Information for consumers – Low Back Pain Clinical Care Standard

What the standard says

The assessment of a patient with a new presentation of low back pain symptoms, with or without leg pain or other neurological symptoms, focuses on screening for specific and/or serious pathology and consideration of psychosocial factors. It includes a targeted history and physical examination, with a focused neurological examination when appropriate. Arrangements are made for follow-up based on an evidence-based low back pain pathway.

What this means for you

 If you see a clinician about your low back pain, they will ask:

• About your pain
• How it is affecting your daily activities
• How it is making you feel
• About your previous health issues and background.

This will help them to understand your needs and goals for your care. Your clinician will examine you and check for signs of serious health issues, and may refer you for further tests or investigations if necessary. However, even though back pain can feel bad and interfere with your life, serious causes are very rare (less than 5% of cases).

If a serious underlying problem is unlikely, low back pain can be treated with simple measures because the pain will get better on its own over time. It is often not possible or necessary to identify an exact cause for low back pain, and it can still be treated even if the cause is not known. If you have leg pain, this can be nerve‑related pain – commonly called ‘radicular pain’, ‘sciatica’ or ‘referred’ pain – which starts somewhere in your back but is felt in your legs. For most people, this is managed the same way as low back pain.

You and your clinician should discuss what follow-up you may need. You may need further visits to check on your symptoms and wellbeing, and to adjust your treatment if necessary. See your clinician urgently if new symptoms appear, such as problems with controlling urine or bowel movements, or numbness or weakness in your legs, back or genitals.

What the standard says

Early in each new presentation, a patient with low back pain, with or without leg pain or other neurological symptoms, is screened and assessed for psychosocial factors that may affect their recovery. This includes assessing their understanding of, and concerns about, diagnosis and pain, and the impact of pain on their life. The assessment is repeated at subsequent visits to measure progress.

What this means for you

It can be harder to recover from back pain if there are other issues that are influencing your experience of pain. These might include:

• Your general mood
• Your understanding about what is causing your pain and what you can do about it
• Other factors in your life such as financial, family or work issues that may be causing you distress
• The impact the pain is having on your life (such as sleep).

Your clinician may ask you about such issues to understand how they relate to your pain. They may use questionnaires to help understand how your pain is affecting your life, and to help identify the best treatment and support for you. For example, you might not be able to change factors causing distress, but you can learn ways to reduce their impact on you, which can also help with your pain. This is why it is important to identify and understand what is influencing your pain and what can be done to help with your recovery.

What the standard says

Expectations of imaging and its limited role in diagnosing low back pain are discussed with a patient. Early and appropriate referral for imaging occurs when there are signs or symptoms of specific and/or serious pathology. The likelihood and significance of incidental findings are reported and discussed with the patient.

What this means for you

In most cases of low back pain, an imaging test such as an X-ray, a CT (computed tomography) scan or MRI (magnetic resonance imaging) is not necessary. These tests are usually only needed when your clinician needs to rule out a serious cause for your back pain. It is important to remember that more than 95% of low back pain cases do not have serious underlying causes.

Your clinician will talk to you about the role of imaging in your situation. Unless there is a good reason, it is best to avoid scans because they are unlikely to find the reason for your pain or change how it is treated. Scans can often show changes that are normal for your age and may not be causing your pain, such as:

• Disc degeneration
• Facet joint changes
• Disc bulges
• Disc protrusions.

Changes such as these are also found on the scans of people who do not have low back pain. Knowing about these changes may worry you and can lead to further tests, consultations or treatments that do not help your back pain. Scans can also be expensive and inconvenient, and some can expose you to radiation.

What the standard says

A patient with low back pain is provided with information about their condition and receives targeted advice to increase their understanding, and address their concerns and expectations. The potential benefits, risks and costs of medicines and other treatment options are discussed, and the patient is supported to ask questions and share in decisions about their care.

What this means for you

One of the best ways to manage low back pain is to learn about the condition, what to expect and how to manage it.  Ask questions to make sure you receive the care that is right for you (see Box 3 for examples of the types of questions you could ask). Your clinician will offer you information and help you understand more about back pain. They may provide you with fact sheets and direct you to useful resources. Information will be provided in a format and language you can understand.

There are many different treatments for low back pain. In most cases, simple, cost-effective measures will give you the most benefit. Your clinician will help you to consider the best treatment for your back pain, considering the evidence, and the potential benefits, risks and costs, so that you can share in decisions about your care.

Box 3: Five questions to ask your doctor or other healthcare provider before you get any test, treatment or procedure

What the standard says

A patient with low back pain is encouraged to stay active and continue, or return to, usual activity, including work, as soon as possible or feasible. Self-management strategies are discussed. The patient and clinician develop a plan together that includes practical advice to maximise function, and limit the impact of pain and other symptoms on daily life. The plan addresses individual needs and preferences.

