Information for clinicians – 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

Early assessment should include a targeted history of symptoms, including attention to the pain, past history, functional capacity and alerting features for specific and/or serious pathology. Consider differential diagnoses – for example, nephritis, colitis, hip osteoarthritis and aortic dissection.

Physical examination should include a postural assessment, bony and soft tissue palpation for tenderness and tone, and movement assessment for range and associated pain. A physical examination supports diagnosis and can help to build the patient’s confidence in the therapeutic relationship.

Consider using an evidence-based low back pain pathway that guides the appropriate assessment of patients who present with low back pain symptoms. The pathway should incorporate screening for specific and/or serious pathology. It should allow the use of validated tools, such as the Brief Pain Inventory (short form) or the Clinically Organized Relevant Exam (CORE) Back Tool, to aid assessment and monitoring of the patient’s progress. It should also allow referral to specialist clinicians, when needed, for management.

For acute leg pain without severe or progressive motor weakness, initial management should be the same as for acute low back pain.

For patients with low back pain symptoms and/or leg symptoms where there is clinical suspicion of neurological impairment, include a focused neurological examination with straight leg raise, deep tendon reflexes, and strength and sensation testing.

Arrange appropriate investigation or intervention if alerting features of specific and/or serious underlying pathology are identified. The presence of multiple alerting features is associated with a greater likelihood of serious pathology compared with the presence of a single alerting feature. Emergency assessment or referral is indicated for clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs or symptoms, suspected spinal infection or cauda equina syndrome, spinal tumour, trauma or fracture.

Determine the most likely diagnosis, document the assessment findings and communicate them to the patient. Arrange follow-up for monitoring or further assessment. Reassess at subsequent visits to check for symptom progression or any new concerning features that need urgent investigation or specialist assessment (refer to Quality statement 8 – Review and referral).

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

Certain psychosocial factors and emotional responses to pain are associated with delayed recovery, and their presence indicates the need for further assessment and appropriate intervention (see Box 1). Use a biopsychosocial approach that considers the relationship between the patient’s beliefs and pain behaviours to manage the patient.

Consider using risk assessment tools early in each new episode (first or second visit) of low back pain (see the clinician practice points). These tools can help to identify a patient‘s risk of poor functional outcome or long-term pain and disability, and reduce the time involved in assessment and investigation.  Examples include:

• STarT Back Screening Tool
• Örebro Musculoskeletal Pain Screening Questionnaire (10-item version).

Repeat risk assessment at subsequent visits to measure progress.

Listen to the patient, and validate that their thoughts and feelings are understandable, and the pain they are experiencing is real. Explore the patient’s reasons for presenting and perception of their pain, and identify harmful misconceptions, including fear-avoidance behaviour. Motivational interviewing techniques can help to explore and dispel misconceptions in a non-threatening way.

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

A patient without alerting features for serious underlying pathology may not receive any clinical benefit from diagnostic imaging. Explain that investigations are rarely helpful or indicated for low back pain. Explain that imaging outside recommendations can create unnecessary concerns and that incidental findings with no clinical significance can lead to unnecessary tests.

Early imaging is appropriate for a patient with alerting features for specific and/or serious underlying pathology; consider specialist involvement to obtain guidance and appropriate imaging studies. MRI is generally preferred because it offers better sensitivity and a superior safety profile. However, it is not covered by the Medicare Benefits Schedule if requested by a general practitioner, a physiotherapist or a chiropractor. CT has a limited role but in the presence of alerting features may be considered in some cases, such as when MRI is unavailable or contraindicated, or early consultation with a specialist is not available.

Ensure that sufficient detail is included on the radiological referral, such as the provisional diagnosis and the clinical question being asked, to ensure appropriate imaging and reporting (see Box 2), and discuss any risks of radiation exposure with the patient.

