Application in clinical practice

In order to select an effective and efficient treatment in daily clinical practice, LBP patients should be classified clinically as either predominantly nociceptive, neuropathic, or central sensitization pain (Nijs, et al., 2015). When using mechanism-based classification of low back pain, it is important to:

• Rule out Red Flags
• Test for and rule out neuropathic pain
• Test for and rule out Neuropathic pain
• Ask if there is a history of trauma or pathology of the nervous system?
• Find out if there are related comorbidities such as cancer, stroke/cardiovascular accident, diabetes, herpes zoster, degenerative diseases and others
• Determine if you describe the pain as burning, shooting, electric, electric, etc.
• Find out if the pain follows a logical neuroanatomical distribution
• Find out if there is sensory dysfunction which is following a logical distribution
• Determine if there are diagnostic tests results such as MRI, EMG to confirm
• Differentiate between predominant Nociceptive or predominant Central Sensitisation pain (Nijs, et al., 2015).

Clinical relevance of radiographic findings

Research has the following to say:

• Facet degeneration is not significantly related with LBP
• Spinal stenosis is significantly related with LBP. This means that there is association between spinal stenosis with occurrence of LBP
• Protrusion or Schmorl nodes are not related with LBP, however other authors have shown a link between protrusions/Schmorl with LBP
• People with a disc herniation are two times more likely to suffer from LBP
• Density of paraspinal muscles is not related with LBP while
• Trigger point number is related with self-reported intensity of LBP

Movement Tests

Active Movement, Muscle Strength and Endurance

At the completion of subjective examination, noting down precautions and contraindications, movement tests can safely be done to reproduce the concordant sign. A concordant sign is defined as a symptom that the patient is familiar with and it is the main reason for seeking treatment.
Active movements refer to the movements performed by the patient. For the back they consist of:

• Extension
• Flexion
• Lateral flexion
• Rotation

Low Back Pain from Weak and Low Endurance Muscles

Endurance of back extensors is highly associated with LBP (Nourbakhsh & Arab, 2002). Poor quadriceps strength and decreased endurance are also associated with LBP. This is suggested to originate from the tendency to stoop and use back muscles in lifting when quadriceps are fatigued (Trafimow, Schipplein, Novak, & Andersson, 1993). Again, it is known that weak muscles tend to tighten. This tightening quadriceps may result in anterior tilting of the pelvis as well as superior translation of the patellar. Anterior tilting of the pelvis will result in increased lumbar lordosis and stretching of hamstrings. Paraspinals will also be stretched and eventually the lumbar and knee biomechanics will be compromised and hence LBP and knee pain as well.

While performing these movements, an overpressure can be added to assess joint involvement via end feels. To offload the spine, extension and flexion can be done in prone or supine respectively. These movements can be repeated 5 to 25 times to see if there is centralisation of the concordant sign. Take note of any shift and reduce it.

Centralisation refers to the relocation of the symptom from distal to more proximal location, i.e. centrally (Cox, 1999). In centralization phenomenon, symptoms migrate from more distal parts to more proximal parts. For example, if there was LBP radiating down to the foot and after active trunk movements the pain is only felt in the LB and buttocks, this is termed centralisation of the pain. Centralization typically occurs rapidly and can be maintained (Ronald, Gregory, & Kenneth, 1990).
Centralisation is possible in discs with intact annular wall i.e. competent discs. Lasting results can be achieved in people with an intact annular wall. When present, centralisation denotes lessening of nerve irritation by mechanical or chemical factors and it is a sign of healing and improvement. Dynamic assessment of change in anatomic pain location during treatment and leg pain at intake are predictors of developing chronic pain and disability. Presence of leg pain in LBP is a strong predictor of chronicity (Mark & Hart, 2001). The opposite effect to centralisation is called lateralization or peripheralization. This is when pain or symptoms extend from proximal to a more distal location (Wise, 2015). An example would be worsening of leg pain than LBP, an indication of increasing nerve root irritation by mechanical or chemical factors.
LBP that centralises leads to improved functional outcome and, thus, quality of life (Sufka, et al., 1998).

Passive movements

Passive movements can be performed in sitting or laying down. In sitting the spine is loaded while in laying it is offloaded. The therapist fingers contact spinous process to feel for normal or abnormal movement.
Note:It should be noted that lumbar spine rotation is only about 1 or 2 degrees so any significant movement might indicate instability and appropriate tests and measures need to be done. The passive movements can be accessory or others.
Accessory passive intervertebral movements may include:

• Posterior-anterior glide on the spinous process (central PA)
• Unilateral posterior anterior glide on facet joints (Unilateral PA)
• Transverse right: PA glides on the left going toward the right
• Transverse left: PA glides on the right side of the spine going toward the left

Palpation

Spinal palpation can help differentiate pain sources (Heller, 2005). Palpation methods that are used to provoke pain responses are more reliable (Seffinger, et al., 2004) than palpation methods in which the clinician purports to find segmental motion restriction. The prone instability test shows good reliability (Schneider, et al., 2008).
Palpation can be used to identify tissues which are generating pain. It can also be used to increased muscle tension in a limited proportion of cases (Maigne, Cornelis, & Chatellier, 2012). For instance, palpation can be used to differentiate pain from L5/S1 facet and SIJ. Palpation can reveal:

• Muscle tone (tight or flaccid)
• Trigger points (tender knots in the muscle or fascia)
• Tenderness (pain from facets, dura, disc etc.)
• Joint mobility (hypermobility and hypomobility)
• Depression in the spine (spondylolisthesis)