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.
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
Assess for psychosocial risk factors (yellow flags) and conduct a detailed review if there is no improvement (see Appendix E for summary of yellow flags, and the companion documents Clinical Assessment for Psychosocial Yellow Flags and Management of Psychosocial Yellow Flags). Psychosocial risk factors include fear, financial problems, anger, depression, job dissatisfaction, family problems, or stress.
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
Psychosocial and occupational factors (‘yellow flags’) appear to be associated with progression from acute to chronic pain; such factors should be assessed early to facilitate intervention.
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther 2016;39:1-22
Biopsychosocial factors (also known as clinical yellow flags) should be identified and addressed as early as possible as part of a comprehensive approach to clinical management.
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
Personality/Psychological/Psychosocial Evaluation: Generally accepted and well-established diagnostic procedures with selective use in the acute low back pain populations and more widespread use in sub-acute and chronic low back pain populations.
NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE Guideline [NG59] November 2016. Available at: https://www.nice.org.uk/guidance/NG59
Based on risk stratification, consider:
-simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)
-more complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy or using a psychological approach).
Consider using risk stratification (for example the STarT Back risk assessment tool) at first point of contact with a health professional for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management.
Agency for Healthcare Research and Quality / National Guidelines Clearinghouse 2012. Low back pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Available at: http://www.guideline.gov/
RISK FACTORS: Current literature does not support a definitive cause for initial episodes of low back pain. Risk factors are multifactorial, population specific, and only weakly associated with the development of low back pain.
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
Delayed-recovery assessment is not fully developed. However, much progress has been made, and it is recommended that the clinician use one or more approaches to identify a patient who is at risk and intervene with specific interventions.
At this point evidence is not sufficient to strongly recommend the clinical prediction rule. However, studies are currently underway that may add further support. Therefore, we suggest consideration of the clinical prediction rule in the category of early low back pain patients.
Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M etal. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2017 Apr 20. doi: 10.1007/s00586-017-5099-2. [Epub ahead of print]
It is not good practice to routinely offer targeted treatment in patients with new onset LBP in addition to usual care over usual care, as the effect is unknown