Low Back Pain Care Pathway

Date of last update: July, 2024

4. Differential Diagnosis Requiring Medical Attention

Note: Peripheral neuropathies may not present with low back pain but are key differentials for radicular pain/radiculopathy. Musculoskeletal peripheral neuropathy does not necessarily require referral to a medical provider, unlike other conditions in this section.

Red Flags: Immediate Referral to Emergency Care:

1. Cauda Equina Syndrome

Pain Location: Severe low back pain.
Signs/Symptoms/Red Flags: Saddle anesthesia, bowel overflow incontinence, bladder retention or overflow incontinence, bilateral progressive radicular signs.
Physical and Neurological Examination: Decreased perianal sensation, decreased anal sphincter tone, progressive lower extremity weakness.
Action: Immediate referral to emergency care.

2. Spinal Infection (osteomyelitis, discitis, epidural abscess)

Pain Location: Localized severe back pain.
Signs/Symptoms/Red Flags: Constitutional (fever, chills, fatigue), localized pain, swelling, redness, immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.
Physical and Neurological Examination: Tenderness over the affected area, possible erythema and warmth, possible neurological deficits.
Action: Immediate referral to emergency care.

3. Traumatic Spinal Fracture

Pain Location: Localized pain in the mid or lower back.
Signs/Symptoms/Red Flags: Sudden onset of severe pain following severe trauma.
Physical and Neurological Examination: Point tenderness.
Action: Immediate referral to emergency care.

Refer to Medical Provider:

1. Non-traumatic Spinal Fracture

Pain Location: Localized pain in the mid or lower back.
Signs/Symptoms: Sudden onset of severe pain following minor trauma or spontaneous in osteoporotic patients, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.
Physical and Neurological Examination: Point tenderness over the affected vertebra, kyphosis in severe cases.
Action: Referral to appropriate medical provider.

2. Spinal Malignancy

Pain Location: Severe, progressive, localized back pain, often with radiation to the chest or abdomen.
Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest; constitutional symptoms (night sweats, unexplained weight loss, fatigue).
Physical and Neurological Examination: Localized tenderness, possible neurological deficits.
Action: Referral to appropriate medical provider.

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis):

Pain Location: Lower back, may radiate to buttocks and thighs.
Signs/Symptoms: Morning stiffness >1 hour, pain improves with activity, pain worse at night, presence of other inflammatory signs (e.g., uveitis, psoriasis), systemic symptoms (fatigue, weight loss, fever).
Physical Examination: Possible reduced spinal mobility, positive Schober’s test, tenderness over joints.
Action: Referral to appropriate medical provider.

2. Rheumatoid Arthritis

Pain Location: Diffuse joint pain, may include lower back.
Signs/Symptoms: Symmetrical joint pain, morning stiffness >1 hour, systemic symptoms (fatigue, weight loss, fever).
Physical Examination: Joint swelling, tenderness, and deformity.
Action: Referral to appropriate medical provider.

3. Systematic Lupus Erythematosus (SLE)

Pain Location: May include lower back and other joints.
Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).
Physical Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.
Action: Referral to appropriate medical provider.

4. Referred Pain (from abdominal/pelvic visceral conditions)

(e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis)

Pain Location: Varies depending on the condition, often radiating to the back.
Signs/Symptoms: Specific to the underlying condition, may include abdominal pain, gastrointestinal symptoms, urinary symptoms, systemic symptoms (fever, chills, weight loss).
Physical Examination: Abdominal or pelvic tenderness, palpable mass, and other specific signs related to the condition (e.g., Murphy's sign for kidney stones, Cullen's sign for pancreatitis).
Action: Referral to appropriate medical provider.

5. Non-Musculoskeletal Peripheral Neuropathy

(e.g., diabetic neuropathy, Guillain-Barré syndrome)

Pain Location: Burning, tingling, or numbness in the feet and legs distally and bilaterally.
Signs/Symptoms: Stocking-like distribution of sensory loss, muscle weakness.
Physical Examination: Reduced sensation, absent reflexes, muscle weakness, balance difficulty.
Action: Referral to appropriate medical provider.

6. Musculoskeletal Peripheral Neuropathy

(e.g., meralgia paresthetica, tarsal tunnel syndrome, peroneal nerve entrapment)

Pain Location: Burning, tingling, or numbness in the feet and legs distally.
Signs/Symptoms: Follows peripheral nerve distribution, unilateral.
Physical Examination: Reduced sensation, absent reflexes, muscle weakness, balance difficulty.
Action: Does not necessarily require referral to a medical provider.

Low Back Pain Care Pathway

1. Record Keeping

Document all findings and recommendations on an ongoing bases, including SOAP notes at each visit (subjective, objective, assessment, plan).
Adhere to jurisdictional standards.

