Provider Guidelines for 3 Risk Types

Low Risk or Acute/subacute (<12 weeks)

The patients in the low risk category are very likely to improve. The aim is to support and enable self-management. The key factors are to address patient concerns and to provide information.

What to DO:

Assessment to include medical issues but also patient worries, concerns and social impact
Brief physical assessment as appropriate
Medication review and advice
Address specific patient issues from the assessment
Provide oral and written information
Explain outlook is good but can re-consult if necessary
Recommend simple first line care: heat, massage, acupuncture, spinal manipulation

What to SAY:

Provide reassurance on the benign nature of LBP, explain that it is unlikely that serious disease is present
Explain that imaging is not required and will not change management
Avoid language that promotes fear of pain and catastrophic thinking (e.g., injury, degeneration, wear and tear)
Encourage activity and self-management over pharmacological treatment

View Patient Education & Self-Care Resources View Patient Exercises View Patient Videos

Medium Risk or Chronic (>12 weeks)

The main aims are to restore function (including work), minimize disability even if pain is unchanged and to support appropriate self-management.

What to DO:

Similar to low risk, elicit concerns and adequate physical examination
Tailored treatment according to physical findings and specific needs / worries of the individual patient
Course of chiropractic or physical therapy, which for some patients may only be brief
Specific chiropractic or physical therapy interventions when clear specific findings from physical assessment (i.e. manual therapy, specific exercises)
Some patients will need onward referral to specialist services (i.e. secondary care spinal services, ortho, neurosurgery, pain clinic)
Introduce cognitive behavioural approaches and mindfulness

What to SAY:

Discuss treatment objectives that are specific and have an end time point; all specific treatment effects should ‘translate’ into functional improvements and reduced disability
Explain that imaging is not required and will not change management
Avoid language that promotes fear of pain and catastrophic thinking (e.g., injury, degeneration, wear and tear)
Encourage activity and self-management, recommend against bed rest
Recommend against the use of surgery, injections or denervation procedures

View Patient Education & Self-Care Resources View Patient Exercises View Patient Videos

High Risk

The aims are to reduce pain and optimize function.

What to DO:

Six individual (45-60 min) physical therapy appointments over three months using a combined physical & cognitive-behavioral approach
Review medications regularly for evidence of benefit and discontinue if there has been no improvement
Identification of potential obstacles to rehabilitation (e.g. Yellow & Red Flags)
Identification of possible targets for intervention

What to SAY:

Discuss treatment objectives that are specific and have an end time point; all specific treatment effects should ‘translate’ into functional improvements and reduced disability
Encourage ongoing therapy to improve cognitive, emotional and behavioral responses to pain.
Recommend against the use of surgery, injections or denervation procedures

View Patient Education & Self-Care Resources View Patient Exercises View Patient Videos

STarT Back Screening Tool Patient Education & Self-Care

Reference Documents

Reference: Common Red Flags Associated with LBP Reference: Guidelines for Pharmacological Options Reference: Radiology Epidemiology Statement

ABI Value	Interpretation	Recommendation
Greater than 1.4	Calcification/vessel hardening	Refer to vascular specialist
1.0 - 1.4	Normal	None
0.9 - 1.0	Acceptable	None
0.8 - 0.9	Some arterial disease	Treat risk factor
0.5 - 0.8	Moderate arterial disease	Refer to vascular specialist
Less than 0.5	Severe arterial disease	Refer to vascular specialist

Red Flag	Concerning Dx	Next Steps
Fever, chills, rigors IV drug use Recent infection	Epidural abscess Osteomyelitis Discitis	Stat MRI or transport to ED
History of cancer, new onset of pain Unexplained weight loss Pain not reproducible	Cancer	X-Ray Sed rate, CRP studies MRI w/o labs
Urinary retention/ incontinence Fecal incontinence Motor deficits at multiple levels Perineal numbness Saddle anesthesia Decreased anal sphincter tone	Cauda equine syndrome	Stat Lumbar MRI or transport to ED
Recent severe trauma or less sever trauma with history of osteoporosis, use of corticosteroids and older age Extreme pain with movement	Vertebral compression fracture	Plain film X-Ray or CT

Among patients in the following age groups who are asymptomatic, a lumbar spine MRI will find about...
	20-30 years old	30-40 years old	40-50 years old	50-60 years old	60-70 years old	70-80 years old	80+ years old
Disc Degeneration	37%	52%	68%	80%	88%	93%	96%
Oisc Signal Loss	17%	33%	54%	73%	86%	94%	97%
Disc Height Loss	24%	34%	45%	56%	67%	76%	76%
Disc Bulge	30%	40%	50%	60%	69%	77%	84%
Disc Protrusion	29%	31%	33%	36%	38%	40%	43%
Annular Fissure	19%	20%	22%	23%	25%	27%	29%
Facet Degeneration	4%	9%	18%	32%	50%	69%	83%
Spondylolisthesis	3%	5%	8%	14%	23%	35%	50%

Provider Guidelines

Provider Guidelines for 3 Risk Types

Low Risk or Acute/subacute (<12 weeks)

What to DO:

What to SAY:

Medium Risk or Chronic (>12 weeks)

What to DO:

What to SAY:

High Risk

What to DO:

What to SAY:

Reference Documents

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