CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
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understanding how clinical practice guidelines are developed;
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discussing best practices and guidelines with colleagues;
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having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Low Back Pain Care Pathway
Date of last update: July, 2024
About Low Back Pain (LBP)
Overview: LBP is a common condition that can be acute or persistent, presenting as a dull ache, sharp pain, or radiating discomfort, especially to the legs. Most cases are amenable to conservative care. However, LBP can also result from serious underlying pathologies requiring medical attention.
Effective Management: Given its multifactorial and recurring nature, influenced by physical, psychological, social, and environmental elements, there is no one-size-fits-all treatment for LBP. It is typically managed rather than cured, necessitating a comprehensive and individualized approach. Effective management is ethical, evidence-driven, transparent, flexible, and responsive to the person's needs. Essential interventions include education, reassurance that LBP is typically of a limited-time nature, addressing psychosocial factors, maintaining daily activities, and self-care practices. Additional interventions are selected through shared decision-making, aiming to optimize function and participation. Continuous monitoring and assessment of outcomes ensure alignment with patient goals. Effective management can occur through in-person, virtual or hybrid care.
About the Care Pathway
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Principles: Grounded in evidence-based practice, integrating research evidence, clinical expertise, and patient values. Developed with insights from professional leaders, clinicians, and members of the scientific community.
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Target Audience: Supports clinicians who deliver conservative care, and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.
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Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current and evidence driven.
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Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.
1. Record Keeping
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Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).
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Adhere to jurisdictional standards.
2. Informed Consent
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Document verbal consent for health history taking, physical examination, contact in sensitive areas.
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Obtain written consent for treatment.
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Adhere to jurisdictional standards.
3. Health History
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Apply cultural awareness and trauma-informed care principles.
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Sociodemographic: Age, gender, sex.
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Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
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Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
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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.
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Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.
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Previous treatments and responses: Effectiveness and any adverse events.
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Beliefs and expectations: Understanding of their condition, treatment expectations.
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Red, yellow, and orange flags (sections 4 – 6).
Meaningful Outcomes:
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Pain: Pain scales (e.g., NRS), pain diagram.
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Function and Participation: Impact of LBP on daily activities (PSFS, WHODAS, ODI, RMDQ, MYMOP, MYMOP Follow-up).
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Recovery: Self-rated recovery scales.
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Quality of Life: SF-12.
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Work Status: Return to work/school/activities.
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Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
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Patient Feedback: Experience and satisfaction with care.
4. Differential Diagnosis Requiring Medical Attention
ACTION: Refer to emergency care immediately for red flags:
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Cauda Equina Syndrome: Saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs.
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Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained constitutional symptoms (e.g., fever/chills), IV drug use, poor living conditions.
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Traumatic Spinal Fracture: Severe trauma.
ACTION: Refer to appropriate medical provider:
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Non-traumatic Spinal Fracture: Sudden onset, localized severe pain, osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.
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Spinal Malignancy: Progressive pain, history of cancer, constitutional symptoms (e.g., fatigue, weight loss).
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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.
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Referred Pain: (from abdominal/pelvic visceral conditions): Abdominal or pelvic tenderness.
6. Psychosocial Factors (Yellow Flags)
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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.
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Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.
7. Physical Examination
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Observation: Abnormalities, asymmetries, posture, balance, gait, movements, facial expression.
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Range of Motion: Active, passive, resisted (flexion, extension, lateral flexion, rotation).
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Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
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Neurological Examination: Motor strength, sensory and reflex testing (L2, L3, L4, L5, S1, S2); upper and lower motor neuron signs.
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Special/Orthopedic Tests: Select as appropriate based on clinical judgment.
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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)
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Pain: Below costal margin and above inferior gluteal folds, with or without leg pain.
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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.
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Exam: Pain reproduced by tests; no neurological deficits.
B. LBP with Radicular Pain/Radiculopathy (from disc protrusion/herniation)
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Pain: Low back radiating down leg.
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Signs/Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.
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Exam: Positive straight leg raise test, sensory deficits, muscle weakness, altered reflexes.
C. Deep Gluteal Syndrome (e.g., piriformis syndrome)
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Pain: Buttock and posterior leg, potentially radiating to foot.
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Signs/Symptoms: Pain exacerbated by sitting, climbing stairs, or performing squats; tenderness in deep gluteal region.
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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.
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Essential Interventions:
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Education and reassurance
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Address yellow flags (psychosocial factors)
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Maintain activities of daily living
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Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)
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Engage in social and work activities
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Optional Interventions (with Rationale and Shared Decision Making):
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Manual therapy (e.g., spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage)
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Medications (e.g., acetaminophen, ibuprofen/prescription). Discuss options/risks with medical provider.
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Psychological or social support
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Mind-body interventions (e.g., mindfulness, meditation)
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Needling therapies, topical cayenne pepper, electrotherapies, traction
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Mobility assistive devices (e.g., walkers, canes)
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Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy and social support)
10. Prognosis
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Recovery: Most people recover, but LBP can recur or persist.
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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
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Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgement.
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Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).
12. Criteria for Discharge
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Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).
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Discuss post-discharge plans, including self-management strategies and potential follow-ups.
References or links to primary sources
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Wong JJ, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017; 21: 201-216. https://doi.org/10.1002/ejp.931.
Contact information for further inquiries or feedback