Specific Low Back Pain
- Fysiobasen
- Sep 13
- 11 min read
Low back pain is a major health problem in developed countries, and most patients are managed in primary care. It is defined as pain, muscle tension, or stiffness in the area between the lowest ribs and the gluteal folds, with or without radiation into the legs (sciatica). The main symptom is pain and functional impairment.
Low back pain is a major health problem in developed countries, and most patients are managed in primary care. It is defined as pain, muscle tension, or stiffness in the area between the lowest ribs and the gluteal folds, with or without radiation into the legs (sciatica). The main symptom is pain and functional impairment.
Approximately 90% of all cases are classified as nonspecific low back pain – an exclusion diagnosis that rules out specific causes¹. Specific causes include:
Radiculopathy
Lumbar disc herniation
Lumbar spinal stenosis
Spondylolisthesis
Ankylosing spondylitis
Osteoporosis
Lumbar vertebral fracture
Skeletal metastases
Cauda equina syndrome
Scheuermann’s disease
Scoliosis
Anatomy
The spine is a load-bearing structure composed of bone, cartilage, ligaments, and muscles. The lumbar spine (lumbosacral column) consists of five vertebrae that carry a large part of body weight. Intervertebral discs act as shock absorbers and provide mobility. Ligaments stabilize the vertebrae, while tendons attach muscles to the spine. Nerves branching from the spinal cord control movement and sensation.
Epidemiology and Causes
Low back pain is a symptom, not a disease, and can arise from many different causes. It typically occurs between the lower ribs and the gluteal folds. The condition is very common, with about 40% of people reporting low back pain within a 6-month period²³. Onset usually occurs in adolescence or between the ages of 20 and 40. A small proportion develop chronic pain⁴. Acute low back pain lasts less than one month, while chronic pain persists for more than two months. Both acute and chronic cases can be nonspecific or specific/radicular⁴.
Clinical Presentation
Scoliosis⁵
Little or no pain
Lateral curvature of the spine
Muscle tension
Asymmetrical posture
Elevated shoulder
Local muscle pain
Ligament pain
Scheuermann’s Disease⁶⁷⁸
Kyphosis during adolescence
Lumbar hyperlordosis
Often associated with scoliosis
Tight hamstrings
Pain below or at the apex of the deformity
Activity-related pain
Fatigue and stiffness
Neurological symptoms
In severe cases: impaired cardiac and pulmonary function, Schmorl’s nodes, irregular endplates, and disc height reduction
Ankylosing Spondylitis⁹¹⁰
Progression occurs in five stages: acute inflammation → cartilage damage → cartilage replaced by bone → loss of joint mobility → bony fusion.Key symptoms:
Eye inflammation
Nerve pain
Morning stiffness >30 minutes
Night pain
Relief with activity
Chest pain
Achilles tendon inflammation
Associated skin and bowel disease (Crohn’s disease)
Large peripheral joints often involved
Shortness of breath
General symptoms: fatigue, weight loss, fever, depression
Lumbar Disc Herniation¹¹
Without nerve involvement: often asymptomatic
With nerve involvement:
Stiffness
Sharp, radiating pain
Paresthesia
Muscle weakness
Pain radiating into the leg
Variable intensity depending on nerve compression
Radicular Syndrome¹²¹³
Sharp or burning pain
Numbness and tingling
Unilateral radiation to the foot or toes
Sensory loss, reflex changes, muscle weakness
Pain with pressure over the affected nerve root
Spinal Stenosis¹⁴¹⁵¹⁶
Continuous low back pain
Radiating leg pain
Worse with standing, better when sitting or lying
Itching or discomfort in non-painful areas
Muscle tension
Sleep disturbances
Urinary or bowel problems
Sexual dysfunction
Reduced mobility
Neurogenic claudication
Spondylolisthesis¹⁷
Spinal instability
Pain in lower back and thighs
Stiffness and reduced range of motion
Pain relief with rest
Muscle atrophy
Tight hamstrings
Impaired coordination
Neurological deficits
Spinal Metastases¹⁸
Night pain
Paralysis
Spinal cord involvement with sensory and motor deficits
Urinary and bowel dysfunction
Gait disturbances
Cauda Equina Syndrome¹⁹
Urinary retention
Reduced sensation in the lower limbs
Low back pain
Radiating leg pain
Perineal sensory loss
Gait disturbances
Differential Diagnoses
Several conditions can mimic specific low back pain and must be carefully considered:
Mechanical causes
Lumbar muscle strain/sprain
Lumbar compression fracture
Systemic causes
Osteomyelitis
Dermatomyositis
Referred pain
Abdominal aortic aneurysm
Pancreatitis
Kidney stones
Diagnostic Evaluation
In clinical practice, the first step in assessment is to identify “red flags” (see box 1/2), which may indicate serious underlying pathology, including nerve root involvement. If the patient shows no red flags, the condition is classified as nonspecific low back pain. In addition, “yellow flags”—factors that may increase the risk of chronic pain and disability—are considered. A validated screening tool based on yellow flags can be applied in clinical settings, though its practical utility requires further study¹⁸.
