ContentsPhysical examinations performed by a doctor When a patient walks in with lower back pain Usual causes of lower back pain Treatment
Physical examinations performed by a doctor
Doctors use physical exams to have a better understanding of where the pain is coming from, whether it be bone, nerve or muscle pain. As an example, here we illustrate how a therapist uses them to examine lower back pain. Included are strength exam, nerve exams and specific musculoskeletal manoeuvres.
Q: What are the steps for checking the strength of a patient?
A: For strength, we usually check shoulder abduction, elbow extension, elbow flexion, and grip. Those are the upper body parts (upper extremities) that I check. Because lower back pain should affect upper body strength, I can establish a base-line muscle strength from the patient to compare with the amount of effort they give for the lower body parts (lower extremities).
Q: What do you do after the strength exam?
A: Then I do a very basic and simple flex exam. Just hit the knees and ankles to make sure they’re ok. If this patient has diabetes, usually I ask them to take off their shoes, to take a quick look at the bottom of the shoes. Sometimes, you may find that one shoe has been worn down more than the other. If there is a noticeable difference, you can check for leg length discrepancy later on during the exam (read below).
Core strength exam
Q: How is core strength checked?
A: A lot of lower back pain comes from insufficient core abdominal strength. So I would ask the patient to stand and I put my hand on their waist and check to see if it tilts. This is to check if they have weak core strength. This for extended periods of time could be the cause of lower back pain.
Straight leg raise test
Q: What can a straight leg raise exam tell you about back pain?
A: When the patient is laid down, I do a straight leg exam just to see if the pain is reproducible. In this exam, I would raise the leg from 30 to 60 degree and the pain has to shoot down to the toes.
Leg abduction, flexion and extension
Q: What do you do after the straight leg exam?
A: After the straight leg exam, I would do perform leg abduction, flexion and extension. If the pain is in the groin, there is a good chance that it’s arthritis contributing to their back pain. But instead of the groin, if the pain is in the back, that’s a pretty good test of onset joint pain.
Leg length discrepancy
Q: At what point does leg length discrepancy become an issue?
A: Usually a leg length discrepancy of less than 1cm is fine. But some people have more than 1cm difference and never realize it. That could be another cause for lower back pain.
Q: What happens if the results show that the patient does not have sufficient strength?
A: After performing the exams above, If I determine that the patient's strength is insufficient or they have neural damage. I would ask for further check up such as an ENG, or further X-ray imagining.
When a patient walks in with lower back pain
First thoughts of a patient with lower back pain
Q: What are your first thoughts when a patient walks in with lower back pain?
A: The exam actually has to start before the patient gets to the clinic room. If you’re able to take a peek on your patients while they’re walking into your room, you can get a pretty good idea of how they are moving. Are they guarding their lower left back or lower right back? Are they hunched over? Are they leaning to the side? That’s when the exam starts.
Once they get in, the most important thing is to get a good medical history. You want to know what bothers them. Some of the basic questions to ask immediately are: does it hurt in the morning, does it hurt with activity, when did it begin, did anything happen when they started feeling the back pain, did they feel a pop, did they feel a snap (the last two would make you think it’s something musculoskeletal)? A lot of times, my patients come in saying, “Oh, my legs hurt,” but they don’t realize is that via their spinal chord, your nerve comes out and reaches down their legs from the back, so a lot of times, the patients suffer leg pain from a cyst or spinal stenosis. So I want to know where the pain is. I often ask my patients to take a pen and draw it out for me and then ask them what makes it better or worse.
Usual causes of lower back pain
There are three typical causes of lower back pain. It can be your bones, your muscles or your nerves.
Bone pain example
Q: What is a common cause of bone pain in elderly people?
A: If they are old, and tell me “it hurts when I turn to the side and lean back” and there are signs of arthritis everywhere else, and I would think it’s probably a bone-bone or joint issue.
Nerve pain example
Q: What kind of symptoms can indicate nerve pain?
A: If the patient tells me that “sometimes when I get in a position and get a shooting pain down my legs,” then I would think it’s a nerve issue. Another indication would be if the patient tells me that when they are walking and all of a sudden they need to sit down after a block but the pain gets immediately better after sitting down. This case sounds a lot like neurogenic claudication. I would be thinking more of spinal stenosis. Last but not least, if you just touch the patient and they are jumping all over the place, that means they have trigger points. The thing about trigger points is that the pain can radiate sometimes. If you push on a trigger point, sometimes the patient would tell me they feel a pain in their thigh. This may be an indication of S1 nerve pinch which produces a type of pain that radiates in a pattern called dermatomal distribution.
Muscle pain example
Q: What are the causes of muscle pain?
A: It could be that the patient’s muscles are cramping up. For example, if the patient comes in and says “oh my muscles hurt” and they are of mid to older age, it could well be muscular pains. This type of pain can usually be alleviated with massaging or rubbing.
Q: Is physical therapy an effective method of treatment?
A: A lot of these symptoms can be resolved through physical therapy but the physician should initiate the therapy. You shouldn't jump to it. The physician should initiate therapy while the patient is undergoing further lookup.
In physical therapy, I would put the patient on core strength training and Myofascial Release therapy. The duration should be 4-6 weeks, 1-3 times a week. If the patient's insurance can pay for it, I also recommend aqua-therapy that the patient performs in water because water enables several types of training that patients really enjoy especially if they are old or with arthritis.
It's important to maintain a dialogue with the physical therapist that you trust to ensure that you are getting the right type of physical therapy and under supervision.
Q: Which medications do you recommend for patients suffering from these symptoms?
A: For patients with nerve pinch induced back pain. Then I would definitely start with Gabapentin. This drug can cause dizziness and tiredness, so I usually recommend taking it at night, 300mg and increase the dosage according to how much the patient can tolerate.
If the patient has pain triggers and I can't quite confirm that they are having nerve pain symptoms like burning sensation, numbness, and weakness but show signs of musculoskeletal pains, then I would likely pick Cymbalta. It's a really good medication. It is an antidepressant, but a lot of patients have found it very effective at treating neuropathic and musculoskeletal pain. I would be pretty receptive to starting that early on unless they have other issues that prevent the patient from using Cymbalta.
I definitely would not start narcotics at the very first meeting. That's definitely a discussion for later on. I want to address the pain and solve it. Narcotics is just a bandaid and can cause addictions. Narcotics is not going to solve the pain issue. So I usually do not recommend starting with that.
Disclaimer: The article does not replace an evaluation by a physician. Information on this page is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes.