Fast Five Quiz: Back and Neck Pain

Stephen Kishner, MD, MHA


June 11, 2020

Mechanical low back pain can result from an acute traumatic event, but it may also be caused by cumulative trauma. The patient who presents with pain in the low back region often places their whole hand against the skin to indicate diffuse pain; in some cases, the patient may indicate a more precise location.

In addition to the history of the present illness, past medical history should be obtained to rule out infections (eg, septic arthritis), congenital abnormalities (eg, dysplasias, juvenile rheumatoid arthritis), metabolic disorders (eg, Paget disease), or previous traumatic causes (eg, athletic participation, military service).

The review of systems is helpful for relating the current symptoms to any other body parts or systems. Interruption in bowel or bladder function should be a reminder to consider more serious causes of back pain such as major disk herniation, a tumor, infection, or fracture. Review of systems also should include a thorough medical history.

Observe the patient walking into the office or examining room. Observe the patient during the history-gathering portion of the visit for development, nutrition, deformities, and attention to grooming. Measure blood pressure, pulse, respirations, temperature, height, and weight. Inspect the back for signs of asymmetry, lesions, scars, trauma, or previous surgery. Note chest expansion. If it is less than 2.5 cm, this finding can be specific, but not sensitive, for ankylosing spondylitis. Take measurements of the calf circumferences (at midcalf). Differences of less than 2 cm are considered normal variation. Measure lumbar range of motion in forward bending while standing (Schober test).

The association between symptoms of mechanical low back pain and imaging results is weak. Ordering of imaging studies should be limited to patients with clinical findings suggestive of systemic disease or trauma. In the absence of any findings from the neurologic examination and no evidence of infection or cancer, imaging studies are not clinically helpful in the first 4 weeks of symptoms.

The treatment program for mechanical low back pain must have specific functional goals and can be outlined in the following six steps:

  1. Control of pain and the inflammatory process: Pain treatment should be initiated early and efficiently to gain control. Excessive bedrest may be detrimental by leading to lumbar segment motion, loss of muscle strength, and general deconditioning with blunting of motivation.

  2. Restoration of joint range of motion and soft tissue extensibility: Extension exercises may reduce neural tension. Flexion exercises reduce articular weight-bearing stress to the facet joints and stretch the dorsolumbar fascia.

  3. Improvement of muscular strength and endurance: Exercise training can begin after the patient has passed successfully through the pain control phase. Start with isometrics, then progress to isotonic exercises with effort directed at concentric strengthening.

  4. Coordination retraining: Dynamic exercise in a structured training program maximizes coordinated muscle group activities that lead to postural control and the fusion of muscle control with spine stability.

  5. Improvement of general cardiovascular condition: Patients are encouraged to remain active and to initiate brisk walking programs, aquatic activities, or use of stationary bicycles/stair steppers.

  6. Maintenance exercise programs: A home program is developed within the tolerance and ability of the patient in order to encourage continued exercise after discharge from physical therapy.

Read more about low back pain.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.