What this means for you

Do not wait for all the pain to be gone before you start moving. Staying active and continuing daily activities as normally as possible (including work) leads to the most rapid and complete recovery. Your clinician will encourage you to stay active and continue or quickly get back to normal activities, including exercise and work, wherever possible. If your pain is worse after activity and persists, you may be advised to take things a little easier at first and gradually build up over a few days or weeks. Avoid long periods of bed rest, which can slow down recovery. Try to remain at work, or get back to work as soon as possible.

Your clinician will suggest ways for you to manage your pain and can develop a self‑management plan with you, so you know what to do. Things that you do yourself to control your pain (like pacing yourself when carrying out physical activity) are more likely to help than treatments that are done to you (like medicines, massage or surgery). Refer to the patient information sheet How to manage your back pain for things that you can do.

You will be encouraged to set treatment goals. Your clinician can also discuss monitoring your symptoms; pacing (or spreading out) activity into small, regular periods; relaxation techniques; and exercise routines and activities. If activities or treatments in your self‑management plan make your pain worse, talk to your clinician about other strategies you can try.

Continue with physical activity even after your back pain has improved, because this is important for preventing future episodes

What the standard says

A patient with low back pain is offered physical and/or psychological interventions based on their clinical and psychosocial assessment findings. Therapy is targeted at overcoming identified barriers to recovery.

What this means for you

Your clinician will offer information and support based on your individual needs, values and preferences, and discuss your goals for improved function and mobility.  For many people with new back pain, additional therapies are not necessary because the pain will improve naturally as you follow the advice of your clinician about physical activity and self‑management. To avoid ongoing issues, treatments that target both the mind and the body will be considered because they are more likely to help with reducing your pain and improving your function long term.

You may be referred to other clinicians for physical therapy, psychological pain management support or a combined treatment approach. Although hands-on therapies may be offered, the overall goal should be to support you to manage your symptoms independently in the longer term. There are many types of clinicians who can help you to set achievable movement and exercise goals, and show you how to pace your activities. For some people with repeated episodes, a psychologist or counsellor can also help you to understand your pain and how it affects your body, thoughts and behaviours, and help you to develop effective coping strategies. Your general practitioner may be able to advise about options for receiving Medicare rebates for these services, if you meet the criteria. You should always receive strategies that support you to manage your symptoms independently in the longer term.

What the standard says

A patient is advised that the goal of pain medicines is to enable physical activity, not to eliminate pain. If a medicine is prescribed, it is in accordance with the current Therapeutic Guidelines, with ongoing review of benefit and clear stopping goals. Anticonvulsants, benzodiazepines and antidepressants are avoided, because their risks often outweigh potential benefits, and there is evidence of limited effectiveness. Opioid analgesics are considered only in carefully selected patients, at the lowest dose for the shortest duration possible.

What this means for you

The aim of taking medicines is to reduce pain enough to help you stay active, rather than to completely stop the pain. Medicines are only one part of pain management. They are most effective in the short term to help get you moving and support you while you learn active self-management strategies. It is important to remain physically active and continue with physical activity and self-management strategies after you start any medicine.

When suggesting a medicine, your clinician will consider your symptoms, any other conditions you may have, other medicines you take and your treatment preferences. They will explain:

• What the medicine is for
• How much to take
• How long to take it for
• The expected benefits and risks, including possible side effects.

Ask questions to decide if the medicines being suggested are right for you, and to make sure you understand how to use them.

Medicines that are generally not recommended for low back pain include benzodiazepines (sometimes prescribed as muscle relaxants), anticonvulsants (also used to treat epilepsy) and antidepressants. This is because these medicines are not very effective for low back pain and can have significant side effects.

Opioid analgesics should only be used short term at the lowest dose that helps your symptoms and as recommended by your clinician. Do not use these for long periods because they can cause significant side effects and can be addictive.

What the standard says

A patient with persisting or worsening symptoms, signs or function is reassessed at an early stage to determine the barriers to improvement. Referral for a multidisciplinary approach is considered. Specialist medical or surgical review is indicated for severe or progressive back or leg pain that is unresponsive to other therapy, progressive neurological deficits, or other signs of specific and/or serious pathology.

What this means for you

Let your clinician know if your pain continues to be a problem, if your symptoms get worse or if new symptoms appear. Your clinician can monitor your symptoms and wellbeing, and adjust your treatment if needed. You may be referred to another clinician or team of clinicians who can help you with your goals for achieving physical activity and mobility, and help you to understand your pain and how to reduce its impact on your body, mental state and behaviours.

In some instances, your clinician may refer you to a specialist spine service, a pain service or a physician (such as a rheumatologist, a spine surgeon, or a pain or rehabilitation physician). These specialists can assess your condition, provide advice and discuss other specialised treatment options.

Your clinician will also refer you to a spine surgeon if they suspect a serious condition for which surgery is appropriate, or if you have any nerve compression that is getting worse.