Clinical Examination, Diagnosis, and Conservative Treatment of Chronic Low Back Pain: A Narrative Review
Abstract
:1. Introduction
2. Method
3. Diagnosis
3.1. History
3.2. Physical Examination
3.2.1. Observation
3.2.2. Palpation
3.2.3. Range of Motion
3.2.4. Neurological Examination
Sensory Examination
Motor Examination
Reflexes
3.2.5. Specific Tests of the Lumbar Spine
Straight Leg Raising
Crossed Straight Leg Raise
Bragard’s Test
Slump Test
Femoral Nerve Stretch
Kemp’s Test
Prone Instability Test
Summary of Specificity and Sensitivity
3.3. Specific Test of the Hips
3.4. Specific Testing of the Sacroiliac Joint
3.4.1. Patrick Test (FABERE)
3.4.2. Provocation Tests
Distraction
Compression
Thigh Trust
Gaenslen’s Test
Shear Test
3.4.3. Specificity and Sensitivity
4. Treatment
4.1. Non-Pharmacological Treatment
4.1.1. Reassurance and Patient Education
4.1.2. Manual Techniques
4.1.3. Massage
4.1.4. Acupuncture/Trigger Point Therapy
4.1.5. Lumbar Supports
4.1.6. Psychological Intervention
4.1.7. Kinesiotape
4.1.8. Exercise
4.1.9. Multidisciplinary Biopsychosocial Rehabilitation (MBR)
5. Some Specific Pathologies
5.1. Anterior Element Pain
5.2. Unilateral Facet Joint Pain
5.3. Sacroiliac Dysfunction
5.4. Hip Pathology
5.5. Other Pathologies
6. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Urgent | ||
Red flag | Action | |
Neurological
| Refer patient to emergency care | |
Traumatic fractures
OR
| Refer patient to emergency care | |
Vascular issues
| Refer patient to emergency care Ultrasound and vascular surgery consultation | |
Semi-urgent (in 48 h) | ||
Red flag | Action | |
Pathological fracture Low back pain after minor trauma or even without a notion of trauma with:
| X-ray (or CT) and consultation with a spine specialist | |
Infection
|
| |
Less urgent | ||
Red flag | Action | |
Tumor
|
| |
Inflammatory condition
| Consultation—rheumatology | |
Miscellaneous
|
|
Flag | Explanation |
---|---|
Yellow flag [2,6,8,16] | Beliefs and perceptions Emotional responses to pain |
Orange flags | Psychiatric symptoms (depression or personality disorder) |
Black flags | System or contextual matters (e.g., profession, family, etc.) |
Blue flags | Perception of the relationship between work and health |
When Pathological? | ||||
Pathological reflex | Plantar reflex Babinski sign | Stimulus is applied to the sole from the lateral border up to and across the ball of the foot | Extension of the big toe and abduction of the other toes | |
Muscle stretch reflex (lower limb) | Assessed by tapping over the muscle tendon with a reflex hammer | Hyporeflexia Hyperreflexia +− Clonus | ||
Patella | Femoral nerve | L2–L4 | ||
Achilles | Tibial nerve | S1–S2 |
Index Test | Gold Standard | Sensitivity (95% CI) | Specificity (95% CI) |
---|---|---|---|
Sensory deficit | Surgery | 0.40 (0.38, 0.43) | 0.59 (0.51, 0.67) |
Imaging | 0.32 (0.28, 0.37) | 0.72 (0.67, 0.77) | |
Imaging by level | 0.35 (0.33, 0.38) | 0.64 (0.61, 0.66) | |
Motor deficit | Surgery | 0.22 (0.21, 0.23) | 0.79 (0.77, 0.80) |
Imaging by level | 0.40 (0.37, 0.42) | 0.62 (0.60, 0.64) | |
Reflex deficits | Surgery | 0.29 (0.28, 0.30) | 0.78 (0.76, 0.80) |
Imaging by level | 0.25 (0.22, 0.28) | 0.75 (0.73, 0.78) |
Test | Sensitivity | Specificity | Source |
---|---|---|---|
Straight Leg Raise | 0.85 0.91 0.73–0.98 0.92 | 0.28 0.52 0.26 0.11–0.61 0.10–1 | [21] [22] [23] [2] [24] |
Crossed SLR | 0.28 0.29 0.23–0.43 | 0.90 0.88 0.88–0.98 | [21] [23] [2] |
Femoral Nerve Stretch | 0.84–0.95 | [12] | |
Kemp’s test | 0.23–1 | 0.116–0.673 | [25] |
Prone Instability test | 0.72 | 0.58 | [26] |
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Custers, P.; Van de Kelft, E.; Eeckhaut, B.; Sabbe, W.; Hofman, A.; Debuysscher, A.; Van Acker, G.; Maes, G. Clinical Examination, Diagnosis, and Conservative Treatment of Chronic Low Back Pain: A Narrative Review. Life 2024, 14, 1090. https://doi.org/10.3390/life14091090
Custers P, Van de Kelft E, Eeckhaut B, Sabbe W, Hofman A, Debuysscher A, Van Acker G, Maes G. Clinical Examination, Diagnosis, and Conservative Treatment of Chronic Low Back Pain: A Narrative Review. Life. 2024; 14(9):1090. https://doi.org/10.3390/life14091090
Chicago/Turabian StyleCusters, Paulien, Erik Van de Kelft, Bart Eeckhaut, Wouter Sabbe, An Hofman, Annick Debuysscher, Gilles Van Acker, and Gaethan Maes. 2024. "Clinical Examination, Diagnosis, and Conservative Treatment of Chronic Low Back Pain: A Narrative Review" Life 14, no. 9: 1090. https://doi.org/10.3390/life14091090