JRLMAR2007 Web


SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 1          3

Physiotherapy Students’ Assessment
of Psychosocial Yellow Flags

in Low Back Pain

R e s e a r c h

A r t i c l e

INTRODUCTION
Low Back Pain (LBP) – that is pain
occurring below the twelfth rib and
above the inferior gluteal folds; afflicts
between 4% and 33% of the worldwide
population at any one time (Woolf and
Pfleger, 2003). This high prevalence of
LBP has financial implications for both
the individual and the state. LBP costs
the National Health Service (NHS) in
the UK an estimated £140.6million
in primary health care with 10% of
physiotherapy time being spent on LBP
(Foster et al., 1999). With LBP making
up such a large proportion of referrals to
physiotherapy it is essential that physio-
therapists are trained in its effective
management. 

The impact of LBP and chronic LBP
(LBP that has been present for more
than 6 months) in particular, on society
has resulted in research focusing on the
risk factors for LBP – an attempt at iden-
tifying causes to limit impact (Burton et
al., 1995). Despite a lack of clarity
regarding the causes for the onset of
LBP there is strong evidence suggest-
ing psychosocial factors are of key

importance (Hoogendoorn et al., 2000). 
Psychosocial factors recognised to

increase the risk of LBP becoming
chronic have been dubbed “yellow
flags” and this term is now commonly
used by physiotherapists. These psycho-
social factors are many and varied and
include people’s beliefs about what has
happened to them, beliefs about their
pain and their beliefs about how work
will affect their pain (Linton and
Hallden, 1998). Although yellow flags
have only been recognised to be linked
with LBP chronicity and have not been
identified as being causative (Linton,
2000); their assessment and manage-
ment has been found to improve outcome
when included in physical treatment and
rehabilitation in both acute and chronic
LBP (Bendix et al., 1998). 

Assessment is the first step in the
treatment process and integral to the
management and progression of effec-
tive treatments. Guidelines for the 
management of LBP recommend imple-
menting a biopsychosocial model in
both assessment and treatment
(Hoogendoorn et al., 2000). In order to

effectively assess LBP physiotherapists
must develop skills in assessing not only
biomedical aspects but also the psycho-
social yellow flags that have been found
to play such a major role. Thus physio-
therapists must be educated and trained
in all the dimensions of LBP in order to
effectively apply the biopsychosocial
model. 

Several assessment tools have been
developed to facilitate assessment of
psychosocial factors including the
Yellow Flags Questionnaire (Linton and
Hallden, 1998). Despite the availability
of these tools however physiotherapists
still appear to struggle in the application

ABSTRACT:  Background: Low Back Pain (LBP) makes up a large
proportion of referrals to physiotherapy worldwide. Thus training
in its effective assessment and management is essential. With 
psychosocial yellow flags having been recognised as the strongest
predictors of chronicity in LBP, guidelines on the management of LBP
emphasise the importance of assessing and managing yellow flags. 

Aim: The aim of this research was to explore whether physio-
therapy students were able to assess risk of chronicity based on the
presence of yellow flags in descriptions of people with LBP. 

Method: A postal semi-structured questionnaire based on clinical
vignettes was sent to all the Level 3 physiotherapy students studying at Queen Margaret University College, Edinburgh.

Results: The survey was responded to by 15 of the students (35%). The respondents overestimated risk of chronic
LBP from the vignettes. Evaluation of risk for chronicity was based on few yellow flags i.e. the strongest predictors of
chronicity were not effectively interpreted resulting in incorrect determination of risk for chronic LBP. All respondents
included at least one risk factor not supported by the evidence. 

Conclusions: Physiotherapy students in this study did not appear to respond appropriately to the presence of
yellow flags in the presented vignettes.

KEY WORDS:  YELLOW FLAGS, PHYSIOTHERAPY STUDENTS, ASSESSMENT.

