1. Evidence-Informed Best Practice Low Back Pain
Dr. Julia Alleyne

2. Clicker Time

3. Which key clinical features are NOT suggestive of mechanical low back pain ?
Morning stiffness less than 30 minutes
Pain associated with movement such as bending
Occasional night waking with moderate pain
Urinary retention followed by overflow incontinence
Pain associated with arching backwards
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4. 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?
Presence of chronic back pain not responsive to conservative treatment after 8 weeks
Presence of non-radicular referred leg pain
Presence of tingling sensation in affected leg
CT/MRI indicating any disc pathology
CT/MRI indicating clinically significant nerve root compression
Clarification of work related modifications and restrictions
Patient would like second opinion on diagnosis and management
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5. A patient who demonstrates positive yellow flags would fit the following behaviours.
Vegetative signs of clinical depression
Fear and avoidance of activities associated with discomfort
Frequent disruptive sleep disturbance
Dependency on passive pain management modalities
1 and 2
2 and 4
All of the above
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6. In which of the following situations would the low back pain guidelines recommend goal-specific rehabilitation?
Acute low back pain of 1 week duration in avid athlete
Persistent low back without response to medication and exercise
Use of lumbar traction for chronic low back pain
Low back pain triggered by a motor vehicle accident

7. Which of the following patient key messages is Not true?
Your assessment today does not indicate any serious pathology so there is no need to order an xray or any investigations.
Keep moving! Staying active helps and most acute low back pain will go away, without treatment, in 4 to 6 weeks.
Returning to your usual activities including work as soon as you can and at a gradual pace will help you recover.
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.
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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8. 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

9. Acute Low Back Pain

10. 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

11. 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”

14. 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.

15. Sub-Acute Low Back Pain

16. 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

17. 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 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

20. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

21. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

22. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

23. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

24. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

25. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

26. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

27. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

28. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

29. Evidence Based Treatment
Intervention
Lumbar Traction
Spinal Manipulation
Heat/Cold
Bed Rest
Therapeutic Ultrasound
Lumbar Support
Orthotics

30. 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.

31. Persistent and Recurrent Low Back Pain

32. 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

33. Recurrent & Persistent Guidelines
< 6 weeks but > 12 months
Treatment
Education
Exercise
Manual Therapy
Acupuncture
Consider Psychological Referral
2009 National Institute for Health and Clinical Excellence (NICE)
“Low back pain: Early management of persistent non- specific low back pain”

37. 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.

38. Chronic Low Back Pain

39. 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

40. Chronic Low Back Pain Guidelines
Exercise
Graduated
Directional preference
Core stability
With pain
Daily
2009 TOP Alberta Guidelines
“Guideline for the Evidence- Informed Primary Care Management of LBP”
2004 EUROPEAN GUIDELINES
“Management of Chronic Non- specific Low Back Pain”

45. 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.

47. Summary Consistent messaging
Limited and Specific Imaging and Investigations
Exercise, Education and Activity Prescription
Patient Self-management
Focused Treatment