1. What is the patient’s age?29 Different conditions affect patients at different ages. For example, disc problems usually occur between the ages of 15 and 40 years, and ankylosing spondylitis is evident between 18 and 45 years. Osteoarthritis and spondylosis are more evident in people older than 45 years of age, and malignancy of the spine is most common in people older than 50 years of age.

2. What is the patient’s occupation?3,30 Back pain tends to be more prevalent in people with strenuous occupations,³¹ although it has been reported that familial influences have an effect as well as occupation.^32,33 For example, truck drivers (vibration) and warehouse workers have a high incidence of back injury.³⁴ Patients who have chronic low back pain develop a deconditioning syndrome, which compounds the problem as it leads to decreased muscle strength, impaired motor control, and decreased coordination and postural control.³⁵ How active is the patient at work (usual job, light duties, full time, frequent days off because of back pain, unemployed because of back, retired)?

3. What is the patient’s sex? Lower back pain has a higher incidence in women. Female patients should be asked about any changes that occur with menstruation, such as altered pain patterns, irregular menses, and swelling of the abdomen or breasts. Has the patient ever been diagnosed with osteoporosis? Knowledge of the date of the most recent pelvic examination is also useful. Ankylosing spondylitis is more common in men.

4. What was the mechanism of injury? Was major trauma (e.g., car accident) involved? Lifting commonly causes low back pain (Tables 9-3 and 9-4). This is not surprising when one considers the forces exerted on the lumbar spine and disc. For example, a 77-kg (170-lb) man lifting a 91-kg (200-lb) weight approximately 36 cm (14 inches) from the intervertebral disc exerts a force of 940 kg (2072 lbs) on that disc. The force exerted on the disc can be calculated as roughly ten times the weight being lifted. Pressure on the intervertebral discs varies depending on the position of the spine. Nachemson and colleagues showed that pressure on the disc can be decreased by increasing the supported inclination of the back rest (e.g., an angle of 130° decreases the pressure on the disc by 50%).^21,22 Using the arms for support can also decrease the pressure on the disc. When one is standing, the disc pressure is approximately 35% of the pressure that occurs in the relaxed sitting position. The examiner should also keep in mind that stress on the lower back tends to be 15% to 20% higher in men than in women because men are taller and their weight is distributed higher in the body.

5. How long has the problem bothered the patient? Acute back pain lasts 3 to 4 weeks. Subacute back pain lasts up to 12 weeks. Chronic pain is anything longer than 3 months. Waddell has outlined predictors (yellow flags) of chronicity with back pain patients.3,36

6. Where are the sites and boundaries of pain? Have the patient point to the location or locations. Note whether the patient indicates a specific joint or whether the pain is more general. The more specific the pain, the easier it is to localize the area of pathology. Unilateral pain with no referral below the knee may be caused by injury to muscles (strain) or ligaments (sprain), the facet joint, or, in some cases, the sacroiliac joints. This is called mechanical low back pain (in older books it is called “lumbago”). With each of these injuries, there is seldom if ever peripheralization of the symptoms. The symptoms tend to stay centralized in the back. If the muscles and ligaments are affected, movement will decrease and pain will increase with repeated movements. If the pain extends to the hip, the hip must be cleared by examination. With facet joint problems, the range of motion (ROM) remains the same (it may be restricted from the beginning), as does the pain with repeated movements. Pain on standing that improves with walking and pain on forward flexion with no substantial muscle tenderness suggests disc involvement.37 The sacroiliac joints will show pain when pain-provoking (stress) tests are used. A minor disc injury (protrusion) may show the same symptoms, but the pain is more likely to be bilateral if it is a central protrusion.³⁸

7. Is there any radiation of pain? Is the pain centralizing or peripheralizing (Figure 9-12)?^39,40 Centralization implies the pain is moving toward or is centered in the lumbar spine.^41–43 Peripheralization implies the pain is being referred or is moving into the limb. If so, it is helpful for the examiner to remember and correlate this information with dermatome findings when evaluating sensation. The examiner must be careful when looking at the lumbar spine that he or she does not consider every back problem a disc problem. It has been reported that disc problems account for only about 5% of low back pain cases.⁴⁴ Some authors feel the only definitive clinical diagnosis of a disc problem is neurological pain extending below the knee.²⁵ This means that although there may be pain in the back and in the leg, the leg pain is dominant.³ Pain on the anterolateral aspect of the leg is highly suggestive of L4 disc problems, whereas pain radiating to the posterior aspect of the foot suggests L5 disc problems if the history indicates a disc may be injured.⁴⁵ Pain radiating into the leg below the knee is highly suggestive of a disc lesion, but isolated back or buttock pain does not rule out the disc. Minor injuries, such as protrusion of the disc, may result only in back or buttock pain.⁴⁵ Such an injury makes diagnoses more difficult because such pain may also result from muscle or ligament injury or from injury or degeneration to the adjacent facet joints.
Lumbar and sacroiliac pain tend to be referred to the buttock and posterior leg (and sometimes to the lateral aspect of the leg). Hip pain tends to be in the groin and anterior thigh although it may be referred to the knee (usually medial side). The hip can be ruled out later in the examination by the absence of a hip capsular pattern and a negative sign of the buttock.46 The examiner must also determine whether the musculoskeletal system is involved or whether the pain is being referred from another structure or system (e.g., abdominal organs). Abnormal signs and symptoms or red flags (see Table 1-1) would lead the examiner to consider causes other than the musculoskeletal system.

