Low Back Pain


Screening

0 Indicators

Diagnosis

7 Indicators

People with LBP should be assessed using a diagnostic triage approach to exclude non-spinal causes and allocate patients to one of three four categories:

  • specific spinal pathology (< 1% of cases), for example:
    • Cauda equina syndrome,
    • Spinal infection,
    • Cancer (“spinal or other malignancy”),
    • Vertebral fracture,
    • Inflammatory arthritis (e.g. axial or other spondyloarthritis)
  • radicular syndrome (approx. 5-10% of cases), or
  • non-specific LBP (NSLBP)
  • other, for example:
    • referred visceral pain (disease of pelvic organs - prostatitis, endometriosis, chronic pelvic inflammatory disease; renal disease - nephrolithiasis, pyelonephritis, perinephric abscess; gastrointestinal disease - pancreatitis, cholecystitis, penetrating ulcer),
    • Viral syndrome,
    • Vascular conditions (e.g. femoral artery occlusion, aortic aneurysm),
    • Hip pathology.

Updated: 14 November 2018, Version: 2

People with LBP should have a detailed history taken to identify those at higher likelihood of red flag and other relevant conditions, and identify personal factors, which may include:

  • personal (e.g. family, social, cultural) beliefs about their condition and pain experience
  • mood
  • distribution and type of pain
  • weakness or sensory disturbance (e.g. presence of bladder/bowel symptoms and saddle anaesthesia)
  • onset and progress (e.g. trauma)
  • medical history (e.g. previous recent medical procedures, previous malignancy, medication history especially corticosteroid use)
     

Updated: 14 November 2018, Version: 2

People with LBP should be assessed at the first visit for factors which may delay recovery (e.g. psychological, mental health, occupational, legal), and reassessed at subsequent visits. 

Updated: 14 November 2018, Version: 1

People with LBP and leg pain and/or neurological symptoms should receive a lower limb neurological examination when first identifed, and have symptoms monitored during subsequent visits.

Updated: 14 November 2018, Version: 1

People with LBP with suspicion of spinal infection or cauda equina syndrome are immediately referred to an emergency department.

Updated: 14 November 2018, Version: 1

People with LBP where this is strong clinical suspicion of cancer (“spinal malignancy”), axial spondyloarthritis (or other inflammatory condition) or fracture should be referred early to the appropriate medical practitioner.

Updated: 14 November 2018, Version: 2

People with non-specific LBP do not receive the following potentially harmful investigations:

  • imaging (including x-rays, CT scans, MRI scan, bone scans, fluoroscopy, myelography, CT myelography, thermography, discography);
  • laboratory testing (including blood tests, urinanalysis);
  • electrodiagnostic studies or electrophysiological testing (such as nerve conduction studies, electromyography, Current Perception Threshold (CPT) evaluation).

Updated: 14 November 2018, Version: 2

Assessment

3 Indicators

People who present to primary care with LBP should be provided with measures, relevant to agreed goals, to use at intervals throughout the course of treatment to monitor progress (e.g. numerical rating scale for pain, exercise tolerance and/or ability to undertake usual activities and work for function).

Updated: 14 November 2018, Version: 2

People with LBP who are commencing multi-disciplinary care should be provided with validated multi-dimensional self-report questionnaires to use to help design their program, and measure and report progress.

Updated: 14 November 2018, Version: 2

People with persistent LBP and signs of radicular syndrome should not receive evaluation with MRI or CT scan unless the results are likely to influence their management (e.g. investigation of progressive neurological deterioration, potential candidates for surgery).

Updated: 14 November 2018, Version: 2

Acute Care

3 Indicators

People with acute/subacute LBP should be offered information on the condition including:

  • it is common and can be uncomfortable, frustrating and affect your mood,
  • your spine is strong and resilient
  • the overall favourable prognosis for low back pain
  • pain does not always mean that there is damage (pain is a protective experience created by the nervous system which processes the signals coming from the body along with many other bits of information simultaneously),
  • that bed rest should be avoided, rather, pace your activities at home and work
  • that most cases improve without treatment within a matter of weeks or months,
  • self-management strategies are recommended in the first instance (as more intensive/invasive treatments may not work or be harmful)
  • minor setbacks in your function or pain are to be expected, but these are usually transient, and
  • that almost all of the things that are found on imaging scans (such as disc degeneration, disc bulges, protrusions, annular fissures and facet joint arthritis) are:
    • common in people without LBP and usually related to ageing,
    • not good predictors of a person's level of pain or ability to function,
    • not necessarily a contributor to the pain experience, and
    • not usually helpful in determining what care is needed.

Updated: 14 November 2018, Version: 2

People with LBP are active in shared-decision making with respect to:

  • discussing expectations and preferences when considering recommended treatments
  • potential value and benefits, risks and costs
  • developing a management plan.

