Low Back Pain Care Path Guide


Clinical Judgment

This care path guide is intended to be broadly applicable, but it is not meant to substitute for clinical judgment. Clinicians and specialists should tailor processes and approaches to align with patient needs, abilities and goals for care.

Low Back Pain: A Heavy Burden on Public Health

One of the most common conditions medical providers treat,1 low back pain affects an estimated 80% of people at least once over a lifetime.2 During a given three-month period, approximately 25% of adults in the United States will experience at least one day-long episode of low back pain.3 The prevalence of this condition and its effects on public health have led some experts to label it an epidemic.4

In the U.S. and globally, disability and healthcare costs associated with spinal pain, including low back pain, are on the rise,5,6 and that trajectory is projected to continue.7 Americans lead more sedentary lifestyles today than at any other time in history, spending more time sitting, which can lead to poor posture—a contributor to low back pain.

Worldwide, low back pain is linked with more disability than any other condition.8 From 1996 to 2013, spending on low back and neck pain increased by an estimated $57.2 billion, second only to the spending increase on diabetes ($64.4 billion) during that time span.7

The Case for a Care Path Guide

Recent studies have demonstrated that inadequate, unnecessary, uncoordinated and inefficient care are responsible for waste in the healthcare system that may account for 35–50%9 of the nearly $3 trillion the U.S. spends annually on healthcare.7 Care path guides, with reduction of unnecessary variability as the primary goal, become tools for education, reporting, measurement and continuous improvement. Care paths are designed to standardize care to reduce variability and assure a consistent level of quality for patients across time, venue and provider, combining workflow-friendly, evidence-based practice principles.

Health Status Measures and Patient-Reported Outcome Measures

Health status measures (HSMs) in general and patient-reported outcome measures (PROMs) in particular (see Sidebar 1, page <?>) are becoming important standard components of patient care. These measures are validated tools that furnish insight into patient relevant issues, improve patient/clinician communication and guide individual management. They provide a method to objectify outcomes and quality in a manner that can be shared with patients. These measures require patient participation and have been shown to improve patient engagement in their own healthcare. The outcome measures are an important component of value-based care and are beginning to be important in health policy and reimbursement.

Sidebar 1
Patient Reported Outcome Measures (PROM) Tools


Comorbid depression can slow response to low back pain treatment. The following PROMs help clinicians evaluate general and behavioral health status that could affect outcomes and guide treatment:

Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10: A 10-question screening tool designed to assess physical, mental and social health, including pain, fatigue and quality of life.

Patient Health Questionnaire-2 (PHQ-2): A two-question depression screening tool that can provide information about the patient’s mental health status.10 The PHQ-2 consists of the first two questions from the PHQ-9. If the patient has a positive PHQ-2 score of 3 or higher, they could be further screened with the PHQ-9 screening tool.

PHQ-9: A nine-question screening tool to evaluate the severity of depression symptoms.11


Keele STarT Back Screening (SBT) Tool: A nine-question agree-disagree screening tool developed in the U.K. to identify biomedical, psychological and social risk factors for ongoing back pain disability.12,42 Through an overall score and a psychological distress score, the SBT can be used to stratify patients into low-, medium- and high-chronicity risk groups and guide referrals and/or therapy plans based on this risk stratification. Explore the Keele online SBT calculator, SBT printout or other SBT resources. Please note: STarT Back screening is not appropriate for patients presenting with acute low back pain in the ER setting but could be used by ER clinicians for patients presenting with a secondary diagnosis of subacute or chronic low back pain (existing for > 6–12 weeks).

Oswestry Disability Index (ODI): A 10-question screening tool for use in spine specialty and physical therapy settings, ODI is an extensively validated PROM that has been used in clinical practice and numerous research studies over the past 20 years13,14 to measure the effectiveness of low back pain treatment. The ODI score ranges from 0–100 with higher numbers indicating greater disability (81–100 is generally consistent with a patient being bed-bound). Changes of 10 points or greater are considered clinically significant.


About This Care Path Guide

This care path was developed by an interdisciplinary team within the Vanderbilt Health Affiliated Network to guide nursing, advanced practice providers, and rehabilitation, primary care and spine specialists in an evidence-based approach to diagnosis and treatment of acute, subacute and chronic low back pain. An evidence-based resource, the care path guide is based on national and international guidelines, as well as the expert opinions of members of our network.

The objective of care paths is to provide a workflow-friendly summary of evidence-based guidelines in an effort to reduce unnecessary variability in the overall management of disease conditions by standardizing assessment, treatment and referral behavior. In so doing, overall quality is maintained or improved and costs invariably decrease.

Low Back Pain Classification and Evaluation


Patients may present with one of three categories of low back pain, based largely on the origin of pain, and may experience more than one type concurrently. Types include:

  • Radicular—nerve-related pain felt most prominently in the legs15
  • Low back pain without radiation—muscle or bone pain with no identifiable cause felt in the low back16 (e.g., no red flags or radicular pain/paresthesias)
  • Other—pain caused by a disease or medical condition that is not radicular or musculoskeletal in nature, such as cancer, spinal infection or pain related to internal organs (abdominal aneurysm, nephrolithiasis, etc.)

