A Diagnostic Approach

Lower Back Pain

Ruling out Red Flags

Questions asked in the subjective portion of examinations can help raise suspicions towards causes of back pain that may be more indicative of a more serious condition or visceral disorder:

Question: Examples of condition to Differentially Diagnose:

Tingling/numbness in legs and especially in the groin: Cauda equina

Any positional relief? No: Infection/Cancer

Abdominal Pain/gassiness/belching. Visceral or GI related pain
Does your pain change after eating?

Are you generally stiff in the a.m. All over – spondyloarthropathy or inflammatory arthritides

Have you had blood in the urine? Genitourinary

Fever or chills? Generally filling ill? Constitutional

Unexplained weight loss? Cancer

Pregnancy Related: bleeding, spotting, Ectopic pregnancy or similar process
bouts of diarrhea unusual discharge?

Assessment of Pain

Once red flag warnings have been ruled out, the specific cause of mechanical back pain can be addressed. The following tissues and structures are the main causes of back pain:

Disc Pain (Centralization signs are detected in the examination.): The examination process involves moving the spine in different directions and monitoring the patient’s symptomatic response to these movements. Confirmation is indicated as pain decreases and centers towards the spine. This approach is known as the McKenzie Method. The McKenzie Method is a philosophy of active patient involvement and education for back, neck and extremity problems. (May & Donelson. Spine J 2008; 8(1) 134-41)

Spinal Joint Pain (Segmental Provocation):
Facet pain localized to the facet joint with referral into buttocks, possibly to above the knee and rarely into the calf. Patients are more likely to be over 50 years old, although it is commonly seen in those under 50 as well. Pain is better with walking and sitting. Patients report that when the pain started it was primarily paraspinal and typically remains in this area. Lumbar extension is not painful until rotation in either direction is added at which point the pain is reproduced. (Laslett et al., Spine J 2006; 6(4):370-9)
SI joints – Pain is rarely at L5 or above and does not typically go below the knee. SI pain is provoked with a sit to stand position (this is also true with disc pain). SI Provocation tests duplicate the patient’s pain. (Laslett et al., Man Ther 2005;10:207-18)

Radiculopathy (Neurodynamic Signs): While sensitive the Straight Leg Raise orthopedic test is not necessarily specific. (Lurie J., Best Prac Res Clin Rheumatol 2005;19(4): 557-75). Localizing stretching maneuvers help increase tension on the nerve, which increases pain helping confirm the presence of radiculopathy. (Boyd et al.., J Orthop Sports Phys Ther 2009;39(11):780-90)(Herrington L et al. Man Ther. 2008;13(4)289-94)

Myofascial Pain (Trigger Points): Often secondary to one of the above disorders, trigger points can be located by palpation in which a nodular or taut band within the muscle is located and is painful with applied pressure. (Simons DG. State-of-the-Art Research (STAR) Perspectives on Musculoskeletal Disorder Causation & Control;2003, Columbus, OH)

Perpetuating Factors

To ensure optimal treatment outcomes perpetuating pain factors must be identified and addressed:

Dynamic Instability – Refers to an impairment in the stabilizing muscles of the spine. When instability is detected, the spine is unable to protect itself against daily perturbations. To identify dynamic instability, chiropractors utilize orthopedic maneuvers and functional testing. Correction includes spine specific exercises that patients are encouraged to perform independently of the clinical setting. (1,2,3)

Central Pain Hypersensitivity – A central nervous system processing disorder in which the pain receptors (nociceptors) amplify and enhance the pain experience. Patients exhibit pain that is out of proportion with what is occurring. Waddel’s non organic signs while often misinterpreted as malingering, can help identify central pain hypersensitivity. (4)

Psychological Factors – Also CNS mediated, the psychological component of spine pain is often poorly understood and appreciated. Depression, Catastrophizing, Passive Coping, Fear Avoidance and Poor Self Efficacy are commonly associated with spine patients.

Various questionnaires can help quantify psychological factors. This important feedback is utilized as an outcome assessment tool to help monitor a patient’s clinical progression. (5,6,7,8,9)

1. Murphy et al., J Manip Physiol Ther. 2006;29(5):374-7
2. Hicks GE et al., Arch Phys Med Rehabil 2003;84:1858-64
3. Mens JMA, et al. Spine 2001; 26 (10): 1167-71
4. Fishbain DA et al., Pain Med 2003; 4(2):141-81
5. Severigns R et al., Clin J Pain. 2001 (17)2:165-72
6. Swinkels-Meewisse IEJ et al.,Spine 2006;31(6):658-64
7. Woby SR et al., Eur J Pain. 2004;8(3):201-10
8. Vlaeyen JWS., et al. Pain. 1995:62:363-72
9. Murphy, Hurwitz. Poster Amer Academy Pain Mgmt. 2010