People with LBP should be assessed using a diagnostic triage approach to exclude non-spinal causes/contributors and allocate patients to one of four categories:
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 symptoms. 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 guidance on:
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
Terms to describe acute low back pain with no identifiable pathology include ‘lumbar spinal pain of unknown origin’ or ‘somatic lumbar spinal pain’.
A specific patho-anatomic diagnosis is not necessary for effective management of acute non-specific low back pain.
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.
The first qualified practitioner with the ability to do a full assessment (i.e., history, physical and neurological red flags, and psychosocial yellow flags) should assess the patient and undertake diagnostic triage (see Appendix E for summary of red and yellow flags, and the companion documents Clinical Assessment for Psychosocial Yellow Flags and Management of Psychosocial Yellow Flags – see complete list of companion materials)
If serious spinal pathology is excluded, manage as non-specific low back pain.
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
Conditions of illness and injury are typically classified by severity and/or duration. Common descriptions of the stages of illness and injuries are acute, subacute, chronic, and recurrent, and further subdivided into mild, moderate, and severe.
• Acute—symptoms persisting for less than 6 weeks.
• Subacute—symptoms persisting between 6 and 12 weeks.
• Chronic—symptoms persisting for at least 12 weeks' duration.
• Recurrent/flare-up—return of symptoms perceived to be similar to those of the original injury at sporadic intervals or as a result of exacerbating factors.
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/
DIFFERENTIAL DIAGNOSIS: 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.
DIAGNOSIS/CLASSIFICATION: Low back pain, without symptoms or signs of serious medical or psychological conditions, associated with clinical findings of (1) mobility impairment in the thoracic, lumbar, or sacroiliac regions, (2) referred or radiating pain into a lower extremity, and (3) generalized pain , is useful for classifying a patient with low back pain into the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: low back pain, lumbago, lumbosacral segmental/somatic dysfunction, low back strain, spinal instabilities, flatback syndrome, lumbago due to displacement of intervertebral disc, lumbago with sciatica, and the associated International Classification of Functioning, Disability, and Health (ICF) impairment-based category of low back pain (b28013 Pain in back, b28018 Pain in body part, specified as pain in buttock, groin, and thigh) and the following, corresponding impairments of body function:
Bardin, L.D., King, P. and Maher, C.G., 2017. Diagnostic triage for low back pain: a practical approach for primary care. The Medical Journal of Australia, 206(6), pp.268-273.
Apkarian, A.V. (2018). Nociception, pain, consciousness, and society: A plea for constrained use of pain-related terminologies. The Journal of Pain. In Press, Accepted Manuscript - June. https://www.sciencedirect.com/science/article/pii/S152659001830244X