Parker R,
BSc(Phys); BSc(Med)(Hons)

Ex Sci(Phys); Msc(Pain)1

1
Division of Physiotherapy, School of Health and
Rehabilitation Sciences, University of Cape Town.

CORRESPONDENCE TO:
Romy Parker
Division of Physiotherapy
School of Health and Rehabilitation
Sciences, UCT.
F45 Old Main Building
Groote Schuur Hospital
Observatory
7925
Email: romy.parker@uct.ac.za



4 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 1

of psychosocial assessment and integra-
tion of these factors into treatments
(Harland and Lavallee, 2003). 

Research into physiotherapists’ and
physiotherapy students’ management of
LBP has been limited. The focus of
research has been on treatment with
little investigation into the processes of
assessment. This is perhaps surprising 
as assessment should be regarded as
integral to the treatment process. The
investigation of treatments in isolation
from assessment processes providing
limited insight. Only one paper was
found on physical therapists’ ability to
recognise established risk factors for
LBP (Overmeer et al., 2004). Previous
research on physiotherapy students
appears to have been focused on their
knowledge of pain and attitudes towards
pain (Latimer et al., 2004). 

The identification of yellow flags is
an essential component in assessing
LBP as these are presently the only 
evidence-based factors predictive of
chronicity. Physiotherapy students’ abi-
lity to identify yellow flags in people
with LBP does not appear to have been
previously investigated. This element is
of particular importance when con-
sidering the influence of psychosocial
factors on the management of a person
with LBP. In this study, a clinical vignette
approach was used to explore physio-
therapy students’ recognition and inter-
pretation of the yellow flags which place
people with LBP at risk of chronicity.

The following research question 
was posed: “Can level 3 physiotherapy
students respond appropriately to the
presence of psychosocial yellow flags
indicating risk of chronicity in descrip-
tions of people with LBP?” This ques-
tion was explored with two main aims,
firstly to evaluate whether the students
could correctly identify people at risk of
chronic LBP from vignettes. The second
aim was to evaluate what risk factors the
students identified from the vignettes
which may have influenced their eva-
luation of risk. 

METHOD 
A cross-sectional investigation of level
three physiotherapy students at Queen
Margaret University College (QMUC)
was conducted using a questionnaire

based on patient vignettes. Ethical
approval was applied for and granted 
by QMUC.

Sample
A convenience sample of 43 physiothe-
rapy students completing their third year
of study at QMUC was investigated.
This group of students had completed
three years of a four year course leading
to a BSc in Physiotherapy. The first two
years of study focused on university
based learning with studies in the sciences
and applied sciences. The third year of
study entailed 30 weeks of clinical edu-
cation where the theoretical knowledge
and concepts developed in the first two
years were practically applied. Clinical
education was interspersed with periods
of university based study. The final year
physiotherapy students were unavailable
to participate in the study as they had
recently graduated at the time the
research was conducted.

Instrumentation
A questionnaire was developed using
three patient vignettes (Appendix I –
vignettes T, N and NN). Clinical
vignettes are recognised as one of the
most powerful methods of assessing
clinician behaviour, allowing for the
exploration of assessment and treatment
processes (Rainville et al., 2000).
Vignettes have been found to be a use-
ful, valid and reliable method of
researching clinician approaches
(Hughes and Huby, 2002). While there
is always the risk of questionnaire
respondents answering a questionnaire
with the “correct” answer rather than a
description of their actual behaviour this
is equally a risk with observed patient
interactions. 

The first page of the questionnaire
was standardised to establish the demo-
graphic characteristics of the students.
Thereafter the vignettes were presented
in random order.

Factors such as gender (female), age
group (30-40) and job type, which are
known to  influence clinician manage-
ment of LBP were standardised in the
vignettes (Rainville et al., 2000). Red
flags – signs and symptoms indicative of
serious spinal pathology, were also 
standardised. The goal was for the main

differences between vignettes to be in
yellow flags. 

