0
August 12, 1992, Vol 268, No. 6 >
ARTICLE | August 12, 1992

What Can the History and Physical Examination Tell Us About Low Back Pain? FREE

Richard A. Deyo, MD, MPH; James Rainville, MD; Daniel L. Kent, MD
[+] Author Affiliations

Reprint requests to Back Pain Outcome Assessment Team, JD-23, University of Washington, Seattle, WA 98195 (Dr Deyo).


JAMA. 1992;268(6):760-765. doi:10.1001/jama.1992.03490060092030
Text Size: A A A
Published online
Article
References

BACK pain ranks second only to upper respiratory illness as a symptomatic reason for office visits to physicians.1 About 70% of adults have low back pain at some time, but only 14% have an episode that lasts more than 2 weeks. About 1.5% have such episodes with features of sciatica.2,3 Most causes of back pain respond to symptomatic and physical measures, but some are surgically remediable and some are systemic diseases (cancer or disseminated infection) requiring specific therapy, so careful diagnostic evaluation is important. Features of the clinical history and physical examination influence not only therapeutic choices but also decisions about diagnostic imaging, laboratory testing, and specialist referral.

ANATOMIC/PHYSIOLOGIC ORIGINS OF FINDINGS IN THE LOW BACK  Low back pain may arise from several structures in the lumbar spine, including the ligaments that interconnect vertebrae, outer fibers of the annulus fibrosus, facet joints, vertebral periosteum, paravertebral musculature and fascia,

