How to get great results

with
Acute low back pain
Starting with an awesome subjective

presented by David Pope, clinicaledge.co

What you will discover:

How to perform a great subjective
history
What questions you NEED to ask
How you can identify structures you
can assess and treat
What movements you need to assess
What clues in your patient’s history will
help your treatment
How to be very sensitive with your
subjective history
How can you differentiate lumbar spine
from hip and sacroiliac (SI) pain

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 What you will discover
in the subsequent part:
Can we be any more specific in our
diagnosis than NSLBP?
How your assessment will guide
your treatment for great results
The next part will contain practical
videos with demonstrations of how
you can assess patients with low
back pain
How to know when to use exercises,
and when to use manual therapy

Acute or chronic low back pain?

Focus on acute low back pain
Some common factors
Require different approach to assessment and
treatment
We will have another separate online course on CLBP 






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Red flags & imaging?

Red flags & imaging?

We want to focus this
co u rs e o n h ow t o
perform an assessment
Covered in a separate
online course

6
Neuro assessment & neurodynamics?

Neuro assessment & neurodynamics?

Both very important aspects to look at
with ALBP
Subjective components that will guide
you towards neurodynamic
components is included
How to incorporate into your
treatment when indicated is included
in this course
Exactly how to perform neurodynamic
testing will be covered in a separate
online course

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Incorporating a case study example

COMMon acute LBP

patient

Can acute LBP be enjoyable to
treat?

Incorporating a case study example

acute LBP patient


Active 55 year old male
Goes to the gym 6 days per week
14/12 Hx of 6-7/10 RHS low back pain
(ache), posterior hip and into anterior
thigh to knee
Nil P&N
Some numbness over R medial ankle, not
into foot

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 Low back pain recovery
79% of Australians (Walker, Muller, & Grant, 2004).

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Low back pain recovery

Usually benign, self-limiting disease of the
musculoskeletal system, requiring minimal
intervention (Brox et al., 2008).

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Low back pain recovery
58% decrease in one month
82% RTW in one month 





(Pengel et al., 2003)

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Low back pain recovery

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Low back pain recovery
10-20% develop chronic pain
and disability as a result of
their LBP (Maher, 2004).
Costa et al. (2009) reported
that at 12 months after injury,
two-thirds of patients with
recent onset non-radicular LBP
will still report some pain or
disability related to their low
back.

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What aren’t we good at?

Recurrence
60% within 2 years (Choi et al. 2010)

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Subjective assessment
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Subjective assessment
By the end of our subjective,
along with the CH, PH and PMH
& red flag questions, we need
to have:
A solid plan of what you are
going to assess

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Subjective assessment

Likely sources of symptoms

or impairments

19

Subjective assessment

E x p e c t e d fi n d i n g s
(hypothesis)

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Subjective assessment

Ways to test and confirm/

disprove your hypothesis

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Subjective assessment

Patient goals

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Subjective structure
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Subjective structure

Important to have a
structure to our subjective
assessment, to ensure we
don’t miss anything

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Subjective structure

Stick to the structure ie

avoid it getting hijacked

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Subjective structure
“I would like to hear more
about that in a minute, first I
want to find out a bit more
about…. Eg where your pain
is exactly, this pain in your
leg, etc”

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Subjective structure

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Subjective structure
Why is the patient here?
Body chart
Current history
Aggs & Easing
24/24 behaviour
Past history & treatment
Medical history
Red flag questions

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Open vs closed questions
What is an open question?
What is a closed question?

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Open questions
Open questions - how, why,
what, when, where
Invite detailed responses

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Open questions
Open questions - how, why,
what, when, where
Invite detailed responses
Eg Why did you jump off the
cliff with a wing suit?
Eg Why do you think your
low back pain started

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Closed questions
Closed questions - did you,
do you, can you, have you
Invite Yes or No responses
Eg Did you jump off the cliff
with a wing suit?
Eg Do you have P&N or
Numbness anywhere?

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Open vs closed questions
Which are best?

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Open vs closed questions

Which are best?

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Open vs closed questions
When do we use open or closed
questions?

