Persistent Lower Back Pain

Assessment and Diagnosis of Persistent Low Back Pain

All patients with low back pain should have a comprehensive evaluation including measurement of pain intensity.^5-8 Pain intensity can be assessed using a unidimensional scale; use of the same scale at each visit will help monitor pain progression, remission, and response to therapy. Patients also should be asked to describe how the pain interferes with activities of daily living (ADLs); patients with severe or prolonged pain may describe a loss of interest in social activities, excessive or insufficient sleep, loss of interest or function in sexual activity and weight gain or loss.

Elements of the patient history which may be particularly relevant to the assessment of low back pain include a history of the present pain (including failed treatments), risk factors for cancer, medication use, complaints of numbness or weakness in the legs, bladder or bowel dysfunction and a psychosocial history (including history of substance abuse and disability compensation).The timing, circumstances surrounding onset, aggravating and alleviating factors, and the quality of the pain (e.g., sharp, dull) may provide clues regarding etiology.

The physical examination^5-8 should include palpation for spinal tenderness and neuromuscular testing (i.e., strength at hip and knee, and ankle and knee reflexes). A straight leg raise should be assessed bilaterally to evaluate for nerve root impingement including, but not limited to, disc herniation. The sensory examination should assess pin prick sensation in the medial, dorsal and lateral aspects of the foot. The presence of a neurological deficit should prompt early referral for specialist evaluation, especially if the deficit is progressing. As with many persistent pain syndromes, patients with debilitating, persistent back pain may benefit from a psychological evaluation.^6,8