Low Back Pain With or Without Sciatica: Assessment, Risk Stratification and Active Rehabilitation

Clinical frame

Most low back pain is managed without identifying one painful structure. The first job is to screen for serious pathology and neurological compromise, then identify modifiable functional problems, irritability and recovery barriers.

Assessment and red flags

• Ask about new bladder/bowel dysfunction, saddle sensory change and progressive bilateral neurological symptoms.
• Consider fracture, infection, malignancy and inflammatory disease when history and examination support those hypotheses.
• For leg symptoms, assess myotomes, dermatomes, reflexes and relevant neurodynamic findings.
• Track pain plus function using a disability measure and patient-specific activity goals.

Differential reasoning

Radicular pain and radiculopathy are not synonyms: radiculopathy implies neurological loss such as weakness, sensory change or reflex change. Referred leg pain can occur without nerve-root dysfunction. Imaging should be used when it is likely to change management rather than as a routine explanation for pain.

Management and dosage

• Provide reassurance and advice to remain active within tolerance.
• Use repeated movement, mobility, trunk or general strengthening according to the dominant impairment and preference.
• Begin resistance at a repeatable dose, commonly 2–3 sessions per week, and progress load or volume when recovery is predictable.
• Manual therapy may be an adjunct when it helps movement or exercise participation; avoid dependence on passive care.

Progression and reassessment

• Progress one variable at a time: range, repetitions, resistance, speed or task complexity.
• Reassess neurological status when leg symptoms change.
• Escalate if new progressive neurological deficits or cauda-equina-type symptoms emerge.

Common mistakes

• Equating MRI findings with the pain source.
• Prescribing bed rest.
• Using a generic core programme for every presentation.
• Ignoring work, sleep, fear and activity tolerance.

Clinical pearls

• Screen first, classify second.
• Function matters more than tenderness alone.
• A symptom flare is information about dose, not automatic evidence of damage.

Concise summary

Low back pain rehabilitation is strongest when serious pathology is screened, neurological findings are tracked, education supports activity and exercise is progressively matched to the person’s functional goals.