Subjective Assessment of the Lumbar Spine: Difference between revisions

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<div class="noeditbox">Welcome to the [[EIM Orthopaedic Manual Physical Therapy Fellowship Project|Evidence in Motion Orthopaedic Manual Physical Therapy Fellowship Project]]. This space was created by and for the fellows in the Evidence in Motion Fellowship program. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
<div class="noeditbox">Welcome to the [[EIM Orthopaedic Manual Physical Therapy Fellowship Project|Evidence in Motion Orthopaedic Manual Physical Therapy Fellowship Project]]. This space was created by and for the fellows in the Evidence in Motion Fellowship program. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
'''Original Editors '''-&nbsp;Brian Duffy, Carleen Jogodka, Jeff Ryg, James&nbsp;White&nbsp;
'''Original Editors '''-&nbsp;Brian Duffy, Carleen Jogodka, Jeff Ryg, James&nbsp;White&nbsp;  


'''Lead Editor''' - Jeff Ryg
'''Lead Editor''' - Jeff Ryg  


Instructions
Instructions
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Evidence for the subjective exam. What evidence do we have the strength of the history in our examination? What information can we glean from it? How important is it in providing effective treatment?  
Evidence for the subjective exam. What evidence do we have the strength of the history in our examination? What information can we glean from it? How important is it in providing effective treatment?  


== Introducti<span id="fck_dom_range_temp_1321882331785_562" /><span id="fck_dom_range_temp_1321882331785_52" />on&nbsp; ==
== Introducti&lt;span id="fck_dom_range_temp_1321882331785_562" /&gt;&lt;span id="fck_dom_range_temp_1321882331785_52" /&gt;on&nbsp; ==


Low back pain (LBP) is a common, disabling condition with both musculoskeletal and non musculoskeletal contributions. It has been reported that greater than 80% of individuals will experience LBP within their lifetime and 20-30% of individuals are affected with these symptoms at any point in time<ref name="Freburger">Freburger JK, Holmes GM, et al. The rising prevalence of chronic LBP. Arch Intern Med. 2009. 169(3):251-8.</ref>. Katz et al. reported the cumulative cost to manage this condition is greater than 100 billion dollars per year<ref name="Katz 2006">Katz, J. et al. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006. 88(2):21-4.</ref>. Given the high economic costs associated with LBP it is imperative for the clinician to obtain the necessary information needed to determine the appropriate plan of care, either outside referral or Physical Therapy treatment, for their patient. Matching appropriate interventions based on a patient’s symptoms has been shown to decrease healthcare costs in patients with LBP<ref name="Brennan">Brennan, G. et al. Identifying Subgroups of Patients With Acute/Sub acute “Nonspecific” Low Back Pain: Results of a Randomized Clinical Trial. Spine. 2006.</ref><ref name="Fritz 2007">Fritz, J. et al. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT. 2007. 37(6):290-302.</ref>.  
Low back pain (LBP) is a common, disabling condition with both musculoskeletal and non musculoskeletal contributions. It has been reported that greater than 80% of individuals will experience LBP within their lifetime and 20-30% of individuals are affected with these symptoms at any point in time<ref name="Freburger">Freburger JK, Holmes GM, et al. The rising prevalence of chronic LBP. Arch Intern Med. 2009. 169(3):251-8.</ref>. Katz et al. reported the cumulative cost to manage this condition is greater than 100 billion dollars per year<ref name="Katz 2006">Katz, J. et al. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006. 88(2):21-4.</ref>. Given the high economic costs associated with LBP it is imperative for the clinician to obtain the necessary information needed to determine the appropriate plan of care, either outside referral or Physical Therapy treatment, for their patient. Matching appropriate interventions based on a patient’s symptoms has been shown to decrease healthcare costs in patients with LBP<ref name="Brennan">Brennan, G. et al. Identifying Subgroups of Patients With Acute/Sub acute “Nonspecific” Low Back Pain: Results of a Randomized Clinical Trial. Spine. 2006.</ref><ref name="Fritz 2007">Fritz, J. et al. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT. 2007. 37(6):290-302.</ref>.  
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The patient interview is the first opportunity for the clinician to gather information regarding the patient’s condition. Information gathered during the subjective history can increase the clinician’s confidence in either ruling in or ruling out a suspected condition through the utilization of likelihood ratios (LR) to determine the probability of a condition’s presence or absence. After determining the condition responsible for a patient’s LBP symptoms, the subjective examination may help determine which referral or intervention is warranted. <br>
The patient interview is the first opportunity for the clinician to gather information regarding the patient’s condition. Information gathered during the subjective history can increase the clinician’s confidence in either ruling in or ruling out a suspected condition through the utilization of likelihood ratios (LR) to determine the probability of a condition’s presence or absence. After determining the condition responsible for a patient’s LBP symptoms, the subjective examination may help determine which referral or intervention is warranted. <br>