REFERENCES

1 +
Cypress BK.  Characteristics of physician visits for back symptoms: a national perspective. Am J Public Health . 1983;;73:389-395.
2 +
Deyo RA, Tsui-Wu JY.  Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine . 1987;;12:264-268.
3 +
Deyo RA, Loeser JD, Bigos SF.  Herniated lumbar intervertebral disk. Ann Intern Med . 1990;;112: 598-603.
4 +
White AA, Gordon SL.  Synopsis: workshop on idiopathic low-back pain. Spine . 1982;;7:141-149.
5 +
Nachemson A.  The lumbar spine: an orthopedic challenge. Spine . 1976;;1:59-71.
6 +
Weisel SE, Tsourmas N, Feffer H, Citrin CM, Patronas N.  A study of computer-assisted tomography, I: the incidence of positive CAT scans in an asymptomatic group of patients. Spine . 1984;;9:549-551.
7 +
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW.  Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joint Surg Am . 1990;;72:403-408.
8 +
Liang M, Komaroff AL.  Roentgenograms in primary care patients with acute low back pain: a cost-effectiveness analysis. Arch Intern Med . 1982;; 142:1108-1112.
9 +
Deyo RA.  Early diagnostic evaluation of low back pain. J Gen Intern Med . 1986;;1:328-338.
10 +
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.
11 +
Scavone JG, Latshaw RF, Weidner WA.  Anteroposterior and lateral radiographs: an adequate lumbar spine examination. Am J Radiol . 1981;;136: 715-717.
12 +
GehweilerJA, Daffner RH.  Low back pain: the controversy of radiologic evaluation. Am J Radiol . 1983;;140:109-112.
13 +
Brekkan A.  Radiographic examination of the lumbosacral spine: an 'age-stratified' study. Clin Radiol . 1983;;34:321-324.
14 +
Carter ET, McKenna CH, Brian DD, Kurland LT.  Epidemiology of ankylosingspondylitisin Rochester, Minnesota, 1935-1973. Arthritis Rheum . 1979;; 22:365-370.
15 +
Hawkins BR, Dawkins RL, Christiansen FT, Zilko PJ.  Use of the B27 test in the diagnosis of ankylosing spondylitis: a statistical evaluation. Arthritis Rheum . 1981;;24:743-746.
16 +
Waldvogel FA, Vasey H.  Osteomyelitis: the past decade. N Engl J Med . 1980;;303:360-370.
17 +
Sapico FL, Montgomerie JZ.  Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis . 1979;;1:754-776.
18 +
Baker AS, Ojemann RG, Swartz MN, et al.  Spinal epidural abscess. N Engl J Med . 1975;;293: 463-468.
19 +
Chandrasekar PH.  Low back pain and intravenous drug abusers. Arch Intern Med . 1990;;150: 1125-1128.
20 +
McCombe PF, Fairbank JCT, Cockersole BC, Pynsent PB.  Reproducibility of physical signs in low-back pain. Spine . 1989;;14:908-918.
21 +
Bauer RL, Deyo RA.  Low risk of vertebral fracture in Mexican American women. Arch Intern Med . 1987;;147:1437-1439.
22 +
Calin A, Porta J, Fries JF, Schurman DJ.  Clinical history as a screening test for ankylosing spondylitis. JAMA . 1977;;237:2613-2614.
23 +
Gran JT.  An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin Rheumatol . 1985;;4:161-169.
24 +
Van der Linden S, Valkenburg HA, Cats A.  Evaluation of diagnostic criteria for ankylosing spondylitis: a proposal for modification of the New York criteria. Arthritis Rheum . 1984;;27:361-368.
25 +
Calin A, Kaye B, Sternberg M, Antell B, Chan M.  The prevalence and nature of back pain in an industrial complex: questionnaire and radiographic and HLA analysis. Spine . 1980;;5:201-205.
26 +
Reynolds PMG.  Measurement of spinal mobility: a comparison of three methods. Rheumatol Rehabil . 1975;;14:180-185.
27 +
Rae PS, Waddell G, Venner RM.  A simple technique for measuring lumbar spinal flexion. JRColl Surg Edin . 1984;;29:281-284.
28 +
MollJMH, Wright V.  An objective clinical study of chest expansion. Ann Rheum Dis . 1972;;31:1-8.
29 +
Potter NA, Rothstein JM.  Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther . 1985;;65:1671-1675.
30 +
Russell AS, Maksymowych W, LeClercq S.  Clinical examination of sacroiliac joints: a prospective study. Arthritis Rheum . 1981;;24:1575-1577.
31 +
Blower PW, Griffin AJ.  Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain. Ann Rheum Dis . 1984;;43:192-195.
32 +
Mayer TG, Tencer AF, Kristoferson S, Mooney V.  Use of non invasive techniques for quantification of spinal range of motion in normal subjects and chronic low-back pain dysfunction patients. Spine . 1984;;9:588-595.
33 +
Spangfort EV.  Lumbar disc herniation: a computer aided analysis of 2504 operations. Acta Orthop Scand . 1972;;( (suppl 142) ):1-93.
34 +
Alpers BJ.  The neurological aspects of sciatica. Med Clin North Am . 1953;;37:503-510.
35 +
