Low Back Pain Care Pathway

Date of last update: November, 2024

About Low Back Pain (LBP)

LBP is a common condition that can be acute or persistent, presenting as a dull ache, sharp pain, or radiating discomfort, especially to the legs. Most cases respond well conservative care, though some may result from serious underlying pathologies that require medical attention..

Given its multifactorial and recurring nature, influenced by physical, psychological, social, and environmental factors, there is no one-size-fits-all treatment for LBP. Effective management must be ethical, evidence-driven, transparent, flexible, and responsive to individual needs. Incorporating shared decision-making ensures care aligns with patient goals. Continuous monitoring and assessment of outcomes help maintain a person-centered approach. Management may also be delivered through virtual or hybrid care options.

About the Care Pathway

Purpose: This pathway offers structured, evidence-based guidance for clinicians delivering conservative care, covering key steps of the clinical encounter. It also serves as a resource for referral or co-management for those not directly providing conservative care. Key information is available in a one-page quick guide, with more detailed content accessible through specific sections.

Development and evidence selection:

The pathway integrates established clinical knowledge with the latest research, drawing from high-quality systematic reviews and guidelines assessed using critical appraisal tools. Recommendations reflect consistent evidence of benefit or harm, while evolving or conflicting recommendations are addressed in expanded notes. Input from clinical leaders, educators, and researchers ensures practical alignment with current evidence and practical application.

Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Low Back Pain Management Quick Guide

Info

Low Back Pain Care Pathway

1. Record Keeping

Document findings and recommendations using structured notes (e.g., SOAP format) at each visit, adhering to jurisdictional standards.

Info

2. Informed Consent

Obtain and document verbal consent for history taking, examinations, and contact in sensitive areas; secure written consent for treatments per jurisdictional standards.

Info

3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic: Age, gender, sex, race/ethnicity.
Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
Body systems review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, and history: Past medical conditions, medications (including opioids, oral contraception, etc.), 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, social isolation.
Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.
Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
Flag considerations: Identify red, orange, and yellow flags for potential referrals [see Sections 4 – 6].

Outcome Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

Pain: Use pain scales (e.g., NRS) and diagrams.
Function and participation: Evaluate impact on daily activities (PSFS, WHODAS, ODI, RMDQ, MYMOP, MYMOP Follow-up).
Recovery: Use self-rated recovery scales.
Quality of life: Assess using tools such as SF-12.
Work/school status: Monitor return to activities.
Sleep quality: Assess using tools such as PSQI.
Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
Patient feedback: Gather and integrate patient experience and satisfaction.

Info

4. Red Flags: Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

Cauda equina syndrome: Severe back pain, saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs, progressive lower limb weakness, decreased perineal sensation, reduced anal sphincter tone.

Spinal infection: Severe, localized LBP with systemic symptoms (e.g., fever, chills), possible swelling/redness/tenderness, recent infection/surgery, TB history, immunosuppression, IV drug use, poor living conditions, potential neurological deficits.

Traumatic spinal fracture: Sudden onset of severe, localized pain and tenderness following trauma.

ACTION: Refer to appropriate medical provider:

Non-traumatic spinal fracture: Sudden, localized pain/tenderness following minor trauma or spontaneous in individuals with osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture/cancer.

Spinal malignancy: Severe, progressive localized back pain radiating to chest/abdomen; worse at night, not relieved by rest; history of cancer, constitutional symptoms (e.g., fatigue, weight loss), localized tenderness, potential neurological deficits.

Inflammatory arthritides (e.g., ankylosing spondylitis): LBP potentially radiating to buttocks/thighs, improves with activity, worse at night, morning stiffness > 1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), reduced spinal mobility, positive Schober’s test, joint tenderness, inflammatory signs (e.g., uveitis, psoriasis).

Referred pain from abdominal/pelvic visceral conditions (e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis): Abdominal pain, GI or urinary symptoms, systemic signs (e.g., fever, weight loss), abdominal/pelvic tenderness, palpable mass, specific findings (e.g., Murphy's sign for kidney stones, Cullen's sign for pancreatitis).