== Subjective Examination ==
== Subjective Examination ==


A thorough and detailed subjective history and review of systems allows the clinician to gather information regarding the location, quality, severity, irritability, and behavior of a patient’s symptoms. This information is then assimilated to identify patients appropriate for Physical Therapy and those who require a referral to an outside healthcare provider. The subjective examination facilitates this decision by providing a strong diagnostic resource given the patient’s presenting symptoms. Hampton, et al. reported the subjective history alone assisted in the medical diagnosis of 83% of patients seen in a primary care practice<ref name="Hampton">Hampton, J. et al. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ. 1975. 2:486-489.</ref>. Specifically, 4 subjective examination questions have demonstrated a sensitivity of 1.0 in screening for cancer in patients with LBP<ref name="Deyo 1988">Deyo, R. et al. Cancer as a cause of low back pain. J Gen Int Med. 1988. 3:230-239.</ref>. Despite its importance authors have reported the average time given to a patient to explain their symptoms without interruption is 18 seconds and once interrupted patients often do not return to their previous complaints<ref name="Beckman">Beckman HB, Frankel RM. The use of videotape in internal medicine training. J Gen Intern Med. 1994 Sep;9(9):517-21.</ref>. In contrast, an uninterrupted patient only needs 150 seconds to fully express their concerns<ref name="beckman" />.  
A thorough and detailed subjective history and review of systems allows the clinician to gather information regarding the location, quality, severity, irritability, and behavior of a patient’s symptoms. This information is then assimilated to identify patients appropriate for Physical Therapy and those who require a referral to an outside healthcare provider. The subjective examination facilitates this decision by providing a strong diagnostic resource given the patient’s presenting symptoms. Hampton, et al. reported the subjective history alone assisted in the medical diagnosis of 83% of patients seen in a primary care practice<ref name="Hampton">Hampton, J. et al. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ. 1975. 2:486-489.</ref>. Specifically, 4 subjective examination questions have demonstrated a sensitivity of 1.0 in screening for cancer in patients with LBP<ref name="Deyo 1988">Deyo, R. et al. Cancer as a cause of low back pain. J Gen Int Med. 1988. 3:230-239.</ref>. Despite its importance authors have reported the average time given to a patient to explain their symptoms without interruption is 18 seconds and once interrupted patients often do not return to their previous complaints<ref name="Beckman">Beckman HB, Frankel RM. The use of videotape in internal medicine training. J Gen Intern Med. 1994 Sep;9(9):517-21.</ref>. In contrast, an uninterrupted patient only needs 150 seconds to fully express their concerns<ref name="beckman" />.  
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Based on the information gathered from the subjective examination, the clinician will determine which tests to perform designed to confirm or refute their hypothesis on the source of a patient’s symptoms. A selection of the most appropriate questions, with the highest diagnostic utility, will increase the clinician’s confidence in ruling in or out sinister disorders. The following paragraphs will describe questions demonstrating the strongest shifts in probability of a condition being present (+ LR) or absent (-LR). These shifts in probability provide an excellent resource to the clinician treating patients with LBP. <br>
Based on the information gathered from the subjective examination, the clinician will determine which tests to perform designed to confirm or refute their hypothesis on the source of a patient’s symptoms. A selection of the most appropriate questions, with the highest diagnostic utility, will increase the clinician’s confidence in ruling in or out sinister disorders. The following paragraphs will describe questions demonstrating the strongest shifts in probability of a condition being present (+ LR) or absent (-LR). These shifts in probability provide an excellent resource to the clinician treating patients with LBP. <br>