Abnormal findings on X-ray and MRI are equally common in individuals with and without low back pain and therefore correlate poorly with symptoms¹⁹. Van Tulder and Roland reported that degeneration and spondylosis can be detected radiologically in 40–50% of individuals without low back pain²⁰. Radiologists should include such epidemiological information in their reports. Many patients with back pain present without observable abnormalities. Clinical guidelines therefore recommend being conservative with imaging in nonspecific low back pain. Imaging is only indicated when red flag conditions are suspected. Jarvik et al. demonstrated that CT and MRI are equally accurate in identifying disc herniation and spinal stenosis, which can be differentiated from nonspecific back pain through red flag criteria. MRI is more sensitive for detecting infection and malignancy, but these conditions are rare²¹.
Outcome Measures
To evaluate disability and treatment outcomes in low back pain, several validated questionnaires are used. The choice depends on the clinical context and patient group:
Quebec Back Pain Disability Scale– Evaluates functional loss in acute or chronic low back pain, including lumbar spinal stenosis and post-decompression cases.
Oswestry Disability Index– Patient-reported measure indicating functional impairment in daily activities; applicable for both acute and chronic low back pain.
Roland-Morris Disability Questionnaire– Patients select statements that apply to their symptoms; most sensitive for mild to moderate disability.
Back Pain Functional Scale– Twelve items assessing functional limitations in back pain patients.
Visual Analogue Scale (VAS)– Measures pain intensity.
Examination
Introduction
The primary aim of physiotherapeutic examination in low back pain is to classify the patient according to diagnostic triage, as recommended by international guidelines. Serious and specific causes with neurological deficits are rare (1–2% of all cases), but must be carefully screened. When serious and specific causes are excluded, the condition is categorized as nonspecific (mechanical) low back pain.
Undersøkelsesmetodikk
Observasjon
Examination Methods
Observation
How does the patient enter the room?
Postural deviations in flexion or lateral tilt, or limping may be noted.
How does the patient sit down, and how comfortable are they?
How do they rise from a chair? Patients with back pain often avoid pain-provoking movements.
Postural assessment:
Scoliosis (Adam’s forward bend test)
Increased lordosis or kyphosis
Other observations:
Body build
General posture
Facial expression
Skin and hair
Legs: evaluate length (functional or structural difference)
Movement Examination
Active lumbar spine motion is assessed in standing position. Movements are divided into three planes and four directions:
Forward flexion: 40–60°
Extension: 20–35°
Side bending (left/right): 15–20°
Rotation (left/right): 3–18°
Isometric Muscle Strength Testing
Tests lumbar musculature and major movement muscles around the spine.
Purpose: assess strength and identify pain provocation.
Palpation
Locate tender areas
Confirm findings from previous tests
Neurological Tests
Straight Leg Raise (SLR) Test
Assesses nerve root involvement in the lumbar spine.
Performed passively, one leg at a time.
Sensitivity: 35–97%
Specificity: 10–100%
Slump Test
Used when nerve root involvement is suspected.
Positive finding: radicular symptoms.
Sensitivity: 44–84%
Specificity: 58–83%
Femoral Nerve Tension Test
Evaluates pathology in L3–L4 nerve roots or femoral nerve.
Joint Dysfunction Tests
Sacroiliac Compression Test
Detects SI joint pathology.
One Leg Standing Test (Stork Test)
Screens for pars interarticularis stress fracture (spondylolysis).
Sensitivity: 50–55%
Specificity: 46–68%
FABER Test (Flexion, Abduction, External Rotation)
Assesses SI joint pathology.
Sensitivity: 54–66%
Specificity: 51–62%
Lumbar Quadrant Test
Identifies hip joint as the pain source.