35

Subjective assessment
Start with open questions - how, why,
what, when that allow detailed
responses, and the person to express
their concerns

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Subjective assessment
Followup questions can be used to
clarify, and can include closed
questions - do you, can you, are you
that provide Yes or No answers
Eg Do you have any pain in your calf
or foot, can you sit without pain

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Subjective assessment
Use positive rather than negative
questions
Eg “Do you have any P&N?”,
rather than “You don’t have any
P&N?” or “You don’t have any
pain in your calf?”
Negative questions can be leading,
and may not get you the correct
information as the person can just
go along with what you are saying

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Subjective assessment
90 second rule
Open first question eg How can
I help you today, What can I do
for you today
Allow 60-90 seconds for the
patient to fully answer this
question without interruption
Wait until they stop talking (or
you get to 90 seconds) before
asking followup questions

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Body chart
Exact area of pain
Get the person to show you on their body,
rather than get them to draw it on a body
chart
How far across exactly does their pain go in
their back
Exactly how far down the leg does their pain
go eg to the buttock crease, knee, mid calf

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Body chart
Find out if they have any pain into
the hip, buttock, leg or foot

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Body chart
Pain levels for each area - at it’s
worst (“How bad does it get to out
of 10?), right now
Type of pain - ache, sharp, burning
Burning pain

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Body chart
Constant or intermittent
Intermittent pain is a much better
prognostic indicator
Constant pain that is non-
mechanical in nature will increase
your suspicion of red flags

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Body chart
Are there any other areas that have
any symptoms e.g. thoracic spine
stiffness that may lead you to
explore the thoracic spine, or groin
pain that may implicate the hip
Eg Do you have any pain or
stiffness anywhere else?

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Body chart
Can ask P&N/N/Cauda questions
now, or leave to the end when
asking other red flag questions
I like to ask now, and other red flag
questions later, so I can map these
on the body chart

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Body chart
By now we should have an idea of
the structures that are irritated
Radicular pain
Radiculopathy
Somatic referred pain
Any neural irritation

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Our case study

acute LBP patient


Active 55 year old male
Goes to the gym 6 days per week
14/12 Hx of 6-7/10 RHS low back pain
(ache), posterior hip and into anterior
thigh to knee
Nil P&N
Some numbness over R medial ankle, not
into foot

47

Current history
Tell me about this episode of back
pain
Find out:
When did the pain start

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 Current history
Has your pain been getting better or
worse?
Overall and over the last few days

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Current history
Sudden or gradual onset -
looking for potential trauma
or fractures

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Current history
What led to this current
episode
Any changes in activity,
work, exercise, more
sitting, bending, etc?

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Current history

Have they had any

treatment this episode?

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 Our case study

current history

On and off since Jan 16, since
started training with weights
again
Unsure why
Gradual onset

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Aggravating activities
Open first question eg
“Which movements bring
on or make your pain feel
worse?”

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 Aggravating activities
Identify if aggravating
m ove m e n t s a re m o re
flexion, extension based or
something else eg gait,
bowling, neurodynamic
positions, etc

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Aggravating activities - Flexion

Flexion based aggravating
activities are common with
lumbar spine irritation,
S i tt i n g ( h ow l o n g ,
immediately, 5 minutes,
or on standing after
extended sitting)

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Aggravating activities - Flexion
If sitting, does it keep
getting worse, do they
need to get up?

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Aggravating activities - Flexion

Does it hurt on sit to
stand, then feel better
after a few steps?

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Aggravating activities - Flexion
Are there sitting positions
that make it worse? Eg
Sitting with feet up on foot
stool, or when driving that
may give you an indication
of neurodynamic
involvement

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Aggravating activities - Flexion

F l e x i o n b a s e d a g g ra v a t i n g
activities
Bending
Doing shoelaces
More when one leg is
forward or back
Lifting (load element as well)
When rotation is involved

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Aggravating activities - Extension
Extension based aggravating
activities
Pain on getting out of a
chair is NOT EXTENSION
BASED, it is flexion
based - related to sitting,
and is very common with
L/Sp irritation

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Aggravating activities - Extension

Extension based
aggravating activities
May also involve
extension/lateral flexion
End of stance phase
of gait

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Aggravating activities - Extension
Top of tennis serve

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Aggravating activities - Extension

Bowling in cricket
Yoga extension movements
Other extension activities

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Lateral shift

Patient may report a lateral shift ie

shoulders or hips off to one side
Often associated with unilateral
pain, may also be central

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Lateral shift

Lateral shift away from side of pain

- better and faster prognosis
Lateral shift towards side of pain -
often much harder to treat, slower
to respond

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 Pain with gait or stairs
Is it with each footfall at a particular point
in range, or does it increase with
increased walking and eased with rest?
Increased pain as the person walks, and
eased with rest, may suggest spinal
claudication
If it is with each step, which point in
range does the pain occur - eg heel
strike, mid stance, end of stance phase,
toe off, swing phase

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Other aggravating positions

Lying down - Identify if the person has
aggravating or easing positions
Supine is often aggravating with both
SIJ and lumbar irritation
Identify positions that ease their pain
eg R SL, which may provide initial
treatment positions in irritable patients
If sidelying causes pain, check if they
have tried using a pillow between their
legs, or a thin pillow under their side