Ensure that the patient understands the radiological findings. When no serious pathology is found, discuss the report in the context of history, examination and other investigations. Patient interpretations of imaging findings can lead to unnecessary distress and fear-avoidance behaviour. Advise the patient that findings such as disc degeneration; facet joint arthritis; and disc bulges, fissures and protrusions are very common in people without pain and are usually a normal feature of ageing. Epidemiological reporting of imaging findings may help patients understand the probability and significance of incidental findings.

The need for imaging should be reassessed for patients with changing or worsening symptoms. Patients with unchanged symptoms should not undergo repeated imaging unless a diagnosis that was not considered on previous imaging is being contemplated.

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

Recognise and validate the patient’s experience of pain. Reassure patients about the benign nature of low back pain, the low risk of serious underlying disease and the likelihood of recurrence. Provide educational materials that are consistent with your verbal advice to reinforce key messages, taking into consideration the patient’s culture and health literacy. Address any unhelpful beliefs and thoughts identified in the psychosocial assessment that may affect how the patient manages their symptoms, including anxiety or fear about their condition. Use motivational interviewing techniques to help explore and dispel misconceptions in a non-threatening way. Check for understanding and whether the patient feels reassured. Repeat education at subsequent visits.

Discuss the patient’s expectations about management of their condition, and address any misconceptions about tests and interventions. Explain the evidence for treatment options, so the patient can understand why some strategies are, or are not, being recommended. Inform patients about the potential benefits, risks and costs of any treatment being considered.

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

Explain the importance of maintaining or quickly returning to normal activities, including physical activity and a graded return to work and/or other meaningful activity (see Box 4).  Listen to the patient, and validate that their thoughts and feelings are understandable, and the pain they are experiencing is real (see Quality statement 2 – Psychosocial assessment). Discuss strategies to support the patient to continue to engage or quickly re-engage socially. Prolonged bed rest is harmful and should be discouraged.

Consider the impact of lifestyle factors that are associated with occurrence of low back pain episodes, such as smoking and obesity.

Encourage patients to take control of their condition by following advice about ways to self-manage their back pain symptoms.  Assess the patient’s confidence and ability to engage in self-management, particularly for patients with a history of recurrent back pain and identified psychosocial risk factors. Where potential barriers appear to exist for the patient to undertake self-management and active strategies, discuss strategies to overcome them.

Self-management will differ for each patient depending on their history, pain severity and confidence to undertake self-management. A self-management plan may vary from brief advice to a more detailed management plan, according to the needs of the patient, and may include:

• Prioritising active management strategies (such as physical activity, social connection, healthy sleep habits and use of heat) over passive strategies (such as pain medicines, activity avoidance and massage)
• Gradually increasing activity levels by using pacing to prevent overexertion followed by inactivity
• Supporting the patient to set SMART (specific, measurable, achievable, realistic and time‑bound) goals that are important to them.

If physical activity causes the patient’s symptoms to spread (pain or other symptoms radiating to the leg), activity limitation but not cessation may be required.

Box 4: Advice to stay active for people with acute low back pain

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

Use the findings from the psychosocial assessment (see Quality statement 2 – Psychosocial assessment) to determine the complexity and intensity of support the patient may need.

For patients with few psychosocial risk factors, who are likely to improve quickly, consider simpler and less intensive support such as reassurance, guidance on self-management and advice to keep active (see Box 4 in Quality statement 5). Offer a review at one to two weeks to assess recovery and the need for further physical or psychological interventions.

For patients at higher risk of a poor outcome, consider early referral for physical and/ or psychological therapies. A patient with moderate to high levels of distress who has difficulty overcoming fear of movement or changing their beliefs or behaviours may require more specific psychological interventions, such as cognitive behavioural therapy, progressive relaxation or mindfulness-based stress reduction. A cognitive behavioural approach can help the patient to develop adaptive coping strategies to self‑manage their pain.9 Where possible, refer patients to a clinician who has experience in pain management and understands the biopsychosocial factors that influence it.  Assess and resolve any concerns the patient may have about such a referral.

For patients with an acute exacerbation of persistent or chronic low back pain, advise that physical activity and exercise therapy can help to relieve pain and improve function (see Box 5), and check adherence to, and effectiveness of, any previous physical and psychological treatments.

