Low Back Pain


Screening

0 Indicators

Diagnosis

2 Indicators

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

  • specific spinal pathology (< 1% of cases), or
  • radicular syndrome (approx. 5-10% of cases), or 
  • non-specific LBP (NSLBP).

Updated: 29 November 2017, Version: 1

People with LBP should be checked for red flag (specific spinal pathology) and other conditions: 

  • Cauda equina syndrome
  • Spinal infection
  • Cancer (“spinal malignancy”)
  • Vertebral fracture
  • Inflammatory arthritis (e.g. ankylosing spondylitis or other spondyloarthritis)
  • Referred visceral pain (e.g. disease of pelvic organs - prostatitis, endometriosis, chronic pelvic inflammatory disease; renal disease - nephrolithiasis, pyelonephritis, perinephric abscess; gastrointestinal disease - pancreatitis, cholecystitis, pentrating ulcer)
  • Viral syndrome
  • Vascular causes (e.g. femoral artey occlusion, aortic aneursym)
  • Hip pathology

Updated: 29 November 2017, Version: 1

People with LBP should have a history and examination performed to exclude red flag and other conditions and identify relevant factors, which may include:

  • personal (e.g. family, social, cultural) and medical history
  • onset and progress
  • distribution and type of pain
  • weakness or sensory disturbance
  • gait / posture
  • lumbar range of motion
  • palpation

 

Updated: 29 November 2017, Version: 1

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: 29 November 2017, 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: 29 November 2017, Version: 1

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

Updated: 29 November 2017, Version: 1

People with LBP where this is strong clinical suspicion of cancer (“spinal malignancy”), ankylosing spondylitis or fracture are referred early to the appropriate medical practitioner.

Updated: 29 November 2017, Version: 1

People with non-specific LBP do not receive:

  • 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: 30 November 2017, Version: 1

Assessment

3 Indicators

People who present to primary care with LBP should use simple measures, relevant to agreed goals, 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: 30 November 2017, Version: 1

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

Updated: 30 November 2017, Version: 1

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. potential candidates for surgery).

Updated: 30 November 2017, Version: 1

Acute Care

3 Indicators

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

  • it is common and can be uncomfortable,
  • the overall favourable prognosis for low back pain
  • pain does not always mean that there is damage,
  • that bed rest should be avoided,
  • that most cases improve without treatment within a matter of weeks or months, 
  • self-management strategies are often the most beneficial (and more intensive/invasive treatments may not work or be harmful) 
  • minor setbacks in your function or pain are to be expected, and
  • that many of the things that are found on imaging scans are:

          common

          not important, and 

          not necessarily causing pain.

Updated: 30 November 2017, Version: 1

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 for as long as possible
  • use of heat wraps/therapy for short-term symptomatic relief.

Updated: 30 November 2017, Version: 1

Ongoing Care

9 Indicators

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

Updated: 30 November 2017, Version: 1

People with LBP that does not improve with self-managed care may receive a short-course of manual therapy (including acupuncture for pain relief in acute/subacute LBP) as one component of their overall care. 

Updated: 30 November 2017, Version: 1

People with persistent/chronic LBP are advised to exercise, either individually or in a group, according to programmes which include: 
- type / mode determined in partnership with consumer 
- dose
- supervision
- progression

Updated: 30 November 2017, Version: 1

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)
- commenced at the lowest effective dose for the shortest possible period of time. 

Updated: 30 November 2017, Version: 1

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

Updated: 30 November 2017, Version: 1

People with severe LBP may be offered strong opioids for short term use, and with a plan and follow-up for when to cease use.

Updated: 01 December 2017, Version: 1

People with LBP who are on long term opioid therapy are considered for referral for specialist assessment. 

Updated: 01 December 2017, Version: 1

People with LBP may be offered non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak opioids.

Updated: 05 December 2017, Version: 1

People with acute and severe radiculopathy may be considered for epidural injection of local anaesthetic and steroid.

Updated: 01 December 2017, Version: 1

People with clinical and radiological signs of radiculopathy, who have experienced no improvement in their pain or function following non-surgical treatment (e.g. after 8-12 weeks), may be considered for surgical review and potentially spinal decompression if indicated

Updated: 01 December 2017, Version: 1

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 GP care and exercise or manual therapy are considered for referral to a combined physical and psychological treatment programme (multi-disciplinary)

Updated: 01 December 2017, Version: 1

People with LBP are not offered:

  • Antibiotics
  • Anticonvulsants
  • Duloxetine
  • Glucosamine
  • Marijuana/dried cannabis
  • Opioids (e.g. Buprenorphine Transdermal system, Tapentadol)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Selective serotonin-norephrine reuptake inhibitors
  • Steroids (e.g. intravenous, oral) 
  • Systemic corticosteroid
  • Tricyclic antidepressants.

Updated: 30 November 2017, Version: 1

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

Updated: 30 November 2017, Version: 1

People with non-specific LBP are not offered:

  • traction, including spinal decompression
  • participation in "back school"
  • touch therapies
  • 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: 30 November 2017, Version: 1

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