== Risk<span id="fck_dom_range_temp_1321883449769_489" /><span id="fck_dom_range_temp_1321883449769_871" /> Factors&nbsp; ==
== Risk&lt;span id="fck_dom_range_temp_1321883449769_489" /&gt;&lt;span id="fck_dom_range_temp_1321883449769_871" /&gt; Factors&nbsp; ==


The symptoms reported by patients collected through the intake paperwork, review of systems, and subjective examination can assist in clinical hypothesis generation and identification of risk factors shown to influence the prognosis of a patient with LBP. A recent review of the evidence and epidemiological data reports risk factors for LBP include advancing age with first onset between 30-40, sedentary lifestyle, history of back surgery, occupational demands, smoking, depression, corticosteroid use, and obesity<ref name="Fritz 2002">Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83.</ref><ref name="Hill 2011">Hill, J. et al. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011. 91(5):712-21</ref><ref name="Shiri 2010">Shiri, R. et al. The association between obesity and low back pain: a meta analysis. Am J. Epidemiology. 2010. 171(2):135-154.</ref><ref name="Shiri 2010 b">Shiri, R. et al. The association between smoking and low back pain: a metal analysis. Am J Med. 2010. 123(1):87. e7-35</ref>. Many of these variables have been correlated with an increased risk of developing LBP in population based studies. Further, studies have identified features that are associated with chronicity of symptoms, such as lower extremity radiating pain, low expectations for recovery, elevated initial pain score, coping style, fear, and psychosocial stress<ref name="shiri 2010 b" /><ref name="koes 2010">Koes, B. et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010. 19(12):2075-94</ref>.  
The symptoms reported by patients collected through the intake paperwork, review of systems, and subjective examination can assist in clinical hypothesis generation and identification of risk factors shown to influence the prognosis of a patient with LBP. A recent review of the evidence and epidemiological data reports risk factors for LBP include advancing age with first onset between 30-40, sedentary lifestyle, history of back surgery, occupational demands, smoking, depression, corticosteroid use, and obesity<ref name="Fritz 2002">Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83.</ref><ref name="Hill 2011">Hill, J. et al. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011. 91(5):712-21</ref><ref name="Shiri 2010">Shiri, R. et al. The association between obesity and low back pain: a meta analysis. Am J. Epidemiology. 2010. 171(2):135-154.</ref><ref name="Shiri 2010 b">Shiri, R. et al. The association between smoking and low back pain: a metal analysis. Am J Med. 2010. 123(1):87. e7-35</ref>. Many of these variables have been correlated with an increased risk of developing LBP in population based studies. Further, studies have identified features that are associated with chronicity of symptoms, such as lower extremity radiating pain, low expectations for recovery, elevated initial pain score, coping style, fear, and psychosocial stress<ref name="shiri 2010 b" /><ref name="koes 2010">Koes, B. et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010. 19(12):2075-94</ref>.  


