This chapter shows how a structured history, pain measurement, objective testing and red-flag screening combine into a defensible, staged treatment plan.
From Assessment to Plan: The Reasoning Sequence
Assessment follows a repeatable sequence: history, screening for serious pathology, impairment-level examination, functional and outcome measures, then a working hypothesis. The hypothesis drives treatment and defines the baseline for reassessment. Findings are only useful if they are reproducible, so every measure should be recorded with its method (position, instrument, side, units) to allow comparison at later visits.
Patient History and Red Flags
A good history covers:
Prostate cancer, progressive back pain, bilateral leg numbness and 10 kg weight loss form a red-flag cluster: limit the exam to a rapid neurological screen and make an emergency referral the same day.
- Onset and mechanism: traumatic or insidious.
- Behaviour of symptoms: 24-hour pattern, aggravating and easing factors.
- Irritability: how easily symptoms are provoked and how long they take to settle.
- Past history, medications and comorbidities: diabetes, cancer, osteoporosis, steroid use.
- Psychosocial factors ("yellow flags"): fear of movement, catastrophising, work dissatisfaction.
- Goals.
Red flags are screened in every patient and clustered rather than read singly. For the spine, the main concerns are:
- Malignancy: past history of cancer, unexplained weight loss (e.g. >5 kg over 3 months), night or constant pain unrelieved by position, age >50 at first onset.
- Cauda equina syndrome / cord compression: saddle anaesthesia, new urinary retention or incontinence, bilateral or progressive leg weakness or numbness, sexual dysfunction.
- Fracture: significant trauma, prolonged corticosteroid use, osteoporosis.
- Infection: fever, immunosuppression, recent infection or intravenous drug use.
A 55-year-old man with prostate cancer, progressive back pain, bilateral leg numbness, 10 kg weight loss and reduced reflexes or strength has a red-flag cluster for metastatic spinal cord or cauda equina compression. Examination should be limited to a rapid neurological screen, treatment withheld, and emergency medical referral made the same day. Time to decompression determines neurological outcome.
Pain Assessment
Quantify pain with the Numeric Pain Rating Scale (NPRS, 0–10) for current, best and worst pain over 24 hours. The minimal clinically important difference is about 2 points or 30% (Farrar 2001). Also record:
- Body chart location and distribution (local, referred, dermatomal).
- Quality: burning or electric pain suggests neuropathic involvement.
- Behaviour: mechanical versus inflammatory.
- Irritability.
Add condition-specific tools: the Oswestry Disability Index (ODI; MCID about 10 points) or Roland-Morris Disability Questionnaire (MCID about 5 points) for low back pain, and the Fear-Avoidance Beliefs Questionnaire (FABQ). An FABQ physical activity subscale score above about 14 suggests clinically relevant fear avoidance. The STarT Back Tool stratifies patients into low, medium and high risk to guide treatment intensity.
Low Back Pain: Pathophysiology and Presentation
Most low back pain is non-specific and mechanical, involving combinations of facet, disc, muscle and ligament sensitisation. Acute lumbar strain involves microtearing of muscle fibres and an inflammatory response (days 0–7), with proliferation to about day 21 and remodelling beyond. Chronic pain (>3 months) is increasingly driven by central sensitisation, deconditioning and psychosocial factors rather than tissue damage.
Presentations suggest patterns, not diagnoses:
- Worse with sitting and flexion, better with walking: a flexion-sensitive (disc-related) pattern. Test for directional preference with repeated or sustained extension.
- Worse with standing, extension and bending, with painful limited extension: a facet-loading or extension-related pattern. Extension is often provoked by Kemp's quadrant loading, but this test has limited diagnostic accuracy.
- Leg symptoms eased by sitting or flexion and provoked by walking or extension: consider lumbar stenosis.
- Radicular signs: a positive slump test or straight leg raise (reproduction of leg symptoms at 30–70° of hip flexion, sensitised by ankle dorsiflexion) with dermatomal and myotomal changes.
Chronic back pain with full range of motion but pain at end range, and with no neurological signs, is a good fit for activity-based management.
Manual Muscle Testing
Manual muscle testing (MMT) uses the Oxford/MRC 0–5 scale:
| Grade | Criterion |
|---|---|
| 0 | No contraction |
| 1 | Palpable or visible flicker, no movement |
| 2 | Full range with gravity eliminated |
| 3 | Full range against gravity |
| 4 | Full range against gravity plus moderate resistance |
| 5 | Full range against gravity plus maximal resistance |
Standard knee extension testing is seated, hips and knees at 90°, moving from 90° of flexion to 0° with resistance applied proximal to the ankle. A patient six weeks after patellar dislocation who completes the full range against gravity but cannot tolerate any added resistance is grade 3. Quadriceps inhibition and an extensor lag are common after dislocation. Pain, effusion, patellar apprehension and the medial patellofemoral ligament (MPFL) status modify how much resistance can be applied. Grades 4 and 5 are subjective; where precision matters, use hand-held dynamometry and compare limb symmetry (a limb symmetry index of at least 90% is a typical return-to-sport criterion).
Special Tests: Selecting and Interpreting
Special tests are best used in clusters, with attention to sensitivity (rule-out, SnNout) and specificity (rule-in, SpPin).
Shoulder. For a 45-year-old woman with insidious shoulder pain, night pain and painful active abduction to 100°, assess:
- Painful arc (60–120°).
- Hawkins-Kennedy and Neer tests (sensitive, not specific).
- Empty Can (supraspinatus).
