Making Sense of

Abstract

In 1987, the Quebec Taskforce noted, “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Identify- ing these patterns begins with the patient’s history: “Where is your pain the worst?” “Is your pain constant or intermittent?” “Has there been any change in your bowel or bladder function?” This questioning establishes the mechanical nature of the pain, and a physical

examination verifies or refutes the pattern established in the history. The examination involves two essential tests to detect upper motor and low sacral root involvement. A fail- ure of the results to fit into one of four syndromes—two back dominant and two leg domi- nant—suggests a non-mechanical or more complex problem.

Key words: patterns of back pain, pain location, pain characteristics, history,

ost patients complaining of grounded in a medical paradigm that low back pain experience emphasizes the serious but uncom- Msymptoms from a minor mon causes of back pain, most physi- mechanical malfunction. Fewer than cians hesitate to offer reassurance. 5% have a more sinister explana- Given the relative rarity of back pain tion such as inflammatory disease, resulting from a systemic illness or infection, or malignancy.1,2 Faced grave local pathology, investigat- with a patient in acute distress and ing all patients with back pain for a

About the Authors

Yoga Raja Rampersaud, MD, FRCSC, Associate Julia Alleyne, BHSc Professor Department (PT), MD, CCFP, Dip. of Surgery, University of Hamilton Hall, MD, Sport Med MScCH, Toronto, Divisions of Ortho- FRCSC; Professor, Depart- Associate Professor, paedic and Neurosurgery, ment of Surgery, Univer- Department of Family and University Health Network sity of Toronto; Medical Community Medicine, Medical Director, Back and Director, Canadian Back University of Toronto, Neck Specialty Program, Institute; Executive Medical Director, Sport Altum Health, Immediate Director, Canadian Spine CARE, Women’s College Past President Canadian Society, Toronto, ON. Hospital, Toronto, ON. Spine Society, Toronto, ON.

12 Journal of Current Clinical Care Educational Supplement • January 2013 Making Sense of Low Back Pain

range of inflammatory back diseases failure to distinguish a clear pattern (spondyloarthropathies), for exam- or failure of a syndrome to improve ple, will generate unnecessary con- with the specified therapy demands cern, add unjustified expense, and reassessment, including a review of give minimal return for the effort. the symptoms, additional physical Yet these potentially significant diag- tests, and, perhaps, ancillary investi- noses must not be missed; no one gations.3,4,7–11 wants to be guilty of overlooking a In the example of spondyloar- spinal metastasis.3,4 thropathy, the patient who lacks a There is another way. In 1987, clear-cut mechanical presentation or the Quebec Taskforce noted, “Dis- who continues to experience sig- tinct patterns of reliable clinical nificant symptoms after four weeks findings are the only logical basis of suitable care demands particular for back pain categorization and observation.3,4,7–11 The filtering out subsequent treatment.”5 The use of those patients with low back pain of syndromes in the initial assess- who have been accurately identified ment of back pain is gaining renewed and successfully managed (over 90% interest and clinical acceptance. It of the total) greatly increases the avoids many of the pitfalls of the probability of discovering potentially conventional medical model, which menacing non-mechanical diagnoses requires obtaining a patho-anatomi- among the remainder. Syndrome cal diagnosis before proceeding with recognition is a rapid, reliable, management.6 The use of syndromes and efficient triage technique that allows the great majority of patients increases diagnostic accuracy, ena- with back pain to be sorted into four bles patient-specific management, clearly defined groups that have rec- and decreases needless investiga- ognizable mechanical characteristics, tions. and it sets apart the much smaller number who present with atypical, The History possibly ominous symptoms. Identifying the pattern begins with a A syndrome can be defined as a concise history, which starts with two constellation of signs and symptoms questions: “Where is your pain the Key Point that appear together in a consistent worst?” and “Is your pain constant or manner and respond in a predict- intermittent?” Two of the syndromes The use of able fashion. With low back pain, the are back dominant, with the pain felt syndromes key is to identify the correct pat- most intensely in the low back, in the in the initial tern.6 This identification depends buttocks, or over the outer aspects of the assessment on a precise history and a concord- hips. The other two syndromes exhibit of back pain ant physical examination. The third leg dominant pain, where the symptoms is gaining component of the process is the are worst around and below the inferior renewed anticipated positive response. A gluteal fold: in the thigh, calf, or foot. interest mechanical syndrome will respond to Patients frequently have pain in both the and clinical the appropriate mechanical therapy back and leg; but with careful question- acceptance. within weeks, often within days. The ing, it is possible to determine which site