Brieg A, Troup JDG.  Biomechanical considerations in the straight-leg-raising test: cadaveric and clinical studies of medial hip rotation. Spine . 1979;; 4:242-250.
36 +
CharnleyJ.  Orthopedic signs in the diagnosis of disc protusion with special reference to the straight leg raising test. Lancet . 1951;;1:186-192.
37 +
Kosteljanetz M, Bang F, Schmidt-Olsen S.  The clinical significance of straight-leg-raising (Lasegue's sign) in the diagnosis of prolapsed lumbar disc. Spine . 1988;;13:393-395.
38 +
Waddell G, Main CS, Morris EW, et al.  Normality and reliability in the clinical assessment of backache. BMJ . 1982;;284:1519-1523.
39 +
Hoehler FK, Tobis JS.  Low back pain and its treatment by spinal manipulation: measures of flexibility and asymmetry. Rheumatol Rehabil . 1982;; 21:21-26.
40 +
Hsieh CY, Walker JM, Gillis K.  Straight leg raising test: comparison of three instruments. Phys Ther . 1983;;63:1429-1432.
41 +
Kosteljanetz M, Espersen JO, Halaburt H, Miletic T.  Predictive value of clinical and surgical findings in patients with lumbago-sciatica: a prospective study (part 1). Acta Neurochir . 1984;;73: 67-76.
42 +
Hakelius A, Hindmarsh J.  The comparative reliability of preoperative diagnostic methods in lumbar disc surgery. Acta Orthop Scand . 1972;;43:234-238.
43 +
Hakelius A, Hindmarsh J.  The significance of neurological signs and myelographic findings in the diagnosis of lumbar root compression. Acta Orthop Scand . 1972;;43:239-246.
44 +
Hudgins RW.  The crossed straight leg raising test: a diagnostic sign of herniated disc. J Occup Med . 1979;;21:407-408.
45 +
Shiqing X, Quanzhi Z, Dehao F.  Significance of straight-leg-raising test in the diagnosis and clinical evaluation of lower lumbar intervertebral disc protrusion. JBone Joint Surg Am . 1987;;69:517-522.
46 +
Kortelainen P, Puranen J, Koivisto E, Lahde S.  Symptoms and signs of sciatica and their relation to the localization of the lumbar disc herniation. Spine . 1985;;10:88-92.
47 +
Blower PW.  Neurologic patterns in unilateral sciatica. Spine . 1981;;6:175-179.
48 +
Schwartz RS, Morris JGL, Crimmins D, et al.  A comparison of two methods of eliciting the ankle jerk. Aust N Z J Med . 1990;;20:116-119.
49 +
Keegan JJ.  Dermatome hypalgesia associated with herniation of intervertebral disk. Arch Neurol Psychiatry . 1943;;50:67-83.
50 +
Aronson HA, Dunsmore RH.  Herniated upper lumbar discs. J Bone Joint Surg Am . 1963;;45:311317.
51 +
Morris EW, DiPaola M, Vallance R, Waddell G.  Diagnosis and decision making in lumbar disc prolapse and nerve entrapment. Spine . 1986;;11:436-439.
52 +
Turner JA, Ersek M, Herron L, Deyo R.  Surgery for lumbar spinal stenosis: attempted metaanalysis of the literature. Spine . 1992;;17:1-8.
53 +
Hawkes CH, Roberts GM.  Neurogenic and vascular claudication. J Neurol Sci . 1978;;38:337-345.
54 +
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D.  Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am . 1986;;68: 386-391.
55 +
O'Laoire SA, Crockard HA, Thomas DG.  Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse. BMJ . 1981;;282:1852-1854.
56 +
Tay ECK, Chacha PB.  Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina. J Bone Joint Surg Br . 1979;;61:43-46.
57 +
Spitzer WO, LeBlanc FE, Dupuis M, et al.  Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians: report of the Quebec Task Force on Spinal Disorders. Spine . 1987;;12( (suppl 7) ):S16S21.
58 +
Deyo RA, Bigos SJ, Maravilla KR.  Diagnostic imaging procedures for the lumbar spine. Ann Intern Med . 1989;;111:865-867.
59 +
Walsh NE, Dumitru D.  The influence of compensation on recovery from low back pain. Occup Med . 1988;;3:109-121.
60 +
Gatchel RJ, Mayer TG, Capra P, Diamond P, Barnett J.  Quantification of lumbar function, VI: the use of psychological measures in guiding physical functional restoration. Spine . 1986;;11:36-42.
61 +
Korbon GA, DeGood DE, Schroeder ME, Schwartz DP, Shutty MS.  The development of a somatic amplification rating scale for low-back pain. Spine . 1987;;12:787-791.
62 +
Burnam AM, Wells KB, Leake B, Landsverk J.  Development of a brief screening instrument for detecting depressive disorders. Med Care . 1988;;26: 775-789.
63 +
Rucker L, Frye EB, Cygan RW.  Feasibility and usefulness of depression screening in medical outpatients. Arch Intern Med . 1986;;146:729-731.
64 +
Waddell G, McCullochJA, Kummel E, Vernner RM.  Nonorganic physical signs in low back pain. Spine . 1980;;5:117-125.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Cypress BK.  Characteristics of physician visits for back symptoms: a national perspective. Am J Public Health . 1983;;73:389-395.