Each vignette contained a different
number of yellow flags. The types of
yellow flags occurring in each vignette
are described in Table 1. For example in
Vignette T the person described presents
with catastrophizing issues relating to
Attitudes and Beliefs about her pain
with a description of feeling “that it
won’t be long before she’ll be like her
mother who had to stop working at 40
because of her back”.  Risk of chronicity
increases with higher numbers of yellow
flags thus one of the vignettes (vignette T)
was loaded with several yellow flags
(six) to clearly increase risk. Vignettes N
and NN had only one and three yellow
flags present respectively. These factors
alone would not be sufficient to increase
their risk of chronic LBP.

The same questions were applied to
each vignette. They were: 
1. Is this person at risk for developing

chronic low back pain?
2. If yes, list the factors that indicate the

person is at risk. 

Procedure
A pilot study was conducted using six
senior physiotherapists working in NHS
outpatient departments who had been
involved in student clinical education.
Face validity was established with the
clinicians responding that the vignettes
were a valid way to establish under-
standing of yellow flags in the clinical
context.

The students were pre-notified about
the study in person prior to their depar-
ture from campus on their summer 
vacation. Following ethical approval
information sheets/consent forms, ques-
tionnaires and stamped self-addressed
envelopes were posted to the home
addresses of the students. One month
was allowed for return of the question-
naires. Consent forms and questionnaires
were separated prior to analysis to 
maintain anonymity.

Analysis 
Demographic data including students’
age, gender and route of entry into the
study of physiotherapy were gathered. 
A modified framework approach was
used to develop a thematic framework



SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 1          5

identifying key issues in each of the
vignettes (Pope et al., 2000).  Responses
were evaluated and grouped under the
headings identified in the frameworks 
as listed in Table 1. This analysis was
conducted by a single researcher to
maintain consistent analysis and group-
ing of results.

Once categorised the number of
respondents per category was summed.
Total numbers of responses for risk fac-
tors and yellow flags were established
and as the results were non-parametric,
median numbers were calculated. Statis-
tical analyses of normality, measures of
centrality and measures of dispersion
were conducted using Microsoft Excel
2000 and SPSS (version 11.5).

RESULTS
A response rate of 35% was obtained
with 15 of the 42 students returning
questionnaires. All respondents were
female with a median age of 21 years
(range 20-30). Fourteen of the subjects
had entered university direct from
school, while one was a graduate of a
previous degree. This respondent’s
results were analysed independently to
the rest of the group and found not to
differ in any way. 

Identification of risk for chronic LBP
All 15 respondents answered this question
for all three vignettes. While all respon-
dents correctly identified vignette T as
being at risk for chronic LBP, the results
for vignette N were split. For vignette
NN 14 respondents responded incorrectly.
Table 2 presents an overview of the
responses to this question. 

Risk factors described
Table 3 summarises the median number
of yellow flags identified for each
vignette. For all three of the vignettes
respondents identified a median of one
risk factor not supported by evidence. 

For all three vignettes at least one
respondent identified each of the yellow
flags present. Table 4 summarises the
yellow flags present for each of the
vignettes and the percentage of respon-
dents describing that factor as a risk for
chronicity for that vignette. 

The only respondent correctly identi-
fying Vignettes N and NN as not being

at risk for chronicity was also the
respondent identifying the highest 
number of yellow flags for Vignette T
(five of six). 

DISCUSSION

Respondents
While the small sample size and restricted
number of respondents limits the gene-
ralisability of the results several interest-

ing factors were highlighted which may
be of value for the future training of
clinicians dealing with LBP.

The 15 respondents were all female
with a median age of 21 years.
Interestingly none of the males in the
sample group responded. This may sim-
ply be a reflection of the previously
reported tendency of males being less
responsive to prenotification in mail 
surveys (Hornik, 1982). 

