Cooking up Lumbar Examinations for Low Back Pain

To kick off the low back series in high gear, we interviewed Chad Cook. Chad is a professor at Duke University. He is well published in the text and journals regarding lumbar pain. 

Chad Cook recommends getting a thorough history, detailed movement examination, special tests to rule in or out a condition, and taking into considerations which affect prognosis. Chad then utilizes the classification of low back pain based on these findings.

For demographic findings, Chad states chronicity, female gender, advanced age, occupation, social situation, presence of wide spread pain or neurogenic pain, emotion and ability to cope with their problem, pain behaviors affect outcomes. This information is primarily found during the subjective examination or by using a thorough new patient form.

Chad also discussed the impact of insurance. Chad states those patients on work comp, third party, who have pending litigation tend to have confounding factors to their prognosis and outcomes.

For intake forms, Chad recommends the form captures medications, medical history, employment. His text book “100 Orthopedic Patient Cases” has a history form which was built by looking at those of multiple clinics. Chad feels that case based learning is one of the best ways to learn which is what inspired him to publish this text.

During the objective examination, Chad focuses on movement based examination. He talks about “comparable sign” based on Maitland theory. This is the movement which reproduces symptoms. Patients who are able to reproduce their comparable sign have better outcomes. A within and between session change of the condition that worsens or improves symptoms impacts outcomes. Within session changes lead to improved outcomes. If there is a between session positive change, this has an even stronger positive predictor of outcomes.

Triage special tests rule out hip issues (hip scour), neurological (straight leg raise) can rule out stenosis or lumbar radiculopathy, bike or treadmill test can point to vascular component. Tests to rule out the SI joint are lacking, Laslett’s cluster is utilized more as a confirmatory bundle.

Reflex, manual muscle testing, sensory testing are used more towards the end of the examination to confirm neurological involvement.

Chad feels imaging is over used and too early. Chad uses referral to imaging more for cases that he feels are outside the scope of physiotherapy. These would be candidates for injection, surgery, or have a fracture. Unusual pain behaviors may occur with cancer and would not have a mechanical presentation. 

When considering prognosis, readiness to participate in physiotherapy, mechanical behaviors are key. Assessing barriers is also key. Central or wide spread pain is likely to lend to delayed recovery and alter how the physiotherapist proceeds with the patient. Depression, anxiety, coping, self efficacy play a larger role in prognosis then the physical examination.

Pearls of wisdom guided towards newer physiotherapists were targeted at two main goals. Chad notes a good based McKenzie based examination will lend to a thorough examination. A good passive physiological and passive accessory examination also is key and engages the patient.

Some of Chad’s Research:

  • Cook CE, Landry MD, Covington JK, McCallum C, Engelhard C. Scholarly research productivity is not related to higher three-year licensure pass rates for physical therapy academic programs. BMC Med Educ. 2015 Sep 11;15(1):148.
  • Hegedus EJ, McDonough SM, Bleakley C, Baxter D, Cook CE. Clinician-friendly lower extremity physical performance tests in athletes: a systematic review of measurement properties and correlation with injury. Part 2–the tests for the hip, thigh, foot and ankle including the star excursion balance test. Br J Sports Med. 2015 May;49(10):649-56.
  • Cook C, Learman K, Houghton S, Showalter C, O’Halloran B. The addition of cervical Unilateral Posterior Anterior Mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial. Man Ther. 2014 Feb;19(1):18-24.
  • Cook CE, Sizer PS, Isaacs RE, Wright A. Clinical identifiers for detecting underlying closed cervical fractures. Pain Pract. 2014 Feb;14(2):109-16.
  • Reneker JC, Moughiman MC, Cook CE. The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An International Delphi Study. J Sci Med Sport. 2014 May 17. pii: S1440-2440(14)00085-1. doi: 10.1016/j.jsams.2014.05.002. [Epub ahead of print].
  • Cook C, Learman K, O’Halloran B, Showalter C, Kabbaz V, Goode A, Wright A. Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains. Phys Ther. 2013 Jan;93(1):32-40.
  • Cook C, Learman K, Showalter C, Kabbaz V, O’Halloran B. Early Use of Thrust Manipulation versus Non-Thrust Manipulation: A Randomized Clinical Trial. Man Ther. 2013 Jun;18(3):191-8.

Find out more about Chad