Non-musculoskeletal peripheral neuropathy (e.g., diabetic neuropathy, Guillain-Barré syndrome): Typically does not present with LBP but can be a key differential for radicular pain/radiculopathy. Symptoms include burning, tingling, or numbness in a bilateral stocking-like distribution in the lower extremities, with sensory loss, reduced reflexes, muscle weakness, balance difficulties

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.
Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

Triage: Ensure primary management by medical/psychiatric providers.
Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
Social: Lack of family/social support, limited connections.
Socioeconomic: Employment status, financial stress, litigation/compensation.
Environmental/cultural: Social inequality, unsafe/unsupportive environments.
Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers:

Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).
Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

7. Physical Examination

Observation: Evaluate for abnormalities, asymmetries, posture, balance, gait, movements, facial expressions.

Range of motion (ROM): Assess active, passive, and resisted lumbar spine ROM in flexion, extension, lateral flexion, and rotation. Note regional or segmental hypo-/hypermobility and aberrant movements.

Palpation: Examine for tenderness, swelling, tightness, or temperature changes in bones, joints, and soft tissues of the lumbar region.

Neurological examination:
- Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
  - L2: Hip flexors (hip flexion)
  - L3: Quadriceps (knee extension)
  - L4: Tibialis anterior (foot dorsiflexion)
  - L5: Extensor hallucis longus (big toe extension)
  - S1: Gastrocnemius (plantar flexion)
  - S2: Hamstrings (knee flexion)
- Sensory testing: Assess for sensory deficits in dermatomal distributions:
  - L3: Medial thigh at the knee
  - L4: Medial calf
  - L5: Top of foot and toes
  - S1: Lateral foot and little toe
- Reflex testing: Assess for asymmetry, diminished/absent reflexes:
  - L4: Patellar reflex
  - L5: Medial hamstring reflex
  - S1: Achilles reflex
- Upper motor neuron signs: Asses for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate central nervous system disorders (e.g., myelopathy, multiple sclerosis, stroke).
- Lower motor neuron signs: Assess for muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate systemic neurological conditions (e.g., radiculopathy, peripheral neuropathy, ALS).

Special/Orthopedic Tests: Perform as clinically indicated.

Advanced Diagnostics: Radiography is generally not recommended without red flags or specific individual factors (e.g., contraindications to treatment).

Info

8. Diagnostic Criteria for LBP Amenable to Conservative Care

Common LBP (e.g., non-specific, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, facet joint irritation, osteoarthritis)
- Accounts for 90% of LBP cases.
- Pain dominant between the costal margin and inferior gluteal folds, with or without leg pain.
- Pain can be sharp, dull, shooting, or aching, often worsened by specific movements and associated with muscle stiffness or spasms.
- Pain is reproducible with testing; typically, no neurological deficits.

LBP with Radicular Pain/Radiculopathy (from disc protrusion/herniation)
- Common, especially in younger adults.
- LBP radiating down the leg in a dermatomal pattern, with symptoms like sharp, shooting, or burning pain, numbness, tingling, and weakness.
- Positive straight leg raise test, sensory deficits, muscle weakness, altered reflexes.

Deep Gluteal Syndrome (e.g., piriformis syndrome)
- Less common than lumbar radiculopathy; often affects individuals with prolonged sitting or repetitive hip movements.
- Buttock and posterior leg pain, potentially radiating to the foot; worsens with sitting, stair climbing, or squatting.
- Tenderness in the gluteal region with sciatic nerve irritation signs, without a nerve root pattern; typically no neurological deficits unless severe compression occurs.

Info

9. Treatment Considerations for LBP Amenable to Conservative Care

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

Guideline-Supported Interventions for LBP

Treatments should integrate clinician experience, patient preferences, and individual needs with a multimodal approach to reduce pain, optimize function, and promote daily activity participation. Informed consent must follow a comprehensive report of findings.

1. Education and Self-Management (NICE, 2016; Qaseem et al., 2017; WHO, 2023; Zaina et al., 2023)

These interventions address modifiable prognostic factors for recovery [see Section 10].

Education & reassurance: Emphasize LBP’s often self-limiting nature. Use tailored, evidence-based information in various formats (written, digital, visual) to empower individuals. Limited evidence suggests no single superior type of education for improving patient outcomes, but consistent reinforcement improves understanding and engagement.
Self-care: Encourage regular exercise, nutrition, sleep hygiene, stress management, weight maintenance, and avoidance of smoking/substance abuse. Employ SMART goals and Brief Action Planning for sustained engagement.
Daily activities: Promote continued movement and discourage prolonged bed rest to enhance recovery and prevent functional decline.
Social & work engagement: Encourage participation using pacing strategies and workplace accommodations to support social functioning and productivity.
Mobility devices: Recommend assistive devices (e.g., walkers, canes) to enhance safety and independence as needed.