Low back pain is recognized as acute, subacute or chronic, based on pain duration.

  • Acute—symptoms lasting four to six weeks. Most cases of acute low back pain will resolve without intervention.
  • Subacute—symptoms lasting six to 12 weeks
  • Chronic—symptoms present for more than 12 weeks17

Sidebar 2
Low Back Pain Causes


These spinal causes of low back pain may or may not require more aggressive evaluation, treatment or specialty referrals, depending on the presence of red flags or duration of symptoms:

  • Ankylosing spondylitis
  • Nerve compression or related disorders (radiculopathy)
  • Spinal stenosis, spondylosis, spondylolisthesis
  • Cancer
  • Infection
  • Fracture


It is important to keep internal organ and adjacent joints in mind as other causes of back pain during the patient history and physical examination because not all low back pain is of spinal origin. The following list of conditions may cause a patient to present with back pain. A thorough review of systems can help to screen for these non-spinal causes of back pain.

  • Abdominal aortic aneurysm (AAA)
  • Degenerative and inflammatory changes of adjacent musculoskeletal structures (e.g., hip joint pathology)
  • Nephrolithiasis
  • Peptic ulcer disease
  • Pyelonephritis




Red Flags

Red flags that may warrant departure from the care path guide and initiation of disease specific work-up and/or referral are typically identified from a patient medical history and physical exam (see Red Flags Algorithm, page<?>).

  • Patient History Red Flags
  • Bowel or bladder incontinence
  • Saddle anesthesia
  • History of cancer
  • Unexplained weight loss
  • Unexplained fever, chills, night sweats
  • Immunocompromised status
  • Intravenous (IV) drug use
  • Recent spinal procedure
  • Significant trauma
  • History of osteoporosis
  • Medications that can cause bone loss (glucocorticoids, phenytoin, phenobarbital)
  • Gait difficulties (drop foot, spastic gait)
  • Incoordination, loss of fine motor skills
  • Increasing weakness

Physical Exam Red Flags

  • Gait abnormality
  • Atrophy
  • Point tenderness over spinal column or step-off deformity
  • Weakness
  • Abnormal reflexes
  • Hyperreflexia, clonus, +Babinski—Upper motor neuron signs that can indicate a cord or brain lesion (myelopathy, tumor, demyelinating disease)
  • Hyporeflexia—A lower motor neuron sign that can indicate nerve root impingement, radiculopathy or peripheral neuropathy. This may improve with conservative care, but red flag signs of severe nerve dysfunction include weakness, gait abnormality and atrophy.

Patient History

For acute, subacute and chronic low back pain, obtain a clinical history and review of systems:

  • Obtain a patient history.
    • Onset – When did the pain start? Was there a precipitating event?
    • Location – Where is the pain located? Does the pain radiate?
    • Duration – How long has the patient had this pain? Does the patient have a history of pain like this that resolved previously?
    • Character – What is the quality of pain (dull ache, sharp, stabbing, throbbing, etc.)?
    • Aggravating factors – What makes the pain worse (prolonged standing or sitting, lifting, etc.)?
    • Relieving factors – What makes the pain better (position, medications, stretching, ice/heat, etc.)?
    • Timing – Is the pain constant or intermittent? What time of day is the pain noticeable?
    • Severity – Clinicians should assess pain intensity by asking their patients to rate their pain on the pain scale.
  • Review of systems should include abdominal pain, urinary symptoms or other symptoms found with internal organ causes of non-musculoskeletal back pain (AAA, pyelonephritis, nephrolithiasis, peptic ulcer disease, etc.) as this would require disease specific work-up.
  • Evaluate for red flags—signs of trauma, cancer, infection, cauda equina syndrome, etc., which may warrant urgent testing and/or spine specialty referral.
  • Establish baseline measures of pain, function and mental health. The pain scale and PROM tools may help gain insight into patient perceptions of pain (SBT) and function (ODI).4
  • Identify and address psychosocial issues related to low back pain, as doing so may remove barriers to treatment and prevent pain progression.18 Again, PROMs are useful tools for gathering this information. Inquire about psychosocial factors (using PROMIS-10, PHQ-2 (first two questions from PHQ-9) or PHQ-9, SBT—see Sidebar 1, page <?>) to identify patients who may need more aggressive treatment. Ask patients about effects on daily function (ODI), missed days of work due to pain, comorbid mental health issues, etc.

