Lombalgie

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences. Ask how cultural, family, community, Indigenous or other healing practices should be included (Agence de la santé publique du Canada, 2018; Government of Canada 2023).
• Informations sur le patient et le contexte : age; sex and gender when clinically relevant; preferred language and communication needs; work or school; caregiving; and the activities, roles and cultural or community connections important to the patient.

Primary low back concern:

• Location, onset and possible mechanism; duration and course; first episode or recurrence; and whether symptoms are improving, stable, fluctuating or worsening.
• Back-dominant or leg-dominant symptoms; distribution of leg symptoms; and numbness, paresthesia, weakness, gait change or other neurologic symptoms.
• Aggravating and easing factors; pattern over the day and night; response to movement, positions and activity; and any directional preference.
• Effects on sleep, mobility, self-care, work or school, caregiving, recreation and other valued activities.
• Revue des systèmes corporels : constitutional/general, neurologic, cardiovascular and vascular, genitourinary, gastrointestinal, musculoskeletal and bone health, respiratory, skin, mental health and reproductive systems; pursue findings indicated by the presentation.
• Health and care history: relevant medical conditions; prior LBP episodes, injuries, surgery or hospitalization; pregnancy or postpartum status when relevant to examination, imaging or care decisions; medicines and supplements, including corticosteroids, anticoagulants and opioids; allergies; prior imaging or tests; and prior care, benefits and adverse effects.
• Lifestyle and recovery context: physical activity, sleep, nutrition, smoking, alcohol or substance use and other factors the patient identifies as relevant.
• Social and access context: consider relevant social and structural determinants of health, including work or school demands and supports, caregiving, finances or compensation, housing, transportation, safety at home or in relationships, discrimination, social support, access to care and culturally relevant or community supports. Ask only what is relevant and safe to discuss, and use the information to adapt care or connect the patient with support when possible (Public Health Agency of Canada 2026).
• Croyances, attentes et objectifs : the patient’s understanding and concerns, recovery expectations, confidence, previous experiences of care, preferences, cultural approaches, and what meaningful improvement would look like.
• Signaler un avis : check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess relevant features if the presentation changes.

Mesures des résultats

• Use measures that are meaningful to the patient and practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Fonctionnement propre au patient : Échelle fonctionnelle propre au patient (PSFS)
• Handicap et participation : Échelle d'évaluation du handicap de l'OMS 2.0 (WHODAS 2.0).
• Additional measures: pain impact or interference and intensity when useful; work, school, caregiving or other role participation; and sleep, mood or other concerns when relevant to care.
• Objectifs individuels : agree on patient-defined goals and how progress will be recognized. SMART wording may be used.

Les signaux d'alerte orange indiquent qu'un problème de santé mentale ou de toxicomanie peut nécessiter une évaluation d'urgence ou rapide, voire une prise en charge partagée, et peut influencer la prise en charge musculo-squelettique. Ce n'est pas un diagnostic. En cas d'inquiétude, posez des questions directes et respectueuses en tenant compte de la sécurité immédiate, de la gravité du problème, de tout changement par rapport au fonctionnement quotidien habituel et du contexte. Les facteurs psychosociaux susceptibles d’affecter le rétablissement, mais ne nécessitant pas d’évaluation médicale ou psychiatrique distincte, sont abordés sous la rubrique « Signaux d’alerte jaune ».

ACTION : Organisez immédiatement une évaluation d'urgence en cas de danger immédiat ou de besoin médical urgent :

• Suicide, automutilation ou violence envers autrui : intention ou plan actuel, tentative récente, incapacité à rester en sécurité ou comportement suggérant un risque immédiat de préjudice grave.
• Changement grave de l'état mental : agitation extrême, confusion, désorganisation, psychose ou manie possible avec altération du jugement ou comportement dangereux, ou incapacité à satisfaire les besoins fondamentaux lorsque cela crée un danger immédiat.
• Urgence médicale ou liée à la consommation de substances : Suspicion de surdosage, intoxication grave, sevrage dangereux, délire ou autre changement soudain nécessitant des soins médicaux urgents.

En cas de danger immédiat, ne laissez pas la personne seule pendant que les secours sont organisés. Suivez les procédures d'urgence locales et composez le 911 en cas de danger immédiat ou d'urgence médicale. Si la personne a des pensées suicidaires, téléphonez ou envoyez un SMS. 9-8-8 : Ligne d’assistance en cas de crise suicidaire avec eux ou les aider à le faire.

En cas de violence, d'abus ou d'exploitation avérés ou soupçonnés, assurez immédiatement la sécurité des personnes concernées et respectez les procédures de sécurité et de signalement applicables.