2 +
Deyo RA, Tsui-Wu JY.  Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine . 1987;;12:264-268.
3 +
Deyo RA, Loeser JD, Bigos SF.  Herniated lumbar intervertebral disk. Ann Intern Med . 1990;;112: 598-603.
4 +
White AA, Gordon SL.  Synopsis: workshop on idiopathic low-back pain. Spine . 1982;;7:141-149.
5 +
Nachemson A.  The lumbar spine: an orthopedic challenge. Spine . 1976;;1:59-71.
6 +
Weisel SE, Tsourmas N, Feffer H, Citrin CM, Patronas N.  A study of computer-assisted tomography, I: the incidence of positive CAT scans in an asymptomatic group of patients. Spine . 1984;;9:549-551.
7 +
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW.  Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joint Surg Am . 1990;;72:403-408.
8 +
Liang M, Komaroff AL.  Roentgenograms in primary care patients with acute low back pain: a cost-effectiveness analysis. Arch Intern Med . 1982;; 142:1108-1112.
9 +
Deyo RA.  Early diagnostic evaluation of low back pain. J Gen Intern Med . 1986;;1:328-338.
10 +
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.
11 +
Scavone JG, Latshaw RF, Weidner WA.  Anteroposterior and lateral radiographs: an adequate lumbar spine examination. Am J Radiol . 1981;;136: 715-717.
12 +
GehweilerJA, Daffner RH.  Low back pain: the controversy of radiologic evaluation. Am J Radiol . 1983;;140:109-112.
13 +
Brekkan A.  Radiographic examination of the lumbosacral spine: an 'age-stratified' study. Clin Radiol . 1983;;34:321-324.
14 +
Carter ET, McKenna CH, Brian DD, Kurland LT.  Epidemiology of ankylosingspondylitisin Rochester, Minnesota, 1935-1973. Arthritis Rheum . 1979;; 22:365-370.
15 +
Hawkins BR, Dawkins RL, Christiansen FT, Zilko PJ.  Use of the B27 test in the diagnosis of ankylosing spondylitis: a statistical evaluation. Arthritis Rheum . 1981;;24:743-746.
16 +
Waldvogel FA, Vasey H.  Osteomyelitis: the past decade. N Engl J Med . 1980;;303:360-370.
17 +
Sapico FL, Montgomerie JZ.  Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis . 1979;;1:754-776.
18 +
Baker AS, Ojemann RG, Swartz MN, et al.  Spinal epidural abscess. N Engl J Med . 1975;;293: 463-468.
19 +
Chandrasekar PH.  Low back pain and intravenous drug abusers. Arch Intern Med . 1990;;150: 1125-1128.
20 +
McCombe PF, Fairbank JCT, Cockersole BC, Pynsent PB.  Reproducibility of physical signs in low-back pain. Spine . 1989;;14:908-918.
21 +
Bauer RL, Deyo RA.  Low risk of vertebral fracture in Mexican American women. Arch Intern Med . 1987;;147:1437-1439.
22 +
Calin A, Porta J, Fries JF, Schurman DJ.  Clinical history as a screening test for ankylosing spondylitis. JAMA . 1977;;237:2613-2614.
23 +
Gran JT.  An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin Rheumatol . 1985;;4:161-169.
24 +
Van der Linden S, Valkenburg HA, Cats A.  Evaluation of diagnostic criteria for ankylosing spondylitis: a proposal for modification of the New York criteria. Arthritis Rheum . 1984;;27:361-368.
25 +
Calin A, Kaye B, Sternberg M, Antell B, Chan M.  The prevalence and nature of back pain in an industrial complex: questionnaire and radiographic and HLA analysis. Spine . 1980;;5:201-205.
26 +
Reynolds PMG.  Measurement of spinal mobility: a comparison of three methods. Rheumatol Rehabil . 1975;;14:180-185.
27 +
Rae PS, Waddell G, Venner RM.  A simple technique for measuring lumbar spinal flexion. JRColl Surg Edin . 1984;;29:281-284.
28 +
MollJMH, Wright V.  An objective clinical study of chest expansion. Ann Rheum Dis . 1972;;31:1-8.
29 +
Potter NA, Rothstein JM.  Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther . 1985;;65:1671-1675.
30 +
Russell AS, Maksymowych W, LeClercq S.  Clinical examination of sacroiliac joints: a prospective study. Arthritis Rheum . 1981;;24:1575-1577.
31 +
Blower PW, Griffin AJ.  Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain. Ann Rheum Dis . 1984;;43:192-195.
32 +
Mayer TG, Tencer AF, Kristoferson S, Mooney V.  Use of non invasive techniques for quantification of spinal range of motion in normal subjects and chronic low-back pain dysfunction patients. Spine . 1984;;9:588-595.
33 +
Spangfort EV.  Lumbar disc herniation: a computer aided analysis of 2504 operations. Acta Orthop Scand . 1972;;( (suppl 142) ):1-93.
34 +
Alpers BJ.  The neurological aspects of sciatica. Med Clin North Am . 1953;;37:503-510.
35 +
