/4

  • Upper motor neuron signs: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)."

  • Lower motor neuron signs: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)."

 

Special/Orthopedic Tests:

  • Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary.

  • Document: Test side, results (positive/negative), and responses (e.g., “SLR R(-), L(+) patient reports pain to left heel”).

 

Tests for Nerve Root Compression and Irritation (Radiculopathy):

  1. Passive Straight Leg Raise: Positive test: exacerbates leg pain at or below 45° of hip flexion.

  2. Slump Test: Positive test: neurological symptoms (e.g., shooting pain, numbness, or burning down leg).

  3. Milgram Test: Positive test: cannot lift legs, unable to hold up legs, or symptoms reproduced in the affected limb.

  4. Valsalva Maneuver: Assesses presence of potential space-occupying lesion (e.g., disc herniation). Positive test: exacerbates person’s back pain, leg pain, or both.

  5. Femoral Nerve Traction Test: Positive test: reproduces symptoms (e.g., pain in low back, buttock, posterior thigh).

  6. Directional Preference:

    • Back dominant flexion intolerant: bending forward increases pain (pain may increase with both bending forward and bending backward in some cases) (e.g., disc-related pathology).

    • Back dominant extension intolerant: bending backward increases pain (e.g., facet joint pain).

    • Leg dominant pain that is constant and pain with all movements: nerve root compression.

    • Leg dominant pain that is intermittently worse with walking/standing: neurogenic claudication (or a previous Leg Dominant Constant Pain that is improving).

 

Tests for Sacroiliac Joint (SIJ) Dysfunction:

  1. Thigh Thrust Test: Positive test: reproduces pain in SIJ region.

  2. Compression Test: Positive test: reproduces pain in SIJ region.

  3. Distraction Test: Positive test: reproduces pain in SIJ region.

  4. Sacral Thrust Test: Positive test: reproduces pain in SIJ region.

  5. Gaenslen’s Test: Positive test: reproduces pain in SIJ region.

  6. FABER (Patrick’s) Test: Positive test: test leg remains above opposite leg.

  7. Piriformis Test: Positive test: pain in buttocks, radiating pain into leg.

  8. Gillet Test: Positive Test: asymmetry in sacral movement or restriction in SIJ movement.

 

Tests for Lumbar Spine and Hip Function:

  1. Kemp’s / Quadrant / Extension-Rotation Test: Positive test: pain in the lumbar region, or referred pain into the lower extremity.

  2. Trendelenburg Test: Positive test: dropping/lowering of the hip region.

  3. Thomas Test: Positive test: affected thigh raises indicating a loss of extension in the hip.

  4. Prone Instability Test: Positive test: pain is reduced by actively lifting legs.

  5. Schober Test: Positive test: small amount of lumbar flexion difference (e.g., <4 cm).

 

Tests for Myofascial Pain:

  1. Myofascial Trigger Point Examination: Positive test: localized pain and referred pain upon compression of trigger points.

 

Advanced Diagnostics:

Imaging: Generally not recommended within the first six weeks unless red flags are present, to avoid unnecessary radiation exposure, overdiagnosis, and costs. ​Currently, there is insufficient evidence in the scientific literature that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g., persistent pain and functional limitations).

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