Guidelines - Low back pain

This tool provides information to facilitate the management of recent onset and persistent low back pain for adults. 

Focused examination

1. Patient History 

  • Rule out risk factors for major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery (e.g., using the STartBack Tool).

Major structural or other pathologies (red flags):

  • Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral infection (fever, intravenous drug use, recent infection), cauda equina syndrome (urinary retention, motor deficits at multiple levels, fecal incontinence, saddle anesthesia), osteoporotic fractures (history of osteoporosis, use of corticosteroid, older age), ankylosing spondylitis (morning stiffness, improvement with exercise, alternative buttock pain, awakening due to back pain during the second part of the night, younger age), inflammatory arthritis (morning stiffness, swelling in multiple joints)

Examples of other conditions/co-morbidities:

  • Physical conditions: neck pain, headache

  • Psychological conditions: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Rule out major structural or other pathologies​.

  • Assess for neurological signs.

  • Identify type of low back pain.

  • Avoid routine imaging.

Non-specific low back pain: pain not caused by specific pathologies (e.g., fracture, dislocation, tumor, or systemic disease)

Low back pain with radiculopathy (sciatica): spine-related symptoms or deficits, interference with function or activities of daily living and focal pathology compromising neural structures

3. Management 

  • Offer information on nature, management, and the course of low back pain (i.e., most low back pain is benign and self-limiting). See patient handouts for more information to provide to patients.

  • Discuss the range of effective interventions with the patient and, together, a therapeutic intervention.

Patient Handouts

CCGI_low back pain_patient handout.jpg
CCGI_low back pain_patient handout_non-s
CCGI_low back pain for office workers_pa
CCGI_low back pain_patient handout_FRENC
 

Management of recent onset (0-3 months duration) non-specific low back pain

 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider exercise (strengthening/range of motion, aerobic, mind-body or a combination of approaches); group-based or individual, supervised or home-based

  • Consider manipulation 

  • Consider multimodal careᶧ:

    • combination of exercise and cognitive behavioral therapy (CBT) (for patients who have high levels of disability or significant distress) with or without manual therapy (spinal manipulation, mobilization or soft tissue techniques)​

    • combination of exercise and manual therapy (spinal mobilization or soft tissue techniques) with or without psychological therapy

  • Consider muscle relaxants

  • Consider non-steroidal anti-inflammatory drugs (short course for pain only, assess pain relief and discontinue if lack of clinical benefit)

  • Do not offer massage alone

  • Do not offer traction

  • Do not offer passive physical modalities (PENS, TENS, ultrasound, interferential therapy, belts or corsets, foot orthotics, rocker sole shoes)

  • Do not routinely offer opioids, paracetamol, selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants, anticonvulsants

Management of persistent (4-6 months duration) non-specific low back pain

 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider exercise (strengthening/range of motion, aerobic, mind-body or a combination of approaches); group-based or individual, supervised or home-based

  • Consider manipulation or mobilization

  • Consider clinical or relaxation massage

  • Consider needle acupuncture

  • Consider multimodal careᶧ:

    • exercise and cognitive behavioral therapy (CBT) (for patients who have high levels of disability or significant distress) with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques)

    • exercise and manual therapy (spinal manipulation, mobilisation or soft tissue techniques) with or without psychological therapy

  • Consider non-steroidal anti-inflammatory drugs (short course for pain only, assess pain relief and discontinue if lack of clinical benefit)

  • Do not offer passive physical modalities (PENS, TENS, ultrasound, laser, interferential therapy, belts or corsets, foot orthotics, rocker sole shoes)

  • Do not offer traction

  • Do not offer botulinum toxin injections

  • Do not offer paracetamol, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants, anticonvulsants, epidural injections of local anaesthetic and steroid, epidural injections for neurogenic claudication

Management of recent onset (0-3 months duration) lumbar disc herniation with radiculopathy

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider manipulation

  • Consider multimodal careᶧ:

    • manipulation and exercise​

Management of persistent (4-6 months duration) lumbar disc herniation with radiculopathy

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and:

  • ​refer to appropriate healthcare provider for consideration of further investigation of the neurological deficits

*Interventions are recommended if guidelines used terms such as ‘recommended for consideration’ (e.g., ‘offer’, ‘consider’), ‘strongly recommended’, ‘recommended without any conditions required’, or ‘should be used’. Recommendations from low-quality evidence are not listed.
ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines.

Care Pathway for the management of

non-specific low back pain

(click here for French version)

Care pathway for the management of lumbar disc herniation with radiculopathy

(click here for French version)

Exercise Videos

The low back pain videos are based on the recommendations from the Clinical Practice Guideline for the Treatment of Low Back Pain Pain. Select a link below to view the patient exercise videos for low back pain. 

 

4. Reevaluation and Discharge

  •  Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors for delayed recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms​.

 
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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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