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Neurodynamics/neural irritation
Identify if the person has aggravating
positions that may tension peripheral
nerves
For example:
Feet on footstool
Driving with leg extended or when
pushing clutch in (knee extension)
Reading in bed
Stretching the hamstrings with DF

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Neurodynamics/neural irritation
Heel strike (or just before)
Cyling at bottom of pedal
stroke
End of stance phase of gait
(femoral n./obturator n with
hip ER)
Quadriceps stretches or
during faster running

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 Lumbar spine vs SIJ
These are by no means
hard and fast rules, but
will guide you to
investigate these areas
further in your
assessment, and may
inform your treatment

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Indicators of potential SIJ involvement

Area of pain
“The most common areas of referred pain
are the buttocks (94 %), lower lumbar
region (72 %), lower extremity (50 %), and
groin (14 %)” Hamidi-Ravari et al. (2014)
“The most consistent factor for identifying
SIJ pain is unilateral pain below L5”
Hamidi-Ravari et al. (2014)9
If they point to SIJ only should think SIJ
until proven otherwise

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Indicators of potential SIJ involvement
Non-dermatomal might make you think SIJ
more
SIJ can be generally described as “deep tooth
achey type sharpness”
Van der Wurff et al. (2006) found that patients
with SIJ pain described pain in a 3cm wide x
10cm long area just inferior to PSIS, referred
to as “Fortin’s area” and never described pain
inferolaterally to the ischium an area referred
to as “Tuber’s area”. 10

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Indicators of potential SIJ involvement

Other indicators, especially when combined
with area of pain:
Pain during:
Weight bearing
Stance phase of gait
Lifting leg in supine (ASLR)
Kneeling on one leg eg carpenter
kneeling to hammer in nails (like
reverse thigh thrust position)
Patient may report their pain was improved
with pelvic belt or tight underwear

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Followup questions
Try and narrow down as much as
possible the exact positions and
movements that aggravate pain
Eg “Sitting pain” vs “Sitting in his
armchair with feet on footstool for 5
minutes => sit to stand pain A”
Eg “Pain walking” vs “Pain A on
every step at EOR stance phase,
remains the same when walking”

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Followup questions
Identifying structures and
movements to assess
Help you reproduce your
patient’s pain, as an asterisk
sign, to identify if your
treatment was successful
Identify potential treatment
areas & positions

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Hip pain
Groin is the most common area of pain
from the hip joint. You can question your
patient about the presence of groin pain
The hip may refer into the groin, anterior,
lateral or posterior hip or into the thigh.
The hip will rarely refer into the lumbar
spine or below the knee
Hip flexion may be a false positive with L/
sp referral, does not indicate the hip is
involved

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Hip driver
Is the hip involved aka the
driver of your patient’s pelvis/
low back pain?
Does the patients aggravating
factors relate to hip position
eg hip adduction or rotation
Limited hip extension may
lead to extension based
lumbar irritation

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Our case study
Aggravating activities

Sitting 20 minutes
Standing at work - starts after 1-2 hours, gets
worse through the day
Driving - especially with wallet under R hip, or
with longer drive eg down and back to Sydney.
Stiff and sore getting out of car. In the back and
in the leg
Walking up hill
DB Rows
Pushing up/EOR extension when walking up hill
Squats and deadlifts - don't do this anymore
Leg press - only do seated ones, which are ok
OH seated Shoulder press

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Easing factors

Identify positions and

movements that ease the
person’s pain

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Easing factors
I s t h e re a p a tt e r n t o t h e
movements that ease their pain
eg lying prone
Commonly they feel better when
they lie supine, but then have
trouble/pain getting up again
Find out how long the relief lasts
f ro m t h e s e m ove m e n t s o r
positions - often returns
immediately when they stop

81

Easing factors
What stretches have they tried?
Most people have tried something, and
often this involves flexion (eg knees to
chest), glute/piriformis/hamstring
stretches or some other stretch that is
likely contributing to their ongoing pain
You will often need to stop these
stretches to allow their pain to settle

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Easing factors - Lumbar flexion irritation
Standing will often be more
comfortable than sitting
Pain from sitting will often
improve after walking a few
steps

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Easing factors - Lumbar flexion irritation

Are there more comfortable sitting
positions?
Is sitting more comfortable with
lumbar support - helps give more
indication of lumbar flexion irritation
and using extension based treatment
If sitting and rest helps pain that
increases with walking - suspect
spinal claudication

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 Easing factors

Medications?