Patient Physical Exam

For acute, subacute and chronic low back pain, perform a physical exam, which at minimum should include:

  • Observation of the patient’s gait and of their seated and standing posture
  • Palpation of the lumbar spinous processes, sacroiliac joints and paraspinal muscles to assess for tenderness, step-off deformity or hypertonicity
  • Straight leg raise (SLR), which should reproduce radicular pain or paresthesias (not just back pain) between 30–70 degrees in order to be considered positive
  • Patellar and Achilles deep tendon reflexes with note of hyporeflexia—which could indicate peripheral pathology, such as nerve root impingement—or hyperreflexia— which could indicate central pathology, such as myelopathy.
  • Strength testing of knee extension (L4), ankle dorsiflexion (L4, L5), great toe extension (L5) and ankle plantar flexion (S1) with note of strength less than or equal to 4/5, asymmetric strength loss of at least one grade with contralateral comparison, or progressive strength loss
  • Additional physical examination testing, including dermatomal sensory testing, active range of motion of the lumbar spine and hips, dynamic balance testing and flexion, abduction and external rotation (FABER) testing, to be considered if clinical suspicion mandates


In the absence of red flags suggestive of serious underlying conditions, imaging does not have measurable value in the evaluation or conservative management of patients with low back pain (with or without radiation). Early imaging, especially in the acute phase of low back pain, does not improve findings or clinical outcomes compared with usual clinical care without imaging. Furthermore, there is significant potential for confounding information, unnecessary therapy and worry. If imaging is indicated in the presence of red flags or for procedural planning, MRI is the exam of choice. In cases of trauma or if a vertebral fracture is suspected, conventional radiographs or CT would be the most appropriate imaging choice.19-22

Whenever imaging is performed, it is important to remember the very high prevalence of morphologic abnormalities in the asymptomatic population when factoring the significance of findings. Research studies of patients who have never had back pain have shown that 25% of these individuals will have a herniated disk and over 50% have a disk bulge.23,24 MRIs are typically used to evaluate the need for surgical intervention or injections, which, in the absence of dysfunction, is typically deferred until response to conservative care is measured. Exam findings that may warrant imaging include:

  • Spinal deformities (significant scoliosis, kyphosis, etc.) may require a scoliosis survey radiograph to evaluate degree of curvature or, in the case of kyphosis, to rule out compression fracture18
  • Point tenderness of the spine in patients with known osteoporosis, higher risk of osteoporosis or recent trauma, which may warrant radiography to evaluate for fracture
  • Other concerning physical exam findings, such as hyperreflexia, weakness not secondary to pain and gait abnormality, as these findings may suggest a cord or brain lesion
  • Atrophy, weakness, gait abnormality (e.g., drop foot) or lower motor neuron signs in patients with radicular pain

Psychosocial Impediments to Care

Psychosocial factors (see Psychosocial Flags, Sidebar 3, below) can significantly affect a patient’s prognosis by adversely influencing care through catastrophizing, depression and fear avoidance.4,25,26 When psychosocial factors are present, patients benefit from further evaluation and treatment of these conditions. The PROMIS-10, PHQ-2 (first two questions from PHQ-9) and SBT PROMs (Sidebar 1, page <?>) are useful in identifying patients with psychosocial impediments to care for low back pain of any duration.

Psychosocial flags should be evaluated more aggressively in patients for whom clinical suspicion is high initially or for those who do not respond appropriately to conservative care. For instance, a clinician may decide to use the PHQ-9 over the PHQ-2 screening tool for patients with a history of mood disorder in order to ensure optimal treatment of comorbid psychiatric issues and determine the need for medication adjustments or referrals to psychiatry or psychology. Patients found to have psychosocial impediments to care may benefit from cognitive behavioral therapy and/or medications to treat an underlying mood disorder if having moderate to severe depression. SSRIs are first-line therapy for depression, but SNRIs (duloxetine, venlafaxine) can also help manage neuropathic pain symptoms.

Sidebar 3
Psychosocial Flags

  • Mental illness, including depression
  • Negativity, belief that pain will not improve
  • Restricted activity due to fear of pain or belief that activity and pain are harmful
  • History of work absenteeism due to back pain
  • Pain disproportionate to the diagnosis
  • Drug-seeking behavior (see Sidebar 5, page <?>)
  • Treatment noncompliance or prolonged bed rest
  • Stressful job
  • Social isolation
  • Marital issues
  • Financial concerns related to cost of care, workers’ compensation or lawsuits


Treatment Recommendations


    Recommendation 1: Because the majority of people with low back pain recover within four to six weeks no matter the treatment, the American College of Physicians strongly recommends choosing non-drug treatments for acute and subacute low back pain, including superficial heat, massage, acupuncture and spinal rehabilitation efforts.

    Formalized rehabilitation/PT should be instituted if the patient’s STarT Back Tool (SBT) assessment indicates a high risk of disability [a total score ≥ 4 and a distress subscale score (questions 5–9) ≥ 4] and should be considered if the SBT stratification indicates moderate risk [a total score ≥ 4 or more and a distress subscale score (questions 5–9) ≥ 3]. If patients and clinicians desire the use of medication for low back pain, choose a nonsteroidal anti-inflammatory medicine or muscle relaxers. Patients with low-risk SBT scores [a total score ≤ 3] usually recover within six weeks of low back pain onset without PT and should be encouraged to be active.

