General pain, quality of life and disability assessment has been discussed previously as has general management issues and you may want to cross reference with the appropriate articles while reading through the next section. Before continuing, it is important that the assessment and management of low back pain is based on effective communication by the clinicians so that the patients understand the key messages conveyed. The Australian Acute Musculoskeletal Pain Guidelines Group  produced consensus statements regarding communication:
- Clinicians should work with patients to develop a management plan so that the patients know what to expect and understand their role and responsibilities;
- Information should be conveyed in correct but neutral terms, avoiding alarming diagnostic labels, and jargon should be avoided;
- Explanation is important to overcome inappropriate expectations, fears or mistaken beliefs that patients may have about their condition or its management;
- Printed materials and models may be useful for communicating concepts;
- Clinicians should adapt their method of communication to meet the needs and abilities of each patients;
- Clinicians should check that information that has been provided has been understood, barriers to understanding should be explored and addressed.
Muir Gray , a leader in evidence-based practice, had a chapter ‘Doing the right things right’. When considering treatment regimens for patients, it is important to assess what the patient actually needs rather than basing prescribing on the basis of ‘one fit for all’. An intriguing study from Norway suggests that treating the right patient right can have real benefits . The study contained two studies in one with the main study looking at different levels of intervention for people off sick from work with musculoskeletal problems for more than eight weeks. The subsidiary study examined the effectiveness of treatment depending on an initial prognosis determined by a screening instrument.
See more: Low Back Pain: The Problem
The final sample consisted of 654 individuals who agreed to participate from a total of 1,988 approached. The participants were examined by a physiotherapist and given a questionnaire and graded as having a good, medium or poor prognosis to return to work. The outcome was return to work one year after the intervention.
There were three treatment groups and these were well matched at baseline with three quarters of the patients having back, neck or shoulder pain. Haland Haldorsen et al found that for patients with a good prognosis there was no difference between what treatments they received, for those with a medium prognosis there was no additional effect of extensive over light multidisciplinary treatment.
Ordinary treatment gave poor results. And for the patients with poor prognosis, extensive multidisciplinary treatment was superior to ordinary or light multidisciplinary treatment. Most patients returned to work if they were given treatment appropriate to their screening category.
Therefore, this study reveals that doing the right thing for the right patient pays dividends. One size does not fit all and the average results from studies need not apply to individuals. Therefore, when weighing up the evidence of effect, maybe we should be more thorough in searching out whether the ‘right’ patients were involved.
Click here for a presentation by Dr. Sally Venn which gives an accurate interpretation of how we should be interpreting the current available evidence on low back pain.
For further information on performing a physical examination for low back pain and extremities please consult Hoppenfeld  (although an old text book it is extremely useful).
The website http://www.patient.co.uk/showdoc/40001079/ reinforces the key messages discussed by Dr. Sally Venn and provides an overview of assessment and management. Red flags are dealt with in a text by Greenhalgh et al  and Main et al  discuss the biopsychosocial assessment.
A number of components make up the assessment and diagnostic regimen and these have been outlined in previous articles. In consulting the evidence, some of the components in assessing and diagnosing acute low back pain lack rigorous research to inform practice whereas other assessment and diagnostic tools are well supported:
- Patient history enables screening for features of serious conditions, however, the reliability and validity of individual features in histories have low diagnostic significance (,).
- Common findings in patients with low back pain (e.g. osteoarthritis, lumbar spondylosis, spinal canal stenosis) also occur in asymptomatic people, hence such conditions may not be the cause of the pain .
- Clinicial signs detected during physical and psychosocial assessment must be interpreted cautiously as many tests lack reliability and validity (, ).
- In the presence of lower limb pain and other neurological symptoms, a full neurological examination is warranted (, )
- Plain X-rays of the lumbar spine are not routinely recommended in acute non-specific low back pain because they are of limited diagnostic value and no benefits in physical function, pain or disability are observed (, , ).
- Appropriate investigations are indicated in cases of acute low back pain when ‘red flags’ alert the clinician of serious pathology .
The following are useful reviews in the assessment of low back pain:
- A review of psychological risk factors in back and neck pain .
- Prognostic factors for musculoskeletal pain in primary care .
- Do psychosocial factors predict disability and health at a 3-years follow up for patients with non-acute musculoskeletal pain? .
- Screening to identify patients at risk .
- Primary care back pain screening tool .
- Screening for yellow flags in first-time acute low back pain .
- Group, A.Acute Musc, 2004. Evidence-Based Management of Acute Musculoskeletal Pain.
