Low Back Pain

Care for Adults With Acute Low Back Pain

Resources The Quality Standard In Brief Advisory Committee About

Summary

This quality standard addresses care for those 16 years of age and older with acute low back pain, with or without leg symptoms. It examines the assessment, diagnosis, and management of people with this condition by health care professionals across all health care settings, with a focus on primary care.

This quality standard provides guidance on reducing unnecessary diagnostic imaging, encouraging physical activity, providing education, giving reassurance, assisting with self-management support, prescribing pharmacological therapies, and suggesting additional nonpharmacological therapies.

Scope of This Quality Standard

This quality standard addresses care for adults aged 16 years and older who have a first episode of acute low back pain, or who have recurrent episodes of acute low back pain that last less than 12 weeks. The standard addresses mechanical low back pain with or without associated leg symptoms, such as radiculopathy caused by compression of a spinal nerve root (a pinched nerve) and neurogenic claudication (painful cramping or weakness in the legs with walking or standing).

Although it applies to care in all settings, this quality standard focuses on primary care and community-based care that can be provided by an interprofessional team of health care providers. It includes the assessment and management (including pharmacological and additional nonpharmacological interventions) of acute low back pain with or without leg symptoms, as well as physical activity, education, self-management, and psychosocial support for people with acute low back pain. This standard includes referral to nonsurgical and surgical speciality care providers for patients who require additional medical care for their low back pain, but it excludes information on specialty-based interventions.

This quality standard does not address the management of chronic low back pain (lasting more than 12 weeks). It also excludes low back pain in pregnancy; and the diagnosis and treatment of specific causes of low back pain, such as inflammatory conditions (e.g., ankylosing spondylitis), infections (e.g., discitis, osteomyelitis, epidural abscess), fracture, neoplasm, and metabolic bone disease (e.g., osteoporosis, osteomalacia, Paget’s disease), nonspinal causes of back pain (e.g., from the abdomen, kidney, ovary, pelvis, bladder), chronic pain syndromes, and surgical interventions (e.g., fusion and disc replacement, discectomy, laminectomy).

Terminology Used in This Quality Standard

Red Flags

In this quality standard, the term “red flag” indicates a sign or symptom of a serious underlying pathological disease that may require tests or investigations. Red flag signs or symptoms can be identified as follows:

Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome (Note: Acute cauda equina syndrome is a surgical emergency. Symptoms include new bowel or bladder disturbance, including unrecognized fecal incontinence, saddle numbness, lower motor neuron weakness, and distinct loss of saddle/perineal sensation)
Infection: fever, history of intravenous (IV) drug use, immunosuppression
Fracture: trauma, osteoporosis risk/fragility fracture
Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue
Inflammation: chronic low back pain for more than 3 months, an age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain

Yellow Flags

In this quality standard, the term “yellow flag” indicates a psychosocial risk factor for developing chronic low back pain. Yellow flags may be identified through the answers to the following questions:

“Do you think your pain will improve or become worse?”
- What to listen for: a belief that back pain is damaging or potentially severely disabling
“Do you think you would benefit from activity, movement, or exercise?”
- What to listen for: fear and avoidance of activity or movement
“How are you coping emotionally with your back pain?”
- What to listen for: a tendency to have a low mood or withdrawal from social interaction
“What treatments or activities do you think will help you recover?”
- What to listen for: expectations of passive treatment, rather than expectations that active participation will help

Why This Quality Standard Is Needed

Low back pain is defined as pain localized between the 12^th rib and the inferior gluteal folds. Most cases of acute low back pain are “mechanical” or nonspecific, and are characterized by tension, soreness, or stiffness in the low back area. Although the source of pain and other symptoms might be attributed to several structures in the back, including discs, facet joints, muscles, and connective tissue, the specific source is often not identifiable.

Worldwide, low back pain causes more disability, activity limitation, and work absenteeism than any other condition. An estimated 80% of adults experience an episode of acute low back pain at least once in their life. Most low back pain episodes improve with initial primary care management, and without further investigations or referral to specialists.

It is important to recognize that the decrease in function and mobility associated with acute low back pain has an impact on the social and economic contexts of people’s health, well-being, and life in general. Evidence shows that people of low socioeconomic status are more likely to receive medication (opioids and/or nonsteroidal anti-inflammatory drugs) to manage their acute low back pain than are people of high socioeconomic status. People of low socioeconomic status also have a higher risk of recurrent, persistent low back pain and an overall poorer prognosis. People with acute low back pain who live in low socioeconomic areas do not have the same access to care as those living in high socioeconomic areas, and are disadvantaged by their restricted access to health care services. Despite evidence that opioids are not a useful treatment for acute low back pain, back pain is the most common reason physicians prescribe opioids in family medicine and the emergency department.

In Canada, about 30% of adults have low back pain that recurs within 6 months, and 40% within 1 year of their first episode. Most people with low back pain can benefit from lifestyle modifications (such as physical activity) and additional interventions (such as pharmacological therapies, heat, manual therapy, and therapeutic exercise). Although the literature provides consistent recommendations for managing low back pain, there is poor uptake of these recommendations and a lack of consistency in the provision of educational materials and resources to patients with low back pain.