ACTION : Organisez rapidement une évaluation médicale ou psychiatrique si :

• Pensées suicidaires ou d'automutilation : Des pensées sans danger immédiat.
• Symptômes ou effets importants : symptômes graves, persistants ou s'aggravant de dépression, d'anxiété, de traumatisme, de psychose ou de manie possible, de troubles alimentaires ou de consommation de substances qui affectent considérablement la vie quotidienne, la prise de décision ou la participation en toute sécurité aux soins.
• Autres motifs d’évaluation : un changement marqué par rapport au comportement ou au fonctionnement habituel ; une inquiétude concernant les effets des médicaments ou des substances ; une présentation qui dépasse les compétences du clinicien ; ou une demande d'aide.

Informer le patient des personnes à contacter, du délai de contact et de la marche à suivre en cas d'aggravation de son état. S'assurer que le patient a bien pris contact avec le service lorsque cela est cliniquement nécessaire.

ACTION : Adapter et coordonner les soins musculosquelettiques :

• Soins en toute sécurité : Les soins peuvent se poursuivre lorsqu'ils sont sécuritaires et acceptables et ne retardent pas l'évaluation nécessaire. Adaptez la communication, l'examen et les soins ; obtenir un consentement continu ; et coordonnez-vous avec les autres professionnels de la santé avec la permission du patient.
• Poursuivre l'évaluation musculosquelettique : Ne présumez pas qu'un problème de santé mentale ou de toxicomanie explique les symptômes musculo-squelettiques. Continuez à considérer les causes physiques et à tenir compte du récit du patient.
• Questionnaires: Ils peuvent soutenir la discussion et le suivi, mais ne permettent pas d’établir un diagnostic et ne remplacent ni les questions directes, ni le jugement clinique, ni les mesures à prendre.
• Soutien acceptable : Demandez à la personne quel type d’aide lui convient et si le soutien linguistique, culturel, familial, communautaire ou autre est important pour elle.

ACTION : Documentation et suivi :

Consignez la préoccupation, les questions pertinentes et les réponses de la personne, la décision relative à la sécurité et les raisons qui la justifient, les mesures prises, les conseils donnés et les références effectuées, les communications et le consentement, le suivi prévu ainsi que toute préoccupation non résolue. Respectez les exigences applicables en matière de confidentialité, de sécurité et de signalement.

Pour obtenir des renseignements sur les services provinciaux, territoriaux et nationaux, consultez : Soutien en santé mentale : obtenir de l’aide (Agence de la santé publique du Canada, 2026).

Les signaux d’alerte psychosociaux (drapeaux jaunes) sont des facteurs personnels, sociaux, professionnels, scolaires, liés aux soins de santé, environnementaux ou structurels qui peuvent influencer les symptômes, le fonctionnement, la participation aux activités ou la réponse aux soins. Ils sont liés au contexte et ne constituent ni des diagnostics ni des prédictions certaines. Ils ne signifient pas que les symptômes sont d’origine psychologique. Ils permettent d’adapter la prise en charge et ne nécessitent pas, à eux seuls, une orientation urgente vers un autre professionnel de la santé. Explorez ces facteurs par la discussion et le suivi continu des résultats, en tenant compte des priorités, des forces et de la situation de la personne. Il n’est pas nécessaire d’utiliser un score distinct pour les signaux d’alerte psychosociaux (drapeaux jaunes). Les nouveaux signes ou l’aggravation de signes d’une maladie physique grave doivent être traités selon la procédure relative aux signes d’alerte (drapeaux rouges). Les préoccupations liées à la santé mentale ou à la consommation de substances qui nécessitent une évaluation distincte, ainsi que toute préoccupation immédiate concernant la sécurité, doivent être traitées selon la procédure relative aux signaux d’alerte psychosociaux urgents (drapeaux orange) et aux protocoles d’urgence ou de protection applicables.

Explorez les facteurs pertinents :

• Compréhension, attentes et expériences en matière de soins de santé : Préoccupations liées aux blessures ou aux dommages, incertitude, attentes quant au rétablissement, confiance en ses capacités, conseils contradictoires, expériences antérieures de banalisation des symptômes ou de préjudices subis, et confiance envers les soins reçus.
• Réactions aux symptômes et à l’activité : Inquiétude, peur, évitement, alternance entre périodes d’activité excessive et périodes de repos prolongées, difficulté à gérer le rythme des activités, stratégies d’adaptation, sommeil, confiance en sa capacité à gérer ses symptômes et reprise des activités significatives.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question and may change care. Prioritize safety, comfort, dignity and relevance to functioning; adapt the pace, positioning, draping and extent of examination to the presentation and the patient’s preferences.

