Red Flags

Even though a specific pathoanatomic source cannot be identified in most individuals with LBP, the cause in most cases can be attributed to mechanical factors. In a much smaller percentage of patients, the cause may be something more serious such as a fracture, cauda equina syndrome, neoplastic condition, or inflammatory disease. Red flags are signs or symptoms that suggest a more serious underlying pathology and may necessitate referral for medical or surgical intervention.

Several findings from the patient’s history should alert the clinician to the potential for a serious underlying pathology. Spinal fractures can occur as a result of major trauma or falls. Compression fractures most commonly occur in postmenopausal women or in individuals with other bone-weakening conditions such as chronic corticosteroid use. Stress fractures are also not uncommon in athletes with persistent LBP. Stress fractures of the sacrum have been reported as a cause of LBP in athletes. The pars interarticularis of the vertebral arch is the most common site of stress fractures in the spine, particularly in athletes involved in sports activities that involve repeated extension and rotation movements. The term spondylolysis describes a bony defect in the pars interarticularis region. Rates of spondylolysis are particularly high in gymnasts, weight lifters, throwing athletes in track and field, divers, and rowers. ^, Spondylolysis may progress to spondylolisthesis, or forward slippage of one vertebra in relation to the vertebra below ( Fig. 17-1 ). Red flags that may indicate the presence of spondylolysis or spondylolisthesis include teenage athletes with LBP, participation in sports involving repetitive hyperextension of the spine, and pain with extension activities. If a spondylolytic lesion is suspected, referral for further diagnostic imaging should be considered. Early identification of these conditions may prevent a nonunion fracture or progression of the slippage. Treatment may involve bracing and limitation of activity. Rehabilitation typically focuses on stabilization exercises.

Grade 1 spondylolisthesis of the L4 vertebra in a 17-year-old football offensive lineman with low back pain.

LBP caused by a spinal neoplasm is rare and occurs in less than 1% of individuals with LBP. A missed or delayed diagnosis is possible if an awareness of red flags for the condition is lacking. Deyo and Diehl identified several red flags that should raise suspicion for spinal tumors, including older than 50 years of age, unexplained weight loss, and no relief with bed rest. The most significant red flag is a previous history of cancer. The most common cancers that may result in metastases to the spine involve the breast, lung, and prostate. LBP caused by infectious conditions such as osteomyelitis or septic discitis are also rare; red flags include fever, chills, a recent history of an infectious condition such as a urinary tract infection, or intravenous drug use. The medical history may also provide the first clues for detecting ankylosing spondylitis, a rheumatic inflammatory disorder more common in male individuals and characterized by fibrosis and ossification of ligaments and joint capsules. Most affected individuals are younger than 35 years of age when they first experience symptoms and will describe morning stiffness. The finding of relief with exercise and the need to get out of bed at night are also important in raising suspicion for ankylosing spondylitis. ^,

Cauda equina syndrome occurs when a large midline disk herniation causes compression of the cauda equina nerve roots. The condition is rare, with estimates of it occurring in less than 0.01% of patients with LBP, but when present it represents a surgical emergency that requires immediate referral. Red flags for cauda equina syndrome are sensory deficits in the perineal (i.e., “saddle”) region, urinary retention, or loss of sphincter control. Box 17-1 provides a contrasting view of red flags that could potentially be a serious condition causing LBP.

Yellow Flags

LBP is a common experience, and most affected individuals are able to recover and resume normal activities within a few weeks. Research has shown that psychosocial variables are far more important than findings on physical examination for predicting which patients are at risk for not making a rapid recovery. ^, Yellow flags are findings that indicate an increased risk for prolonged pain and disability because of psychosocial factors. Research suggests that fear-avoidance beliefs may be the most important psychosocial yellow flag indicating increased risk for prolonged LBP. ^,

The Fear-Avoidance Model was developed to help explain why some individuals with acute painful conditions progress to chronic pain whereas others are able to recover. The model proposes that pain perception has both a sensory component and an emotional reaction component. During normal conditions these two components have a proportional relationship. In some instances, however, the relationship between the sensory component and the emotional reaction component can become dissociated and result in pain experience or behavior, or both, that is out of proportion to the demonstrable pathology. The most important determinant of the relationship between the sensory and emotional components of pain perception is proposed to be an individual’s fear of pain and subsequent avoidance behavior. ^,

The response of an individual to a painful experience may fall somewhere along a continuum between two extremes: avoidance and confrontation. Confrontation is seen as an adaptive response in which the individual resumes activities in a graded manner and eventually returns to a normal level of activity. Conversely, avoidance is viewed as a maladaptive response in which activities anticipated to cause pain are avoided. Avoidance may result in decreased activity levels, continued disability, and adverse psychologic consequences.