Positive finding: reproduction of the patient’s primary pain.
Sensitivity: 75%
Specificity: 43–58%
Medical Management
Spondylolisthesis
General approach²²²³
Rest and avoidance of movements such as lifting, bending, and sports during the acute phase.
Analgesics and NSAIDs to reduce pain in muscles and joints, as well as inflammation in nerve roots and joints.
Epidural steroid injections can relieve low back pain, radicular pain, and neurogenic claudication.
Bracing may reduce segmental instability and pain²⁴.
Surgery
Indicated when symptoms persist despite conservative treatment²⁵.
Scoliosis
Early scoliosis (before age 10)²⁶
Surgery is considered at progression to Cobb’s angle ≥ 50°, as bracing does not prevent growth-related progression.
Spinal fusion is generally not recommended at this age, as it restricts spinal growth and lung development.
Conservative treatment
Bracing can limit the development of secondary curves until skeletal maturity.
Surgical treatment
Early surgery is often advised to prevent severe deformities requiring extensive procedures later. Surgery is usually performed during adolescence, but correction is also possible in adults. The aim is to stop progression and improve posture and balance.
Lumbar Radiculopathy
First-line management is conservative treatment for the initial 6–8 weeks²⁷.
Surgery is considered if symptoms persist beyond 6 weeks despite conservative care²⁸.
The procedure, discectomy, involves removal of the herniated disc material²⁹.
Cauda Equina Syndrome
Once diagnosed, urgent surgical decompression is required to prevent permanent neurological damage³⁰³¹.
Scheuermann’s Disease
Conservative treatment
For kyphosis over 40–45° during growth, with radiological findings, bracing, casting, and exercises are recommended⁶.
Surgical treatment
Surgery is rarely indicated but may be considered in cases of pain or cosmetic concerns with severe curves (>75°) or in adulthood with major deformities⁶³²³³.
Lumbar Spinal Stenosis
If conservative care fails, surgical decompression is considered in cases of disabling pain and significant functional loss³⁴.
Epidural injections and NSAIDs may also be applied³⁴³⁵.
Physiotherapy Management
Spondylolisthesis
Conservative management is first-line, including physiotherapy, rest, medications, and bracing³⁶³⁷.
For degenerative or isthmic spondylolisthesis, non-operative treatment is generally recommended, even with neurological symptoms³⁷³⁸.
Surgery is considered in high-grade slips or persistent symptoms.
Exercises should be performed daily³⁷.
Scoliosis
Physiotherapy and bracing are used in mild cases to maintain posture and delay surgery³⁹.
As scoliosis is a three-dimensional deformity, treatment should address sagittal, frontal, and transverse planes.
Conservative therapy may include exercise, bracing, manual therapy, electrostimulation, and insoles⁴⁰.
Effectiveness remains debated⁴¹.
Lumbar Radiculopathy
Typically treated conservatively initially, though surgery may be necessary for persistent symptoms⁴².
Studies show conservative treatment does not always achieve full symptom relief⁴³.
Patient education about cause and prognosis is advised, although randomized studies are lacking²⁹.
Cauda Equina Syndrome
Physiotherapy focuses on promoting neurological recovery, mobility, lower limb and core strength, gait function, bladder, bowel and sexual function, endurance, and independence³¹⁴⁴⁴⁵.
Scheuermann’s Disease
Management depends on curve magnitude, symptoms, and age.
In mild cases, physiotherapy and exercise are recommended.
Focus: flexibility, strengthening of spinal extensors, and improvement of lumbar lordosis.
Electrotherapy and traction may be used before casting⁸⁴⁶.
Lumbar Spinal Stenosis
Although surgery is often performed, conservative treatment can be appropriate.
In mild cases, physiotherapy may reduce pain⁴⁷.
In severe cases, surgery generally has better outcomes than conservative care⁴⁸.
Physiotherapy may include tailored exercise, aerobic training (treadmill or cycling), strengthening, manual therapy, and stabilization training⁴⁸⁴⁹.
Clinical Conclusion
Physiotherapists must always screen for serious pathology and specific conditions with neurological deficits to ensure proper management. Physiotherapy is often an integral part of treatment for specific low back pain, aiming to reduce pain, strengthen supporting musculature, and restore mobility. Both passive and active exercises are applied. Since 90% of patients have no clear pathological diagnosis and no red flags, they are classified as having nonspecific low back pain.
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