• Ongoing consent: explain each step, ask permission before touch or exposure, offer choices and stop or modify the examination when requested.
• Observation et évaluation générale : gait, movement behaviour, guarding, antalgia, transfers, use of supports and general appearance; measure vital signs when systemic, vascular or other non-musculoskeletal concern makes them relevant.
• Movement and range of motion: active lumbar movement and repeated or sustained movements when useful, noting tolerance, quality, symptom reproduction, centralization or peripheralization and any directional response. Passive or resisted tests are added only when they may inform the differential or plan.
• Examen neurologique: when leg symptoms, weakness, sensory change, gait change or safety concerns are present, assess motor function by myotome, sensation by dermatome, reflexes and gait; compare sides and document deficits and change over time. Look beyond a single nerve root when findings suggest an upper motor neuron, peripheral nerve or systemic pattern.
• Nerve-root provocation: straight leg raise, crossed straight leg raise, femoral nerve stretch or slump testing may support a radicular profile when interpreted with symptoms and neurologic findings; no test is diagnostic by itself.
• Évaluation fonctionnelle : select tasks tied to patient goals, such as sit-to-stand, walking or standing tolerance, lifting, bending, stairs, work simulation or caregiving activities.
• Regional and differential examination: assess the hip, pelvis, sacroiliac region, peripheral nerves, abdomen, vascular system or other regions when the history indicates and within competence and scope.
• Palpation : may help identify focal tenderness, temperature change, swelling or symptom reproduction, but should not be presented as establishing a specific source of pain when the examination cannot do so.
• Imagerie : imaging is generally not needed as a routine part of the examination. Arrange referral when serious pathology is suspected or when the result is likely to change care. Explain the reasoning whether imaging is or is not pursued (Canadian Association of Radiologists 2026; NICE 2020; Oliveira et al. 2026a).
• Radicular pain or radiculopathy imaging: routine imaging is not needed when findings are stable and no Red Flag is present. Arrange referral for imaging when neurological deficits are progressive, another Red Flag is present, or persistent symptoms and findings make specialist, procedural or surgical planning likely and the result would change care (American College of Radiology 2021; NICE 2020).
• Reassessment: repeat the findings and functional tasks needed to track recovery, review the clinical impression, identify adverse effects or detect a change requiring referral.

Use these presentations as working clinical descriptions rather than definitive tissue diagnoses. They can overlap or change, and a non-specific label does not exclude a coexisting neurologic, inflammatory, visceral or other condition (Oliveira et al. 2026a; Oliveira et al. 2026b).

• Non-specific: back-dominant pain and limitation without evidence of a specific pathology requiring different management. Symptoms may be movement- or position-related. Descriptive terms such as myofascial, facet-related or sacroiliac-related may communicate findings, but should not imply a confirmed pain source when the examination cannot establish one.
• Referred leg pain: buttock or leg symptoms that do not follow a clear nerve-root distribution and occur without objective nerve-root deficit. Hip, deep gluteal and other regional sources may overlap.
• Radicular pain and radiculopathy: radicular pain is suspected to arise from a lumbar nerve root and may follow a dermatomal distribution; radiculopathy refers to objective motor, sensory or reflex impairment and may occur with or without prominent pain. Base the working clinical impression on the history, neurological examination and provocation tests together. Record symptom duration, irritability, functional effect and whether neurological findings are stable or progressive. Progressive motor loss changes the urgency of referral.
• Neurogenic claudication: leg-dominant pain, heaviness, numbness or weakness brought on by standing or walking and eased by sitting or spinal flexion, commonly associated with lumbar spinal stenosis. The differential includes vascular claudication and peripheral neuropathy.
• Persistent or recurrent LBP: not a separate pain source. Revisit the differential and review the interaction of symptoms, functioning, sleep, mood, beliefs, work and caregiving demands, social conditions, comorbidities, access to care and prior treatment response.
• Alternative or overlapping presentation: findings may point to hip or pelvic conditions, peripheral neuropathy, vascular disease, abdominal or kidney disease, inflammatory spondyloarthritis, multisite pain or another non-spinal source. Refer or co-manage when assessment or care is needed beyond the clinician’s role.

Base care on the presentation, safety, symptom duration, irritability, neurological status, goals, context and response. Use adaptable options rather than a ranked sequence, and repeat meaningful outcomes to guide change.

Éducation, autogestion et participation aux activités

• Education and communication: validate the person’s experience; explain the working clinical presentation, neurological findings when present, uncertainty and prognosis in plain language; address misinformation without blame; and build confidence in movement and recovery without promising a particular outcome (Oliveira et al. 2026a; WHO 2023; Apeldoorn et al. 2024; NICE 2020).
• Autogestion et participation aux activités : options reflect what the patient can realistically use between visits and may include pacing, task modification, accommodations and strategies for continuing work, school, caregiving, recreation and community roles (Oliveira et al. 2026a; WHO 2023; Apeldoorn et al. 2024).