The presence of an avoidance response to LBP has been associated with increased risk for prolonged disability and work loss. ^{, , ,} Yellow flags indicating increased risk for prolonged disability caused by heightened fear-avoidance beliefs can be assessed by clinical evaluation or by questionnaire. Several attitudes and behaviors may represent yellow flags. Waddell et al developed the Fear-Avoidance Beliefs Questionnaire (FABQ) to quantify fear-avoidance beliefs in patients with LBP ( Fig. 17-2 ). The questionnaire is designed to assess the impact of fear-avoidance beliefs on two aspects of function: physical activity and work.

Fear-Avoidance Beliefs Questionnaire. The physical activity subscale is computed as the sum of questions 2 through 5. The work subscale is computed as the sum of questions 6, 7, 9 to 12, and 15.

(From Waddell, G., Newton, M., Henderson, I., et al. [1993]: A Fear-Avoidance Beliefs Questionnaire [FABQ] and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain, 52:157–168.)

When yellow flags are identified, the rehabilitation approach used with the patient may need to be modified. An emphasis on active rehabilitation and positive reinforcement of functional accomplishments is recommended for patients with increased fear-avoidance beliefs. Graded exercise programs that direct attention toward attaining certain functional goals and away from the symptom of pain have also been recommended. Finally, graduated exposure to specific activities that a patient fears as being potentially painful or difficult to perform may be helpful. Box 17-2 summarizes the attitudes and types of behavior that may be associated with yellow flags.

Self-Report Measures

Several self-report measures provide useful information for the classification process and may also serve as useful indicators of the effectiveness of treatment. Three self-report measures are recommended: a pain diagram and pain rating scale, the FABQ, and a disability measure.

Modified oswestry disability questionnaire

The two most commonly used self-report disability scales are the Modified Oswestry Disability Questionnaire and the Roland Morris Questionnaire. We have used the Oswestry questionnaire for the purposes of staging patients and assessing the outcomes of treatment. The Oswestry questionnaire has 10 sections: 1 section for pain severity and the other 9 representing various functional activities ( Fig. 17-3 ). The patient indicates the degree of limitation in that activity because of LBP. Each section contains six responses, scored from 0 to 5. Each section score is summed to obtain the final score. The final score is then multiplied by 2, and the degree of disability is expressed as a percentage. Higher scores on the Oswestry questionnaire indicate greater levels of perceived disability. The Oswestry score can assist in staging the patient. Generally, patients in stage I will have Oswestry scores at or greater than 30%, and patients in stage II will have scores lower than 30%.

The Modified Oswestry Disability Questionnaire.

(Reprinted with permission from Fritz, J.M., and Irrgang, J.J. [2001]: A comparison of a Modified Owestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys. Ther., 81:776–788.)

Neurologic Assessment

Neurologic evaluation is required for any patient who has symptoms that extend below the buttock. The neurologic examination consists of four components: (1) strength of key muscles for each lumbar and sacral myotome, (2) sensation within dermatomes of the lower quarter, (3) deep tendon reflexes of the lower quarter, and (4) signs of neural tension. Results of the neurologic examination will determine whether signs of nerve root compression are present and need to be monitored throughout treatment. Results of the neurologic assessment may also provide prognostic information. Individuals with positive findings on the neurologic examination may be more likely to experience long-term pain and disability.

Neural tension tests

These tests are procedures designed to place tension on neural structures to assist in the diagnosis of nerve root compression that is typically caused by lumbar intervertebral disk herniation. Two different neural tension tests are used ( Fig. 17-4, A and B ).

A, Straight leg raise. The hip is passively flexed with the knee maintained in extension. The test is positive if the patient’s familiar leg symptoms are reproduced between 30° and 70° of hip flexion. B, Femoral nerve stretch. The knee and hip are passively flexed. The test is positive if the patient’s familiar anterior thigh symptoms are reproduced or intensified with these maneuvers.

Straight Leg Raise

A straight leg raise is used to place tension on the sciatic nerve to aid in diagnosis of the presence of nerve root compression of the lower lumbar nerve roots (L4-S1) (see Fig. 17-4, A ). The patient is prone and the lower extremity is raised by the clinician to the maximum tolerable level of hip flexion range of motion (ROM). The test must be performed passively and the patient’s knee maintained in full extension and the hip in neutral rotation. The opposite leg is kept in extension. For each test, the clinician notes any symptoms produced during the test and also the degree of hip flexion at which the symptoms are produced. A positive test result requires reproduction of the patient’s familiar leg symptoms between 30° and 70° of hip flexion. It is important to distinguish between reproduction of familiar symptoms and hamstring tightness.