== Yellow Flags ==
== Yellow Flags ==


 
Due to the multiple factors associated with pain and their relationship with behavior and personal beliefs, it is necessary to review additional details related to this interaction. Kendall defined yellow flags as factors which increase the risk of developing, or perpetuating long term disability and work loss associated with low back pain<ref name="hill 2011" /> including depression, pain catastrophizing, and elevated fear avoidance beliefs. Arroll et al. reported two questions, “During the past month have you been feeling down, depressed or hopeless?” and “During the past month have you been bothered by having little interest or pleasure in doing things?”, although lacking diagnostic properties (Specificity (Sp) .57-.67), improve our ability to screen (Sensitivity (Sn) .96-.97) for the presence of depression in patients with LBP<ref name="Arroll 2005">Arroll, B. et al. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005. 15. 331(7521):884.</ref>. In addition, asking patients when they would like assistance with these questions can help identify those patients benefiting from help today ((+) Likelihood ratio (LR) 17.5) or help in the future ((+) LR 7.9) for their depression.  
 
Due to the multiple factors associated with pain and their relationship with behavior and personal beliefs, it is necessary to review additional details related to this interaction. Kendall defined yellow flags as factors which increase the risk of developing, or perpetuating long term disability and work loss associated with low back pain<ref name="hill 2011" /> including depression, pain catastrophizing, and elevated fear avoidance beliefs. Arroll et al. reported two questions, “During the past month have you been feeling down, depressed or hopeless?” and “During the past month have you been bothered by having little interest or pleasure in doing things?”, although lacking diagnostic properties (Specificity (Sp) .57-.67), improve our ability to screen (Sensitivity (Sn) .96-.97) for the presence of depression in patients with LBP<ref name="Arroll 2005">Arroll, B. et al. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005. 15. 331(7521):884.</ref>. In addition, asking patients when they would like assistance with these questions can help identify those patients benefiting from help today ((+) Likelihood ratio (LR) 17.5) or help in the future ((+) LR 7.9) for their depression.


Elevated fear avoidance scores associated with the fear avoidance beliefs questionnaire (FABQ) have been associated with an exaggerated perception of pain and an elevated risk for chronic LBP symptoms<ref>Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83</ref>. Specifically, a FABQ Work score &gt;34 and work score &lt;29 produces a (+) LR 3.33 and (-) LR 0.08, respectively, for the development of chronic LBP symptoms. Calley et al. reported the utilization of a two question screen for fear avoidance behaviors including “Are you afraid physical activity will cause an increase in your LBP?” and “Are you afraid that moving your back will be harmful to you?” can be effective for identifying patients requiring further education on their LBP symptoms<ref>Calley, D. et al. Identifying Patient Fear-Avoidance Beliefs by Physical Therapists Managing Patients With Low Back Pain. JOSPT. 2010. 40(12):774-783.</ref>. An education session devoted to improving a patient’s understanding of pain neurophysiology including nociception and central sensitization, as well as, understanding their thoughts and beliefs regarding their symptoms can improve outcomes in these patients<ref name="Main 2011">Main, C. et al. Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. PT. 2011. 91:820-824.</ref><ref>Moreley, S. Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges. Pain. 2011. 152:S99–S106.</ref><ref>Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain. 2004. 8:39-45.</ref><ref>Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain. 2004. 20:324-30</ref><ref>Smeets, R. et al. Reduction of Pain Catastrophizing Mediates the Outcome of Both Physical and Cognitive-Behavioral Treatment in Chronic Low Back Pain. The J Pain. 2006. 7(4):261-271.</ref>. Clinician’s should aim to reduce a patient’s focus on the patho-anatomical sources of their LBP (ex. herniated disc), educate the patient on the resiliency of the spine and limitations of imaging in LBP, and improve a patient’s self efficacy for management of their symptoms.  
Elevated fear avoidance scores associated with the fear avoidance beliefs questionnaire (FABQ) have been associated with an exaggerated perception of pain and an elevated risk for chronic LBP symptoms<ref>Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83</ref>. Specifically, a FABQ Work score &gt;34 and work score &lt;29 produces a (+) LR 3.33 and (-) LR 0.08, respectively, for the development of chronic LBP symptoms. Calley et al. reported the utilization of a two question screen for fear avoidance behaviors including “Are you afraid physical activity will cause an increase in your LBP?” and “Are you afraid that moving your back will be harmful to you?” can be effective for identifying patients requiring further education on their LBP symptoms<ref>Calley, D. et al. Identifying Patient Fear-Avoidance Beliefs by Physical Therapists Managing Patients With Low Back Pain. JOSPT. 2010. 40(12):774-783.</ref>. An education session devoted to improving a patient’s understanding of pain neurophysiology including nociception and central sensitization, as well as, understanding their thoughts and beliefs regarding their symptoms can improve outcomes in these patients<ref name="Main 2011">Main, C. et al. Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. PT. 2011. 91:820-824.</ref><ref>Moreley, S. Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges. Pain. 2011. 152:S99–S106.</ref><ref>Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain. 2004. 8:39-45.</ref><ref>Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain. 2004. 20:324-30</ref><ref>Smeets, R. et al. Reduction of Pain Catastrophizing Mediates the Outcome of Both Physical and Cognitive-Behavioral Treatment in Chronic Low Back Pain. The J Pain. 2006. 7(4):261-271.</ref>. Clinician’s should aim to reduce a patient’s focus on the patho-anatomical sources of their LBP (ex. herniated disc), educate the patient on the resiliency of the spine and limitations of imaging in LBP, and improve a patient’s self efficacy for management of their symptoms.  