Since the evidence does not show that one form of exercise is superior, exercise should be individualised to the patient’s activity preferences, beliefs and functional impairment. The effects of treatment should be documented, with attention to objective and functional improvements. Advise the patient they may be eligible for Medicare rebates as part of a GP Management Plan and Team Care Arrangements.

Physical therapies (such as heat wraps and massage)26 may also help to improve function and mobility, but only as part of a treatment package including physical activity, with or without psychological therapy, and only for a short period of time.

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

Explain that the goal of pain medicines is to reduce pain to support continuation of usual activities, including physical activity and work, rather than to eliminate pain. Offer information on how pain medicines may be combined with physical activity and self‑management strategies to help the patient improve their function and mobility.

If a pain medicine is being considered:

• Discuss the patient’s individual expectations, preferences, comorbidities, needs and treatment goals
• Review the patient’s current medicines, including use of over-the-counter medicines, and previously prescribed medicines used to manage pain
• Provide information about the risks and benefits associated with specific pain medicines, including the potential for dependency and how to manage side effects
• Prescribe the lowest effective dose for the shortest possible time in line with current Therapeutic Guidelines
• Establish and document clear stopping goals
• Encourage the patient to continue other self-management strategies after they start the medicine
• Review early and frequently to assess and monitor the effectiveness of the treatment, adverse effects, misuse and functional gains.

Evidence has shown that anticonvulsants (pregabalin and gabapentin), tricyclic antidepressants, selective serotonin reuptake inhibitors and benzodiazepines have no or limited effectiveness in reducing low back pain or disability, and have significant risks.

Opioid analgesics have limited evidence of short-term effectiveness. In addition to side effects such as constipation and somnolence, they carry the risk of overdose and dependency, and can prolong the time to recovery. If opioid analgesics are used for severe acute pain – for example, in patients who present to the emergency department – prescribe immediate-release formulations on a limited trial basis for a defined duration, as part of an overall pain management strategy that takes into account the patient’s opioid status. Before prescribing an opioid analgesic, it is essential that the patient and anyone involved in their care understand how to use these medicines safely, including their correct storage and disposal.

• See Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

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

If the patient’s pain is persisting or worsening on review, assess if the lack of improvement relates to progression of their condition, or physical, functional or psychosocial factors. Review the initial assessment and current management program, including psychosocial factors that may delay recovery, medicines and adherence to self-management strategies, and adjust the treatment plan accordingly. Any treatments trialled should be assessed for efficacy, and ineffective treatments should be discontinued rather than accumulated.

Discuss ongoing compensation or legal actions that may affect a patient’s response to treatment, because there is an association between compensation-related factors and poorer physical and psychological function.

For a patient with disabling low back or leg pain, or significantly limited function on review at 2–6 weeks, consider referral to a healthcare provider with expertise in using evidence-based approaches to support functional improvement  (see Quality statement 6 – Physical and/or psychological interventions).

A multidisciplinary team approach should be used to address both physical and psychosocial barriers to recovery when required. This should include a mechanism for regular shared communication between healthcare providers and ensuring that consistent information is provided to a patient receiving care from multiple clinicians.

Referral to a multidisciplinary chronic pain management program or clinician with appropriate expertise should be considered for patients with recurrent or persistent low back pain, or any patient who has not recovered from the acute episode by 12 weeks. These services can provide more intensive treatment to support resumption of pre-back pain activities. They have improved function and self-management as the main objectives, and allow ongoing regular review of the patient so that care can be modified according to the patient’s condition.

Earlier referral or review may be warranted for patients with an acute exacerbation of chronic back pain, or when it is clear that pain is persisting or worsening despite appropriate early intervention.

Any new concerning features (for example, serious pathologies, neurological deficits) require urgent investigation or specialist assessment. Patients with severe or progressively deteriorating neurological signs and symptoms should be immediately referred for urgent imaging and surgical review (see Box 6 for essential history to be included in the referral).