Both the symptomatic and contralateral lower extremities are examined. A positive contralateral straight leg raise test result occurs when a straight leg raise of the asymptomatic lower extremity reproduces the symptoms in the symptomatic extremity. A positive contralateral straight leg raise test result is highly specific for lower lumbar disk herniation.

Femoral Nerve Stretch

Femoral nerve stretch is a neural tension test used to place tension on the femoral nerve to diagnose nerve root compression of the midlumbar nerve roots (L2-L4) (see Fig. 17-4, B ). The femoral nerve stretch is performed with the patient prone. The clinician first passively extends the patient’s hip and then passively flexes the knee. If the patient’s familiar anterior thigh symptoms are reproduced or intensified with these maneuvers, the test is considered positive. It is important to distinguish between reproduction of the patient’s familiar symptoms caused by tension on the femoral nerve and stretching of the rectus femoris muscle.

Examination for the Manipulation/Mobilization Classification

Patients who are most likely to respond to a manipulation/mobilization intervention are generally those with a more recent onset of symptoms and localization of the symptoms to the low back region, to the buttock, and possibly into the thigh. Patients with signs of nerve root compression (i.e., positive straight leg raise and strength tests, reflex, or sensory deficits) are likely to respond more favorably to an alternative treatment approach. Traditionally, classifying a patient for a manipulation/mobilization intervention has relied predominately on mobility assessments and special tests. Many of these diagnostic tests have been found to have poor reliability and questionable validity, ^{, ,} and therefore clinicians should be cautious about basing classification decisions on any one of these findings in isolation. Confirmatory findings from the physical examination are outlined later in this chapter.

Further examination of the sacroiliac region

Tests of Bony Landmark Symmetry

The clinician assesses the symmetry of the pelvic landmarks, including the posterior superior iliac spines (PSISs), anterior superior iliac spines (ASISs), and the iliac crests with the patient standing. The iliac crests are evaluated from the posterior aspect of the patient with the clinician’s hands at the pelvic level. The clinician judges the symmetry of the heights of the iliac crests. A difference between the right and left sides can indicate a leg length discrepancy, iliac rotation, or both. Asymmetry of the iliac crests must be correlated with the positional findings of the PSISs and ASISs. PSIS levels are determined by placing the tips of the index fingers directly beneath the inferior aspect of the PSIS on each side and visually comparing the height. The same procedure is used in comparing ASIS heights.

After each of the landmarks has been palpated, the results are compiled to arrive at one of three possible determinations:

• •
  

  Long leg: symmetrically increased height of the ASIS, PSIS, and iliac crest on one side

  
  
• •
  

  Innominate rotation: asymmetric heights of the ASISs, PSISs, and iliac crests (e.g., low PSIS on the right, high iliac crest on the right, and high ASIS on the right)

  
  
• •
  

  Normal: even pelvic landmarks while standing

PSIS levels are palpated in a similar manner with the patient sitting. Palpation of the ASISs is difficult with the patient seated and is not performed. Interpretation of the position of the PSISs with the patient sitting is correlated with the results of palpation in the standing position. Asymmetry that was present while standing and remains while sitting may indicate dysfunction in the SI region. If the asymmetry is eliminated by sitting, a leg length discrepancy should be suspected.

The Standing and Seated Flexion Tests

The clinician places the tips of the index fingers directly beneath the PSISs on both sides. The fingers are directed against the inferior margin of the PSISs with maintenance of upward pressure. The patient is instructed to bend forward as far as possible while the clinician continues to monitor the position of the PSISs and observes for symmetry of cranial movement of these bony landmarks ( Fig. 17-5, A ). Normally, the superior movement of each PSIS should be equal. A positive finding occurs when the cranial excursion of one PSIS is judged to be greater than the other. The side that moves further in a cranial direction is presumed to be the hypomobile side that requires manipulation/mobilization.

A, Standing flexion test. The clinician palpates the posterior superior iliac spines (PSISs) while the patient flexes forward. The test is positive if one PSIS moves further in a cranial direction. B, Gillet test. The clinician palpates the PSIS while the patient flexes the hip and knee. The test is positive if the PSIS does not move in a caudal direction. C, Gaenslen test. The clinician flexes the knee and hip and then applies overpressure. The test is positive if the patient’s familiar symptoms are reproduced.

