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Low Back Pain Care Pathway

Date of last update: July, 2024

3. Health History

 

Taking a patient's history is about forging a therapeutic relationship. Actively and empathetically listening to the patient's story offers insights into their condition and its optimal approach to management.

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Clinicians should exercise judgment during history-taking. Adopting cultural awareness and principles of trauma-informed care could help minimize potential barriers. This might involve reframing questions from "what's wrong with you" to "what happened". This might also involve explaining the rationale behind sensitive questions or tests.

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While history-taking needs to be thorough, it does not need to be linear. Certain topics like prior episodes of LBP, past care experiences, and recovery expectations are crucial but can be addressed at different times during the patient encounter.

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When re-evaluating existing patients, especially those with new complaints, a thorough clinical examination is as imperative as with new patients. Explore the new issue's onset, duration, and associated factors, and gauge its impact on pre-existing conditions and treatments.

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Meaningful Outcomes:

Incorporating outcome measures before treatment and reviewing them regularly ensures that care remains patient-centered and evidence-driven. This allows for adapting the management plan to achieve the best possible results. Selected outcome measures should align with the patient’s goals and expectations.

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).

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Meaningful Outcomes:

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, constitutional 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

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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