2. Exercise Therapy (Bussières et al., 2018; NICE, 2016; Wong et al., 2017; WHO, 2023; Zaina et al., 2023)

Develop individualized programs focused on improving strength, mobility, and aerobic fitness, tailored to patient needs and preferences. Exercise has demonstrated benefits in reducing pain, improving functional capacity, and enhancing quality of life. No single exercise type is shown to be superior, so programs should align with patient capabilities and goals. Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.

3. Manual Therapy (Bussières et al., 2018; NICE, 2016; Wong et al., 2017; WHO, 2023; Zaina et al., 2023)

Incorporate spinal manipulation, mobilization, and soft tissue techniques to reduce pain and improve function. Manual therapy should be integrated as part of a broader care plan to maximize effectiveness.

4. Psychosocial and Psychological Support (Côté et al., 2015; Qaseem et al., 2017; WHO, 2023)

Address barriers: Screen for psychosocial barriers (e.g., fear of movement, low recovery expectations, anxiety) using tools (e.g., FABQ, PHQ-9, GAD-7, ORT, PCS). Addressing psychosocial factors improves overall treatment outcomes and engagement. Provide education and strategies within the scope of care to support recovery (e.g., stress management, self-efficacy building, social/occupational engagement) [see Sections 5 and 6].
Resources & instruction: Offer resources (e.g., online tools, written materials, mindfulness programs). Refer mind-body practitioners (e.g., yoga, meditation, tai chi) for further support when conservative care is insufficient.
Medical/mental health referral: Refer people with severe, persistent, or impairing symptoms to qualified medical/mental health providers or community support services to address psychological and social barriers to recovery [see Sections 5 and 6].

5. Medication (Qaseem et al., 2017; WHO, 2023)

Short-term relief: Consult a medical provider. Options may include short-term use of analgesics, NSAIDs, or muscle relaxants. Long-term opioid use is discouraged due to dependency risk.

6. Multimodal Biopsychosocial Care (Côté et al., 2015; WHO, 2023; Zaina et al., 2023)

Integrate physical, psychological, and social interventions tailored to individual needs, particularly for persistent LBP, to support function, work, and community engagement through predominantly non-pharmacologic care.

Note: Expand this section for further details about delivering a report of findings, contraindications to spinal manipulation, interventions not supported by guidelines, and case-management examples.

Info

10. Risk and Prognostic Factors for LBP

Common Risk Factors: (Hincapié et al., 2024; Parreira et al., 2018)
- Individual (e.g., older age, male, previous LBP), poor general health (e.g., smoking, chronic illness, sleep problems, other pain, frequently tired), physical stress on spine (e.g., vibration, prolonged standing/walking, frequent bending forward/backward, prolonged driving, flexed posture), psychological stress (e.g., depression, stress).
- Lumbar disc herniation with radiculopathy: Middle-age (30–50 years), smoking, higher BMI, presence of cardiovascular risk factors (in women), greater cumulative occupational lumbar load by forward bending postures and manual materials handling.

Prognosis: (Dunn et al., 2011; Nieminen et al., 2021; Otero-Ketterer, et al. 2022; Stevans et al., 2021; Wallwork et al., 2024)
- Most individuals with LBP recover, though recurrences are common.
- Common negative prognostic indicators include: High initial pain intensity, severe disability, psychological factors (e.g., fear-avoidance behaviors, anxiety, depression, high pain catastrophizing), poor coping strategies, negative recovery expectations, poor self-rated health, work-related factors (e.g., high physical demands, difficult positions, physical work, job dissatisfaction, unemployment), low social support, smoking, obesity, and previous LBP episodes.

11. Ongoing Follow-up

Adjust treatment plan: Continuously realign the treatment plan based on the patient’s evolving goals, feedback, clinical outcomes, and professional judgment.

Referral/co-management: Consider referring or co-managing the patient with other providers if there is no significant improvement within the established treatment timeline (e.g., 6-8 weeks).

12. Criteria for Discharge

Discharge criteria: Establish clear criteria, such as achieving initial goals, reaching a plateau in progress, or significant improvement/management of signs and symptoms.