8. Is the pain deep? Superficial? Shooting? Burning? Aching? Questions related to the depth and type of pain often help to locate the structure injured and the source of pain.

9. Is the pain improving? Worsening? Staying the same? The answers to these questions indicate whether the condition is settling down and improving, or they may indicate that the condition is in the inflammation phase (acute) or in the healing phase. Does the patient complain of more pain than the injury would suggest should occur? If so, psychosocial testing may be appropriate.

10. Is there any increase in pain with coughing? Sneezing? Deep breathing? Laughing? All of these actions increase the intrathecal pressure (the pressure inside the covering of the spinal cord) and would indicate the problem is in the lumbar spine and affecting the neurological tissue.

11. Are there any postures or actions that specifically increase or decrease the pain or cause difficulty?39,47 For example, if sitting increases the pain and other symptoms, the examiner may suspect that sustained flexion is causing mechanical deformation of the spine or increasing the intradiscal pressure.⁴⁸ Classically, disc pathology causes increased pain on sitting, lifting, twisting, and bending.⁴⁹ It is the most common space-occupying lesion in the lumbar spine and, therefore, is the most common cause of radiating pain below the knee. If standing increases the pain and other symptoms, the examiner may suspect that extension, especially relaxed standing, is the cause. If walking increases the pain and other symptoms, extension is probably causing the mechanical deformation, because walking accentuates extension. If lying (especially prone lying) increases the pain and other symptoms, extension may be the cause. Persistent pain or progressive increases in pain while the patient is in the supine position may lead the examiner to suspect neurogenic or space-occupying lesions, such as an infection, swelling, or tumor. Remember that pain may radiate to the lumbar spine from pathological conditions in other areas as well as from direct mechanical problems. For example, tumors of the pancreas refer pain to the low back. Stiffness or pain after rest may indicate ankylosing spondylitis or Scheuermann disease. Pain from mechanical breakdown tends to increase with activity and decrease with rest. Discogenic pain increases if the patient maintains a single posture (especially flexion) for a long period. Pain arising from the spine almost always is influenced by posture and movement.
The pelvis is the key to proper back posture. Ideally, an individual should be able to stand with the pelvis in neutral. In this position, the anterior superior iliac spines (ASISs) are one to two finger widths lower than the posterior superior iliac spines (PSISs). For the pelvis to “sit” properly on the femora, the abdominal, hip flexor, hip extensor, and back extensor muscles must be strong, supple, and “balanced” (Figure 9-13). Any deviation in the normal alignment should be noted and recorded. For example, shoe heel height can modify the pelvic angle and lumbar curve, altering the stress on the spine.⁵⁰

12. Is the pain worse in the morning or evening? Does the pain get better or worse as the day progresses? Does the pain wake you up at night? For example, osteoarthritis of the facet joints leads to morning stiffness, which in turn is relieved by activity.

13. Which movements hurt? Which movements are stiff? Table 9-5 demonstrates some of the causes of mechanical low back pain and their symptoms. The examiner must help the patient differentiate between true pain and discomfort that is caused by stretching. Postural, or static, muscles (e.g., iliopsoas) tend to respond to pathology with tightness in the form of spasm or adaptive shortening; dynamic, or phasic, muscles (e.g., abdominals) tend to respond with atrophy. Pathology affecting both types of muscles can lead to a pelvic crossed syndrome (discussed later). Does the patient describe a painful arc of movement on forward or side flexion? If so, it may indicate a disc protrusion with a nerve root riding over the bulge or instability in part of the ROM.⁴⁷ Patients with lumbar instability or lumbar muscle spasm have trouble moving to the seated position, whereas patients with discogenic pain usually have pain in flexion (e.g., sitting) and the pain may increase the longer they are seated.

14. Is paresthesia (a “pins and needles” feeling) or anesthesia present? A patient may experience a sensation or a lack of sensation if there is pressure on a nerve root. Paresthesia occurs if pressure is relieved from a nerve trunk, whereas if the pressure is on the nerve trunk, the patient experiences a numb sensation. Does the patient experience any paresthesia or tingling and numbness in the extremities, perineal (saddle) area, or pelvic area? Abnormal sensations in the perineal area often have associated micturition (urination) problems. These symptoms may indicate a myelopathy and are considered by many to be an emergency surgical situation because of potential long-term bowel and bladder problems if the pressure on the spinal cord is not relieved as soon as possible.51,52 The examiner must remember that the adult spinal cord ends at the bottom of the L1 vertebra and becomes the cauda equina within the spinal column. The nerve roots extend in such a way that it is rare for the disc to pinch on the nerve root of the same level. For example, the L5 nerve root is more likely to be compressed by the L4 intervertebral disc than by the L5 intervertebral disc (Figure 9-14). Seldom is the nerve root compressed by the disc at the same level, except when the protrusion is more lateral.

