Diagnosing Lower Back Pain

Posted By: Andy Barker

Often therapists treating patients with lower back pain fear doing more harm than good.

You understand the importance of certain injuries in this area and worry that you might miss something more serious…

…and as a result, cause your patient more pain.

There are many possible differential diagnoses in the lumbar area and for many therapists this causes a big problem.

Because it is sometimes difficult to find a definitive diagnosis you fear getting your hands-on or prescribing rehab as you might make symptoms worse.

So you end up doing nothing, or at best, your management is very conservative.

Doing nothing or ‘resting’ ANY injury, is usually not the best approach and often leads to poor patient progress and results, with patients losing faith in the rehab plan which sees them stop doing their exercises.

You need to be mindful of serious pathology and use your RED FLAG questioning to screen all patients with lower back pain.

However, I know that even when New Grad therapists identify patients that are ‘clear’ of RED flags, many therapists, maybe you, are still reluctant to get their hands-on and prescribe rehab for their patients with lower back pain.

This blog will help you gain more confidence in diagnosing and treating lower back pain.

After reading this post you will better understand the anatomy and movements of the lower back, learn an easy way to simplify your lumbar spine assessment and learn why trying to fix ‘posture’ might not be the best rehab strategy.

Understanding The Lumbar Spine Anatomy

Knowing your anatomy vital.

Unless you know your anatomy well, it makes it difficult for you to identify what structures might be causing your patients lower back pain.

Where your patients point and tell you their symptoms are…

…when you are observing or palpating your patients lower back…

…unless you know what structures are in which place i.e. your anatomy, you may struggle to identify what specific structure are causing this pain.

This is vitally important as the management of a facet joint, disc or muscle injury can be very different.

Additionally, it is important to understand the lumbar spine is built to MOVE!

The lumbar spine can flex, extend, side-flex and rotate.

There is a big misconception with patients and some therapists that the lumbar spine is meant to be strong and stable only.

It does need to be strong and stable with certain activities like picking up something heavy from the floor.

But it also needs to be able to move, otherwise simple tasks like putting your socks on will prove very difficult!

Much of the focus around lower back pain is on ‘core stability’ and developing strength in and around the lower back and abdominals.

This is important for sure, but should not be done at the expense of movement.

What we want is a lower back that is stable and strong when it needs to be but also able to move in all 3 planes of movement when it needs to!

Simplify Your Diagnosis

When I first assess any patient or athlete with lower back pain the first thing I want to do is this…

I want to know if their main problem relates to FLEXION or EXTENSION.

I want to identify as early as possible which of these two movements is most problematic.

What I am trying to do is simplify my diagnosis and put my patient or athlete in an assessment ‘bucket.’

Either a ‘flexion’ bucket or a ‘extension’ bucket.

A patient explaining that prolonged sitting makes their back pain worse would go in my ‘flexion’ bucket.

A patient explaining that prolonged standing, walking or running makes their back pain worse would go in my ‘extension’ bucket.

Patients may have mixed patterns, where they have symptoms with both movements, but almost always they will have one dominant problem.

I use this simple technique as it allows m to identify the biggest problem.

And this is the problem that I will fix first.

Why Improving Posture Might Not Help

Posture and lower back pain seem to go hand in hand.

It is believed by many that poor posture results in pain, but this might not be case (more about this later).

What is important to know is that the body adapts to the stresses put on it…

Whether those stresses are a particular occupation, activity or sport, the body will change as a result of the positions and loading (stress) put upon it.

Many patients we see with lower back pain have often had problems for a long time.

It is not uncommon for patients to tell us that they have had this problem on an off for 5, 10, even 20 years plus!

Trying to undo 20 years plus of poor sitting posture in a patient complaining of a 20 year history of lower back pain is a big job.

They have adapted over a long period of time and undoing this ‘poor’ posture is going to take more than a few rehab exercises.

Patients often believe there is a big association with their lower back pain and poor posture.
Patients will often say things like…

‘I know my posture when I sit at work is not great…’

‘I often find myself in a poor sitting position at my desk which I know doesn’t help…’

But, emerging research is showing a poor link between static posture and pain.

Posture is important to identify as ‘poor postures’ or patterns e.g. a big lumbar lordosis may contribute to a patients symptoms.

But this is NOT a definitive cause…

So whilst ‘poor’ posture may contribute it may not be the main factor and I turn, the main problem that you want to fix.

Additionally, people will likely need these positions and postures to do what they do – for example, sit at a desk for 8 hours a day.

Improving a patients sitting posture and position for an office worker with lower back pain will no doubt help but…

…with populations like this I tend to use a different strategy.

Instead of correcting posture I tend to use movement.

I might instruct a patient to get up every 45 mins for a minimum of 1 minute.

This might coincide with going to the toilet or making a cup of coffee at work.

It might also be a signal for them to do the rehab you have set them!

The aim of this strategy is to break the cycle of static posture rather than change posture itself in the first instance.

If you can help to reduce pain quickly with any patient with lower back pain, this will allow you to progress rehab much quicker, then later, if you feel posture is still a problem then you can act to try fix it up.

Focus on the easy wins first…

Then the more difficult wins after that…

Key Points

Understand The Lumbar Anatomy & Movement: It is important you know your lumbar anatomy well to help you to distinguish what structures might be causing your patients pain and understand that as well as needing to be stable and strong, the lumbar spine is also made to MOVE!

Simplify Your Diagnosis: Make your assessment simpler by putting your patient in a ‘bucket’ – either a flexion ‘bucket’ or an ‘extension’ bucket to identify their main problem, then go to work to fix that up first.

Why Improving Posture Might Not Help: Emerging evidence is suggesting a poor link between static posture and pain. Posture can also be difficult to change quickly, especially with patients with chronic symptoms, so focus on movement first, then fix posture later, if it is still a problem.

PS. Do you struggle with the management of lower back pain?

I’d love to hear what you struggle with and to help you out overcoming the problems you have with the lumbar spine, to give you greater confidence with your assessments, treatments and rehab.

Email me at andy@newgradphysio.com and I’ll let you know how to do this…