- External rotation lag sign and drop arm test (specific for full-thickness tears).
- Resisted external rotation.
Compare passive and active range. If passive external rotation is also markedly restricted in a capsular pattern, consider adhesive capsulitis. If active is limited but passive is full, suspect rotator cuff-related shoulder pain. Normal flexion is 0–180° and abduction 0–180° (goniometer).
Hand and wrist. Tinel's sign, Phalen's test (60 seconds of wrist flexion) and Durkan's carpal compression test support carpal tunnel syndrome, as do thenar atrophy and weak thumb abduction. In a diabetic patient with bilateral symptoms, also consider peripheral polyneuropathy and cervical radiculopathy (Spurling's test, upper limb neurodynamic test, cervical rotation <60°). Document the Boston Carpal Tunnel Questionnaire, and refer for nerve conduction studies when there is thenar wasting or when conservative care fails.
Gait Analysis and Gait Assessment
Observational gait analysis uses the stance phase (about 60% of the cycle) and swing phase (about 40%), with double support of about 20%. Typical adult values are cadence of 100–120 steps/min and step length of about 0.65–0.80 m. Observe from the front, behind and the side, noting:
- Trunk lean.
- Pelvic drop.
- Hip and knee excursion.
- Heel strike and toe-off.
- Arm swing.
- Antalgic pattern (shortened stance on the painful limb).
Objective measures:
- 10-Metre Walk Test: comfortable walking speed in healthy adults aged 40–59 is about 1.3–1.5 m/s (Bohannon 1997). Speeds below 0.8 m/s indicate limited community ambulation. The MCID is about 0.10 m/s.
- Timed Up and Go: a time over about 12–13.5 s suggests elevated fall risk in older adults.
- 6-Minute Walk Test: assesses endurance.
- Step length symmetry ratio: with a stopwatch and a measured walkway, you can time a 10 m walk and count steps. For a patient limping on the left leg, use floor markers to measure left and right step length and calculate the short-to-long ratio. A ratio near 1.0 is symmetrical, and a ratio improving toward 1.0 shows progress.
Physiotherapy Management: Staged and Graded
Acute lumbar strain (days 0–14). Protect without immobilising:
Acute lumbar strain (days 0–14): reassurance, advice to stay active and short walking bouts of 5–10 min several times a day. No routine imaging.
- Education and reassurance, and advice to stay active.
- Short walking bouts (5–10 min, several times daily).
- Gentle pain-limited mobility.
- Heat or manual therapy for short-term relief.
- No routine imaging.
Sub-acute stage (weeks 2–6). Use graded activity and graded exposure, which is the best-supported approach for fear of re-injury. Build a hierarchy of feared tasks (e.g. lifting) and progress by time or load rather than by pain. Include:
- Trunk motor control and hip hinge training: 2–3 sets of 8–12 repetitions, 3 times weekly.
- Progressive lifting from 5 kg increments.
- A work plan with modified duties, aiming for pain at or below about 4/10 that settles within 24 hours.
Chronic stage (>12 weeks). Combine:
- Exercise therapy at 150 minutes/week of walking plus 2 days of strengthening.
- Pain neuroscience education.
- Cognitive-behavioural principles.
- Manual therapy or directional-preference exercises as adjuncts.
Post-patellar dislocation (week 6).
- Phase 1: quadriceps isometrics (5 × 10 s holds at 60° of flexion), straight leg raise without lag, and the early addition of resistance.
- Phase 2: closed-chain exercises (mini-squats 0–45°, step-ups), 3 sets of 10–12 repetitions at about 60–70% 1RM, 2–3 times weekly, plus hip abductor and external rotator strengthening.
- Phase 3: running, agility and sport-specific work once effusion is absent, strength is above 90% LSI and apprehension has resolved.
Rotator cuff-related pain. Progress from isometrics (5 × 30–45 s) to isotonic strengthening of the cuff and scapular stabilisers (3 × 10–15 reps, 3 times weekly) and overhead function, load-managed against night pain.
Carpal tunnel syndrome. Neutral wrist night splinting for 6–8 weeks, activity modification, and nerve and tendon gliding exercises. Refer for surgical review if there is thenar atrophy or no improvement.
Evidence and Clinical Pearls
- Cluster tests rather than relying on one: no single shoulder test reliably rules in or out cuff pathology.
- Pain intensity alone is a poor predictor of disability; use the FABQ and STarT Back to identify who needs graded exposure.
- Re-screen for red flags at each visit. Progressive neurological deficit, unremitting night pain, or a change in bladder or bowel function means a change of plan.
- Record a baseline for every treated impairment (NPRS, range in degrees, MMT grade, gait speed) so that change can be judged against the MCID.
- Grade 3 strength means gravity-resisted full range. Do not progress to resisted loading before the patient can control the full range.
- Bilateral hand symptoms and diabetes should trigger consideration of systemic or cervical causes before attributing symptoms to the wrist.
Summary
A thorough history and red-flag screen determine whether a patient is safe for physiotherapy. Validated measures (NPRS, ODI, FABQ, goniometry, MMT, gait speed) quantify the problem, and clustered special tests refine the hypothesis. Management is staged by tissue healing, irritability and psychosocial profile, with reassessment against MCID thresholds.
References
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- Finucane LM, Downie A, Mercer C, et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350–372.
- Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560–1571.
- Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149–158.
- Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Br J Sports Med. 2012;46(14):964–978.
- Bohannon RW. Comfortable and maximum walking speed of adults aged 20–79 years: reference values and determinants. Age Ageing. 1997;26(1):15–19.
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