Diagnosis

Active Movements

Resisted Movement

  • Back flexion & extension
  • Back lateral flexion
  • Rotation

Reflexes

  • Patellar
  • Achilles

Sensory Testing

Muscle Testing

  • Hip flexion (L2)
  • Knee extension (L3)
  • Ankle dorsiflexion (L4)
  • Toe extension (L5)
  • Ankle eversion/plantar flexion (S1)
  • Hip extension (S1)
  • Knee flexion (S1,S2)

Peripheral Joint Examination

  • Hip flexion & extension
  • Hip abduction & adduction
  • Hip internal & external rotation
  • Sacroiliac joints
  • Knee flexion & extension
  • Ankle dorsiflexion & plantarflexion
  • Foot supination & pronation
  • Toe flexion & extension

Differential Diagnosis

The causes of back pain can be broken down as follows [Deyo2001], [deLeon_Casasola2016]:
  1. Mechanical causes (97%):
    1. Axial: Herniated disc with nerve root compression (neuropathic) (4%).
    2. Axial: Intervertebral disc degeneration
    3. Axial: Osteoporotic compression fractures (4%).
    4. Axial: Spinal stenosis (3%).
    5. Lateral: Facet arthropathy.
    6. Lateral: Myofascial pain
    7. Lateral: Ligament strain
  2. Visceral disease, such as pancreatitis, prostatitis, and aortic aneurysm (2%).
  3. Nonmechanical spinal conditions such as tumors, infections, and rheumatologic disorders (1%).

The differential diagnosis of low back pain includes the following:

Treatment

For most patients, "active recovery" is best - and "bed rest" is counter-productive, as it not only delays recovery, but also worsens symptoms. Although patients should remain active, they should avoid specific movements or activities that provoke pain, especially lifting weights, sitting or standing for extended periods, and impact activities. During the acute phase of back pain, walking is perhaps the best activity, and application of ice may be helpful in relieving pain [ACE2009, pg 492].

After the acute phase has passed, application of heat to relieve muscle spasms may be better, instruction in proper body mechanics and targeted exercise forms the cornerstone of recovery and prevention of future exacerbations [ACE2009, pg 494].

The most effective exercise programs are individually designed, at least partially supervised, and extend over 20 total hours. Stretching exercises have the greatest impact on pain, while strengthening exercises give the greatest functional improvements [Hayden2005].

It is important to note that attempting to "work through the pain" when exercising the back is usually counterproductive. As Stuart M. McGill points out, if an exercise causes pain, the patient is probably "doing the exercise incorrectly, or more likely, doing the wrong exercise" [ACE2009, pg 499].

  • Acupuncture:
    • Lu-1 (pain in chest, shoulder & back).
    • Lu-2 (pain of lateral costal region and back) [PIHMA].
    • Lu-6 (pain of upper lumbar or lower thoracic, Taiyang channel - contralateral [PIHMA], [Tan2007]
    • SI-3 (proximal 5th MCP; open Du-meridian)
    • UB-40 (popliteal; command back; Dr. Shi, Xinmen demonstrated vigorous needling of this point with the knee bent, until the experiences three electric-shock-like sensations [Personal communication, 2010]). Distal point of thoracic and lower back [Backer2010, pg 128]
    • UB-17 (T7; move Xue)
    • UB-17 to UB-23 (local points of back) [Backer2010, pg 128]
    • UB-23 (local point of lower back at L2) [Backer2010, pg 128]; Shen Xu
    • UB-25 (local point of lower back at L4) [Backer2010, pg 128]
    • UB-37 (distal point of lower back) [Backer2010, pg 128]
    • UB-57 (distal point of thoracic and lower back) [Backer2010, pg 128]
    • UB-60 (close Du-meridian)
    • Du-3 (local point of lower back) [Backer2010, pg 128]
    • Du-6 (distal point of thoracic back) [Backer2010, pg 128]
    • Du-26 (distal point of lower back) [Backer2010, pg 128]
    • Huatuo Jiaji (local points of back) [Backer2010, pg 128]

References