<br>


== Red Flags  ==


== Red Flags ==
Although uncommon, non musculoskeletal conditions may present as LBP in approximately 5% of patients presenting to primary care offices (see table)<ref>Deyo, R. et al. What Can the History and Physical Examination Tell Us About Low Back Pain? JAMA. 1992. 268(6):760-766.</ref><ref>Jarvik, J. et al. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med. 2002;137:586-597.</ref>. Within this 5%, 1% are attributed to non mechanical disorders including cancer, infection, and inflammatory arthropathies; 1-2% are attributed to the viscera (abdominal aortic aneurysm (AAA), pelvic, renal, GI); and 2-3% are attributed to other diseases (Paget’s disease, parathyroid disease). &lt;span id="fck_dom_range_temp_1321884105925_74" /&gt;
 
Although uncommon, non musculoskeletal conditions may present as LBP in approximately 5% of patients presenting to primary care offices (see table)12,22. Within this 5%, 1% are attributed to non mechanical disorders including cancer, infection, and inflammatory arthropathies; 1-2% are attributed to the viscera (abdominal aortic aneurysm (AAA), pelvic, renal, GI); and 2-3% are attributed to other diseases (Paget’s disease, parathyroid disease). <span id="fck_dom_range_temp_1321884105925_74" />
 


*Estimated 5% of LBP is caused by serious disease
*1% Non mechanical spine disorders (cancer, infection, seronegative spondyloarthritides)
*1-2% Visceral disease (Pelvic, renal, aortic aneurysm, GI)
*2-3% Other Disease (Paget's disease, parathyroid disease, hemoglobinopathies)


== ==
== Cauda Equina Syndrome (CES) ==


==  ==
Cauda Equina Syndrome (CES) commonly involves a large midline lumbar disc herniation at L4/5, L5/S1, or less commonly L3/4 which impairs lumbosacral nerve function<ref>Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163</ref>. This disorder is most frequently seen in individuals aged 40-60 with a prevalence estimated at .04% of the population<ref>Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163</ref>. Up to 70% of patients with this disorder will complain of a chronic history of LBP and may report symptoms including incontinence, loss of sphincter tone, saddle anesthesia, gait disturbances, unilateral or bilateral sciatica, and urinary retention depending on the severity and duration of symptoms. Early identification of CES is important considering surgical decompression is most successful in patients &lt; 72 hours since onset<ref>Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163</ref>. Each of these reported symptoms provide the clinician with additional information necessary to rule in or out this condition. Specifically, saddle anesthesia (Sn .75) and unilateral or bilateral sciatica (Sn. 80) may assist in the screening of this patient<ref>Kostuik, J. et al. Cauda equina syndrome and lumbar disc herniation. Bone Joint Surg Am. 1986 Mar;68(3):386-91.</ref>. More importantly, the presence (Sp .95, +LR 9.9) or absence (Sn. 90, –LR .11) of urinary retention offers the greatest diagnostic utility for CES <ref>Deyo, R. et al. What Can the History and Physical Examination Tell Us About Low Back Pain? JAMA. 1992. 268(6):760-766.</ref>,<ref>Kostuik, J. et al. Cauda equina syndrome and lumbar disc herniation. Bone Joint Surg Am. 1986 Mar;68(3):386-91.</ref>.<br>


