Evaluation Procedure and Interpretation Method for Differential Diagnosis of Flexion-Type Low Back Pain

What is Flexion-Type Lower Back Pain?

Flexion-type lower back pain refers to a type of back pain that occurs when the body is bent forward.

Common examples include forward bending movements and crouching postures.
Other postures and movements that may cause this pain include sitting in a chair, putting on socks, and maintaining a seated position for long periods.

A characteristic feature is that pain may be alleviated by movements in the opposite direction, such as extending or arching the back.

The tissues causing the pain may include the muscles and fascia of the lower back, intervertebral discs, joint capsules, and facet joints.

How to differentiate and evaluate these causative tissues,
and how to logically interpret the evaluation by combining different assessments,

We will focus on these two points and summarize the evaluation procedure.

Evaluation Procedure for Flexion Movements

When conducting evaluations, first confirm active movements, and then perform passive movements as a rule.

Additionally, gradually change the position from standing → sitting → lying down.
By changing positions, you can reduce the influence of other areas related to the lower back.

Below is the flow of evaluation for spinal flexion movements.

First, confirm ① Standing Forward Bend. Then proceed from ① to ④, evaluating ② Seated Spinal Flexion. If there is no pain during the differential diagnosis procedure, you may stop the evaluation there.

For the evaluation procedure and interpretation method for dysfunction in forward bending movements, please refer to this article.

Evaluation Procedure and Interpretation Method for Identifying Dysfunction in Forward Bending Movements

Lower back pain, buttock pain, and leg pain associated with forward bending movements are frequently encountered in clinical settings. It is important to focus not only on the quantity of forward bending movements but also on the quality of the movements to appropriately evaluate and identify which area has dysfunction. This article summarizes the evaluation procedure and interpretation method. Understanding this article will clarify the intervention points.

bpm-function.com

Interpretation here is considered by patterning based on the presence or absence of pain.

① Pain Present ② No Pain

① Pain Present ② Pain Present

② Pain Present ③ No Pain

② Pain Present ③ Pain Present

③ Pain Present ④ No Pain

③ Pain Present ④ Pain Present

Interpretation Method for Evaluation

② Differences in Interpretation Based on Pain Presence

If there is no pain in ②, the likelihood that the cause of pain is dysfunction in the lower back is greatly reduced, making it important to proceed with evaluating other areas rather than the lower back.

If there is pain in ②, it is necessary to proceed to evaluate kneeling spinal flexion or supine lumbar flexion.

In seated spinal flexion, it is considered that both lumbar and hip dysfunctions may influence the condition.

③ Differences in Interpretation Based on Pain Presence

If there is no pain in ③, it means that spinal flexion movements can be performed without issues, and further evaluation is unnecessary.

If there is pain in ③, it is considered that there is a problem with spinal flexion, particularly lumbar flexion. Evaluation in a kneeling position allows palpation to determine which segments are flexing and which are not.

④ Differences in Interpretation Based on Pain Presence

The evaluation in ④ differs from previous evaluations as it involves passive movement.
The method involves moving both hip joints to the end range of flexion, tilting the pelvis posteriorly, and applying overpressure to flex the lumbar spine.

If there is no pain in ④, lumbar flexion is likely preserved, and it can be interpreted mainly as a dysfunction in motor control.

If there is pain in ④, it is considered that there is a dysfunction in the mobility of lumbar flexion, and it is necessary to combine evaluations described later for interpretation.

If there is pain in ④ but it gradually eases with repeated attempts, it is considered that lumbar flexion mobility is preserved.
This suggests a high possibility of a motor control issue, similar to the absence of pain, but a detailed evaluation should be conducted just in case.
If time is limited, it might be better to focus on dysfunction in hip flexion.

Evaluation Procedure and Interpretation for Lumbar Flexion

During the evaluation process mentioned above, assisting movements manually can provide clues to differentiate whether the issue is muscular-fascial or related to intervertebral discs or facet joints.

It is important to note that this does not provide a clear differentiation but should be considered as a suggestion.

Evaluation Using SNAGS

If pain occurs during seated spinal flexion, the patient's lumbar spinous processes are grasped and the movement is performed (SNAGS: Sustained Natural Apophyseal Glides).

For example, in the L4/5 segment, guiding the L4 spinous process anteriorly and superiorly during flexion may reduce pain. This is thought to be because guiding the spinous process reduces the compressive force on the intervertebral disc, suggesting discogenic pain.

If Discogenic Pain is Suspected

If discogenic pain is suspected, perform the 'Compression Test' by applying compressive force to the spine in a seated position.

If pain is induced while maintaining a seated position, it might be better to start with the Compression Test before performing flexion movements.

The interpretation is simple: if pain is reproduced, suspect discogenic pain; if pain is reduced, suspect muscular-fascial pain.

Trial Treatment: Traction Mobilization

If discogenic pain is suspected, conduct a trial treatment of 'Traction Mobilization' and re-evaluate.

If pain decreases during spinal flexion movements, seated maintenance, or the Compression Test, the suspicion of discogenic pain becomes stronger, clarifying the treatment intervention points.

If Muscular-Fascial Pain is Suspected

If pain does not decrease with SNAGS-guided spinous process manipulation, rule out discogenic pain and suspect muscular-fascial pain.

If further evaluation is needed, assess muscle tenderness, muscle tension, muscle bulging, muscle stiffness, and extensibility (PLF: Posterior Lumbar Flexibility) to rule in muscular-fascial pain.

In Cases of Flexion + Rotation Type

If pain occurs not only during flexion movements but also during rotational movements, the interpretation needs to be slightly adjusted.

In addition to flexion movements, perform SNAGS for rotational movements as well.
If pain is alleviated, suspect not only discogenic but also facet joint-related issues.

During flexion movements, the facet joints open, and during rotational movements, the facet joints on one side open.
Pain can occur due to the stretching of ligaments and joint capsules covering the facet joints, suggesting that dysfunction in the mobility of the facet joints may be the source of pain.

In this case, evaluate the mobility of the lumbar facet joints. For detailed procedures, please refer to this article.

Evaluation Method for Lumbar Facet Joints

This article summarizes manual evaluation methods for lumbar facet joints. By considering a combination of manual evaluations such as the Lumbar Quadrant Test (Kemp Test), Springing Test, and Rotation Test, it is possible to differentiate which level of the facet joint is problematic.

bpm-function.com

Furthermore, if trial treatment on the facet joints is conducted and pain decreases upon re-evaluation, the likelihood of facet joint-related origin increases.

Summary

This concludes the evaluation procedure and interpretation for flexion-type lower back pain.

It is a necessary approach to differentiate the causative tissues of pain from flexion movements.

First, thoroughly consider the muscles and fascia, intervertebral discs, and facet joints around the lower back.

Additionally, if there is buttock pain or leg pain, consider the sacroiliac joint, lumbar nerve roots, sciatic nerve, and cluneal nerves.