Evidence shows that 90% of low back pain is not caused by serious underlying injury or disease that requires MRIs, CT scans, medication, surgical referrals, or opioid prescriptions. Less than 5% of low back x-ray examinations reveal a finding associated with red flags, which include neurological disorders, infection, fracture, tumour, or inflammation. Medical imaging for low back pain is being used more often than necessary. Imaging of the lumbar spine accounts for about one-third of all MRI examinations, and the use of diagnostic imaging has grown more rapidly than almost any other type of Canadian health service. In Ontario, there is considerable regional variation in the use of diagnostic imaging for low back pain. The total cost for spinal imaging, including x-ray examination, CT scanning, and MRI, was estimated to be $40.4 million in 2001/2 and increased to $62.6 million in 2010/11—a 55% increase over 10 years.

There are many opportunities for improving low back pain care in Ontario. These include decreasing the progression from acute low back pain to chronic low back pain; ensuring timely access to education to help patients manage their symptoms; ensuring access to an appropriate health care provider when it is required; decreasing the use of inappropriate imaging for low back pain; and decreasing the use of opioids. Several programs aim to address these issues, although there is limited access to acute low back pain resources and marked geographic variation in access across the province.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect, equity, and equality.

People with acute low back pain should receive services that are respectful of their rights and dignity and that promote shared decision-making. People with acute low back pain should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious backgrounds), and disability. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, services should be actively offered in French and other languages.

People with acute low back pain should have access to care through an integrated approach that facilitates access to primary care providers, rehabilitation care providers, surgical and nonsurgical specialists, and programs in the community, according to a patient’s needs over time. Interprofessional collaboration, shared decision-making, coordination of care, and continuity of care (including follow-up care) are distinct aspects of a patient-centred approach. Collaborative practice in health care “occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings.”

Care providers should be aware of the historical context of the lives of Canada’s Indigenous peoples and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides safe, effective, patient-centred, efficient, timely, and equitable care for everyone in Ontario, no matter where they live, what they have, or who they are.

How Success Can Be Measured

The Low Back Pain Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

In this section, we list indicators that can be used to monitor the overall success of the standard provincially, given currently available data. If additional data sources are developed, other indicators could be added.

Process indicators:

Percentage of people who seek physician or emergency department care for acute low back pain who undergo diagnostic imaging (x-ray, CT, MRI, bone scan) of the spine
Percentage of people who seek physician or emergency department care for acute low back pain who are prescribed an opioid medication

Outcome indicators:

Percentage of people who seek physician or emergency department care for acute low back pain who subsequently present to the emergency department for low back pain

Note: We excluded red flags from the indicators to the best of our ability. However, owing to the limitations of using administrative data, some red flags could not be excluded. Please see the Measurement Guide that accompanies this quality standard for details of red flag exclusions.

How Success Can Be Measured Locally

Providers may want to monitor their own quality improvement efforts and assess the quality of care they provide to people with acute low back pain. It might be possible to do this using their own clinical records, or they might need to collect additional data. We recommend the following list of indicators, in addition to those listed above, to measure the quality of care patients are receiving; these indicators cannot be measured provincially using currently available data sources:

Percentage of people with acute low back pain who have surgeon or specialist consultations
Percentage of people with acute low back pain who report an improvement in their quality of life
Percentage of people with acute low back pain who rate their interaction with their health care professional as “definitely helping them feel better able to manage their low back pain” (response options: definitely, for the most part, somewhat, not at all)

In addition, each quality statement within the standard is accompanied by one or more indicators. These indicators are intended to guide the measurement of quality improvement efforts related to implementing the statement. To assess the equitable delivery of care, the quality standard indicators can be stratified by patient socioeconomic and demographic characteristics, such as income, education, language, age, sex, and gender.

What Does It Mean for Patients and Caregivers?

When I experienced an acute episode of low back pain more than 15 years ago, my primary care provider referred me to a physiotherapist who not only helped me manage my pain but educated me on ways I could prevent low back pain in the future. Since then, while I have experienced episodes of low back pain, due to lifestyle factors (prolonged periods of sitting at work, lifting children, lifting heavy loads while gardening, etc.), I have rarely had to seek medical treatment. The self-management tools I received empowered me to take charge of myself.

I joined the Quality Standards Advisory Committee to ensure that other patients are similarly educated about how to effectively manage their pain. The quality standard is really good tool to enable communication between medical professionals and patients, and [the patient guide] tells you what to expect; when patients read it they learn about the care pathway and know what to express to the medical professional. Patients can take the initiative and give a better description of their pain, learn how to take care of themselves, and know when to seek medical attention. In turn medical professionals can use resources most effectively.

- Jenny Tang, Lived Experience Advisor, Low Back Pain Quality Standards Advisory Committee

What Does It Mean for Providers?

This quality standard offers a unified approach to managing low-back pain for patients across Ontario, and will help health professionals to work as a team to do what’s best for the system and their patients. Moreover, it represents an opportunity for clinicians and patients to refer to the same sources of information, offering a common ground.

“Patient education is necessary for engagement – recovery and prevention depend on it. Low back pain is a complicated issue, with many factors at play, and it’s important that when the patient leaves the appointment they understand the diagnosis and the appropriate next steps, particularly the importance of movement and physical activity, available adjunctive therapies, and the reasons why imaging and pharmacological treatment are usually unnecessary.”

– Scott Shallow, LBP Quality Standard Advisory Committee member

Timeline for This Quality Standard

This quality standard was completed in January 2019.

Evidence to Improve Care