Evidence-Informed Best Practice
Low Back Pain
Dr. Julia Alleyne
Clicker Time
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Which key clinical features are NOT suggestive of
mechanical low back pain ?
1. Morning stiffness less than 30 minutes
2. Pain associated with movement such as bending
3. Occasional night waking with moderate pain
4. Urinary retention followed by overflow incontinence
5. Pain associated with arching backwards
3
In the absence of red flags, what are the most
common reasons for you to refer your patient with
low back pain to a spinal surgeon?
1. Presence of chronic back pain not responsive to conservative treatment after 8
weeks
2. Presence of non-radicular referred leg pain
3. Presence of tingling sensation in affected leg
4. CT/MRI indicating any disc pathology
5. CT/MRI indicating clinically significant nerve root compression
6. Clarification of work related modifications and restrictions
7. Patient would like second opinion on diagnosis and management
4
A patient who demonstrates positive yellow flags
would fit the following behaviours.
1. Vegetative signs of clinical depression
2. Fear and avoidance of activities associated with discomfort
3. Frequent disruptive sleep disturbance
4. Dependency on passive pain management modalities
5. 1 and 2
6. 2 and 4
7. All of the above
5
In which of the following situations would the low
back pain guidelines recommend goal-specific
rehabilitation?
1.
Acute low back pain of 1 week duration in avid athlete
2.
Persistent low back without response to medication and
exercise
3.
Use of lumbar traction for chronic low back pain
4.
Low back pain triggered by a motor vehicle accident
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Which of the following patient key messages is Not
true?
1. Your assessment today does not indicate any serious pathology so there is no
need to order an xray or any investigations.
2. Keep moving! Staying active helps and most acute low back pain will go away,
without treatment, in 4 to 6 weeks.
3. Returning to your usual activities including work as soon as you can and at a
gradual pace will help you recover.
4. If you are in pain and feeling stiff, use muscle relaxants for the first six weeks
so you can maintain your activities of daily living.
5. For pain management, start with over-the-counter medicine, your doctor can
prescribe other medication if your pain is interfering with activity or is severe.
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Objective
 Describe the key patient features as presented through the
continuum of acute, sub-acute, persistent, recurrent and chronic
low back pain supported by current Clinical Guidelines and Key
Messages
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Acute Low Back Pain
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Ms. Espina
 42 year old
 Occupation: Nurse
 Early season tennis lessons linked to
onset of pain, 3 weeks ago
 Bilateral, radiating to buttock
 Difficult to sit
 Prolonged positions aggravate
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Acute Low Back Guidelines
 Duration 4-6 weeks
 History, physical, neurological
assessment
 Screen for red and yellow flags
 No imaging unless red flags
 Educate, exercise, activity
prescription
 Self-care strategies
 Consider analgesics
 2009 TOP Alberta Guidelines
“Guideline for the Evidence-Informed
Primary Care Management of LBP”
 2007 American College of
Physicians and American Pain
Society
“Diagnosis and Treatment of Low
Back Pain: A Joint Clinical Practice
Guideline”
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Key Messages
Provider
 Rule out fed flags that may
indicate serious pathology. If
present, proceed with
immediate investigation
and/or urgent referral.
Patient
 If your pain persists beyond 6
weeks, contact your health
care provider for a follow up
appointment to reassess and
possibly consider additional
treatment, investigations or
referral to a specialist.
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Sub-Acute Low Back Pain
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Mr. Ryggrad
 39 year old, sedentary worker
 10 weeks of low back pain of
gradual onset with “good days and
bad days”
 Attended some therapy with
temporary symptomatic relief
 Intermittent but common
medication use
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Sub-Acute Guidelines
 Ongoing from acute to subacute
without full resolution
 6-12 week duration
 Re-evaluate red flags/ yellow
flags
 Trial of goal specific therapy
 Consider stenosis /
radiculopathy
 Re-consider imaging needs
 Short-acting opioid
management
 Guidelines cover acute and
subacute
 2009 TOP Alberta Guidelines
“Guideline for the EvidenceInformed Primary Care
Management of LBP”
 2007 American College of
Physicians and American Pain
Society
“Diagnosis and Treatment of Low
Back Pain: A Joint Clinical Practice
Guideline
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics
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Key Messages
Provider
 Reassure the patient there is
no reason to suspect a serious
cause. Most episodes of low
back pain will improve in 1-6
weeks, but recurrence within
12 months is common.
Patient
 It is important to keep moving
when you have back pain. Lying in
bed for prolonged periods will not
cure this problem and it will cause
you to become stiffer and weaker,
making it more difficult for you to
resume your normal activities later
on.
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Persistent and Recurrent Low Back Pain
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Ms. Coluna
 10 month history of low back
pain
 Initially a 2 week self resolving
episode
 3 recurrences in 6 months
progressing in length
 Pain constantly x 4 months
 Feeling frustrated
 Unable to work or self manage
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Recurrent & Persistent Guidelines
 < 6 weeks but > 12 months
 Treatment
› Education
› Exercise
› Manual Therapy
 2009 National Institute for
Health and Clinical
Excellence (NICE)
“Low back pain: Early
management of persistent nonspecific low back pain”
› Acupuncture
› Consider Psychological
Referral
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Key Messages
Provider
For the acute or recurrent low
back pain patient, consider
analgesics
 Acetaminophen
 Anti-inflammatories
 Short duration muscle
relaxants
 Short-acting opioids
Patient
 You may initially need pain
medication to help you
resume your daily activities
more comfortably.
 It is activity however, and not
the medication, that will help
you recover more quickly. It is
important to keep moving
when you have back pain.
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Chronic Low Back Pain
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Mr. Slabinski
 12 months of low back pain
 Modifies most activities due to
pain
 Daily frequent medication
 Intermittent massage therapy
for pain relief
 Feels discouraged
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Chronic Low Back Pain Guidelines






Exercise
Graduated
Directional preference
Core stability
With pain
Daily
 2009 TOP Alberta
Guidelines
“Guideline for the EvidenceInformed Primary Care
Management of LBP”
 2004 EUROPEAN
GUIDELINES
“Management of Chronic Nonspecific Low Back Pain”
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Key Messages
Provider
 Educate the patient and
describe the typically benign,
long-term course of low back
pain at most visits.
 Provide education materials
that are consistent with this
advice to reduce fear and
anxiety, and emphasize
active self-management
Patient
 You do not always need a
Health Care Provider to
manage your back
 Frequently however, low
back pain episodes may
recur. When you learn how to
manage one of these
episodes, you can use this
information to help you to
recover the next time.
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Summary
 Consistent messaging
› Limited and Specific Imaging and Investigations
› Exercise, Education and Activity Prescription
› Patient Self-management
› Focused Treatment
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