Screening Low Back Patients For Serious Conditions in Physical
Therapy
Low back pain is one of the most common complaints that a
physical therapist will come across in their practice.
According to Koopmeiner (1), “Any good physical therapist
will find some biomechanical abnormality on any patient over
20 years of age. The problem is relating it to the patients
presenting complaints.” As PT’s transition towards direct
access and become more of an integral part of a patient’s
care, they must be able to identify red flags that may
present as low back pain.
There are many reasons why physical therapists need to screen their
patients for potentially serious conditions. One reason may
be that a patient was referred without seeing the physician.
This can happen in states where they already have direct
access or rural areas where the nearest physician may be too
far. Another reason may be that the physician had time
constraints and did not properly screen the patient
themselves. With managed care, physicians may also not order
as many diagnostic tests that could potentially catch
underlying medical conditions. Patients also forget to tell
physicians their true symptoms because of fear, denial or
embarrassment. The bottom line is, there is definitely a
need for medical screening and here is a short table (2) on
what to possibly screen for during a low back evaluation.
| Condition |
Red Flags to look for during Subjective Exam |
Red Flags to look for during the Physical Exam |
|
Back Related Tumor (3,4) |
• Over 50 years old
•
History of Cancer
•
Unexplained weight loss
•
No progress with conservative therapy |
• Vague, general
presentation of symptoms
•
Constant pain not affected with position or activity
•
Worse with weight bearing
•
Worse at night
•
Neurological signs in lower extremity |
|
Back Related Infection (Spinal Osteomyelitis) (5) |
• Recent infection (eg
urinary tract or skin infection)
•
IV drug user
•
Concurrent Immunosuppressive disorder |
• Deep constant pain,
increases with weight bearing; may radiate
•
Fever, malaise, swelling
•
Spine rigidity, hypomobile joints |
|
Cauda Equina Syndrome (3,6) |
• Urine Incontinence or
retention
•
Fecal Incontinence
•
Saddle Anesthesia
•
Global or progressive weakness in the lower
extremities |
• Sensory deficits in
the feet (L4-S1)
•
Weakness in ankle dorsiflexion and plantar flexion,
toe extension |
|
Spinal Fracture (3,7) |
• History of trauma
(including minor falls or heavy lifts)
•
Osteoporosis
•
Prolonged steroid use
•
Over 70 years old
•
Loss of function or mobility |
• Point tenderness over
site of fracture
•
Increased pain with weight bearing
•
Edema in local area |
|
Abdominal Aneurysm (8,9) |
• Back, abdominal or
groin pain
•
History of peripheral vascular disease, coronary
artery disease
•
Age over 50, HTN, DM
•
Symptoms not related to movement |
• Abnormal width of
aortic or iliac arterial pulses
•
Presence of a bruit in the central epigastric area
upon auscultation |
|
Kidney Disorders (10) |
• Unilateral flank or
low back pain
•
Difficulty with initiating urination, painful
urination, blood in the urine
•
Recent UTI
•
History of Kidney Stones |
• Positive Fist
percussion test over kidney |
This article is just a small piece of a vast amount of
information available on medical screening of patients. Physical
therapists
are advised to continue to research and take continuing
education to practice and enhance their screening skills.
I feel that the real purpose of medical screening is to
evaluate a patient’s complaints and determine whether the
patient has signs and symptoms of a systemic disease or
medical condition that needs to be further evaluated by a
more appropriate health care provider. Therefore,
medical screening should not be used to diagnose a disease,
but rather safely screen for potential life threatening
conditions that are beyond the scope of physical therapy.
The take home message: “When in Doubt, Refer Out.”
Last revised: February 4, 2010
by Denny Patel, DPT, CSCS
REFERENCES
1) BoissonnaultW, Koopmeiners M. Medical History Profile:
Orhtopaedic Physical Therapy Patients. JOSPT . 1994;20(1):2-10.
2) Godges, Joe. Kaiser Permanente California Orthopedic
residency. 2000.
3) Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in
Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642.
Rockville, MD: Agency for Health Care Policy and Research, Public health
Service, U.S. Department of Health and Human Services. December 1994.
4) Deyo RA, Diehl AK. Cancer as a cause of back pain; frequency,
clinical presentation, and diagnostic strategies. J Gen Intern Med 1988; 3:
230-238.
5) Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med 1997;
336:999-1007.
6) Hakelius A, Hindmarsh J. The comparative reliability of
preoperative diagnostic methods in lumbar disc surgery. Acta Orthop Scand
1972; 43: 234-238.
7) Deyo RA, Rainville J, Kent DL. What can the history and
physical examination tell us about low back pain? JAMA 1992; 268; 760-765.
8) Halperin JL. Evaluation of patients with peripheral vascular
disease. Thrombosis Research. 2002; 106: V303-V311.
9) Krajewski LP, Olin JW. Atherosclerosis of the aorta and lower
extremities arteries. In: Youn JR, Olin JW, Bartholomew JR, editors.
Peripheral Vascular Diseases. 2nd ed. St Louis: Yearbook Medical Publishing,
1996.
10) Bajwa ZH. Pain patterns in patients with polysystic kidney disease.
Kidney Int. 2004; 66: 1561-1569.
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