== Key Research  ==
== Key Research  ==

Revision as of 17:00, 21 November 2011

Welcome to the Evidence in Motion Orthopaedic Manual Physical Therapy Fellowship Project. This space was created by and for the fellows in the Evidence in Motion Fellowship program. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Brian Duffy, Carleen Jogodka, Jeff Ryg, James White 

Lead Editor - Jeff Ryg

Instructions

Evidence for the subjective exam. What evidence do we have the strength of the history in our examination? What information can we glean from it? How important is it in providing effective treatment?

Introducti<span id="fck_dom_range_temp_1321882331785_562" /><span id="fck_dom_range_temp_1321882331785_52" />on [edit | edit source]

Low back pain (LBP) is a common, disabling condition with both musculoskeletal and non musculoskeletal contributions. It has been reported that greater than 80% of individuals will experience LBP within their lifetime and 20-30% of individuals are affected with these symptoms at any point in time[1]. Katz et al. reported the cumulative cost to manage this condition is greater than 100 billion dollars per year[2]. Given the high economic costs associated with LBP it is imperative for the clinician to obtain the necessary information needed to determine the appropriate plan of care, either outside referral or Physical Therapy treatment, for their patient. Matching appropriate interventions based on a patient’s symptoms has been shown to decrease healthcare costs in patients with LBP[3][4].

The patient interview is the first opportunity for the clinician to gather information regarding the patient’s condition. Information gathered during the subjective history can increase the clinician’s confidence in either ruling in or ruling out a suspected condition through the utilization of likelihood ratios (LR) to determine the probability of a condition’s presence or absence. After determining the condition responsible for a patient’s LBP symptoms, the subjective examination may help determine which referral or intervention is warranted.

Subjective Examination[edit | edit source]

A thorough and detailed subjective history and review of systems allows the clinician to gather information regarding the location, quality, severity, irritability, and behavior of a patient’s symptoms. This information is then assimilated to identify patients appropriate for Physical Therapy and those who require a referral to an outside healthcare provider. The subjective examination facilitates this decision by providing a strong diagnostic resource given the patient’s presenting symptoms. Hampton, et al. reported the subjective history alone assisted in the medical diagnosis of 83% of patients seen in a primary care practice[5]. Specifically, 4 subjective examination questions have demonstrated a sensitivity of 1.0 in screening for cancer in patients with LBP[6]. Despite its importance authors have reported the average time given to a patient to explain their symptoms without interruption is 18 seconds and once interrupted patients often do not return to their previous complaints[7]. In contrast, an uninterrupted patient only needs 150 seconds to fully express their concerns[8].

Based on the information gathered from the subjective examination, the clinician will determine which tests to perform designed to confirm or refute their hypothesis on the source of a patient’s symptoms. A selection of the most appropriate questions, with the highest diagnostic utility, will increase the clinician’s confidence in ruling in or out sinister disorders. The following paragraphs will describe questions demonstrating the strongest shifts in probability of a condition being present (+ LR) or absent (-LR). These shifts in probability provide an excellent resource to the clinician treating patients with LBP.

