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Parcours de soins pour les lombalgies

Date de la dernière mise à jour : février 2024

Report of Findings (ROF)

Clinical Cornerstone:

  • The ROF aims to educate the patient about their condition, set a common understanding of expectations, and build trust. It's essential to communicate effectively, using language that the patient can comprehend, and to create an environment where the patient feels comfortable asking questions and participating in their care. Depending on the patient, it may be necessary to involve family or caregivers at this stage.

1. Review of Patient's History: Summarize main complaints, concerns, and relevant history.

2. Clinical Examination Findings: Discuss key results that shaped your understanding or planning.

 

3. Diagnostic Results: If applicable, explain imaging or test results in plain language.

4. Diagnosis: State the diagnosis and explain contributing factors through a biopsychosocial approach, particularly for persistent LBP cases. This should include reviewing any yellow flags identified. It may include summarizing the following sections of their History assessment as well: Narrative (how the issue affects their daily living, PSFS), Social History (support system), Social determinants of health (occupational or domestic stressors), Lifestyle (exercise, nutrition/smoking, stress) . It may also include summarizing relevant outcome questionnaires (e.g. ODI).

5. Prognosis: Outline the expected course, discuss negative prognostic factors, and provide an anticipated recovery time.

 

6. Treatment Recommendations: Engage in shared decision-making for the management plan treatment goals and expected outcomes, discuss benefits and risks of treatment, discuss alternate treatment options (e.g., medication, CBT, self-management only, treatment with other providers/disciplines), explain how any proposed interventions fit with the set treatment goals and expected outcomes (e.g., manual therapy, exercises, modalities).

 

7. Patient's Role in Recovery: Engage conversation emphasizing the importance of patient involvement and self-management; suggest home exercises, lifestyle modifications, behaviour changes, and any other self-care measures; emphasize adherence to recommendations.

8. Address Concerns and Questions: Encourage patient queries and provide clear answers.

Conclusion: Summarize the ROF and emphasize collaborative care.

Documentation: Record all findings, discussions, and recommendations in the patient's record.

Conduct patient assessment

Red flags present

Red flags present

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Refer to appropriate emergency or healthcare provider

Non-specific LBP or LBP with radiculopathy:

  • Education

  • Self-care

  • Exercise

  • Manual therapy

  • Medicines

  • Psychological therapy

  • Social support

  • Mind-body interventions

  • Needling therapies, electrotherapies*

  • Mobility assistive devices

  • Multicomponent biopsychosocial care

  • Topical ceyenne pepper

Additionally for LBP with radiculopathy:

  • Medical/surgical consultations

Other specific LBP:

  • Refer to appropriate emergency or healthcare provider

Major symptom/sign change

Goals not achieved

Re-evaluate

Adjust treatment and management plan or refer

References or links to primary sources

Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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