Activité physique et exercices

• Activity modification and graded loading: temporary changes in task, position, volume or load are options for maintaining activity during symptom flares. Progression toward meaningful activity reflects tolerance, symptom response and neurological status when relevant (Oliveira et al. 2026a; WHO 2023; Apeldoorn et al. 2024; NICE 2020).
• Non-specific or primary LBP: exercise options include aerobic, strengthening, mobility, motor-control, mindful-movement, aquatic, walking or other forms. Type, amount and progression reflect the goals, preferences, capacity, access and response (Oliveira et al. 2026a; WHO 2023; George et al. 2021).
• Referred leg pain: select activity and exercise according to the working source and symptom response. Reassess hip, peripheral nerve or other regional sources when findings do not behave as expected.
• Radicular pain or radiculopathy: options include individualized trunk strengthening and endurance, movement-control or specific trunk-activation exercise, and gradual return to activity. Type and progression reflect symptom irritability and neurological response (Apeldoorn et al. 2024; George et al. 2021; Stochkendahl et al. 2018).
• Neurogenic claudication: follow the CCG Lumbar Spinal Stenosis Care Pathway for presentation-specific treatment and monitoring.

Thérapies manuelles et interventions visant à soulager les symptômes

• Non-specific or primary LBP and referred leg pain without radiculopathy: options include spinal manipulation, mobilization, massage or related soft-tissue techniques as adjuncts to active care and self-management (Bussières et al. 2018; Oliveira et al. 2026a).
• Radicular pain or radiculopathy: selected spinal manipulation, mobilization or soft-tissue techniques can form part of multimodal care when neurological findings are stable. Integrate them with active care and monitor symptom and neurological response (Apeldoorn et al. 2024; Bussières et al. 2018; NICE 2020; Stochkendahl et al. 2018).
• Culturally grounded and community-based care: traditional or Indigenous healing approaches, spiritual practices and community supports identified by the patient can form part of care when compatible with safety, scope and other care. The choice reflects goals, culture, access and observed response.

Soutien psychologique, social et interdisciplinaire

• Prise en charge tenant compte des facteurs psychologiques : for chronic primary low back pain, supportive communication and behavioural strategies can form part of care when fear, distress, mood, trauma or coping affects recovery. Care beyond the clinician’s competence is coordinated with an appropriate mental health professional (WHO 2023).
• Interdisciplinary and social support: for chronic primary low back pain, coordinated physical, psychological, occupational, medical or social care can help when complex comorbidity, substantial participation restrictions or access barriers cannot be addressed by one clinician (WHO 2023).

Médicament

• Medication decisions: review current use, intended benefit, contraindications, interactions and adverse effects. Medication initiation, change or review is coordinated with an authorized prescriber or pharmacist using current guidance (NICE 2020; Oliveira et al. 2026a; WHO 2023).

Suivi et réévaluation

• Convenez d’un moment pour la réévaluation en fonction du tableau clinique, de la sécurité, des objectifs, des interventions mises à l’essai, des besoins de la personne et de l’accès aux soins, plutôt que de suivre un calendrier de visites prédéterminé.
• Review the baseline outcome set, symptoms, functioning, participation, benefits, harms and goals. Continue, adapt or stop care according to response. Revisit the clinical presentation and referral needs when progress differs from expectations.
• Surveillance neurologique : repeat motor, sensory, reflex and gait findings when radiculopathy is present or radicular symptoms change. Progressive weakness, worsening sensory loss, functional decline, new bilateral findings or cauda equina features follow the Red Flags and referral actions.

• Évolution attendue : prognosis is individual. In non-specific LBP, improvement often occurs most during the first six weeks, while persistent symptoms usually change more slowly and vary widely. Research on groups cannot predict a particular person’s course, and recurrence or residual symptoms are common (Wallwork et al. 2024).
• Facteurs associés à une évolution moins favorable : in non-specific LBP, higher pain and disability at baseline, emotional distress, negative recovery expectations, high physical demands at work and pain catastrophizing may be linked to a less favourable course. Other health, social and occupational factors may matter for an individual (Otero-Ketterer et al. 2022).
• Radicular pain or radiculopathy: prognosis depends on the cause, symptom severity and neurological course. For disc-herniation-related radicular pain managed conservatively, severe baseline symptoms may be associated with a less favourable outcome, but prognostic evidence is limited (De Bruyn et al. 2025).
• Facteurs pouvant favoriser le rétablissement : positive but realistic expectations, self-efficacy, active coping, supportive relationships and workplaces, feasible accommodations, access to care and progress toward meaningful activity may support recovery. These are modifiable care considerations, not guarantees or reasons to blame the patient.
• Discussion du pronostic : describe uncertainty, ask what the patient wants to know, and use repeated outcomes that matter to the patient and the course over time to adjust the plan rather than treating a prognostic factor or screening score as a fixed prediction.