Journal of Current Clinical Care Educational Supplement • January 2013 13 PMhthaakinglate Sens inse 5-ofA Lmowino Bsackalicy Plainates

predominates. This can be challenging, about relying so heavily on the his- but distinguishing the site of dominant tory and physical examination. pain is essential for pattern recognition. The third mandatory ques- Axial (back dominant) pain arises from tion is, “Since the start of your back trouble, has there been any change in your bowel or bladder function?” Determining if the pain is constant or Rather than initially searching for a detailed description, the query is intermittent can be equally or more deliberately vague in nature. Speci- difficult. fying changes only since the start of the attack avoids unnecessary worry about previous, unrelated a spinal structure but may have accom- disorders. A report of “no change” panying referred pain into the leg. When removes the necessity to go further. forced to choose, patients with axial Any positive response requires a pain will acknowledge that the back pain more thorough investigation. Uri- is worse. Radicular (leg dominant) pain nary retention followed by insen- indicates direct nerve root involvement sible, uncontrolled overflow and in addition to the mechanical malfunc- fecal incontinence is indicative of tion. Again, patients often report pain an acute cauda equina syndrome: a in the back as well as in the leg; but for surgical emergency.3,12 those with radicular pain, leg pain below Five remaining questions com- the buttock will be the chief complaint. plete the clinical picture and estab- Determining if the pain is con- lish a link to the past history and the stant or intermittent can be equally level of present disability: or more difficult. Most patients who endure prolonged discomfort 1. “What are the aggravating Key Point describe their symptoms as con- movements or positions?” stant. The inquiry, therefore, must 2. “What are the relieving Syndrome be clear and specific. It is best asked movements or positions?” recognition in two parts: “Is there ever a time 3. “Have you had this same is a rapid, in the day when your pain stops, pain before?” reliable, and for a brief moment, even though it 4. “What treatment have you efficient triage quickly returns?” and “When your had in the past, and did it technique pain stops, does it disappear com- work?” that increases pletely? Are you then totally free of 5. “What can’t you do now diagnostic pain?” Truly intermittent back domi- that you could do before accuracy, nant pain is never the result of spi- you had the pain?” enables nal malignancy or an infection. The patient-specific power of these questions, properly Mechanical back pain is responsive management, asked and answered, is enormous. to movement and position. Discover- and decreases They can eliminate the chance of the ing the aggravating and relieving fac- needless clinician missing a sinister pathol- tors helps identify the syndrome and investigations. ogy, one of the commonest concerns suggests a pain control strategy. Back

14 Journal of Current Clinical Care Educational Supplement • January 2013 The Patient with NewlyMaking Diagnose Sensde Uoflcera Lowt Biveack Coli Paintis

