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Low Back Pain Care Pathway

Date of last update: July, 2024

8. Diagnostic Criteria for LBP Amenable to Conservative Care

 

Diagnosis requires a thorough understanding of the patient's condition. It integrates patient stories; clinical findings; risk factor evaluations; and physical, psychological, social, and environmental aspects of pain.

 

A. Common LBP

(Other terms used to describe common LBP: non-specific, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, osteoarthritis, facet joint irritation).

  • Definition: Common LBP that is not due to serious underlying pathology requiring medical attention such as infection, tumor, or fracture and is typically amenable to conservative care (e.g., education, manual therapy, exercise).

  • Prevalence: Approximately 90% of all LBP cases.

  • Risk Factors: Include poor posture, sudden movements, heavy lifting, repetitive physical stress, low physical activity levels, smoking, obesity.

  • Prognostic Factors for Delayed Recovery: Include high pain intensity at onset, high levels of disability, poor general health, history of LBP, psychological factors (e.g., fear-avoidance behaviors, anxiety, depression), poor coping strategies, low social support, job dissatisfaction.

  • Pain Location: Localized below the costal margin and above the inferior gluteal folds, with or without leg pain.

  • Duration: Pain can be acute (less than 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks).

  • Signs and Symptoms:

  • Pain can be sharp, dull, shooting, or aching.

  • Intensity varies from mild to severe.

  • Aggravated by specific movements, postures, or activities; relieved by others.

  • Associated muscle stiffness or spasms.

  • Referred pain into the legs may be present but usually does not extend below the knee.

  • Physical and Neurological Examination: Pain reproduced by tests. Typically, no neurological deficits. If present, they are mild and do not follow a specific nerve root distribution.

 

Note: Common LBP represents the most frequent causes of low back pain with similar mechanisms, clinical symptoms and signs in a primary care setting. Evidence suggests that identifying the specific nociceptive cause of common LBP is difficult. However, breaking down common LBP into different categories helps in guiding treatment strategies and managing patient expectations. Common LBP includes:

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1. Sacroiliac Joint Dysfunction

  • Definition: Pain stemming from the sacroiliac joint.

  • Prevalence: Accounts for 15-30% of LBP cases.

  • Risk Factors: Pregnancy, leg length discrepancy, previous lumbar fusion, trauma.

  • Pain Location: Low back and buttocks, possibly radiating to groin or thighs.

  • Duration: Acute or chronic with intermittent exacerbations.

  • Signs and Symptoms: Worsens with sitting, standing, or weight-bearing activities; improves with lying down.

  • Physical and Neurological Examination: Positive sacroiliac joint tests; no neurological deficits.

 

2. Myofascial Pain Syndrome

  • Definition: A chronic pain disorder caused by sensitivity and tightness in the myofascial tissues.

  • Prevalence: Common in adults, especially those with sedentary lifestyles or repetitive motion jobs.

  • Risk Factors: Poor posture, stress, muscle overuse, direct muscle injury.

  • Pain Location: Muscle pain in low back, potentially referred pain.

  • Duration: Chronic, with variable intensity.

  • Signs and Symptoms: Trigger points in muscles, painful on compression.

  • Physical and Neurological Examination: Taut bands and trigger points; no significant neurological deficits.

 

3. Osteoarthritis

  • Definition: Degenerative joint disease affecting the lower back.

  • Prevalence: Common in older adults.

  • Risk Factors: Aging, obesity, joint injuries, repetitive stress, genetic predisposition.

  • Pain Location: Localized or radiating pain in low back, may involve the hips.

  • Duration: Chronic with episodic flare-ups.

  • Signs and Symptoms: Worsens with activity, relieved by rest; morning stiffness.

  • Physical and Neurological Examination: Reduced range of motion; crepitus and joint swelling. No significant neurological deficits unless advanced.

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4. Facet Joint Irritation

  • Definition: Inflammation or degeneration of the facet joints in the spine.

  • Prevalence: Common in middle-aged and older adults.

  • Risk Factors: Aging, previous back injuries, repetitive spinal stress.

  • Pain Location: Localized to the low back, may radiate to the buttocks or thighs.

  • Duration: Acute or chronic with periods of exacerbation.

  • Signs and Symptoms:

    • Pain exacerbated by extension, twisting, and prolonged standing.

    • Morning stiffness and pain relieved by rest.

  • Physical and Neurological Examination: Tenderness over the facet joints, pain with extension and rotation, no significant neurological deficits.

 

B. Low Back Pain with Radicular Pain/Radiculopathy (from disc protrusion/herniation)

  • Definition: Displacement of disc material that causes irritation or compression of nerve roots.

  • Prevalence: Common cause of LBP with radiculopathy, particularly in younger adults.

  • Risk Factors: Heavy lifting, repetitive activities, smoking, obesity.

  • Pain Location: Low back radiating down leg.

  • Duration: Acute or chronic, with episodes lasting weeks to months.

  • Signs and Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness; worsens with bending forward, lifting, or sitting.

  • Physical and Neurological Examination: Positive straight leg raise test, sensory deficits, muscle weakness, altered reflexes.

 

C. Deep Gluteal Syndrome (e.g., piriformis syndrome)

  • Definition: Compression or irritation of the sciatic nerve by the piriformis muscle or other structures in the deep gluteal region.

