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ASSESSMENT

DIAGNOSING LOW BACK PAIN:
WHAT GUIDELINES ACTUALLY RECOMMEND

STANDING Collaboration · Wiles et al. (2021)

< 1 %
of LBP cases have
a specific spinal pathology.

What does appropriate point-of-care assessment actually look like? Here is what guideline evidence and international expert consensus recommend.

The STANDING Collaboration Project (Wiles et al., 2021) synthesises guideline evidence and international expert consensus to establish point-of-care clinical indicators for appropriate assessment of low back pain (LBP). The following is a direct summary of those recommendations.

Step 1 — Diagnostic Triage

People with lower back pain are classified using a diagnostic triage approach into four categories (Wiles et al., 2021):

Specific Spinal Pathologies
Cauda equina syndrome · spinal infection · spinal or other malignancy · vertebral fractures · inflammatory arthritis (e.g. axial or other spondyloarthritis)
< 1 %
Radicular Syndrome
Nerve root involvement with associated lower limb symptoms
5–10 %
Non-Specific Low Back Pain
No specific structural cause identified — the majority of presentations
Majority
Other Conditions
Referred visceral pain (pelvic organ disorders: prostatitis, endometriosis, chronic pelvic inflammation, kidney disease, gastrointestinal diseases, pancreatitis, cholecystitis, ulcers) · viral syndrome · vascular diseases (e.g. femoral artery occlusion, aortic aneurysm) · hip pathology
Variable

Step 2 — Taking a Thorough History

In patients with lower back pain, a detailed history should be taken to identify those with a higher probability of serious and/or specific pathology (Wiles et al., 2021). The following features may be helpful:

Medical history — prior medical interventions (particularly spinal injections), history of cancer, medication use (especially corticosteroids), comorbidities (e.g. diabetes mellitus), prior spinal surgery, chronic pain conditions
Triggers and course of low back pain — e.g. post-traumatic onset
Bladder and bowel symptoms and saddle anaesthesia
Pain localisation and quality
Weakness or sensory disturbances in the lower extremity
Fever or sweating episodes

Patients with LBP should be assessed at the first visit for factors that may delay recovery (e.g. psychological health, occupational or legal circumstances). These should be reassessed at a subsequent visit (Wiles et al., 2021).

Step 3 — Physical Examination

Patients with lower back pain should be thoroughly examined to identify serious underlying causes (Wiles et al., 2021). The following factors should be the focus:

01
Motor & Sensory
Motor weakness or sensory disturbance
02
Gait & Posture
Assessment of gait pattern and posture
03
Lumbar ROM
Assessment of lumbar range of motion
04
Straight Leg Raise
SLR testing
05
Palpation
Palpation of the lumbar spine and surrounding structures

Patients with lower back and leg pain and/or neurological symptoms should receive a neurological examination of the lower extremity (including SLR) when they first present. Symptoms and findings should be reassessed at subsequent visits (Wiles et al., 2021).

Step 4 — Referral Thresholds

Wiles et al. (2021) set clear referral thresholds based on the clinical picture at presentation:

Patients with LBP and suspected spinal infection or cauda equina syndrome should be referred immediately to a neurosurgeon or emergency department (Wiles et al., 2021).

Patients with LBP and strong clinical suspicion of cancer (spinal malignancy), axial spondyloarthritis (or other inflammatory conditions), or fractures should be referred promptly to the appropriate physician (Wiles et al., 2021).

Step 5 — No Routine Investigations for Non-Specific LBP

Patients with a new episode of non-specific LBP without indication of a serious and/or specific cause should not be examined with the following procedures, as these can negatively influence the course of treatment (Wiles et al., 2021):

Imaging
X-ray · CT · MRI · bone scintigraphy · fluoroscopy · myelography · CT myelography · thermography · discography
Laboratory Investigations
Blood tests · urinalysis
Electrodiagnostics
Nerve conduction velocity · electromyography (EMG)

Patients with radicular symptoms should not be examined routinely with MRI or CT. Imaging is only indicated where the findings would directly influence the management plan — for example, in cases of rapid progression of neurological symptoms (Wiles et al., 2021).

Step 6 — Assessment for Non-Specific LBP

Patients with non-specific LBP can be supported by measuring their goals and tracking progress within the course of treatment — for example, exercise tolerance and the ability to perform daily activities (Wiles et al., 2021).

Patients with non-specific LBP should be assessed using a validated multidimensional questionnaire to individualise the treatment plan and measure progress (Wiles et al., 2021):

STarT Back Tool
Recommended by Wiles et al. (2021) to stratify risk, individualise the management plan, and monitor progress over time
Örebro Musculoskeletal Pain Screening Questionnaire
Recommended by Wiles et al. (2021) to stratify risk, individualise the management plan, and monitor progress over time

Reference

  1. Wiles L, et al. What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project). 2021.

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