pain is a recurrent complaint that Straight leg raising is a meas- tends to worsen with time.13 In a sur- ure of sciatic nerve root irritation vey of patients seeking care, over half (L4, L5, S1, S2). Lift the supine had suffered more than 10 attacks patient’s leg while the patient’s knee and over 60% believed that their present attack was, in at least one respect, worse than the preceding The production of back pain with one.14 The degree of physical limita- tion and the value of past therapies straight leg raising merely reflects influence the current choices. the mechanical problem; it is not a The Physical Examination positive test. The history defines the syndrome. But the history must be supported by a con- is extended. To minimize hamstring cordant physical examination. The back tightness and a possible misinterpre- examination is not an independent event. tation of the results, the contralat- Its components are chosen in response to eral hip and knee should be flexed. the patient’s story, and its goal is to verify If positive, the test aggravates the or refute the diagnostic assumptions patient’s typical leg dominant pain. made on the basis of the history. The production of back pain is not Your examination begins with relevant and merely reflects the observation including their gait, underlying mechanical difficulty. The posture and preferred position in test results are positive when straight the office. The patient’s general leg raising causes the typical leg behaviour and level of activity should pain, no matter the degree of eleva- correspond to what has already been tion. Obviously, pain when lifting described. Look at the contour of the leg 30 degrees is more clinically the spine; note any discoloration or significant than pain occurring at 80 scars. is not diagnostic. It degrees, but both constitute a posi- can locate areas of tenderness unre- tive result. Although the test should lated to any local pathology that may be performed on every patient, it can mislead the examiner. be positive only in someone with a Having the patient bend for- true history of leg dominant pain. Key Point ward and backward to reproduce A significant but fortunately the typical back pain, described in rare finding with straight leg rais- A concise the history, usually confirms the ing is the “crossover” sign. When history starts syndrome. The other spinal move- the affected leg is passively elevated, with two ments are assessed as dictated by the the patient feels not only the antici- questions: patient’s functional requirements. pated increase in the typical pain “Where is your pain the Note whether there is a break in in the elevated leg but also pain the normal rhythm of movement. radiating into the other leg as well. worst?” and Recording the range of movement Lifting one leg produces bilateral “Is your pain is of little value in an isolated back symptoms. This crossing over of the constant or examination. pain from one to both sides sug- intermittent?”

Journal of Current Clinical Care Educational Supplement • January 2013 15 MTheaking Pat ienSent swie ofth LNowewly Back Diagnose Pain d Ulcerative Colitis

Figure 1: Physical Examination to Assess Low Back Pain Standing Extension Normal Abnormal Observation Movement to Reproduce Pain

Hip Abduction (Trendelenburg) Test (L5 Nerve Root Conduction)

Flexion

Gait

Toe Walking Test Heel Walking Test (S1 Nerve Root Conduction) (L4-L5 Nerve Root Conduction)

* 5 steps at maximum elevation

Sitting Great Toe Great Toe Flexion Test Extension Test (S1 Nerve Root (L5 Nerve Root Conduction) Conduction)

Normal Abnormal Ankle Dorsi exion Test (L4 and L5 Nerve Root Conduction)

Upper Motor Test

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Kneeling Lying Supine

Straight Leg Raise Test (Sciatic Nerve Root Irritation)

Ankle Re‰ex Test (S1 Nerve Root Conduction)

Saddle Sensation Test (Lower Sacral Nerve Roots)

Lying Prone

Femoral Stretch Test Hip Extension Test (Femoral Nerve Root Irritation) (Palpate Gluteus Maximus Tone) (S1 Nerve Root Conduction)

Classication of Mechanical Patterns of Low Back Pain

Reported Pain ConstancyPain Improved Pain Worsened Neurological Pain Pain Location Findings Origin

1 Back, buttocks Constant or One of 2 cohorts will Forward exion, Normal Most likely or around hips intermittent improve on extension one of the 2 cohorts’ discogenic pain also worsens on extension 2 Back dominant Intermittent Una ected or may be Worsens on extension Normal Most likely improved on exion posterior spinal elements 3 Leg dominant Constant By immobility and By all back movement, Positive Sciatic (or recumbent rest usually more by irritative test occasionally exion and/or femoral) nerve conduction loss root irritation 4 Leg dominant Intermittent Relieved by rest in Activity in extension May have Neurogenic exion (sitting) (walking) positive claudication, conduction test; often mislabelled no irritative test. spinal stenosis

