People with LBP should have their clinical progress reviewed:
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
Think about alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptom. Exclude specific causes of low back pain, for example cancer, infection, trauma, or inflammatory disease such as spondyloarthritis. If serious underlying pathology is suspected refer to relevant NICE guidelines.
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/
Clinicians should consider diagnostic classifications associated with serious medical conditions or psychosocial factors and initiate referral to the appropriate medical practitioner when:
(1) the patient's clinical findings are suggestive of serious medical or psychological pathology,
(2) the reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of these guidelines, or
(3) the patient's symptoms are not resolving with interventions aimed at normalization of the patient's impairments of body function.
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.
Reassess patients whose symptoms are not resolving:
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
After an initial course of treatment has been concluded, a detailed or focused re-evaluation should be performed.
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 good practice that patients with recent onset lumbar nerve root compression are assessed by a back surgeon within 12 weeks in cases where severe and disabling pain persists despite non-surgical treatment
Patients who are not improving may benefit from referral for spinal manipulation provided by a spinal care specialist such as a physical therapist, chiropractor, osteopathic physician, or physician who specializes in musculoskeletal medicine. Risk of serious complication after spinal manipulation is low (estimated risk: Cauda Equina Syndrome less than one in one million). Current guidelines contraindicate manipulation in patients with severe or progressive neurological deficit.
Refer patients who:
- Are engaged in an optimal package of care including a combined physical and psychological treatment program (usually 6 months of care); and
- Still have severe low back pain for which the patient would consider surgery, particularly if related to spinal stenosis with leg pain or claudication
To optimize surgical outcome, anyone with significant psychological distress should be referred for appropriate treatment