Welcome back to SpineIQ’s Back Blog! Last month, we discussed practical tips, barriers, and facilitators for encouraging self-management in the clinic. This month, we are presenting a series of research articles that we think all spine care clinicians should read, starting with “Evaluation is treatment for low back pain” by Louw et al. (2020)1. We chose this study because it has direct implications for clinical practice, especially for a busy evidence-based practice.

Goals of the study

Many studies have shown that patients find value in what they experience during initial visits with healthcare clinicians.2,3  The general assumption is that any positive effect found is due to treatment interventions alone.4,5 However, there are actually many additional interactions with the patient during that visit – greeting the patient when he or she enters the clinic, a complete history that may include both forms to complete and a conversation with the clinician and/or clinic staff, a comprehensive physical examination, baseline and re-tests of pain/disability, etc. The purpose of this study was to determine if these interactions, in this case the potential effect of the history taking and/or physical examination procedures, can influence low back pain outcomes.


Since this was a pragmatic study, clinicians were asked to guide the history based on their clinical reasoning and patient presentation. Common information gathered during the history included the following:

  • chief complaint
  • mechanisms
  • medical history
  • functional limitations
  • prior level of function
  • social factors
  • environmental factors

The physical examination was also pragmatic, so clinicians were allowed full discretion conducting it. The examination included:

  • systems review
  • functional movement assessment
  • range of motion assessment
  • neurological screening
  • palpation
  • joint and soft tissue mobility
  • special tests

 Primary outcome

A third party not involved in the patient’s care collected outcomes data at baseline, after the patient history, and after the physical examination. The primary outcomes measure was low back pain using the numeric pain rating scale (NPRS). Prior to initiation of the study, investigators determined that a 10% change would be considered a small effect, while 30% and 50% changes were classified as moderate and large, respectively.


At baseline the average low back pain score was 3.97 (0-10). Individually, small effects were found after the history (19%) and examination (17%) were completed, while a moderate change from baseline was found following both the history and examination (36%). The study did not find a correlation pain score and the length of time spent on either the history or physical examination procedures.


This study provides important, albeit preliminary, findings demonstrating the potential value that clinicians can add to patient outcomes in addition to the actual therapeutic interventions provided. While history and physical exam appear to be associated with therapeutic effects, the length of time spent on these processes does not.

Stay tuned for next week’s blog as we look at the social determinants of health and how they can affect spine health!


  1. Louw A, Goldrick S, Bernstetter A, et al. Evaluation is treatment for low back pain. J Man Manip Ther. 29(1):4-13. doi:10.1080/10669817.2020.1730056
  2. Verbeek J, Sengers M-J, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine. 2004;29(20):2309-2318. doi:10.1097/01.brs.0000142007.38256.7f
  3. McRae M, Hancock MJ. Adults attending private physiotherapy practices seek diagnosis, pain relief, improved function, education and prevention: a survey. J Physiother. 2017;63(4):250-256. doi:10.1016/j.jphys.2017.08.002
  4. Tsao H, Hodges PW. Immediate changes in feedforward postural adjustments following voluntary motor training. Exp Brain Res. 2007;181(4):537-546. doi:10.1007/s00221-007-0950-z
  5. Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil. 2003;84(7):1057-1060. doi:10.1016/s0003-9993(03)00048-0