Risk<span id="fck_dom_range_temp_1321883449769_489" /><span id="fck_dom_range_temp_1321883449769_871" /> Factors [edit | edit source]

The symptoms reported by patients collected through the intake paperwork, review of systems, and subjective examination can assist in clinical hypothesis generation and identification of risk factors shown to influence the prognosis of a patient with LBP. A recent review of the evidence and epidemiological data reports risk factors for LBP include advancing age with first onset between 30-40, sedentary lifestyle, history of back surgery, occupational demands, smoking, depression, corticosteroid use, and obesity[9][10][11][12]. Many of these variables have been correlated with an increased risk of developing LBP in population based studies. Further, studies have identified features that are associated with chronicity of symptoms, such as lower extremity radiating pain, low expectations for recovery, elevated initial pain score, coping style, fear, and psychosocial stress[13][14].

Yellow Flags[edit | edit source]

Due to the multiple factors associated with pain and their relationship with behavior and personal beliefs, it is necessary to review additional details related to this interaction. Kendall defined yellow flags as factors which increase the risk of developing, or perpetuating long term disability and work loss associated with low back pain[15] including depression, pain catastrophizing, and elevated fear avoidance beliefs. Arroll et al. reported two questions, “During the past month have you been feeling down, depressed or hopeless?” and “During the past month have you been bothered by having little interest or pleasure in doing things?”, although lacking diagnostic properties (Specificity (Sp) .57-.67), improve our ability to screen (Sensitivity (Sn) .96-.97) for the presence of depression in patients with LBP[16]. In addition, asking patients when they would like assistance with these questions can help identify those patients benefiting from help today ((+) Likelihood ratio (LR) 17.5) or help in the future ((+) LR 7.9) for their depression.

Elevated fear avoidance scores associated with the fear avoidance beliefs questionnaire (FABQ) have been associated with an exaggerated perception of pain and an elevated risk for chronic LBP symptoms[17]. Specifically, a FABQ Work score >34 and work score <29 produces a (+) LR 3.33 and (-) LR 0.08, respectively, for the development of chronic LBP symptoms. Calley et al. reported the utilization of a two question screen for fear avoidance behaviors including “Are you afraid physical activity will cause an increase in your LBP?” and “Are you afraid that moving your back will be harmful to you?” can be effective for identifying patients requiring further education on their LBP symptoms[18]. An education session devoted to improving a patient’s understanding of pain neurophysiology including nociception and central sensitization, as well as, understanding their thoughts and beliefs regarding their symptoms can improve outcomes in these patients[19][20][21][22][23]. Clinician’s should aim to reduce a patient’s focus on the patho-anatomical sources of their LBP (ex. herniated disc), educate the patient on the resiliency of the spine and limitations of imaging in LBP, and improve a patient’s self efficacy for management of their symptoms.


Red Flags[edit | edit source]

Although uncommon, non musculoskeletal conditions may present as LBP in approximately 5% of patients presenting to primary care offices (see table)[24][25]. Within this 5%, 1% are attributed to non mechanical disorders including cancer, infection, and inflammatory arthropathies; 1-2% are attributed to the viscera (abdominal aortic aneurysm (AAA), pelvic, renal, GI); and 2-3% are attributed to other diseases (Paget’s disease, parathyroid disease). <span id="fck_dom_range_temp_1321884105925_74" />

  • Estimated 5% of LBP is caused by serious disease
  • 1% Non mechanical spine disorders (cancer, infection, seronegative spondyloarthritides)
  • 1-2% Visceral disease (Pelvic, renal, aortic aneurysm, GI)
  • 2-3% Other Disease (Paget's disease, parathyroid disease, hemoglobinopathies)

Cauda Equina Syndrome (CES)[edit | edit source]