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gests nerve root irritation from a it makes sense to screen L5 and S1 centrally placed intrusion. A central functions as part of the examination. disc herniation can compress the Motor testing is preferred. Once lost, sacral roots controlling bowel and reflexes may not return, and slight variations can give an erroneous pic- ture of the current problem. Sensory Every low back examination must testing is largely subjective. For patients with back domi- include an upper motor test and a nant pain, an adequate motor test of check of saddle (perineal) sensation. L5 is the power of the long extensor of the big toe. For S1, it is sufficient to test the strength of the great toe’s bladder function and may trigger long flexor. If indicated, for exam- an acute cauda equina syndrome.12 ple in leg dominant pain, additional The crossover sign should not be neurological tests include quadri- confused with the reproduction ceps power and the knee reflex of typical leg pain on the affected for L3 and L4; heel walking, ankle side when lifting the unaffected leg. dorsiflexion (tested with the patient This manoeuvre, correctly desig- seated and attempting to elevate nated “well-leg lifting,” confirms the forefoot against resistance) and an extremely irritated nerve root hip abduction (Trendelenburg test) but signifies unilateral compres- for L5; toe walking, hip extension sion incapable of provoking a cauda (tested by palpating the muscle equina syndrome. tone in the gluteus maximus as the Femoral stretch is a root irri- patient repeatedly tenses and relaxes tation test for the femoral nerve the muscle) and the ankle reflex for (L2, L3, L4). It is carried out with S1. Both L4 and L5 innervate ankle the patient prone and the affected dorsiflexion but, since L4 is only leg extended. Lift the patient’s leg occasionally involved with low back into extension; a positive test result pain, the test is generally employed reproduces the typical leg pain, for the latter root. in this case in the anterior distal Every low back examina- Key Point thigh. The manoeuvre frequently tion must include an upper motor induces back pain, an incidental test and a check of saddle sensa- The goal of albeit unpleasant finding. Because tion. The upper motor examina- the physical the femoral nerve is so infrequently tion, usually the plantar response, is examination is affected, the test can be limited to always negative in low back pathol- to verify or refute those patients who present with an ogy. Any indication of direct spinal the diagnostic account of constant anterior thigh cord involvement warrants a more assumptions dominant pain. detailed proximal neurological made on the About 80% of nerve root com- examination. This finding negates a basis of the promise associated with low back mechanical diagnosis. Saddle sensa- history. pathology occurs at L5 or S1 (L4 tion is subtended by the same lower adds approximately another 8%), so sacral nerves that supply the bowel

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Key Points

90% of Low Back Pain is not related to serious pathology Findings on radiological imaging including x-ray, CT and does not require surgical intervention scan and MRI have not been found to correlate to pain- generating pathology, can increase patient anxiety and Mechanical Low Back Pain can be categorized to patterns detract from successful recovery that are identified in history and confirmed in the physical examination

and bladder. An altered response to use of this manoeuvre for pain man- sensory testing in this area raises the agement. possibility of an acute cauda equina The goal of syndrome recogni- syndrome, which must be carefully tion is to dispense with the need to pursued including, when indicated, a establish a pathological diagnosis . before proceeding to primary treat- ment; but it is impossible not to The Four Syndromes speculate on the most likely source At the conclusion of the history and of the pain. In this case, the picture physical examination, the overwhelm- strongly suggests a discogenic origin. ing majority of patients can be classified The focus, however, should remain into one of four mechanical patterns. on the clinical presentation and not In the first and most common on the putative pain generator. A syndrome, patients describe pain that degenerative disc seen on magnetic is most excruciating in the back, in the resonance imaging does not nec- buttocks, or around the hips and is essarily equate with this first syn- increased by bending forward. The pain drome.7,10 may be constant or intermittent. The The second mechanical pattern neurological findings will all be normal. is also back dominant but is much Within this group, there are two less common. Patients report pain on well-defined cohorts: one gains relief bending backward but have no trou- Key Point with extension, the other has pain ble, and are often more comfortable, with movement in either direction. bending forward. The pain is inter- Managing low The physical examination will support mittent. Again, the physical exami- back pain is the history, with the patient’s typical nation reinforces the history. The not a one-time back pain aggravated on flexion and patient’s usual back pain is worsened event. Low back either improved or further exacerbated on extension but is either unaffected pain is a chronic on extension. For some patients, the or improves on flexion. The neuro- condition that extension movement must be per- logical examination is normal. demands formed in a non-weight bearing posi- The source of pain in this ongoing care tion of prone lying. This is an ideal syndrome is less clear, possibly the and follow-up. time to educate these patients on the posterior elements of the spine. But