    Recommendation 2: The American College of Physicians strongly recommends clinicians and their chronic low back pain patients begin care for chronic low back pain with non-drug treatments, such as exercise, rehabilitation, spinal manipulation, acupuncture, stress reduction and relaxation techniques, motor control exercises, tai chi, yoga, and laser, cognitive behavioral and operant therapies.

    Recommendation 3: For chronic low back pain patients who do not respond satisfactorily to non-drug treatments, the American College of Physicians recommends (weak recommendation) considering pharmacologic treatment with NSAIDs as first-line therapy, or duloxetine or tramadol as second-line therapy. Only after more conservative treatments have not provided relief and when benefits outweigh risks should opioids be considered. When prescribing opioids, clinicians must talk with their patients about the risks and benefits.

    Follow-up and Return Precautions

    Patients should be instructed to schedule a follow-up appointment for new or worsening symptoms or for symptoms persisting for longer than four to six weeks. They should also be counseled on alarm signs (red flags) that would warrant emergent evaluation (e.g., bowel or bladder incontinence, saddle anesthesia, gait difficulties or significant weakness).

    Sidebar 4
    Physical Therapy

    Refer to a physical therapist who specializes in working with low back pain patients for spinal rehabilitation. Physical therapy may provide additional education about body mechanics and posture, as well as exercises (core strengthening, trunk coordination, endurance, centralization and directional preference exercises),4 assistive devices to correct gait abnormalities and manual therapy (manipulation and mobilization).4,25


    • Manual therapy—Passive or hand movement techniques used by physical therapists, osteopathic clinicians and chiropractors to improve range of motion and flexibility, reduce inflammation or swelling, decrease muscle spasms, and regulate pain.27 Examples of manual therapy techniques are manipulation/mobilization, lymphatic drainage, massage, traction and passive range of motion exercises.
    • Manipulation—Passive joint movements, typically high-velocity, low-amplitude,28 applied manually to improve joint mobility. Thrust joint manipulation, which sometimes produces an audible popping sound, is an example of joint manipulation. Some states do not allow physical therapists to perform manipulations. Please follow your state’s guidelines.
    • Mobilization—Passive joint or soft tissue movements, typically low-velocity, applied manually28 to improve joint mobility and reduce inflammation.
      • Myofascial release is an example of a soft tissue mobilization technique used to reduce muscle spasm associated with painful range of motion and improve flexibility and physical functional ability.
      • Passive range of motion and traction are examples of low-velocity joint mobilization techniques used to improve range of motion and physical functioning.











    BBW = Black Box Warning

    *All opioids have a BBW: addiction, abuse, misuse, respiratory depression, accidental overdose potential, neonatal withdrawal syndrome, concomitant use w/ benzodiazepines or other CNS depressants.

    Medications for pain (see table starting on page <?>) should be used to help facilitate less painful motion patterns. Medication use should be reassessed monthly.

    Additional medication information is listed below:

    • Non-steroidal anti-inflammatory drugs (NSAIDs) – After two to four weeks of taking NSAIDs, the patient should be evaluated to reassess the need for NSAID and, if still needed, switched to a more selective NSAID, such as celecoxib or meloxicam,40,41 which carry a lower risk of GI bleed. The PRECISION trial of 2016 shows a similar risk of CV events for both COX-2 selective and non-selective NSAIDs.
    • Acetaminophen (APAP) may provide short-term relief of symptoms, but its ability to aid recovery is unknown.25 Low-quality evidence has shown it may have little to no effect on pain relief, function or recovery within three weeks.29 Patients should be counseled to check all OTC medications for other APAP-containing products and limit their total daily intake of APAP to 4 grams/day (3 grams in the elderly).
    • Skeletal muscle relaxants (SMRs) may be an appropriate secondary option for certain patients, particularly those with associated muscle spasm, but should be used with caution and only for a short time.25 SMRs can be used in conjunction with NSAIDs or APAP. All SMRs have a potential for sedating side effects, but some tend to be more sedating than others. Choose SMRs in consultation with the patient and based on each drug’s risk of side effects.17 Advise patients to avoid performing tasks that could be dangerous if experiencing sedating effects, (e.g., driving or operating heavy machinery). Carisoprodol (Soma) is not recommended because of the potential for abuse and addiction and because it offers no significant benefit over other SMRs. Benzodiazepines are not recommended for low back pain.
    • Systemic corticosteroids are not recommended for acute low back pain, including radiculopathy.25
    • Opioids are not recommended for acute or subacute low back pain but, if selected, should be prescribed with caution and only in very short courses (two to three days).25 Tramadol can lower the seizure threshold and, therefore, should be avoided in patients with epilepsy. There is a risk of serotonin syndrome when tramadol is combined with SSRIs, SNRIs, trazodone or cyclobenzaprine. Patients should be counseled that opioids may mask their pain but provide no therapeutic effect to aid in recovery.

    Acute Low Back Pain Specifics

      (Duration: 4–6 weeks)

      Acute low back pain is very common and, in most cases, has a favorable natural history, resolving or significantly improving within four to six weeks.25,30,31 It is important to evaluate for serious causes of low back pain, as certain etiologies, although very uncommon, can be life-threatening or can result in impaired function and long-term disability. See Acute Low Back Pain Algorithm, page 27.

