An expert’s step-by-step guide to assessing persistent low back pain

Low back pain is a leading reason for general practitioner and physiotherapy visits. While some low back pain has a clear cause, often, there is no acute injury and the pain persists beyond the typical healing time-frame. When pain persists for more than three months and is non-specific (lacking a clear patho-anatomical cause), we refer to this as “persistent low back pain”. Assessing persistent low back pain requires a multifactorial approach, examining factors beyond back function, such as coping strategies and psychological risk factors. Our aim is to identify the top pain drivers to create a targeted management approach. In this blog we’ll walk through Dr. Kevin Wernli’s Practical on the assessment of persistent low back pain.

If you’d like to see exactly how expert physio Dr. Kevin Wenli assesses persistent low back pain, watch his full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

Subjective assessment

The subjective part of the exam includes understanding the patient’s story, defining their goals and expectations, assessing psychosocial risk factors, and screening for appropriate referrals.

Outcome measures

Measures such as the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) and Patient Specific Functional Scale (PSFS) can be useful to start with. The ÖMPSQ screens for risk factors related to long-term disability, while the PSFS assesses how well patients can engage in specific activities. These outcome measures can highlight areas which may require further investigation.

Pain experience

Pain is a multilayered experience, so we want to understand the patient’s experience, including the pain story, the onset of pain, and how pain impacts their day-to-day life. Our questions might include variations of the following:

• “Tell me your story” : Such open ended questions can uncover gems of information a patient might not otherwise share.
• “How did the pain start? What else was going on at the time?” : Sometimes we’ll find a clear trigger of pain, such as lifting awkwardly. But often there is no such trigger. In such cases, we need to inquire about concurrent risk factors such as poor sleep and high stress levels.
• “How is this pain impacting you now?” : A large part of the pain burden is the activities it stops you from doing. Thus we need to understand how pain has affected a patient’s life so we can prioritise our management plan.

Pain and psychosocial assessment

After understanding the patient’s general pain experience, we’ll assess their pain and psychosocial dynamics more closely. We’ll ask questions about:

• Pain location.
• Aggravating and easing factors.
• Beliefs about pain: We need to understand beliefs about the causes of pain and its long-term consequences.
• Pain coping strategies: This refers to how patients alter their behavior as a result of their back pain i.e. reducing, or perhaps avoiding activities altogether.
• Impact on emotional state: Persistent pain correlates with anxiety and depression in a likely bi-directional relationship.
• Social situation: Here we examine social connections, support, and social stressors (e.g. divorce).
• Work situation: This encompasses work postures, movement demands, and stressors.
• Lifestyle factors: Relevant lifestyle factors include sleep, diet, and self-care habits.

Screening

As with any back pain presentation, we must screen for red flag conditions such as cauda equina syndrome, cancer, infection, and other systemic causes of pain.

Goals and expectations

To wrap up the subjective, we ask the patient to share their goals and expectations of physiotherapy. What do they want to achieve? What sort of management strategy do they want? What is their recovery timeline?

We need to create alignment between the plan we provide and what they see as the best path forward. A common point of contention here is the use of manual therapy. Some patients may request manual therapy. As a physiotherapist, part of our craft is knowing when and how to educate. While manual therapy should not be the sole solution to a patient’s persistent pain, we lose rapport if we abruptly negate such a request from a patient. Manual therapy can be a useful tool for pain relief, however active management strategies should be prioritised. It’s important to balance your management plan with these factors in mind.

Objective assessment

The objective portion of a persistent low back pain exam should include subjective examination principles. While we examine various movements and postures, we also ask the patients about their beliefs and what they are experiencing during such movements (e.g. “This feels unsafe”, “my back is locking up”). During the objective exam, we can also start the education process with “behavioral experiments”, where we have the patient move in different ways and assess how that changes their pain experience.

Seated assessment

We first examine sitting posture, looking for major left-right asymmetries, compensatory strategies (e.g. Maintaining a stiff, erect posture), and breathing patterns (e.g. Excessive upper chest expansion). In the below video taken from his full Practical, Dr. Wernli shows us how he blends the seated assessment with patient education:

Sit-to-stand assessment

The sit to stand is a crucial functional task that many patients struggle with. We are looking for how they perform the movement; do they need to push off with their hands? Do they try to stay upright? Is the patient’s weight evenly distributed through their lower extremities? Watch Dr. Wernli demonstrate how he assesses a sit-to-stand in this snippet from his Practical:

If appropriate, we can also assess a modified single leg squat in which the patient will have one leg extended out front for support, as the stance leg powers the movement. We are looking at both the movement quality, and the load capacity of each leg, as well as asking questions about symptoms.

Standing assessment

As with sitting, we start with our standing examination by simply observing posture, looking for symmetric weight distribution, compensatory strategies, and pain levels. Then we’ll get into a basic Range Of Motion (ROM) assessment including flexion, extension, lateral flexion, and rotation. We are measuring ROM, as well as the patient’s symptoms during these movements.

Neurological assessment and special tests

With all back pain patients it is important to perform a basic neurological screen, assessing myotomes, reflexes, and sensation. We can also examine neural sensitivity with assessments like the slump and straight leg raise.

Walking and lifting assessment

When examining walking, we look for major deviations such as asymmetric gait patterns and decreased arm swing. Bending and lifting assessment can be a progression from the flexion ROM assessment by having the patient lift a real load. See the below excerpt from his Practical in which Dr. Wernli demonstrates his assessment of a lifting task:

Wrapping up

Assessing persistent low back pain requires a multifactorial approach, including examining potential pain drivers and how a patient moves. Such assessments usually require more open ended conversation, as we are looking for influences such as psychosocial risk factors and behavioral coping strategies. We also want to understand what matters most to our patients, to ensure our management approach is engaging and meaningful to them.

For a step-by-step walk-through on assessing persistent low back pain check out expert physio Dr. Wernli’s full Practical HERE.