15. Has the patient noticed any weakness or decrease in strength? Has the patient noticed that his/her legs have become weak while walking or climbing stairs? This may be the result of an injury to the muscles themselves, their nerve supply, or reflex inhibition caused by pain.28,53

16. What is the patient’s usual activity or pastime? Before the injury, did the patient modify or perform any unusual repetitive or high-stress activity? Such questions help the examiner determine whether the cause of injury was macrotrauma, microtrauma, or a combination of both.

17. Which activities aggravate the pain? Is there anything in the patient’s lifestyle that increases the pain? Many common positions assumed by patients are similar to those in some of the provocative special tests. For example, getting into and sitting in a car is similar to the slump test and straight leg raise test. Long sitting in bed is a form of straight leg raise. Reaching up into a cupboard can be similar to an upper limb tension test. A word of caution: There can be a 10° to 20° difference in straight leg raise in lying and sitting because of the change in lordosis and position of the pelvis.3

18. Which activities ease the pain? If there are positions that relieve the pain, the examiner should use an understanding of anatomy to determine which tissues would have stress taken off them in the pain-relieving postures, and these postures may later be used as resting postures during the treatment.

19. What is the patient’s sleeping position? Does the patient have any problems sleeping? What type of mattress does the patient use (hard, soft)? The best sleeping position is in side lying with the legs bent in a semifetal position. If the patient lies prone, the lumbar spine often falls into extension increasing the stress on the posterior elements of the vertebrae. In supine lying, the spine tends to flatten out, decreasing the stress on the posterior elements.

20. Does the patient have any difficulty with micturition? If so, the examiner should proceed with caution, because the condition may involve more than the lumbar spine (e.g., a myelopathy, cauda equina syndrome, tabes dorsalis, tumor, multiple sclerosis). Conversely, these symptoms may result from a disc protrusion or spinal stenosis with minimal or no back pain or sciatica. A disc derangement can cause total urinary retention; chronic, longstanding partial retention; vesicular irritability; or the loss of desire or awareness of the necessity to void.

21. Are there any red flags that the examiner should be aware of, such as a history of cancer, sudden weight loss for no apparent reason, immunosuppressive disorder, infection, fever, or bilateral leg weakness?

22. Is the patient receiving any medication? For example, the long-term use of steroid therapy can lead to osteoporosis. Also, if the patient has taken medication just before the assessment, the examiner may not get a true reading of the pain.

23. Is the patient able to cope during daily activities? Psychosocial issues often play a role in low back pain, especially if it is chronic.54–57 It is normal for people suffering prolonged pain to exhibit altered psychosocial behaviors that are subject to wide individual differences and the effects of learning.⁵⁸ Fear avoidance questionnaires, especially Waddell, et al.,⁵⁹ Fear-Avoidance Beliefs Questionnaire (FABQ) (Figure 9-15) and Linton and Hallden’s Acute Low Back Pain Screening Questionnaire⁶⁰ (Figure 9-16), are becoming more commonly used in lumbar examination.^61–67 The New Zealand Acute Low Back Pain Guide outlines yellow flags indicating psychosocial barriers for recovery with questions related to attitudes and beliefs about back pain, behavior, compensation issues, diagnosis and treatment, emotions, family and work.⁵⁸ These yellow flags should be seen as factors that can be influenced positively to facilitate recovery and reduce work loss and long term disability.⁵⁸ Haggman, et al.⁶⁸ felt that two questions were particularly significant to ask the patient to screen for depressive symptoms:1) “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and 2) “During the past month, have you been bothered by little interest or pleasure in doing things?”^37,69 If the answers to these questions are positive, the patient should be monitored closely and if progress does not occur, then further psychological follow-ups should be considered.⁷⁰ Does the patient have trouble with work, leisure activities, washing, or dressing? How far can the patient walk before the pain begins?⁷¹ What is the patient’s level of disability? Disability implies the effect of the pathology on activity, not pain. Thus, disability testing commonly revolves around activities of daily living (ADLs) and functional activities. Thus, this question may be tied in with the use of the questions in the functional assessment discussed later.

Finally, the examiner must be aware that although in most cases, people who have low back pain have simple mechanical back problems or have nerve root problems involving the disc, there is always the possibility of nonmusculoskeletal causes (e.g., kidney stones, abdominal aortic aneurysm, pancreatic problems) or serious spinal pathology (e.g., tumors).23,37 Waddell outlined signs and symptoms that would lead the examiner to conclude that more serious pathology is present in the lumbar spine (Table 9-6).³