      Acute Evaluation

      • Obtain a history and review of systems; perform a physical exam. See Evaluating, page <?>.
      • Avoid diagnostic imaging in the absence of suspected serious pathology. See Imaging, page <?>.
      • Avoid electromyography and nerve conduction studies (EMG/NCV) for localized pain or for radicular pain or paresthesias that have been present for less than three weeks. These tools may be useful if the patient reports radicular pain and neurological involvement is suspected.10,32-34 However, EMG/NCV are helpful only if radicular symptoms have been present for more than three weeks and could result in a false negative test if performed prematurely. Additionally, radicular symptoms can often be secondary to peripheral nerve impingement due to muscle spasm and often respond well to conservative care. This is especially true for leg pain/paresthesia that stops above or at the knee (e.g., piriformis syndrome), intermittent radicular symptoms or in individuals with negative straight leg raise (SLR) testing.

      Acute-Specific Treatment

      See overall treatment recommendations for low back pain starting on page <?>. Most people experiencing acute low back pain (including radiculopathy) without red flags respond well to conservative measures. The following may help facilitate a quicker recovery.

      • Reassure the patient of the favorable outcome for most cases of acute low back pain.
      • Provide patient education and self-care information (see pages 32–34).
      • Explore standalone or multimodal non-drug therapies if self-care alone is ineffective or if screening tools show the patient may have moderate to high risk of chronic pain or disability. Referral for outpatient physical therapy is appropriate in high-risk patients.
      • Additional treatments for those with psychosocial impediments to care:
        • Refer to psychology or psychiatry or prescribe treatment (SNRI) if indicated on STarT Back (SBT) tool or PHQ PROM questionnaires  and psychosocial impediments to care.
      • Evaluate options for non-pharmacologic and pharmacologic therapy (NSAIDs, APAP, topical treatments). 

      Subacute Low Back Pain Specifics

        (Duration: 6–12 weeks)

        Patients with low back pain (with or without radiating pain) that persists longer than six weeks should undergo re-evaluation of their condition to reassess for red flags, psychosocial barriers, and new or worsening symptoms. Reasons for delayed recovery include previously unrecognized pathology, excessive passive behavior (e.g. prolonged bed rest), and most frequently, unrecognized or unaddressed psychosocial issues.

        Subacute Evaluation

        • Obtain a detailed history and review of systems; perform a physical exam.
        • Ask patients about pain level, radicular symptoms and response to treatment:
          • Are symptoms improving, worsening or staying the same?
          • If patient had radicular symptoms, are they improving (less frequent episodes of leg pain or paresthesias) or worsening?
          • Did they develop new symptoms?
          • What treatment and self-care protocols did the patient try, and what was the response?
          • Evaluate for red flags .
        • Evaluate and screen for any psychosocial barriers to treatment. When a patient has back pain that is worsening or not responding to conservative measures after six weeks, it is important to screen again for psychosocial issues (PROMIS-10, ) that could be contributing to a delayed response to care, as these are often missed on initial evaluation. Even if the screening was negative at the first visit, the patient situation may have changed, or his or her pain could be causing new depression, fear avoidance or catastrophic thoughts that the pain will never subside, which can impede recovery. , for a list of psychosocial flags. Identifying and addressing psychosocial issues may remove barriers to treatment and prevent pain progression.18
        • Evaluate measures of pain and function. The ODI or other functional tool may be administered to evaluate objective progress or decline in the patient’s functional ability. Patients at higher risk of chronic back pain or disability should be managed with more aggressive treatment and might benefit from cognitive/behavior therapy due to risk of mood disorder with chronic pain and functional impairment.
        • Perform a physical exam.
          • If red flags are present, pursue appropriate imaging and other testing for suspected condition. At this stage, hyporeflexia with radicular pain or paresthesias may warrant MRI of the lumbar spine

        Subacute-Specific Treatment

        Treatment recommendations specific to the subacute phase of low back pain include:

        • If red flags are found in history or during physical exam, obtain imaging and other testing as outlined in Red Flags Algorithm, for suspected condition.
        • For patients who are responding well to care and have no progression of symptoms, continue self-care and follow up as needed in four to six weeks.
        • Consider referral to a physical therapist who specializes in spine rehabilitation if symptoms are not significantly improved.
        • Consider acupuncture, therapeutic dry needling or massage if myofascial pain is not significantly improved.
        • For patients who are worsening, not improving or have developed new symptoms, consider obtaining imaging. Advanced neuroimaging such as MRI may be needed if red flags are present or radicular pain has been present more than four to six weeks.
        • Pharmacotherapy:
          • Consider switching to a selective NSAID if this medication has been beneficial to the patient during a previous episode of low back pain.
          • Consider SNRIs for those with psychosocial impediments to care and for neuropathic pain.