2. Informed Consent

Document verbal consent for health history taking, physical examination, contact in sensitive areas.
Obtain written consent for treatment.
Adhere to jurisdictional standards.

3. Health History

Apply cultural awareness and trauma-informed care principles
Sociodemographic: Age, gender, sex.
Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.
Previous treatments and responses: Effectiveness and any adverse events.
Beliefs and expectations: Understanding of their condition, treatment expectations.
Red, yellow, and orange flags (sections 4 – 6).

Meaningful Outcomes:

Pain: Pain scales (e.g., NRS), pain diagram.
Function and Participation: Impact of LBP on daily activities (PSFS, WHODAS, ODI, RMDQ, MYMOP, MYMOP Follow-up).
Recovery: Self-rated recovery scales.
Quality of Life: SF-12.
Work Status: Return to work/school/activities.
Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
Patient Feedback: Experience and satisfaction with care.

4. Differential Diagnosis Requiring Medical Attention

ACTION: Refer to emergency care immediately for red flags:

Cauda Equina Syndrome: Saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs.
Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, systemic symptoms (e.g., fever/chills), IV drug use, poor living conditions.
Traumatic Spinal Fracture: Severe trauma.

ACTION: Refer to appropriate medical provider:

Non-traumatic Spinal Fracture: Sudden onset, localized severe pain, osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.
Spinal Malignancy: Progressive pain, history of cancer, constitutional symptoms (e.g., fatigue, weight loss).
Inflammatory Arthritides (e.g., ankylosing spondylitis): Morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), pain improves with activity, pain worse at night.
Referred Pain: (from abdominal/pelvic visceral conditions): Abdominal or pelvic tenderness.

5. Psychiatric Disorders (Orange Flags)

Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.
Screening tools: PHQ-9, GAD-7
Action: Refer to appropriate provider/psychiatric specialist.

6. Psychological Factors (Yellow Flags)

Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims; maladaptive coping mechanisms.
Screening tools: PHQ-9, GAD-7, FABQ, ORT, PCS
Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

Observation: Abnormalities, asymmetries, posture, balance, gait, movements, and facial expression.
Range of Motion: Active, passive, resisted (flexion, extension, lateral flexion, rotation).
Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
Neurological Examination: Motor strength, sensory and reflex testing (L2, L3, L4, L5, S1, S2); upper and lower motor neuron signs.
Special/Orthopedic Tests: Select as appropriate based on clinical judgment.
Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment).

8. Diagnostic Criteria for LBP Amenable to Conservative Care

A. Common LBP (e.g., non-specific, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, facet joint irritation, osteoarthritis)

Pain: Below costal margin and above inferior gluteal folds, with or without leg pain.
Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; associated muscle stiffness or spasms; may refer into legs but not below knees.
Exam: Pain reproduced by tests; no neurological deficits.

B. LBP with Radicular Pain/Radiculopathy (from disc protrusion/herniation)

Pain: Low back radiating down leg.
Signs/Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.
Exam: Positive straight leg raise test; sensory deficits, muscle weakness, altered reflexes.

C. Deep Gluteal Syndrome (e.g., piriformis syndrome)

Pain: Buttock and posterior leg, potentially radiating to foot.
Signs/Symptoms: Pain exacerbated by sitting, climbing stairs, or performing squats; tenderness in deep gluteal region.
Exam: Signs of sciatic nerve irritation, but not following a radicular pattern associated with nerve roots.

9. Treatment Considerations for LBP Amenable to Conservative Care

(Common LBP, LBP with radicular pain/radiculopathy from disc pathology, deep gluteal pain)

After providing a report of findings and obtaining written informed consent.

Essential Interventions:
- Education and reassurance
- Address yellow flags (psychosocial factors)
- Maintain activities of daily living
- Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)
- Engage in social and work activities

Optional Interventions (with Rationale and Shared Decision Making):
- Exercise therapy
- Manual therapy (e.g., spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage)
- Medications (e.g., acetaminophen, ibuprofen/prescription). Discuss options/risks with medical provider.
- Psychological or social support
- Mind-body interventions (e.g., mindfulness, meditation)
- Needling therapies, topical cayenne pepper, electrotherapies, traction
- Mobility assistive devices (e.g., walkers, canes)
- Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy and social support)

10. Prognosis

Recovery: Most people recover, but LBP can recur or persist.
Negative Prognostic Factors: Smoking, obesity, higher initial pain levels, poor recovery expectations, mental health issues, persistent symptoms, leg pain, work-related factors, previous LBP, functional limitations.

11. Ongoing Follow-up

Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgement.
Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).
Discuss post-discharge plans, including self-management strategies and potential follow-ups.

References or links to primary sources