Screening
Is there evidence of progressive neurological deficit? ......................................................................................	❑ No	❑ Yes
Is there evidence of pathologic fracture, infection or malignancy? ..................................................................	❑ No	❑ Yes
Are there gait difficulties, spasticity or other signs of myelopathy? .................................................................	❑ No	❑ Yes
Recent history of unplanned or unexplained weight loss? ................................................................................	❑ No	❑ Yes
Is there evidence of acute injury? .....................................................................................................................	❑ No	❑ Yes
Is there evidence of seronegative spondyloarthropathy? ..................................................................................	❑ No	❑ Yes
Nociceptive Pain
Discogenic Pain
Centralization with repeated motion .................................................................................................................	❑ No	❑ Yes
Any two: (Centralization w/ repeated motion, vulnerable/apprehensive when stooped, & exten. loss) ..........	❑ No	❑ Yes
SI Joint Pain (3 or more of 6 tests)
Three or more of 6 + SI Joint tests without centralization with repeated motion .............................................	❑ No	❑ Yes
(Gaenslen’s L & R, Thigh Thrust [symptomatic side], Distraction, Iliac Compression, Sacral Thrust)
Zygapophyseal (Facet) Joint Pain (3 or more)
Age > 50 ............................................................................................................................................................	❑ No	❑ Yes
Pain relieved when walking ..............................................................................................................................	❑ No	❑ Yes
Pain relieved when sitting .................................................................................................................................	❑ No	❑ Yes
Onset of pain was paraspinal ............................................................................................................................	❑ No	❑ Yes
Positive Extension-Rotation test .......................................................................................................................	❑ No	❑ Yes
Myofascial Pain
Ache-type pain with aggravation by use of involved muscle ...........................................................................	❑ No	❑ Yes
Trigger point in muscle with possible radiation ................................................................................................	❑ No	❑ Yes
Neuropathic Pain
Compressive Radiculopathy
Absent ankle/knee reflex ...................................................................................................................................	❑ No	❑ Yes
Leg pain worse than back pain? ........................................................................................................................	❑ No	❑ Yes
Dermatome distribution (cough, sneeze, strain) ...............................................................................................	❑ No	❑ Yes
Paresis (extremity motor strength loss) .............................................................................................................	❑ No	❑ Yes
Finger floor distance during flexion >25cm ......................................................................................................	❑ No	❑ Yes
LANSS score >12 .............................................................................................................................................	❑ No	❑ Yes
Non-compressive Radiculopathy
LANSS score >12 .............................................................................................................................................	❑ No	❑ Yes
Compressive Radiculopathy criteria are satisfied .............................................................................................	❑ No	❑ Yes
Neurogenic Claudication
Score of 7 or more on clinical prediction rule ..................................................................................................	❑ No	❑ Yes
ABI greater than 0.9 (if indicated) ....................................................................................................................	❑ No	❑ Yes
Central Pain
Pain disproportionate to injury/pathology ........................................................................................................	❑ No	❑ Yes
Disproportionate, non-mechanical, unpredictable pattern of aggravating/relieving factors .............................	❑ No	❑ Yes
Strong association with maladaptive psychosocial factors ...............................................................................	❑ No	❑ Yes
(neg. emotions, poor self efficacy, maladaptive beliefs & pain behaviors, conflicts [family, work…])
Diffuse or non-anatomic distribution of tenderness to palpation ......................................................................	❑ No	❑ Yes
Functional Instability (Lumbar Segmental Instability)
Prone passive lumbar extension positive ..........................................................................................................	❑ No	❑ Yes
One or more lumbar hypermobile segment(s) ..................................................................................................	❑ No	❑ Yes
One or more lumbar hypomobile segment(s) ...................................................................................................	❑ No	❑ Yes
Other diagnoses
Evidence for other diagnoses (Thoracolumbar syndrome, Piriformis syndrome, Hip pain)... .........................	❑ No	❑ Yes