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while the location of the pain genera- by rest in flexion (sitting). Since the tor is uncertain, the pattern of the patient is not active during the assess- pain is obvious. ment, the physical examination is The next two syndromes usually normal. The correct diagnosis involve leg pain dominant, and both for this pattern is neurogenic clau- dication, but in clinical practice, it is often mislabelled spinal stenosis.16 Managing low back pain is not a one- Spinal canal narrowing is a structural time event ow back pain is a chronic abnormality that may induce neuro- . L genic claudication but that may be condition that demands ongoing asymptomatic. Spinal stenosis is not care and follow up a diagnosis, and its presence on an - . image does not predict the patient’s symptoms. Syndrome recognition, correspond to well-established diag- which emphasizes the clinical presen- noses. Here the challenge is the con- tation, is the proper approach. tamination of the terminology, with the resultant blurring of the clinical Conclusion picture. Low back pain is not an impenetrable The third syndrome is one of morass. Recognizing a syndrome within constant leg dominant pain with a myriad of other complaints requires a associated positive neurological meticulous history, a precise support- findings, indicated by either irrita- ing physical examination, and practice, tive tests such as the straight leg but it enables immediate mechanically raise or a loss of motor, reflex, or based treatment without misleading and sensory function. This is the exact unnecessary spinal imaging. Managing description of sciatica: constant leg low back pain is not a one-time event. dominant pain with a necessarily Low back pain is a chronic condition positive neurological examination.15 that demands ongoing care and follow- This most accurately equates to up.13,14 When the clinician can reliably radiculitis, inflammation of a spinal separate nine of 10 patients into one nerve root. But sciatica has come to of the four groups, each with its own mean simply leg pain. Patients and distinct characteristics and appropriate too many health care providers are treatment, and when the outliers can be convinced that any time the pain quickly and clearly identified, low back spreads to the leg, there must be a pain begins to make sense. pinched nerve. As a result, many patients with referred leg pain from a References back dominant pattern are given the wrong diagnosis. 1. Deyo RA, Weinstein JN. Low The final syndrome also has back pain [review]. N Engl J Med leg dominant pain. Here the pain is 2001;344(5):363–70. 2. Henschke N, Maher CG, Refshauge KM, intermittent, comes on with activity et al. Prevalence of and screening for in extension (walking), and is relieved

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+ Clinical Pearls

Questions: Interpretation:

“Where is your pain worst?” Back Dominant Pattern I or II Leg Dominant Pattern III or IV

“Is your pain intermittent or constant?” Intermittent is a mechanical syndrome Constant LBP – rule out Red Flags • Neurological • Infection • Fracture • Tumour • Inflammation • Possible Pain Disorder (Yellow flags)

“Has there been any change in your bowel or bladder If yes, inquire about further neurological symptoms to function since the onset of your back pain?” rule out Cauda Equina (Surgical Emergency).

“What are the aggravating movements or positions?” Pattern 1 Pattern 2 Pattern 3 Pattern 4 a) Flexion Extension Flexion Extension Aggravated Aggravated Aggravated Aggravated “What are the relieving movements or positions?” B) Flexion/ Flexion Extension Relieved or Aggravated Unchanged

Management Strategies:

“Have you had this same pain before?” Reinforce the key messages that recurrence is typical and is not linked to worsening pathology

“What treatment have you had in the past and did Dispel myths of passive treatment. it work?” Identify active approaches related to the mechanical patterns

“What can’t you do now that you could do before Begin self-management strategies focused on the patients you had the pain?” needs.

