Low Back Patterns of Pain: Classification Based on Clinical Presentation

Abstract

The ubiquitous presence of low back pain with its multiple natural histories makes classification difficult. Any categorization begins by defining the essential elements of the problem to build a structure that reflects the values of the organizer, values determined by experience, personal concerns, and a point of view. Although a grouping of back pain patients based on responses to a particular treatment may be as valid as one based upon the varying degrees of socioeconomic impact produced by the pain, any classification’s ultimate value depends on the interests of the user. Patterns of pain focuses on the initial presentation delineated by a specific set of questions in the history and confirmed by selected features of the physical examination. History divides mechanical low back pain into four distinct syndromes while the physical examination further delineates two of these patterns. A pattern of mechanical low back pain can be defined by the location of the dominant pain (back or leg), the consistency (constant or truly intermittent), and the effect of flexion on the symptoms. Response to flexion separates two cohorts of intermittent leg dominant pain patients with very different clinical scenarios and treatment demands. The physical examination divides back dominant pain patients needing only a straightforward treatment strategy from those who require more complex supervision. Additional questions and tests highlight or eliminate sinister, nonmechanical pathologies. The classification both directs initial management and provides a reasonable prognosis for speed and completeness of recovery.