        For subacute low back pain without radiation or red flags:

        • Continue treatment and delay imaging. Without red flags, imaging is not necessary and may be harmful or lead to unnecessary procedures.

        For patients with severe or worsening pain without red flags:

        Consider imaging and non-surgical spine specialist (physical medicine and rehabilitation, pain management, or interventional radiology) referral for spinal injections or other non-surgical interventions.

        For stable subacute low back pain:

        • Consider AP and lateral lumbar spine radiographs to evaluate for ankylosing spondylitis, and refer to rheumatology if positive

        For subacute radiating pain that is improving with conservative care:

        • Recommend continuing conservative treatment and follow up in six weeks if pain persists or sooner if pain worsens. Use same treatments as subacute low back pain without radiation listed above, if necessary.

        For subacute radiating pain that is not improving with conservative care:

        • Obtain imaging at the appropriate level of the spine to match the history and physical exam findings, typically MRI of the lumbar spine without contrast, and refer to appropriate specialty if positive . Take the patient’s symptoms into consideration when reading MRI results to ensure they match with any positive findings.
        • EMG/NCV may be helpful in determining treatment if MRI is not diagnostic. If EMG/NCV show evidence of active axon loss, consultation with a spine surgeon is recommended. If EMG/NCV are negative, refer to a non-surgical spine specialist (physical medicine and rehabilitation, pain management, or interventional radiology) for spinal injections or other non-surgical interventions and continue conservative care plan.
        • Facet block can be used for pain related to degenerative changes.
        • Epidural can be used for radicular pain related to bulging or herniated disks.
        • Radiofrequency ablation/rhizotomy can be used for axial pain from spondylosis that has responded to diagnostic and subsequent confirmatory medical branch blockade.
        • Trigger point injection(s) with local anesthetic can be used for radiating symptoms related to myofascial spasm that are reliably reproducible with palpation.
        • Sacroiliac joint injection can be used for sacroiliitis and pain related to sacroiliac dysfunction.
        • Kyphoplasty can be used by appropriately trained spine specialists for treatment of compression fracture.

        Chronic Low Back Pain Specifics

          (Duration >12 weeks)

          Low back pain lasting longer than 12 weeks is a risk factor for long-term disability35 and functional impairment. Patients with low back pain lasting more than 12 weeks should be evaluated for previously unrecognized structural physiologic causes (see Chronic Low Back Pain Algorithm, page 29). Psychosocial issues (Sidebar 3, page <?>) should also be evaluated using PROMs (Sidebar 1, page <?>). Psychosocial flags are commonly seen in patients with chronic low back pain and can impede treatment. If psychosocial issues are identified, the patient may benefit from cognitive/behavioral health therapies.

          Chronic Evaluation

          • Obtain a detailed history and review of systems; perform a physical exam .
            • Evaluate pain character, location, severity and timing, and ask about the development of new symptoms.
            • Review other associated symptoms that could indicate a non-spinal cause of low back pain.
            • Ask about development of red flag symptoms.
            • Evaluate response to treatments
            • Screen for psychosocial barriers to care. (Recommended tools: PROMIS-10, PHQ-2, PHQ-9, SBT
            • Obtain measures of pain and function. (Recommended tools: SBT, ODI)
            • Evaluate for new objective findings or red flag examination findings. If red flags are present on the history and physical, refer to Red Flags Algorithm, page <?>, for the appropriate response based on clinical suspicion.
          • Evaluate with imaging or other diagnostics if needed.
            • If psychosocial issues are present with no red flags, it is reasonable to ensure these are adequately addressed and treated prior to obtaining imaging.
            • In the absence of red flags and psychosocial issues, imaging (MRI of the lumbar spine) may be warranted in patients with non-radiating low back pain that is worsening or does not respond appropriately to 12 weeks of conservative care treatments to assess for any issues that may benefit from non-surgical spine consult or to evaluate for otherwise asymptomatic spinal tumors.
            • Evaluate which imaging tests have been performed, if any. If MRI has already been performed and there are no new neurologic deficits, hold off on further imaging.
            • Low back pain with radicular symptoms should be evaluated with imaging and possibly nerve studies if not previously performed:
              • Obtain MRI of the lumbar spine to look for signs of nerve root impingement at the level of concern based on history (dermatomal distribution) and physical (reflexes, weakness, atrophy, sensory exam, etc.). Nerve root impingement can be associated with significant neuroforaminal stenosis, degenerative disk disease, bulging disk, herniated disk, osteophytes, spondylolisthesis, spinal tumor, etc.
                • If the MRI is positive, refer to a spine specialist.
                • If the MRI is negative (no abnormality identified) or inconclusive (e.g., only mild or moderate degree of foraminal stenosis), refer to neurology or physical medicine and rehabilitation (PM&R) for an EMG/NCV of the lower extremities to evaluate for radiculopathy or other peripheral neuropathies and assess the need for surgical referral.
                • If the NCV/EMG is positive, refer to a spine specialist.
                • If NCV/EMG is also negative, use conservative management:
                    • Physical therapy
                    • PM&R, pain management or interventional radiology consult to evaluate the need for possible spinal injections, radiofrequency ablation and other treatments

          NCV/EMG may identify other causes of leg pain, such as peripheral neuropathies not related to the spine, including peripheral polyneuropathy, lateral femoral cutaneous syndrome, sural mononeuropathy or other compressive neuropathies.