Updated: 30 November 2017, Version: 1

People with LBP (and their carers) should be provided with information and advice (written, online, audio, interactive, culturally-sensitive and opportunity to discuss) to promote self-management, including:

  • encouragement to remain active and at work and at home, as much as possible, by pacing activities;
  • keep moving gently in a way that you enjoy (e.g. short walks, stretches);
  • adopt some relaxation strategies if your pain is becoming more bothersome or mood being affected;
  • seek health professional advice if you are concerned; and
  • use of heat wraps/therapy for short-term symptomatic relief.

Updated: 14 November 2018, Version: 2

Ongoing Care

13 Indicators

People with LBP who haven't responded to appropriate primary care are considered for multidisciplinary and/or interdisciplinary rehabilitation programs.

Updated: 14 November 2018, Version: 2

People with LBP who do not improve with self-managed care may receive a short-course of manual therapy (e.g. 2-4 week trial) as an adjunct to their self-managed care.

Updated: 14 November 2018, Version: 2

People with persistent/chronic LBP are advised to be physically active and/or exercise, either individually or in a group, according to programmes which include:

  • type / mode determined in partnership with consumer (e.g. of functional relevance),
  • appropriate dose (i.e. frequency/intensity of training),
  • supervision, and
  • progression.

Updated: 14 November 2018, Version: 2

People with LBP who are prescribed medicines are:

  • educated on the quality use of medicines (including individual expectations, preferences, comorbidities, balance of risks and benefits, potential for and how to manage side effects)
  • commenced at the lowest effective dose for the shortest possible period of time.

Updated: 14 November 2018, Version: 2

People with non-specific LBP are not offered paracetamol alone for pain management.

Updated: 14 November 2018, Version: 1

People with LBP may be offered non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.

Updated: 14 November 2018, Version: 2

People with LBP who have not responded to simpler pain relief options (including non-drug strategies) and who have been assessed as low risk of adverse outcome, may be offered opioids for short term use, and with a plan and follow-up for when to cease.

Updated: 14 November 2018, Version: 2

People with LBP who are on long term opioid therapy (longer than 6 weeks) are considered for referral for assessment by a pain specialist.

Updated: 14 November 2018, Version: 2

People with LBP should not be offered:

  • Antibiotics
  • Anticonvulsants
  • Duloxetine
  • Glucosamine
  • Marijuana/dried cannabis
  • Selective serotonin reuptake inhibitors (SSRIs) and Selective serotonin-norephrine reuptake inhibitors
  • Systemic corticosteroids
  • Tricyclic antidepressants.

Updated: 14 November 2018, Version: 2

People with  LBP are not offered:

  • acupuncture
  • traction, including spinal decompression
  • participation in "back school"
  • touch therapies, such as Reiki
  • intramuscular stimulation
  • craniosacral massage or therapy
  • spa therapy
  • intramuscular stimulation
  • shock-wave treatment
  • orthoses and braces (such as belts, corsets, foot orthotics, lumbar supports, rocker sole shoes, chairs, mattresses, gravity tables)
  • injections of therapeutic substances, including selective nerve root blocks (SNRBs), prolotherapy, sacroiliac joint injection, zygapophyseal (Facet) blocks, trigger point injections
  • invasive procedures (such as radiofrequency ablation, radiofrequency facet joint denervation, lumbar discography, manipulation under general or joint anaesthesia, shortwave diathermy)
  • surgery (such as spinal fusion, disc replacement, vertebroplasty, laminectomy, epiduroscopy, kyphoplasty, nucleus pulpous replacement, interspinal spacers, sacroiliac joint fusion, implantation of spinal cord stimulators)
  • thermal intradiscal procedures (such as intradiscal electrothermal annuloplasty (IDET), percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), percutaneous radiofrequency disc decompression
  • electrotherapy (such as interferential therapy, laser therapy, percutaneous electrical nerve simulation (PENS), transcutaneous electrical nerve stimulation (TENS), ultrasound, iontophoresis, phonophoresis, electrical stimulation)
  • biofeedback, including electromyographic biofeedback.

Updated: 14 November 2018, Version: 2

People with LBP should have their clinical progress reviewed:

  • within 1-2 weeks for acute/sub-acute LBP
  • within 2-4 weeks for chronic LBP

Updated: 01 December 2017, Version: 1

People with LBP that is resistant or unresponsive to primary care and exercise or manual therapy are considered for referral to a physical and/or psychological treatment programme (multi-disciplinary).

Updated: 14 November 2018, Version: 2

People with symptomatic central spinal canal stenosis should not have epidural injections for neurologic claudication.

Updated: 30 November 2017, Version: 1

Delete Reference

Are you sure you wish to delete this reference?