Gray, J.A.Muir, 1997. Evidence-based healthcare. Churchill Livingstone, New York.
- Haldorsen, E.M., Grasdal, A.L., Skouen, J.S., Risa, A.E., Kronholm, K., Ursin, H., 2002. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.. Pain, Pain 95, 49-63.
- Hoppenfeld, S., 1976. Physical examination of the spine and extremities. Appleton-Century-Crofts, New York.
- Greenhalgh, S., Selfe, J., Gifford, L., 2006. Red Flags: A Guide to Identifying Serious Pathology of the Spine. C
- hurchill Livingstone, Oxford.
Main, C.J., Sullivan, M.J.L., Watson, P.L., 2007. Pain Management: Practical Application of Biopsychosocial Perspectives
- in Clinical and Occupational Settings.. Churchill Livingstone, Oxford.
- Deyo, R.A., Rainville, J., Kent, D.L., 1992. What can the history and physical examination tell us about low back pain?.
- JAMA, JAMA 268, 760-5.
- van den Hoogen, H.M., Koes, B.W., van Eijk, J.T., Bouter, L.M., 1995. On the accuracy of history, physical examination,
- and erythrocyte sedimentation rate in diagnosing low back pain in general practice. A criteria-based review of the
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van Tulder, M.W., Assendelft, W.J., Koes, B.W., Bouter, L.M., 1997. Spinal radiographic findings and nonspecific low
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Truchon, M., Fillion, L., 2000. Biopsychosocial determinants of chronic disability and low back pain: a review.. Journal of
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- K.O., 2002. Motion palpation findings and self-reported low back pain in a population-based study sample.. J
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Waddell, G., Main, C.J., Morris, E.W., Venner, R.M., Rae, P.S., Sharmy, S.H., Galloway, H., 1982. Normality and reliability in the clinical assessment of backache.. Br Med J (Clin Res Ed), Br Med J (Clin Res Ed) 284, 1519-23.
- McCombe, P.F., Fairbank, J.C., Cockersole, B.C., Pynsent, P.B., 1989. 1989 Volvo Award in clinical sciences.
- Reproducibility of physical signs in low-back pain.. Spine (Phila Pa 1976), Spine (Phila Pa 1976) 14, 908-18.
- Suarez-Almazor, M.E., Belseck, E., Russell, A.S., Mackel, J.V., 1997. Use of lumbar radiographs for the early diagnosis of low back pain. Proposed guidelines would increase utilization.. JAMA, JAMA 277, 1782-6.
- Kendrick, D., Fielding, K., Bentley, E., Kerslake, R., Miller, P., Pringle, M., 2001. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.. BMJ, BMJ 322, 400-5.
- Kerry, S., Hilton, S., Dundas, D., Rink, E., Oakeshott, P., 2002. Radiography for low back pain: a randomised controlled
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- Deyo, R.A., Diehl, A.K., 1986. Lumbar spine films in primary care: current use and effects of selective ordering criteria.. J Gen Intern Med, J Gen Intern Med 1, 20-5.
- Linton, S.J., 2000. A review of psychological risk factors in back and neck pain.. Spine (Phila Pa 1976), Spine (Phila Pa
- 1976) 25, 1148-56.
Mallen, C.D., Peat, G., Thomas, E., Dunn, K.M., Croft, P.R., 2007. Prognostic factors for musculoskeletal pain in primary care: a systematic review.. Br J Gen Pract, Br J Gen Pract 57, 655-61.
- Westman, A., Linton, S.J., Ohrvik, J., Wahlén, P., Leppert, J., 2008. Do psychosocial factors predict disability and health
- at a 3-year follow-up for patients with non-acute musculoskeletal pain? A validation of the Orebro Musculoskeletal Pain
- Screening Questionnaire.. Eur J Pain, Eur J Pain 12, 641-9.
- Boersma, K., Linton, S.J., 2005. Screening to identify patients at risk: profiles of psychological risk factors for early
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- Hill, J.C., Dunn, K.M., Lewis, M., Mullis, R., Main, C.J., Foster, N.E., Hay, E.M., 2008. A primary care back pain
- screening tool: identifying patient subgroups for initial treatment.. Arthritis Rheum, Arthritis Rheum 59, 632-41.
- Grotle, M., Vøllestad, N.K., Brox, J.I., 2006. Screening for yellow flags in first-time acute low back pain: reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire.. Clin J Pain, Clin J Pain 22, 458-67.