          Chronic-Specific Treatment

          See overall treatment recommendations for low back pain starting on page <?>. Treatment recommendations specific to the chronic phase of low back pain include:

          • Refer to appropriate specialty if imaging is positive. Non-surgical spine specialist referral, such as physical medicine and rehabilitation, pain management, or interventional radiology, may be beneficial for patients who have:
            • Radicular pain without progressive neurologic deficit
            • Bulging or herniated disk that is not causing significant spinal canal or neuroforaminal stenosis, or those with significant spinal or neuroforaminal stenosis with no red flags or progressive neurologic symptoms
            • Low-grade spondylolisthesis that is not causing nerve impingement, or those with no red flags or progressive neurologic symptoms
            • Persistent axial low back pain with negative or equivocal imaging, as this rarely does well with surgery
            • Painful or recalcitrant compression fracture, as interventional procedures such as kyphoplasty may prove beneficial
            • Positive EMG/NCV with equivocal or negative imaging but no progressive neurologic symptoms
          • Surgical consult may be warranted for:
            • Progressive weakness, cauda equina syndrome or other progressive neurologic deficits
            • Progressive radiculopathy with significant foraminal stenosis or other signs of nerve root impingement on MRI, or with inconclusive MRI but positive NCV/EMG and progressive neurologic deficits
            • Highly symptomatic lumbar stenosis that has not responded to conservative measures or interventional procedures
              • Major deformity, such as significant, symptomatic scoliosis or high-grade or unstable spondylolisthesis causing nerve compression, or for lower-grade spondylolisthesis that has not responded to conservative measures or interventional procedures or with red flags or progressive neurologic symptoms.
            • Refer for a formal psychosocial evaluation if imaging is negative. Unrecognized psychosocial issues are often a contributing factor in chronic pain without identifiable pathology. If no clear cause of pain is found on imaging, it may be helpful to obtain a formal psychosocial evaluation to assess for other issues that may be contributing to somatization and impeding care. Psychosocial factors should be addressed through behavioral health or pharmacologic therapies, or a combination of the two.
              • Behavioral health therapies may include mindfulness-based relaxation, cognitive behavioral therapy, progressive relaxation and biofeedback.25
              • Pharmacologic therapy for those with chronic pain and comorbid psychosocial factors include:
                • Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine or venlafaxine
          • Continue conservative treatments, including non-pharmacologic therapies, patient education and self-care  Physical therapy referral should be considered if not previously explored or if beneficial in the past. TENS unit may also provide temporary relief for chronic pain symptoms but does not aid in functionality.36,37
          • Prescribe pharmacologic therapies if pain does not improve with non-pharmacologic interventions,25 or use a combination of pharmacologic and non-pharmacologic treatments.25
            • NSAIDs are first-line options.25 Consider switching to a selective NSAID 
            • Second-line options include SNRIs (duloxetine) for neuropathic pain.25
            • For non-surgical radicular pain, gabapentin or pregabalin may provide relief for neuropathic pain. Both medications should be titrated up to improve tolerability of side effects, such as sedation and memory impairment, and should be used with caution in the elderly, who may be at higher risk of falling. SNRIs can also be helpful in reducing nerve pain.
            • Opioid treatment requires serious assessment of the potential risks and benefits and should be used as a last resort after other treatments have proved ineffective.17

          Opioid Avoidance and Precautions

          Opioid treatment requires serious assessment of the potential risks and benefits, and should be used as a last resort after other treatments have proved ineffective.17 Opioid overdose was recently declared an epidemic by the CDC, with a six-fold increase in opioid-related deaths in 2017 compared with 1999.38 In 2017, opioid overdose was responsible for an average of 130 deaths per day in the U.S.38

          • Before prescribing opioids, review psychological history for any type of substance abuse, assess Prescription Drug Monitoring Program and/or Controlled Substance Monitoring Database, and perform baseline urine drug screen.
          • Review patient responsibilities, risk of therapy, treatment goals, and shared decision making. Implement a pain contract when prescribing opioids long term.
          • Limit use to when function is compromised, quality of life is affected and after appropriate trials of previously suggested medications. Benefits should outweigh the risks of therapy.
          • Extended-release/long-acting formulations should not be used in opioid-naïve patients.
          • Common side effects include constipation (consider recommending use of a stool softener while taking opioids), nausea (patients should take with food), sedation and cognitive ability.
          • Use with caution in elderly patients and those with renal, hepatic or respiratory disease.
          • Tramadol may be helpful in patients with fibromyalgia but carries the same risks as other opioids.
          • Avoid prescribing opioids and benzodiazepines together. Coordinate care with other providers when necessary.
          • Assess chronic opioid use a minimum of every three months.
          • If tolerance develops, consider an opioid rotation instead of a higher dose.
          • Gradually taper opioids when possible.
          • Check the Prescription Drug Monitoring Program/Controlled Substance Monitoring Database at every visit and when writing an opioid prescription.
          • Prescribe naloxone for patients at high risk for respiratory depression and those on extended release/long-acting formulations.
          • The risk for overdose increases for patients on morphine equivalent doses (MED) > 40mg.
          • Random urine drug screening should be performed at least twice a year during chronic opioid use.
          • Consider referral to pain specialist when doses exceed MED doses > 40mg.
          • Buprenorphine, fentanyl and methadone should be reserved for prescribing by pain specialists.