Cauda Equina Syndrome (CES) commonly involves a large midline lumbar disc herniation at L4/5, L5/S1, or less commonly L3/4 which impairs lumbosacral nerve function[26]. This disorder is most frequently seen in individuals aged 40-60 with a prevalence estimated at .04% of the population[27]. Up to 70% of patients with this disorder will complain of a chronic history of LBP and may report symptoms including incontinence, loss of sphincter tone, saddle anesthesia, gait disturbances, unilateral or bilateral sciatica, and urinary retention depending on the severity and duration of symptoms. Early identification of CES is important considering surgical decompression is most successful in patients < 72 hours since onset[28]. Each of these reported symptoms provide the clinician with additional information necessary to rule in or out this condition. Specifically, saddle anesthesia (Sn .75) and unilateral or bilateral sciatica (Sn. 80) may assist in the screening of this patient[29]. More importantly, the presence (Sp .95, +LR 9.9) or absence (Sn. 90, –LR .11) of urinary retention offers the greatest diagnostic utility for CES [30],[31].

Key Research[edit | edit source]

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Resources
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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. ↑ Freburger JK, Holmes GM, et al. The rising prevalence of chronic LBP. Arch Intern Med. 2009. 169(3):251-8.
  2. ↑ Katz, J. et al. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006. 88(2):21-4.
  3. ↑ Brennan, G. et al. Identifying Subgroups of Patients With Acute/Sub acute “Nonspecific” Low Back Pain: Results of a Randomized Clinical Trial. Spine. 2006.
  4. ↑ Fritz, J. et al. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT. 2007. 37(6):290-302.
  5. ↑ Hampton, J. et al. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ. 1975. 2:486-489.
  6. ↑ Deyo, R. et al. Cancer as a cause of low back pain. J Gen Int Med. 1988. 3:230-239.
  7. ↑ Beckman HB, Frankel RM. The use of videotape in internal medicine training. J Gen Intern Med. 1994 Sep;9(9):517-21.
  8. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named beckman
  9. ↑ Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83.
  10. ↑ Hill, J. et al. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011. 91(5):712-21
  11. ↑ Shiri, R. et al. The association between obesity and low back pain: a meta analysis. Am J. Epidemiology. 2010. 171(2):135-154.
  12. ↑ Shiri, R. et al. The association between smoking and low back pain: a metal analysis. Am J Med. 2010. 123(1):87. e7-35
  13. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named shiri 2010 b
  14. ↑ Koes, B. et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010. 19(12):2075-94
  15. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named hill 2011
  16. ↑ Arroll, B. et al. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005. 15. 331(7521):884.
  17. ↑ Fritz, J. et al. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002 Oct;82(10):973-83
  18. ↑ Calley, D. et al. Identifying Patient Fear-Avoidance Beliefs by Physical Therapists Managing Patients With Low Back Pain. JOSPT. 2010. 40(12):774-783.
  19. ↑ Main, C. et al. Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. PT. 2011. 91:820-824.
  20. ↑ Moreley, S. Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges. Pain. 2011. 152:S99–S106.
  21. ↑ Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain. 2004. 8:39-45.
  22. ↑ Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain. 2004. 20:324-30
  23. ↑ Smeets, R. et al. Reduction of Pain Catastrophizing Mediates the Outcome of Both Physical and Cognitive-Behavioral Treatment in Chronic Low Back Pain. The J Pain. 2006. 7(4):261-271.
  24. ↑ Deyo, R. et al. What Can the History and Physical Examination Tell Us About Low Back Pain? JAMA. 1992. 268(6):760-766.
  25. ↑ Jarvik, J. et al. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med. 2002;137:586-597.
  26. ↑ Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163
  27. ↑ Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163
  28. ↑ Small, S. et al. Orthopedic pitfalls: cauda equina syndrome. American Journal of Emergency Medicine (2005) 23, 159–163
  29. ↑ Kostuik, J. et al. Cauda equina syndrome and lumbar disc herniation. Bone Joint Surg Am. 1986 Mar;68(3):386-91.
  30. ↑ Deyo, R. et al. What Can the History and Physical Examination Tell Us About Low Back Pain? JAMA. 1992. 268(6):760-766.
  31. ↑ Kostuik, J. et al. Cauda equina syndrome and lumbar disc herniation. Bone Joint Surg Am. 1986 Mar;68(3):386-91.
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