Vignette T Vignette N Vignette NN
(at risk of chronicity) (not at risk of chronicity) (not at risk of chronicity)

Yellow • Attitude and Beliefs • Work • Attitude and Beliefs 
Flags about back pain about back pain

• Behaviours relating • Behaviours relating
to pain to pain

• Diagnosis and • Work
treatment issues

• Emotions
• Family
• Work

Evidence- • Time since onset • Time since onset • Time since onset
based risk
factors

Risk factors • Physical findings • Physical findings or • Physical findings
described by or observations observations or observations
subjects with • Physical issues • Physical issues • Physical issues
no supporting • General Fitness • General Fitness • Behaviours relating
evidence Levels Levels to coping

• General Muscular
Strength

Table 1: Thematic Framework of risk factors described in each vignette.

Vignette YES NO
(at risk) (not at risk)

Vignette T 15* (100%) 0 (0%)

Vignette N 8 (53.3%) 7* (46.6%)

Vignette NN 14 (93.3%) 1* (6.6%)

Table 2. Results for Question 1: “Do you think this person is at risk of chronic
low back pain?” ( * indicates preferred answer; n=15).

Vignette Number of yellow Median number of
flags present yellow flags identified

(range)

Vignette T 6 3
(1-5)

Vignette N 1 1
(0-1)

Vignette NN 3 1
(0-2)  

Table 3. Number of yellow flags present and median numbers identified for
each vignette.



6 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 1

6 Yellow Flags Percentage of 1 Yellow Flag Percentage of 3 Yellow Flags Percentage of 
Present in Subjects Present in Subjects Present in Subjects 
Vignette T Identifying Flag Vignette N Identifying Flag Vignette NN Identifying Flag

Work 66.6% Work 75% Work 71.4%

Attitudes and 73.3% - - Attitudes and 7.14%
Beliefs about Beliefs about
back pain back pain

Behaviours 86.6% - - Behaviours 21.4%
relating to pain relating to pain

Diagnosis and
treatment issues 20% - - - -

Emotions 60% - - - -

Family 20% - - - -  

Table 4: Percentages of respondents identifying each yellow flag for each vignette.

Response to yellow flags
Although all 15 respondents correctly
identified Vignette T as being at risk for
chronic LBP; the high numbers of
respondents incorrectly indicating that
Vignettes N (53.3%) and NN (93.3%)
were at risk suggests there is a problem
with the interpretation of risk factors. 

Vignette T contained six yellow flags
indicating risk for chronicity; however a
median of only three yellow flags were
described by the subjects. Vignette NN
contained three yellow flags yet a 
median of only one yellow flag was
described. Vignette N contained only
one yellow flag which was correctly
identified by the subjects. 

It is worth emphasising that it is not
the presence of individual yellow flags
which increases risk for chronicity but
the presence of strong and cumulative
numbers of yellow flags (Linton and
Hallden, 1998). The respondents’ evalu-
ation of risk for chronicity in the present
study appears to be based on relatively
few yellow flags. The students over-
estimated risk for chronicity with the
possible result of inappropriate patient
management.

There are several possible reasons 
for the respondents’ overestimation of
risk for chronicity in the present study.
In common with healthcare students in
several other studies (Chiu et al., 2003),
the respondents had received a limited
amount of pain education, approximately
six hours.  This education on pain was
separated into modules on assessment,
pathology and treatment interventions.

Limited education on pain further sepa-
rated into modules may compound the
situation resulting in difficulty with the
integration of assessments. 

The inclusion of at least one risk fac-
tor not supported by the evidence may
simply be a reflection of lack of training.
However the students may have been
influenced by their supervising clinical
practitioners. Swedish researchers
reported that physical therapists were
selecting a median of 10 factors not sup-
ported by the evidence as indicative of
risk for chronic LBP (Overmeer et al.,
2004). If the respondents participating in
the present study were supervised by
clinicians with similar responses to
those in Sweden, they may have been
negatively influenced.