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+ Clinical Pearls serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072–80. Physical Examination 3. Toward Optimized Practice. Alberta To minimize patient discomfort and maximize efficiency, progress primary care low back pain guide- line: updated and revised Novem- from tests done standing to those in sitting and finally to lying ber 2011. Edmonton (AB): Toward down. The minimum assessment is marked** Optimized Practice, 2011; http:// www.topalbertadoctors.org/cpgs. php?sid=63&cpg_cats=85. Accessed Gait November 9, 2012. • Heel walking (L4-5) 4. Powell G, and the Peterborough Back Rules Working Group. The Peter- • Toe walking (S1) borough Back Rules chart template. September 1997; http://www.iwh. Standing Position on.ca/pocket-red-yellow-flag-cards. • **Movement testing—flexion and extension Accessed November 9, 2012. 5. Scientific approach to the assessment • Trendelenburg test (L5) and management of activity-related • Repeated toe raises (S1) spinal disorders. A monograph for clinicians [review]. Report of the Quebec Task Force on Spinal Disor- Sitting Position ders. Spine (Phila Pa 1976) 1987;12(7 • **Patellar reflex (L3-4) Suppl):S1–59. 6. Hall H, McIntosh G, Boyle C. • Quadriceps power (L3-4) Effectiveness of a low back pain • Ankle dorsiflexion power (L4-5) classification system. Spine J 2009;9(8):648–57. • **Great toe extension power (L5) 7. Srinivas SV, Deyo RA, Berger ZD. • **Great toe flexion power (S1) Application of “less is more” to low back pain [review]. Arch Intern Med • **Plantar response, upper motor test 2012;172(13):1016–20. 8. Chou R, Shekelle P. Will this patient Kneeling Position develop persistent disabling low back • Ankle reflex (S1) pain? JAMA 2010;303(13):1295–302. 9. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta- Supine Lying Position analysis of efficacy, cost-effectiveness, • **Passive and safety of selected comple- mentary and alternative medicine Prone Lying Position for neck and low-back pain. Evid Based Complement Alternat Med • Femoral nerve stretch (L3-4) 2012;2012:953139. Epub 2011 Nov 24. • Gluteus maximus power (S1) 10. Chou R, Qaseem A, Owens DK, Shek- elle P; Clinical Guidelines Committee • **Saddle sensation testing (S2-3-4) of the American College of Physicians. • Passive back extension (patient uses arms to elevate upper body) Diagnostic imaging for low back pain: advice for high-value health care from

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the American College of Physicians. Ann Epub 2010 Dec 31. Intern Med 2011;154(3):181–9. Erratum 13. Itz CJ, Geurts JW, van Kleef M, Nele- in: Ann Intern Med 2012;156(1 Pt 1):71. mans P. Clinical course of non-specific 11. Chou R, Qaseem A, Snow V, et al.; Clini- low back pain: a systematic review of cal Efficacy Assessment Subcommittee prospective cohort studies set in pri- of the American College of Physicians; mary care. Eur J Pain 2012 May 28. American College of Physicians; Ameri- Epub ahead of print. can Pain Society Low Back Pain Guide- 14. Donelson R, McIntosh G, Hall H. Is it lines Panel. Diagnosis and treatment of time to rethink the typical course of low low back pain: a joint clinical practice back pain? PM R 2012;4(6):394–401. guideline from the American College of 15. Valat JP, Genevay S, Marty M, et al. Physicians and the American Pain Soci- Sciatica [review]. Best Pract Res Clin ety. Ann Intern Med 2007;147(7):478– Rheumatol 2010;24(2):241–52. 91. Erratum in: Ann Intern Med 16. Suri P, Rainville J, Kalichman L, Katz 2008;148(3):247–8. JN. Does this older adult with lower 12. Gardner A, Gardner E, Morley T. Cauda extremity pain have the clinical syn- equina syndrome: a review of the cur- drome of lumbar spinal stenosis? rent clinical and medico-legal position [review] JAMA 2010;304(23):2628–36. [review]. Eur Spine J 2011;20(5):690–7.

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