Back Assessment
Physiotherapy · Subjective & Objective Examination
BACK / SPINE
RightLeft
RightLeftBilat
1
Presentation & Red Flags
Red flags — screen & tick
Consider urgent / further review if any of:
No red flagsPain in the saddle areaSaddle anaesthesiaUrinary or faecal incontinenceSignificant muscle weaknessSigns of infectionVascular signsAbdominal aneurysmPulsating abdominal massLumbar pain aggravated by effortSyncope / dizzinessSignificant traumaOsteoporosisCorticosteroid useOlder patientInflammatory featuresTumoral historyNight painNeurological symptoms
2
History
3
Pain
Mark pain location, type & radiation
No pain
Worst
0
1
2
3
4
5
6
7
8
9
10
Morning
Afternoon
Evening
Night
Plot key events along the line — injury, flare-ups, treatments, return to activity, milestones.
4
Lifestyle & Context
Sleep
Diet
Smoking
Alcohol
5
Clinical Reasoning Framework
Characterise the presentation — circle / annotate the relevant descriptors on each strip.
Diagnosis
Stage of disorder
Pain features
6
Flags & Whole-Person Considerations
7
Goals
8
Objective — Back
Range of movement + pain — Lumbar spine record response and pain for each
| Movement | 1 movement | Repetition | Overpressure | Notes |
|---|---|---|---|---|
| Flexion | Seated Standing | Seated Standing | Seated Standing | |
| Extension | Seated Standing | Seated Standing | Seated Standing | |
| Rotation | Seated Standing | Seated Standing | Seated Standing | |
| Side flexion | Seated Standing | Seated Standing | Seated Standing |
Range of movement + pain — Cervical involvement
| Movement | 1 movement | Repetition | Overpressure | Notes |
|---|---|---|---|---|
| Flexion | ||||
| Extension | ||||
| Rotation | ||||
| Side flexion |
Manual assessment
| Passive accessory movement | Segment(s) / level | Finding / mobility |
|---|---|---|
| PA central | ||
| UPA unilateral | ||
| PL transverse glide |
McKenzie assessment
| Directional preference | |
| Movement increasing symptoms | |
| Movement decreasing symptoms |
Neurodynamic tests
| Special test | Right | Left | Finding / Notes |
|---|---|---|---|
| Slump test | |||
| Straight leg raise |
Sacroiliac assessment
| Special test | Right | Left | Finding / Notes |
|---|---|---|---|
| Fortin finger test pain over SIJ | |||
| Heel drop test unilat. painful side |
Laslett's cluster — ≥ 2 of 4 positive implicates the SIJ
| Provocation test | Right | Left | + / − |
|---|---|---|---|
| Distraction | |||
| Thigh thrust | |||
| Compression | |||
| Sacral thrust |
9
Functional Assessment
Static movements movement quality
| Task | Right | Left | Observation / Notes |
|---|---|---|---|
| Single leg bridge | |||
| Stationary lunge — iso | |||
| Walking lunge | |||
| Side step up | |||
| Single leg RDL | |||
| Aeroplane | |||
| Jefferson curl | |||
| Back extension — incline | |||
| Others |
Stability
| Task | Right | Left | Observation / Notes |
|---|---|---|---|
| Reaching-out plank anterior | |||
| Side abduction — on table lateral | |||
| McGill curl-up anti-flexion · anterior | |||
| McGill side plank anti-lateral flexion · lateral | |||
| McGill bird dog anti-rotation · rotational | |||
| Banded dead bug |
10
Adjacent Joints
Hip
Thomas · FABER · FADIR · 90/90 · Neutral-pelvis standing extension · Straight leg raise · Seated internal rotation
Cervical spine
Assess if lumbar symptoms suggest cervical involvement
11
Others
12
Retest
| Date | Test / measure | Result | Notes |
|---|---|---|---|
13
Questionnaires
Patient-reported outcome measures — record the score at baseline and at each retest.
| Questionnaire | Date | Score | Notes / interpretation |
|---|---|---|---|
| Oswestry Disability Index (ODI) | |||
| STarT Back Tool | |||
| Örebro Musculoskeletal Pain Questionnaire | |||
| FABQ — fear-avoidance beliefs | |||
| PHQ-2 — depression screen |
14