Brieg A, Troup JDG.  Biomechanical considerations in the straight-leg-raising test: cadaveric and clinical studies of medial hip rotation. Spine . 1979;; 4:242-250.
36 +
CharnleyJ.  Orthopedic signs in the diagnosis of disc protusion with special reference to the straight leg raising test. Lancet . 1951;;1:186-192.
37 +
Kosteljanetz M, Bang F, Schmidt-Olsen S.  The clinical significance of straight-leg-raising (Lasegue's sign) in the diagnosis of prolapsed lumbar disc. Spine . 1988;;13:393-395.
38 +
Waddell G, Main CS, Morris EW, et al.  Normality and reliability in the clinical assessment of backache. BMJ . 1982;;284:1519-1523.
39 +
Hoehler FK, Tobis JS.  Low back pain and its treatment by spinal manipulation: measures of flexibility and asymmetry. Rheumatol Rehabil . 1982;; 21:21-26.
40 +
Hsieh CY, Walker JM, Gillis K.  Straight leg raising test: comparison of three instruments. Phys Ther . 1983;;63:1429-1432.
41 +
Kosteljanetz M, Espersen JO, Halaburt H, Miletic T.  Predictive value of clinical and surgical findings in patients with lumbago-sciatica: a prospective study (part 1). Acta Neurochir . 1984;;73: 67-76.
42 +
Hakelius A, Hindmarsh J.  The comparative reliability of preoperative diagnostic methods in lumbar disc surgery. Acta Orthop Scand . 1972;;43:234-238.
43 +
Hakelius A, Hindmarsh J.  The significance of neurological signs and myelographic findings in the diagnosis of lumbar root compression. Acta Orthop Scand . 1972;;43:239-246.
44 +
Hudgins RW.  The crossed straight leg raising test: a diagnostic sign of herniated disc. J Occup Med . 1979;;21:407-408.
45 +
Shiqing X, Quanzhi Z, Dehao F.  Significance of straight-leg-raising test in the diagnosis and clinical evaluation of lower lumbar intervertebral disc protrusion. JBone Joint Surg Am . 1987;;69:517-522.
46 +
Kortelainen P, Puranen J, Koivisto E, Lahde S.  Symptoms and signs of sciatica and their relation to the localization of the lumbar disc herniation. Spine . 1985;;10:88-92.
47 +
Blower PW.  Neurologic patterns in unilateral sciatica. Spine . 1981;;6:175-179.
48 +
Schwartz RS, Morris JGL, Crimmins D, et al.  A comparison of two methods of eliciting the ankle jerk. Aust N Z J Med . 1990;;20:116-119.
49 +
Keegan JJ.  Dermatome hypalgesia associated with herniation of intervertebral disk. Arch Neurol Psychiatry . 1943;;50:67-83.
50 +
Aronson HA, Dunsmore RH.  Herniated upper lumbar discs. J Bone Joint Surg Am . 1963;;45:311317.
51 +
Morris EW, DiPaola M, Vallance R, Waddell G.  Diagnosis and decision making in lumbar disc prolapse and nerve entrapment. Spine . 1986;;11:436-439.
52 +
Turner JA, Ersek M, Herron L, Deyo R.  Surgery for lumbar spinal stenosis: attempted metaanalysis of the literature. Spine . 1992;;17:1-8.
53 +
Hawkes CH, Roberts GM.  Neurogenic and vascular claudication. J Neurol Sci . 1978;;38:337-345.
54 +
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D.  Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am . 1986;;68: 386-391.
55 +
O'Laoire SA, Crockard HA, Thomas DG.  Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse. BMJ . 1981;;282:1852-1854.
56 +
Tay ECK, Chacha PB.  Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina. J Bone Joint Surg Br . 1979;;61:43-46.
57 +
Spitzer WO, LeBlanc FE, Dupuis M, et al.  Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians: report of the Quebec Task Force on Spinal Disorders. Spine . 1987;;12( (suppl 7) ):S16S21.
58 +
Deyo RA, Bigos SJ, Maravilla KR.  Diagnostic imaging procedures for the lumbar spine. Ann Intern Med . 1989;;111:865-867.
59 +
Walsh NE, Dumitru D.  The influence of compensation on recovery from low back pain. Occup Med . 1988;;3:109-121.
60 +
Gatchel RJ, Mayer TG, Capra P, Diamond P, Barnett J.  Quantification of lumbar function, VI: the use of psychological measures in guiding physical functional restoration. Spine . 1986;;11:36-42.
61 +
Korbon GA, DeGood DE, Schroeder ME, Schwartz DP, Shutty MS.  The development of a somatic amplification rating scale for low-back pain. Spine . 1987;;12:787-791.
62 +
Burnam AM, Wells KB, Leake B, Landsverk J.  Development of a brief screening instrument for detecting depressive disorders. Med Care . 1988;;26: 775-789.
63 +
Rucker L, Frye EB, Cygan RW.  Feasibility and usefulness of depression screening in medical outpatients. Arch Intern Med . 1986;;146:729-731.
64 +
Waddell G, McCullochJA, Kummel E, Vernner RM.  Nonorganic physical signs in low back pain. Spine . 1980;;5:117-125.

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