The attitudes and beliefs of the
respondents in the present study may
also have influenced their responses.
Inexperienced clinicians and students
have been reported to hold attitudes and
beliefs about pain inconsistent with the
evidence (Latimer et al., 2004). Beliefs
influence an assessor’s frame of refer-
ence and thus affect assessment and
treatment of any painful condition.  

Finally a lack of clinical experience
in which to consolidate learning and
reflect on practice could influence the
respondents’ skill in recognising and
interpreting yellow flags. Skilled clini-
cians constantly reflect on their practice
comparing their knowledge base to past
experience and present findings. In
order to develop these skills physiothe-
rapists need to have a theoretical base,

spend time in clinical activities and
reflect on these activities in light of the
theory (Ladyshewsky, 2004). Considering
the limited clinical experience of the
respondents it may be unreasonable to
expect them to be able to effectively
interpret the yellow flags. 

In light of the length of time it takes
for clinicians to develop clinical reason-
ing skills which enable them to integrate
theory into practice it may be advisable
for students and physiotherapists assess-
ing LBP to use recognised screening
tools to assess yellow flags. Tools such
as the Yellow Flag Questionnaire which
was designed for use in New Zealand
(Linton and Hallden, 1998) can be
administered in relatively short time.
This would allow the clinician to evaluate
risk for chronicity without the subjective
influence of their beliefs and clinical
reasoning abilities. Although this tool
was designed for use in a specific 
demographic group, it could be used as
a learning tool with the aim of helping
clinicians develop clinical reasoning
skills (the Acute Low Back Pain
Screening Questionnaire can be
accessed free on the web through the
New Zealand Guidelines Group website
http://www.nzgg.org.nz/index.cfm)
(N.Z.G.G., 2003).

The results raise a number of ques-
tions for future studies. The influence of
education in pain on these results could
be evaluated in a study using a similar
vignette questionnaire applied before
and after a teaching block on pain.
Longitudinal studies following new



SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 1          7

graduates would provide further insight
into the effect of experience and skill
development on the assessment of yellow
flags in LBP. Insight into the effect of
skill development on assessment of 
yellow flags could also be gained by the
comparison of physiotherapy students’
of different levels results to those of
novice, experienced and expert physio-
therapists. 

CONCLUSION
The respondents of the present study
were overestimating risk for chronic
LBP from the vignettes. The evaluation
of risk factors reported revealed that this
overestimation appears to have occurred
due to poor interpretation of yellow
flags coupled with the identification of
risk factors not supported by the evi-
dence. Thus the strongest predictors of
chronicity (yellow flags) were not effec-
tively interpreted resulting in incorrect
determination of risk for chronic LBP. In
order to limit errors in the recognition
and interpretation of yellow flags in
LBP it would seem advisable for physio-
therapy students and newly qualified
clinicians with limited experience to use
recognised screening questionnaires to
evaluate these factors in patients.

REFERENCES

BENDIX, A. F., BENDIX, T. & HAESTRUP, C.
(1998) Can it be predicted which patients 
with chronic low back pain should be offered
tertiary rehabilitation in a functional restora-
tion programme? Spine, 23, 1775-1784.

BURTON, A. K., TILLOTSON, K. M.,
MAIN, C. J. & HOLLIS, S. (1995) Psycho-
social predictors of outcome in acute 
and subchronic low back trouble. Spine, 20,
722-728.

CHIU, L. H., TRINCA, J., LIM, L. M. & J.A., T.
(2003) A study to evaluate the pain knowledge
of two sub-populations of final year nursing
students: Australia and Philipines. Journal of
Advanced Nursing, 41.

FOSTER, N., THOMPSON, K. A., BAXTER,
G. D. & ALLEN, J. M. (1999) Management of
non-specific Low Back Pain by Physio-
therapists in Britain and Ireland. Spine, 24,
1332-1342.

HARLAND, N. & LAVALLEE, D. (2003)
Biopsychosocial Management of Chronic
Low Back Pain Patients with Psychological
Assessment and Management Tools. Physio-
therapy, 89, 305-312.

