Preventing Chronic Disability from Low Back Pain - Welfare.ie

APPENDIX A2:FORMS DESIGNED FOR USE IN PROJECTThe following 3 forms were designed to:A. assist the medical assessors in the differential diagnosis of LBPB. assess the degree, if any, of resulting disability andC. achieve and maintain consistency.A. DIAGNOSTIC TRIAGE1. SIMPLE LOW BACK PAINYESNO● 20 –55 YRS ❏ ❏● L/S region, buttocks and thighs ❏ ❏● Mechanical in nature ❏ ❏● Patient well ❏ ❏2. NERVE ROOT PAIN● Unilateral leg pain worse than low back pain ❏ ❏● Radiates generally to foot or toes ❏ ❏● Numbness & paraesthesia in same direction ❏ ❏● Nerve irritation signs – SLR restricted ❏ ❏● Nerve compression signs – motor, sensory ❏ ❏or reflex changes16