From the Guidelines
The initial physical exam approach for a patient presenting with lower back pain should include a focused history and physical examination to categorize the patient into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. This approach is supported by the American College of Physicians and the American Pain Society, as outlined in their joint clinical practice guideline 1.
Key Components of the Physical Exam
The physical exam should include:
- Inspection of the spine for deformities
- Palpation for tenderness or muscle spasm
- Assessment of range of motion in all directions (flexion, extension, lateral bending, and rotation)
- Neurological examination, including testing of strength in major muscle groups of the lower extremities, deep tendon reflexes (patellar and Achilles), sensation in dermatomes, and special tests like straight leg raise to assess for nerve root irritation
- Specific provocative maneuvers such as FABER (Flexion, Abduction, External Rotation) test to evaluate sacroiliac joint involvement and percussion of the spine to check for vertebral tenderness
Importance of Red Flags
It is essential to assess for red flags that might indicate serious pathology, such as fever, unexplained weight loss, saddle anesthesia, or bowel/bladder dysfunction, which would necessitate urgent evaluation 1. The presence of these red flags would guide the clinician to perform diagnostic imaging and testing, as recommended by the guideline 1.
Guiding Management Decisions
This systematic approach helps differentiate between mechanical back pain, radiculopathy, spinal stenosis, or more serious conditions requiring immediate intervention, allowing for appropriate management decisions based on physical findings. The guideline recommends that clinicians should provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options 1.
From the Research
Initial Physical Exam Approach
The initial physical exam approach for a patient presenting with lower back pain involves a thorough and conscientious examination to identify the cause of pain and to rule out any serious conditions.
- The 'look, move, feel' paradigm of clinical orthopaedic examination can be used as a simple and effective approach in general practice 2.
- Postural assessment can help identify risk factors for low back pain and determine appropriate follow-up treatment 3.
- The examination process, including history taking and physical examination, can have a therapeutic effect on pain and function, with significant reductions in pain reported after history taking and physical exam 4.
Key Components of the Physical Exam
The physical exam should include:
- Observation of the patient's posture and movement patterns
- Palpation of the lower back and surrounding muscles to identify areas of tenderness
- Assessment of range of motion and flexibility
- Evaluation of neurological function, including sensation, strength, and reflexes
- Special tests, such as the straight leg raise test, to assess for radicular pain
Importance of the Physical Exam
The physical exam is an essential part of the initial evaluation of a patient with lower back pain, as it can help:
- Identify the cause of pain and rule out serious conditions
- Develop an effective treatment plan
- Monitor progress and adjust treatment as needed
- The physical exam can also have a therapeutic effect on pain and function, and can help establish a connection between the patient and the healthcare provider 4.
Additional Considerations
For patients with radicular leg symptoms, a more detailed evaluation, including diagnostic testing, may be necessary to identify the underlying cause of pain 5, 6.
- For patients without significant neurological impairment, initial treatments should include activity modification, nonnarcotic analgesics, and education 5.