The seated flexion test is performed and interpreted in an identical manner, except that the patient is seated. The clinician palpates the PSISs on both sides and the patient is then asked to flex forward while the clinician continues to monitor the position of the PSISs. If one PSIS is found to move further in a cranial direction than the other, the test is considered to be positive. The side that moves further in a cranial direction is presumed to be the hypomobile side.

Gillet Test

With the patient standing, the clinician places one thumb under the PSIS on the side being tested. The other thumb is placed in the midline over the S2 spinous process. The patient is instructed to stand on one leg and flex the hip and knee on the side being testing while bringing the leg toward the chest. The clinician continues to palpate the PSIS on the tested side. The test is considered to be positive if the PSIS fails to move posterior and inferior with respect to the S2 spinous process (see Fig. 17-5, B ).

Gaenslen Test

The Gaenslen test is a provocation test for dysfunction of the SI region. The patient is supine with both legs extended. The leg being tested is passively brought into full hip and knee flexion while the opposite hip is maintained in an extended position. Overpressure is applied by the clinician to the flexed extremity (see Fig. 17-5, C ). A positive test result occurs when the patient’s familiar symptoms are reproduced in either SI region with the application of the overpressure.

Further examination of the lumbar region

Lumbar Active Motion Assessment: The Movement Diagram

Active ROM is performed with the patient standing. In performing these procedures, the clinician needs to determine the ROM present in each direction, as well as the behavior of the patient’s symptoms during and immediately after the movement in question. The patient is asked to perform the following movements:

• •
  

  Side bending to the right and left

  
  
• •
  

  Extension

  
  
• •
  

  Forward bending

Reliable methods of measurement with a single inclinometer have been described for quantification of forward bending and extension. For ease of recording the ROM present and the location of symptoms, we have developed a movement diagram and a shorthand system to denote the effect of movements on the patient’s symptoms and to record the pattern of motion restriction present ( Fig. 17-6 ).

Lumbar movement diagram.

For the classification of manipulation/mobilization, the focus of active movement testing is on identification of a noncapsular pattern of movement restriction that may indicate the need for manipulation or mobilization of the lumbar spine. Noncapsular patterns in the lumbar region were characterized by Cyriax as occurring when a gross limitation in side bending is present in only one direction. Noncapsular patterns may be further distinguished as either opening or closing restrictions. A closing restriction theoretically occurs when side bending is limited toward the side of pain and extension is also limited. The movement diagram of a left closing restriction is shown in Figure 17-7 . An opening restriction is proposed to occur when the restricted motions are side bending away from the painful side and flexion. The movement diagram of a left opening restriction is shown in Figure 17-8 .

Movement diagram depicting a left closing pattern. (See Figure 17-6 for definitions.)

Movement diagram depicting a left opening restriction. (See Figure 17-6 for definitions.)

Passive Segmental Motion Testing

Passive segmental motion tests include both provocation and tests of mobility of the lumbar motion segments. The patient lies prone and the clinician places the hypothenar eminence over the spinous process of the vertebra to be tested. The contact point of the hand is just distal to the pisiform. When the clinician’s hand is positioned appropriately, the wrist and elbow are extended and gentle but firm anteriorly directed pressure is applied to the spinous process. The force is applied not by pushing with the arms but by allowing the body weight to be lowered. The patient is instructed to report any change in symptoms during performance of the test. The clinician also judges the mobility as normal, hypomobile, or hypermobile. The presence of hypomobile lumbar motion segments is an indication for a manipulation/mobilization classification.

Treatment for the Manipulation/Mobilization Classification

Although it has not been studied extensively, a few studies have found greater benefit from manipulative techniques than from mobilization of the lumbosacral region. ^, Patients in whom spondylolisthesis, lumbar instability, or osteoporosis has been diagnosed or with any concern for a stress fracture should be approached with caution, and manipulative techniques are generally contraindicated in these individuals. Many different manipulation and mobilization techniques have been described, but currently no evidence has shown the superiority of one approach over another. Correct identification of a patient who actually needs manipulation/mobilization interventions is probably more important than the particular technique chosen by the clinician. Several manipulation/mobilization techniques are described in Figure 17-9, A to D . After these interventions are applied, the patient should be instructed in non–weight-bearing active ROM exercises. They may be performed in the supine or quadruped positions. In the supine position, the patient is instructed to actively tilt the pelvis anteriorly and posteriorly to create motion in the lumbar spine. In the quadruped position, the patient can be asked to rock backward over the heels and forward over the hands to create lumbar flexion and extension, respectively.

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