4. Pain
Site Time and mode of onset
Severity or Intensity Character or Nature
Progression Referred pain
Aggravating factors Relieving factors
Any diurnal variation Any seasonal variation
5. History
Pain
Referred pain
More in the back
Doesn’t go beyond the knees
Radiating pain
Mainly in the LL , often associated with paresthesia
Neural compression (Sciatica)
7. History
Pain
Red Flags in Back Pain
Age of Onset less than 20 or more than 55
Violent Trauma
Thoracic spine pain
Constant progressive non-mechanical pain
Weight loss or systemic unwell
Widespread neurology
Structural deformity
12. Examination
Develop a standard routine
Alleviate the patient's fears
Adequate exposure - bilateral
Explain to the patient
Start with general and systemic exam
13. Local Examination
• InspectionLOOK
• PalpationFEEL
• Active/Passive movement
• Strength Testing
• Range of Motion
MOVE
• Dermatomes & Myotomes
• ReflexesNeurologic
• Depends upon specific region in considerationSPECIAL TESTS
23. Inspection
Standing
Look from front, back, and side
Spine alignment
Lower limb alignment and length
Shoulder and pelvic balance
Trunk shift
Walking
Gait pattern
24.
25. Palpation
Setting
Occipital protuberance and its muscular attachments
Cervical spinous processes
Paravertebral muscles
Standing
Thoracic and lumbar spine spinous processes ( assess
for any deformity )
Deep palpation by tapping
Sacroiliac joint
33. Neurological Examination- Reflexes
Superficial
Abdominal Reflex
Use a blunt object such as a
key or tongue blade.
Stroke the abdomen lightly
on each side in an inward and
downward direction.
Note the contraction of the
abdominal muscles and
deviation of the umbilicus
towards the stimulus.
36. Neurological Examination- Reflexes
Deep Tendon Reflexes
Biceps C5-6
The patient's arm should be
partially flexed at the elbow
with the palm down.
Place your thumb or finger
firmly on the biceps tendon.
Strike your finger with the
reflex hammer.
Look for contraction of the
biceps muscle and slight
flexion of the forearm.
37. Neurological Examination- Reflexes
Deep Tendon Reflexes
Triceps C6-7
Support the upper arm and
let the patient's forearm hang
free
Strike the triceps tendon
above the elbow with the
broad side of the hammer.
Observe contraction of the
triceps muscle with extension
of the lower arm.
38. Neurological Examination- Reflexes
Deep Tendon Reflexes
Brachioradialis C5-6
Have the patient rest the
forearm on the
abdomen or lap.
Strike the radius about
1-2 inches above wrist.
Watch for flexion and
supination of forearm
39. Neurological Examination- Reflexes
Deep Tendon Reflexes
Knee Reflex L3-4
Have the patient sit with
knee flexed.
Strike the patellar
tendon just below the
patella.
Note contraction of the
quadriceps muscle and
extension of the knee
40. Neurological Examination- Reflexes
Deep Tendon Reflexes
Ankle Reflex S1-2
Dorsiflex the foot at the
ankle.
Strike the Achilles tendon.
Watch and feel for
plantar flexion at the
ankle.
41. Special Tests
Lasegue’s Test for The Arm
The arm is 90 degrees abducted and extended
Ask the patient to tilt the head to the non affected
side
Positive test if the patient feels pain radiating distal
to the elbow and tingling in specific dermatome
42.
43. Special Tests
Spurling’s Test
Ask the patient to extend the neck and to laterally
flex to the affected side
Positive if there is pain radiating distal to the elbow
and tingling in a specific dermatome
Additional pressure applied by the examiner on the
head sometimes needed
44.
45. Special Tests
Straight Leg Raising (SLR) test
Ask the patient to raise the leg without flexing the
knee (actively) and assess for radiating pain from the
back to the leg or the foot
Repeat it passively to confirm
SLR considered positive only if the pain is distal to
the knees
Indicates disc prolapse or foramen stenosis in sciatic
nerve roots
47. Special Tests
Bragard’s Test
After SLR Lower the leg for 5 degrees (from the
degree that shows positive SLR)
Dorsiflex the ankle joint
Positive if similar finding to SLR
48. Special Tests
Femoral Nerve Stretch Test
Hip extension in prone position
Positive when the patient complains of pain at the front
of the thigh
Indicates tension at femoral nerve roots (L2,3,4)