  • Prevalence: Less common cause of LBP compared to lumbar radiculopathy; occurs more frequently in individuals who sit for prolonged periods or engage in repetitive hip movements.

  • Risk Factors: Prolonged sitting, trauma to the buttocks, repetitive activities involving hip rotation, leg length discrepancy.

  • Pain Location: Buttock and posterior leg pain, potentially radiating to the foot.

  • Duration: Acute or chronic, with symptoms lasting days to months.

  • Signs and Symptoms:

    • Pain exacerbated by sitting, climbing stairs, or performing squats.

    • Tenderness in the deep gluteal region, particularly over the piriformis muscle.

    • Possible numbness, tingling, or weakness in the affected leg.

  • Physical and Neurological Examination:

    • Tenderness on palpation of the deep gluteal region.

    • Positive signs of sciatic nerve irritation, such as reproduction of pain with maneuvers that stretch or compress the sciatic nerve (e.g., the Piriformis Test, although its sensitivity and specificity are limited).

    • Typically, no neurological deficits unless severe compression is present.

1. Record Keeping

  • Document all findings and recommendations on an ongoing bases, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standars.

3. Health History

  • ​Apply cultural awareness and trauma-informed care principles

  • Sociodemographic: Age, gender, sex.

  • Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.

  • Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

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Meaningful Outcomes:

4. Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer to emergency care immediately for red flags:

  • Cauda Equina Syndrome: Saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs.

  • Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, constitutional symptoms (e.g., fever/chills), IV drug use, poor living conditions.

  • Traumatic Spinal Fracture: Severe trauma.

 

ACTION: Refer to appropriate medical provider:

  • Non-traumatic Spinal Fracture: Sudden onset, localized severe pain, osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.

  • Spinal Malignancy: Progressive pain, history of cancer, constitutional symptoms (e.g., fatigue, weight loss).

  • Inflammatory Arthritides (e.g.,ankylosing spondylitis): Morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), pain improves with activity, pain worse at night.

  • Referred Pain: (from abdominal/pelvic visceral conditions): Abdominal or pelvic tenderness.

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9,  GAD-7

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychological Factors (Yellow Flags)

  • Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims; maladaptive coping mechanisms.

  • Screening tools: PHQ-9,  GAD-7, FABQ, ORT, PCS

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

  • Observation: Abnormalities, asymmetries, posture, balance, gait, movements, and facial expression.

  • Range of Motion: Active, passive, resisted (flexion, extension, lateral flexion, rotation).

  • Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.

  • Neurological Examination: Motor strength, sensory and reflex testing (L2, L3, L4, L5, S1, S2); upper and lower motor neuron signs.

  • Special/Orthopedic Tests: Select as appropriate based on clinical judgment.

  • Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors  (e.g., potential contraindications to treatment).

8. Diagnostic Criteria for LBP Amenable to Conservative Care

A. Common LBP (e.g., non-specific, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, facet joint irritation, osteoarthritis)

  • Pain: Below costal margin and above inferior gluteal folds, with or without leg pain.

  • Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; associated muscle stiffness or spasms; may refer into legs but not below knees.

  • Exam: Pain reproduced by tests; no neurological deficits.

 

B. LBP with Radicular Pain/Radiculopathy (from disc protrusion/herniation)

  • Pain: Low back radiating down leg.

  • Signs/Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.

  • Exam: Positive straight leg raise test; sensory deficits, muscle weakness, altered reflexes.

 

C. Deep Gluteal Syndrome (e.g., piriformis syndrome)

  • Pain: Buttock and posterior leg, potentially radiating to foot.

  • Signs/Symptoms: Pain exacerbated by sitting, climbing stairs, or performing squats; tenderness in deep gluteal region.

  • Exam: Signs of sciatic nerve irritation, but not following a radicular pattern associated with nerve roots.

9. Treatment Considerations for LBP Amenable to Conservative Care

(Common LBP, LBP with radicular pain/radiculopathy from disc pathology, deep gluteal pain)

After providing a report of findings and obtaining written informed consent.

  • Essential Interventions:

    • Education and reassurance

    • Address yellow flags (psychosocial factors)

    • Maintain activities of daily living

    • Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)

    • Engage in social and work activities

 

  • Optional Interventions (with Rationale and Shared Decision Making):

    • Exercise therapy

    • Manual therapy (e.g., spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage)

    • Medications (e.g., acetaminophen, ibuprofen/prescription). Discuss options/risks with medical provider.

    • Psychological or social support

    • Mind-body interventions (e.g., mindfulness, meditation)

    • Needling therapies, topical cayenne pepper, electrotherapies, traction

    • Mobility assistive devices (e.g., walkers, canes)

    • Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy and social support)

10. Prognosis

  • Recovery: Most people recover, but LBP can recur or persist.

  • Negative Prognostic Factors: Smoking, obesity, higher initial pain levels, poor recovery expectations, mental health issues, persistent symptoms, leg pain, work-related factors, previous LBP, functional limitations.

11. Ongoing Follow-up

  • Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgement.

  • Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

  • Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).

  • ​Discuss post-discharge plans, including self-management strategies and potential follow-ups.

References

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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