Low Back Pain Care Pathway

8. Diagnostic Criteria for LBP Amenable to Conservative Care

 

Diagnosis requires a thorough understanding of the patient's condition. It integrates patient stories; clinical findings; risk factor evaluations; and physical, psychological, social, and environmental aspects of pain.

 

A. Common LBP

(Other terms used to describe common LBP: non-specific, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, osteoarthritis, facet joint irritation).

• Definition: Common LBP that is not due to serious underlying pathology requiring medical attention such as infection, tumor, or fracture and is typically amenable to conservative care (e.g., education, manual therapy, exercise).

• Prevalence: Approximately 90% of all LBP cases.

• Risk Factors: Include poor posture, sudden movements, heavy lifting, repetitive physical stress, low physical activity levels, smoking, obesity.

• Prognostic Factors for Delayed Recovery: Include high pain intensity at onset, high levels of disability, poor general health, history of LBP, psychological factors (e.g., fear-avoidance behaviors, anxiety, depression), poor coping strategies, low social support, job dissatisfaction.

• Pain Location: Localized below the costal margin and above the inferior gluteal folds, with or without leg pain.

• Duration: Pain can be acute (less than 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks).

• Signs and Symptoms:

• Pain can be sharp, dull, shooting, or aching.

• Intensity varies from mild to severe.

• Aggravated by specific movements, postures, or activities; relieved by others.

• Associated muscle stiffness or spasms.

• Referred pain into the legs may be present but usually does not extend below the knee.

• Physical and Neurological Examination: Pain reproduced by tests. Typically, no neurological deficits. If present, they are mild and do not follow a specific nerve root distribution.

 

Note: Common LBP represents the most frequent causes of low back pain with similar mechanisms, clinical symptoms and signs in a primary care setting. Evidence suggests that identifying the specific nociceptive cause of common LBP is difficult. However, breaking down common LBP into different categories helps in guiding treatment strategies and managing patient expectations. Common LBP includes:

​

1. Sacroiliac Joint Dysfunction

• Definition: Pain stemming from the sacroiliac joint.

• Prevalence: Accounts for 15-30% of LBP cases.

• Risk Factors: Pregnancy, leg length discrepancy, previous lumbar fusion, trauma.

• Pain Location: Low back and buttocks, possibly radiating to groin or thighs.

• Duration: Acute or chronic with intermittent exacerbations.

• Signs and Symptoms: Worsens with sitting, standing, or weight-bearing activities; improves with lying down.

• Physical and Neurological Examination: Positive sacroiliac joint tests; no neurological deficits.

 

2. Myofascial Pain Syndrome

• Definition: A chronic pain disorder caused by sensitivity and tightness in the myofascial tissues.

• Prevalence: Common in adults, especially those with sedentary lifestyles or repetitive motion jobs.

• Risk Factors: Poor posture, stress, muscle overuse, direct muscle injury.

• Pain Location: Muscle pain in low back, potentially referred pain.

• Duration: Chronic, with variable intensity.

• Signs and Symptoms: Trigger points in muscles, painful on compression.

• Physical and Neurological Examination: Taut bands and trigger points; no significant neurological deficits.

 

3. Osteoarthritis

• Definition: Degenerative joint disease affecting the lower back.

• Prevalence: Common in older adults.

• Risk Factors: Aging, obesity, joint injuries, repetitive stress, genetic predisposition.

• Pain Location: Localized or radiating pain in low back, may involve the hips.

• Duration: Chronic with episodic flare-ups.

• Signs and Symptoms: Worsens with activity, relieved by rest; morning stiffness.

• Physical and Neurological Examination: Reduced range of motion; crepitus and joint swelling. No significant neurological deficits unless advanced.

​

4. Facet Joint Irritation

• Definition: Inflammation or degeneration of the facet joints in the spine.

• Prevalence: Common in middle-aged and older adults.

• Risk Factors: Aging, previous back injuries, repetitive spinal stress.

• Pain Location: Localized to the low back, may radiate to the buttocks or thighs.

• Duration: Acute or chronic with periods of exacerbation.

• Signs and Symptoms:

  • Pain exacerbated by extension, twisting, and prolonged standing.

  • Morning stiffness and pain relieved by rest.

• Physical and Neurological Examination: Tenderness over the facet joints, pain with extension and rotation, no significant neurological deficits.

 

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

• Definition: Displacement of disc material that causes irritation or compression of nerve roots.

• Prevalence: Common cause of LBP with radiculopathy, particularly in younger adults.

• Risk Factors: Heavy lifting, repetitive activities, smoking, obesity.

• Pain Location: Low back radiating down leg.

• Duration: Acute or chronic, with episodes lasting weeks to months.

• Signs and Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness; worsens with bending forward, lifting, or sitting.

• Physical and Neurological Examination: Positive straight leg raise test, sensory deficits, muscle weakness, altered reflexes.

 

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

• Definition: Compression or irritation of the sciatic nerve by the piriformis muscle or other structures in the deep gluteal region.

• Prevalence: Less common cause of LBP compared to lumbar radiculopathy; occurs more frequently in individuals who sit for prolonged periods or engage in repetitive hip movements.

• Risk Factors: Prolonged sitting, trauma to the buttocks, repetitive activities involving hip rotation, leg length discrepancy.

• Pain Location: Buttock and posterior leg pain, potentially radiating to the foot.

• Duration: Acute or chronic, with symptoms lasting days to months.

• Signs and Symptoms:

  • Pain exacerbated by sitting, climbing stairs, or performing squats.

  • Tenderness in the deep gluteal region, particularly over the piriformis muscle.

  • Possible numbness, tingling, or weakness in the affected leg.

• Physical and Neurological Examination:

  • Tenderness on palpation of the deep gluteal region.

  • Positive signs of sciatic nerve irritation, such as reproduction of pain with maneuvers that stretch or compress the sciatic nerve (e.g., the Piriformis Test, although its sensitivity and specificity are limited).

  • Typically, no neurological deficits unless severe compression is present.