HOOGENDOORN, W. E., VAN POPPEL,
M. N. M., BONGERS, P. M., KOES, B. W. &
BOUTER, L. M. (2000) Systematic review
of psychosocial factors at work and private
life as risk factors for back pain. Spine, 25,
2114-2125.

HORNIK, J. (1982) Impact of pre-call request
form and gender interaction on response to a
mail survey. Journal of Marketing Research,
19, 144-151.

HUGHES, R. & HUBY, M. (2002) The appli-
cation of vignettes in social and nursing
research. Journal of Advanced Nursing, 37,
382-386.

LADYSHEWSKY, R. K. (2004) Impact of
Peer-Coaching on the Clinical Reasoning of
the Novice Practitioner. Physiotherapy Canada,
56, 15-25.

LATIMER, J., MAHER, C. & REFSHAUGE, K.
(2004) The Attitudes and Beliefs of
Physiotherapy Students to Chronic Back Pain.
Clinical Journal of Pain, 20, 45-50.

LINTON, S. J. (2000) A review of Psycho-
logical risk factors in back and neck pain.
Spine, 25.

LINTON, S. J. & HALLDEN, K. (1998) 
Can we screen for problematic back pain? A
screening questionnaire for predicting out-
come in acute and subacute back pain. Clinical
Journal of Pain, 14, 209-215.

N.Z.G.G. (2003) Acute Low Back Pain
Screening Questionnaire. New Zealand
Guidelines Group. Wellington, Accident
Compensation Corporation.

OVERMEER, T., LINTON, S. J. & 
BOERSMA, K. (2004) Do physical therapists
recognise established risk factors? Swedish
physical therapists’ evaluation in comparison
to guidelines. Physiotherapy, 90, 35-41.

POPE, C., ZIEBALND, S. & MAYS, N.
(2000) Analysing Qualitative Data in Quali-
tative Research. IN POPE, C. & MAYS, N.
(Eds.) Health Care. 2nd ed. London, BMJ
Books.

RAINVILLE, J., CARLSON, N., POLAIN, P.,
GATCHEL, R. J. & INDAHL, A. (2000)
Exploration of Physicians’ recommendations
for Activities in Chronic Low Back Pain.
Spine, 25, 2210-2220.

WOOLF, A. D. & PFLEGER, B. (2003)
Burden of major musculoskeletal conditions.
Bulletin of the World Health Organization, 81,
646-656.

Please turn over for Appendix I: Clinical Vignettes used in Questionnaire.

All correspondence to the  editor must be addressed to:

Prof CJ Eales - Editor SASP Journal,

P.O. Box 356 Mossel Bay

Tel: (044) 690-4956 (w), Fax: (044) 690-4956, Cell: 082 776-8097,

E-mail: eales@icon.co.za



8 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 1

Appendix I: Clinical Vignettes used in Questionnaire.

Vignette T

Joanne is a 37-year-old primary
school teacher who presents with a
4-week history of low back pain.
Joanne is not sure when her back
pain started and can’t remember an
incident which brought it on. She says
she has always had a weak back
since being in a car accident as a
teenager. At that time her GP advised
her to rest in bed when it hurt. She
feels that it won’t be long before she’ll
be like her mother who had to stop
working at 40 because of her back.
Joanne says she used to enjoy her
job but this term her workload has
increased as one of her colleagues
has gone off long term sick and she
often has to double up classes. She
says she’s too tired to do anything
outside of work and tends to collapse
at the end of the day. Joanne tried
going to the gym during the school
holidays but after four days her pain
came on and she thought she’d better
stop. Joanne lives with her partner
who is very understanding of her back
problem and he does most of the
housework to allow her to rest.
Joanne has been getting more and
more anxious about her back so her
GP ordered an X-ray which was
normal and then suggested she go
to the physio to see if there was
anything they could do.

