A patient presents in your office with lower back pain(with or without leg pain) looking at you to do something to help them. No need to panic, there are simple steps you can perform in your office to triage the patient and determine whether they need emergency care, referral or whether you can help them. If you can find a direction of movement, that when repeated 10-50 times will reduce or abate the pain. This direction of movement is called a "directional preference", and can be found from clues during the history and putting the patient through different directional movements during the examination.
First, rule out red flags (severe pain/weakness/numbness in the leg below the knee, bowel/bladder function, drop foot, saddle anesthesia, history of cancer, infection, fracture, cauda equina syndrome, cord signs, ankylosing spondylitis, osteoporosis, recent severe accident, feeling of being generally unwell at the time of the back pain, any other symptoms that developed in addition to back pain)
Second, determine during the history whether the pain’s behavior changes at all with any movement, position or activity, if there are periods in the day when they have not pain or the pain severity, frequency or location changes, it is likely that the patient has mechanical pain. Gather functional, symptomatic and mechanical baselines for use in future comparisons.
Third, test the response to single movements in all directions, then repeated movements (10-15 reps). You are observing whether the pain response with each successive repetition gets worse and worse, better and better or has no effect. The direction of movement that makes pain better and better is called a directional preference. The movement should be done to full range of motion, trying to move further and further with each movement to have the best effect on the disc. According to research, if a directional preference is found, the likelihood of a good prognosis is strong. The patient then continues repetitive movements in the directional preference direction in the office until it becomes very clear that the directional preference is confirmed. Then, prescribe the patient to do directional preference exercises every 2-3 hours of awake time and return in 1-2 days. When the patient returns re-evaluate the baselines of range of motion, pain severity, location and frequency and any functional improvements. Ask the patient whether they were able to do the exercises as prescribed and the effects they found. Were they able to reduce pain and improve function with the exercise? If so, continue the same treatment until full function has been restored and pain has abated. If the exercises did not make a significant improvement or even worsened pain, then re-evaluate the direction by returning to the repetitive movement examination and confirm the direction again, as well as the patients technique performing the exercise.
Patients should always be informed that if the pain worsens and remains worsened 15 minutes after the exercise, or if pain peripheralizes further down into the buttock or leg, they are to stop the exercise and see you immediately.
Most Likely Directions Found To Help Lower Back Pain
#1 Extension in Lying or in Standing - 80% of the time
#2 Extension in Lying with Hips Off Center- 15-20% of the time
#3 Flexion in Lying - only for anterior disc lesions 3-5% of the time