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 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 .................................... (Gaenslen’s L & R, Thigh Thrust [symptom side], Distraction, Iliac Compression, Sacral Thrust)	❑ No	❑ Yes
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 ...................................................................... (neg. emotions, poor self efficacy, maladaptive beliefs & pain behaviors, conflicts [family, work…])	❑ No	❑ Yes
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 segments .............................................................................................	❑ No	❑ Yes

Other diagnoses
Evidence for other diagnoses (Thoracolumbar syndrome, Piriformis syndrome, Hip pain) ...................	❑ No	❑ Yes