Complex low back pain assessment checklist
Subjective examination
- Detailed history (from first onset of symptoms, occupational factors, compensation claims, treatment response, exercise/activity pre/post injury)
- Body chart (constancy, location, nature, relationship, severity out of 10)
- Aggravating/easing factors including key activity tolerances - walking, sitting, standing, bending, lifting, housework, gardening, social/recreational. Pathology specific aggravating factors (eg cough/sneeze and sit to stand for discogenic pain). Relationship between aggravating/easing factors and different symptoms
- Detailed 24-hour behaviour particularly sleep (bedding, sleeping posture, time to get to sleep, hours of sleep, waking frequency, getting out of bed frequency), morning pain and/or stiffness duration, naps (frequency/duration), symptoms at end of the day
- Special questions including red flags, imaging results, medication (name, dose, effectiveness, duration of use), general health/comorbidities/previous injuries
Physical examination
- Observation* (sitting/transfer tolerance, standing/sitting posture, gait, functional tests such as sit to stand, BMI)
- Active movement testing* (range, limitation, observation of quality/segmental motion, overpressure if indicated)
- Palpation* (soft tissue, swelling, tenderness, stiffness, end feel, movement diagram features such as P1/P2)
- Local muscle activation* (transversus abdominis, lumbar multifidus, pelvic floor) as well as global muscle pattern during non-weight bearing and functional activity
- Waddell’s signs (distracted SLR, non anatomical tenderness, exaggerated response to AMT/transfers, non-anatomical neurological examination or symptom distribution, simulated rotation and compression)
Other testing as required
- Pathology specific such as sacro-iliac joint or reducible discogenic pain
- Lower motor neurone neurological testing
- Provocative neurodynamic testing* (straight leg raise, slump, relevant bias’)
- Response to mechanical loading strategies such as extension in lying*
- Red flags (eg upper motor neurone neurological testing)
- Musculoskeletal screen
- Global muscle overactivity, shortening or weakness (eg erector spinae, iliopsoas, hamstrings)
- Reduced joint mobility (eg hip, thoracic spine)
* Consider reassessment of these tests after performing test and/or correction of potentially maladaptive movement patterns
Questionnaire data supported by follow up questioning
- Activity limitation (Oswestry Low Back Pain Disability Scale)
- Orebro Musculoskeletal Pain Screening Questionnaire
- Optional testing as required
Post Traumatic Stress Disorder Checklist – Civilian
- Depression, Anxiety and Stress Scale – DASS21
- Pain Catastrophising Scale
- Pain Self Efficacy Questionnaire
For copies of these questionnaires and scoring methodology see http://www.stops.physio/resources