Non-Specific Low Back Pain

Procedure

Patient supine, both legs straight, no pillow under the head. Lift the symptomatic leg slowly with the knee held straight until the patient reports symptoms or you reach end of range. Note the angle and where the symptoms are felt. Adding ankle dorsiflexion or neck flexion at that point helps tell nerve pain from hamstring stretch.

Positive Finding

The patient's familiar leg pain, usually below the knee, reproduced as the leg is raised and made worse by ankle dorsiflexion or neck flexion. Back pain alone or a posterior thigh stretch does not count.

Interpretation

In non-specific low back pain this test is a screen, not a diagnosis. A negative test fits the picture of back pain without nerve-root involvement. A positive test points away from non-specific low back pain towards radicular pain, and the neurological examination should follow. Here the SLR is used to check for nerve-root involvement, which by definition is absent in non-specific low back pain. Its published accuracy is for disc herniation causing leg pain (see the lumbar disc herniation page), so no figure is shown here.

Procedure

Patient standing. Mark the midpoint between the two posterior superior iliac spines (the dimples of Venus), then mark 15 cm above it (modified-modified Schober). Ask the patient to bend forward as far as comfortable with knees straight and re-measure the distance between the marks.

Positive Finding

Less increase in the distance than expected, or bending limited by pain or guarding. Record the measurement and what stopped the movement.

Interpretation

A measure of how much the lumbar spine moves, not a diagnostic test. Use it as a baseline and to track change with treatment. Marked, persistent loss of lumbar flexion in a younger adult with inflammatory-type back pain (morning stiffness, better with movement) should prompt assessment for axial spondyloarthritis. This is a range-of-motion measurement, not a test that diagnoses a condition, so sensitivity and specificity do not apply.

Procedure

Patient prone with a pillow under the abdomen if needed. Palpate the spinous processes, the paraspinal muscles and the interspinous spaces from T12 to the sacrum, then apply gentle posterior-to-anterior pressure at each level. Ask whether any pressure reproduces the familiar pain.

Positive Finding

Tenderness, increased muscle tone or reproduction of the familiar pain at one or more levels, compared with levels above and below.

Interpretation

Helps locate the painful region and guides where to start treatment. Agreement between clinicians on which segment is stiff or tender is poor, so the finding should not be used to name a pain source. Tenderness in non-specific low back pain is common and expected.

Procedure

Patient standing. Guide the trunk into extension, then side-bending and rotation towards the painful side, and add gentle overpressure through the shoulders if tolerated. Repeat to the other side.

Positive Finding

Reproduction of the familiar local back pain on the side of the movement. Leg pain in this position is recorded separately, as it may reflect narrowing of the foramen rather than a joint source.

Interpretation

A movement that loads the posterior joints and structures on one side. A positive result tells you which movement provokes the pain, which is useful for treatment and for tracking progress. It cannot identify the facet joint as the pain source. A 2014 systematic review (Stuber et al.; 5 studies, nerve blocks as the reference) looked at this extension–rotation test (Kemp's test) for facet joint pain. In the 2 studies that used confirmatory double blocks (320 patients), it was positive in 46% of people with facet joint pain and negative in 47% of those without, which is no better than chance. The review was about facet joint pain, not non-specific low back pain, so no figure is shown.

Procedure

Patient prone. Bend the knee to about 90° and then lift the thigh into hip extension while stabilising the pelvis with your other hand. Note what the patient feels and where. This combines a hip flexor stretch with the femoral nerve stretch position.

Positive Finding

Either a stretch felt at the front of the hip or thigh (hip flexor tightness), or the patient's familiar anterior thigh pain (possible upper lumbar nerve-root involvement), or low back pain as the lumbar spine is drawn into extension.

Interpretation

Record which of the three responses occurred, because they mean different things. Familiar anterior thigh pain should lead to a neurological examination of L2–L4. Back pain alone is consistent with non-specific low back pain and simply shows that extension is provocative.

Procedure

Patient seated with feet on the floor to lock the pelvis (or standing). Ask the patient to turn the trunk to each side as far as comfortable, arms folded across the chest. Compare the two sides and note any pain.

Positive Finding

Less rotation to one side, pain at end of range, or guarded, hesitant movement.

Interpretation

A range-of-motion and pain-behaviour check, not a diagnostic test. Most trunk rotation happens in the thoracic spine, so a sitting test mainly reflects thoracic movement. Use it as a baseline and to monitor response to treatment.