Joanne describes her pain as a
constant deep ache that becomes
excruciating – she’s not sure why.
Once again she is off sick because of
her back. She’s recently started to
use an old back support of her
mothers. Her forward flexion is limited
and she can just reach below her
knees. She says bending backwards
is very difficult and makes her pain
worse and is unwilling to do this
movement. Lateral flexion to the right
and left are equally limited to about
half range with pain limiting her
movements. Her rotation and straight
leg raise were both normal. She has
no symptoms into her buttocks or
legs and no pain when she coughs
or sneezes. A full assessment of
passive intervertebral movements
is not possible due to pain and
withdrawal with wincing.

Vignette N

Jenny is a 32-year-old nurse who
works in the outpatient department of
the local hospital. Her job involves
assisting in consultations and taking
patient observations – she says she
is always busy, on her feet a lot but
she does get the chance to sit down
and she loves working with different
colleagues and different patients on a
daily basis. Jenny first noticed her
back ache about a month ago after a
particularly long day. It was a bit stiff
the next morning but soon eased off
and she didn’t worry about it. Since
then she has had repeated bouts of
pain, never long lasting or severe but
they seem to be occurring more often.
Jenny used to go to aerobics twice a
week and yoga once a week. Now
though she says she seems to have
got out of the habit of it all. Jenny
admits that her back pain is probably
because she hasn’t been exercising
but wanted to make sure that there
was nothing else going on. Jenny
enjoys the outdoors and is planning a
charity hike in Nepal later in the year.

Jenny has worked in orthopaedics
for many years and has been trying
to read up on back pain but feels
she’s a bit out of her depth. She’s
fascinated by how physio works
though and is looking forward to
getting a grip on things. Jenny has
central pain in her low back that
extends left and right to her waist but
not to her stomach. She says it feels
like stiff muscle aching rather than
pain. She has good posture and her
movements are full in all directions.
She does have some end range pain
on bending forwards and backwards
though. Her rotation and straight leg
raise were both normal. She has no
symptoms into her buttocks or legs
and no pain when she coughs or
sneezes. Passive intervertebral
movements show that she is stiff at
L2, L3 and L4 with some discomfort
at the end of range. She has no
muscle spasm or guarding. On
assessing her deep muscles she is
unable to initiate a contraction of
transverses abdominus.

Vignette NN

Jane is a 35-year-old nursery nurse
who presents with a 6-week history
of aching in her lower back. Jane has
had bouts of back pain since her
mid-twenties when she started
working with toddlers and was bend-
ing over a lot. She has previously
managed to cope and the pain would
settle with the use of paracetomol and
taking it easy for a few days. This time
Jane has decided that she ought to
do something about it as she feels
that her back pain is now starting to
occur with more frequency so she
asked her GP to send her to physio.
Jane goes to aerobics classes once
or twice a week and enjoys going for
a long walk on the weekend with her
dog. She would like to start doing
Pilates but thought she should get her
back seen to before starting anything
new. She knows that her work
situation doesn’t help things but she
loves her job, she hates having to take
any time off and admits she has to be
at deaths door before she will stay
home. She wouldn’t change her job
unless she was totally unable to do it.

Jane’s pain is in the middle of her
lower back and extends equally left
and right – she describes it as a deep
ache that is eased by short rests but
gets stiff after a full nights rest.
Moving about in the morning eases it
but by the end of the day the ache is
worse again. Her forward flexion is
limited and she can just reach her
knees, bending backwards is very
difficult and makes her pain worse.
Lateral flexion to the right and left are
equally limited to about half range but
not as painful as bending backwards.
Her rotation and straight leg raise
were both normal. She has no
symptoms into her buttocks or legs
and no pain when she coughs or
sneezes. Passive intervertebral
movements found that she is stiff
and tender at L3, L4 and L5 with
some associated muscle spasm.
Jane is a smoker who is constantly
trying to give up.