Physical Therapy Diagnosis of Back Pain

Regina Lehnert, PT, Cert. MDT 

July 2009

Back and/or neck pain affects 80-90% of the population at some time in their life resulting in lost work, changes in their ability to perform certain tasks and/or the need to seek medical treatment.  Most low back pain is mechanical in nature, meaning that an applied force caused the pain.  The force can be the result of trauma (such as a motor vehicle accident), postural forces (incorrect posture), forces resulting from lifting an object, or simply bending forward.  The philosophy of mechanical evaluation and treatment is that the appropriate reverse or opposite force may eliminate the pain and restore function.  Patient involvement in the treatment of their current pain and having an understanding for prevention of future episodes is the goal of mechanical diagnosis. 

Mechanical evaluation and diagnosis is a safe and effective method used by physical therapists to identify those patients who are suffering from a mechanical source of pain.  After reviewing a patient’s history of pain, the therapist places the patient through a series of controlled movements with varying degrees of intensity.  In doing this, the therapist assesses what response a patient has to an activity such as bending forward or backward, sitting, standing, walking, and sleeping.  The patient’s response to these movements will assist the therapist in determining the mechanical forces that impact the patient’s pain and directional preferences of the patient.  This determines which exercises the therapist will teach the patient. 

Mechanical evaluation may reveal a derangement, which means that there is a problem within a joint segment in the spine or a dysfunction which is a limitation of movement as a result of abnormal, tightened tissue. 

When derangement is present, there is usually a limitation in the ability to move in particular directions.  This limited movement will affect the pain symptoms in a very predictable and repeatable fashion.  There may also be symptoms in the arm or the leg as a result of irritation on the nerve caused by derangement.  When the therapist identifies the movements that affect the derangement, the pressure on the nerve is reduced resulting in relief of the arm or leg symptoms.  This is called “centralization” and is an excellent predictor that the pain is mechanical and that the patient will benefit from mechanical therapy.  The patient can be instructed in the appropriate exercises to correct the derangement and therefore decrease their pain symptoms.  

When dysfunction is present, there is limitation of movement as a result of a tightened tissue.  The patient’s pain occurs each time abnormal tight structure is stretched.  To eliminate the pain, these tissues need to be lengthened.  Once they are lengthened, pain will no longer result when stretched.      

Postural dysfunction is when static positions create pain symptoms.  This most commonly occurs with prolonged sitting.  The tissue is normal, yet creates pain symptoms when placed in an end of range position for too long a period of time.  When postural dysfunction is diagnosed, the patient is provided instruction in appropriate sitting positions.     

Once any of the above mechanical diagnoses is made, the patient is instructed in the appropriate exercises to provide the mechanical direction to reverse the force creating the pain symptoms.  The patient may then provide self treatment and effectively decrease and/or eliminate their pain symptoms.

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