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Easing factors
Heat or ice?
Ice sensitivity in some people

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Our case study

Easing factors

Lying on back
Brufen and Panadol
Nil else

87

24 hour behaviour
Is there a pattern to the patient’s pain?
Best/worst times of day?
Morning stiffness >15 minutes
How is the person sleeping? Night pain/
resting pain
Is there pain under control at night, or do
they need to discuss medication with their
doctor to allow them to get a good night’s
sleep

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Our case study

24 hour behaviour

Sore getting out of bed, this varies, worse if
long day at work the day before
Stiff for the first 5-10 minutes until have a
shower
Worse at the end of the day especially if
trained and have a busy day at work
Wakes at night every few hours, have to
change position. Keeping him awake

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Irritability

Irritability is often
confused with pain levels
9/10 pain does not = high
irritability

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 Irritability
Irritable low back pain will stir up
very easily and take a long time/
hard to settle down
Irritable patients - You will
perform less repeated aggravating
movements and have to be more
gentle with your handling to not
stir up your patient’s pain eg no
repeated flexion in standing, gentle
with hip flexion & SLR testing

91

Our case study

Irritability

Low irritability

92
Patients thoughts & beliefs

What does the patients think is

causing or contributing to their
pain?
What are their fears?
What are some common beliefs
in your patients about back pain?

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Patients thoughts & beliefs

This is your chance to identify
beliefs that you can address
eg “My pelvis is out”
“I have the back of an 80 year
old”
“I have a weak core”
“I have bad posture”
“It’s probably arthritis”

94
 Patient fears
Note any fears the patient has, that
you can dethreaten throughout the
treatment
eg “I might have to change jobs” -
may demonstrate a fear that this
will permanently disable them and
affect their income/lifestyle

95

Past history
Is this their first episode of
LBP?
If not, how long did the
previous episode(s) last?
What treatment did they try,
what worked and what didn’t?
Is this similar?

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 Special questions
What special questions do we
need to ask ALBP patients?

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Special questions
P&N or Numbness anywhere

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Special questions

Weakness anywhere?

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Special questions

Changes in gait?

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 Special questions
Cauda equina
Saddle area - altered sensation
Changes in bladder or bowel -
retention or incontinence

101

Special questions

Unexpected weight loss

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Special questions

History of cancer

103

Special questions

Family history of cancer

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Special questions

Night pain or night sweats

Any infections

105

Special questions

Do you feel well, how are

your energy levels?

106
 Imaging
Have you had any XR or
images?

107

Patient goals
SMART Goals
Specific
Measurable
Attainable
Realistic, Results oriented
Time based & trackable

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Subjective assessment
109

Subjective assessment
By the end of your subjective, you should
have:
A solid plan of what you are going to
assess
Likely sources of symptoms or
impairments
Likely asterisk signs
Expected findings (hypothesis)
Ways to test and confirm/disprove
your hypothesis
Patient goals

110
Subjective assessment - case study
A solid plan of what you are
going to assess (Flexion in
standing, Gait - EOR
Extension in stance phase)

111

Subjective assessment - case study

Likely sources of symptoms
or impairments (L/Sp ?L4/5
+/- SIJ or hip)

112
Subjective assessment - case study
Likely asterisk signs (FIS &
End of stance phase of gait)

113

Subjective assessment - case study

Expected findings (hypothesis) -
Limited painful FIS secondary to L/
sp irritation), no neuro signs, SIJ
support may assist standing & gait
pain)
Palpation - any pain?
Unlikely to reproduce pain with
palpation/PAIVM’s, or SIJ/Laslett’s
tests
Neurodynamics?
Possible femoral n restriction

114
Subjective assessment - case study
Patient goals: Deadlift and
squat 100kg without pain in
3/12

115

Subjective assessment - case study

A solid plan of what you are going to assess
(Flexion in standing, Gait - EOR Extension in
stance phase)
Likely sources of symptoms or impairments (L/
Sp +/- SIJ or hip)
Likely asterisk signs (FIS & End of stance phase
of gait)
Expected findings (hypothesis) - Limited painful
FIS secondary to L/sp irritation), no neuro signs,
SIJ support may assist standing & gait pain)
Ways to test and confirm/disprove your
hypothesis
Patient goals: Deadlift and squat 100kg without
pain in 3/12

116
What you discovered:
How to perform a great subjective history
What questions you NEED to ask
How you can identify structures you can
assess and treat
What movements you need to assess
What clues in your patient’s history will
help your treatment
How to be very sensitive with your
subjective history
How you can identify potential lumbar
spine pain from hip and sacroiliac (SI)
pain

117

In the next part….

Can we be any more specific in
our diagnosis than NSLBP?
How your assessment will guide
your treatment for great results
Practical videos with
demonstrations of how you can
assess patients with low back pain
How to know when to use
exercises, and when to use
manual therapy

118
How to assess and treat

Acute low back pain

presented by David Pope

119