          Sidebar 5
          Signs of Drug-Seeking Behavior

          • History of substance abuse
          • Prescription-monitoring database shows controlled substance prescriptions from multiple providers
          • Previous provider discharged the patient from the practice for breaking contract or for unclear reasons
          • Patient may request an opioid saying they are allergic to all conservative medications
          • Failed drug testing (other substances or negative)
          • Noncompliance with other aspects of care, such as completion of diagnostic studies or specialist referrals
          • Patient reporting lost or stolen opioid prescription without a viable police report to corroborate
          • Multiple pain-related visits to urgent care or emergency room






          Patient Education and Resources

            Educating patients about the typical course of low back pain and what they can do at home to reduce symptoms and maintain function is an essential element of treatment.25 Key components include sharing this information with the patient:

            • Low back pain is likely to improve in a few weeks. For most patients, the first four to six weeks bring major improvement. The cause of pain is often benign.25
            • Learning how to do things differently can help relieve pain and prevent future pain. The patient should be educated about proper body mechanics, posture, sleep position and protecting the spine during everyday activities (e.g., lifting) to avoid pain flare-ups.
            • Bed rest is not helpful. Bed rest does not improve low back pain or boost function.33 The patient should remain as active as possible to maintain function.17 Graduated activity as tolerated with the intent to keep the patient active is recommended.
            • Patient engagement in care is important. Patients and clinicians should work cooperatively to identify the treatment that best aligns with patient preferences while taking potential harms and costs into account.17
            • Psychosocial impediments to care (Sidebar 3, page <?>) should be addressed.4 Fear avoidance and catastrophizing can cause symptoms to linger.25 Educating patients about and addressing psychosocial issues therapeutically may improve outcomes.
            • Several non-pharmacologic forms of self-care (see Table 1, page 11) may yield improvement in pain and/or function. Advise the patient to remain active to help maintain function. Encourage cardiovascular exercise, stretches, yoga, tai chi and core-strengthening exercises (See resources below and to the right). Inform the patient about self-care options to relieve pain, such as the use of heat, ice packs or Epsom salt soaks.17,25 Massage may be beneficial for patients with associated muscle spasm.17 Acupuncture or therapeutic dry needling may also be beneficial for some patients with myofascial pain.

            Vanderbilt Health Affiliated network Patient Resources

            Click to link to digital sources:
            Exercises for a Healthy Back

            Self-Care for Low Back Pain [Article]

            Reduce Your Risk for Low Back Pain [Article]

            Low Back Strengthening Exercises [Instructional PDF]

            Low Back Flexibility Exercises [Instructional PDF]

            Other Online Resources

            National organizations, including The American College of Physicians and the National Institutes of Health, publish useful patient education materials. Among recommended resources are:

            Noninvasive Treatments for Acute, Subacute and Chronic Low Back Pain
            An informative article from the American College of Physicians, designed to help patients understand low back pain and to suggest options for self-care.

            Back Pain
            This National Institutes of Health micro-website is dedicated to providing back pain information to the public, covering topics ranging from who is at risk for back pain to non-pharmacologic and pharmacologic treatments, when to see a clinician, and how to prevent back pain. Available in online format and also as a downloadable, printable PDF or epub in multiple languages, including Spanish, Chinese, Korean and Vietnamese.

            Tobacco Cessation
            Reduced blood flow caused by smoking may contribute to spinal disk degeneration, a common source of back pain. Smoking, which slows the healing process, is also a risk factor for osteoporosis. Additionally, a smoker’s cough can irritate back pain.39 Advise patients who smoke to quit and provide support if needed. Nicotine replacement therapy and other smoking cessation aids may be beneficial, especially in conjunction with counseling. Patients can call the Tennessee Tobacco QuitLine at 1-800-784-8669 (1-800-QUIT-NOW) or find support at SmokeFree.gov.

            A health and fitness program for adults 65 and older, SilverSneakers may be covered by Medicare Advantage. The website allows people to check their eligibility, locate classes or participate in exercise sessions via online instruction; however, the online instruction is paywalled.

            Tennessee Disability Pathfinder
            A statewide database of social services, low-income medical clinics, recreational programs and other resources for disabled persons.

            This resource may be useful to patients with cost barriers to care:
            Applying for TennCare

            Any Department of Health and Human Services office in
            Tennessee can help people apply and pick a plan.


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