About Low Back Pain (LBP)

LBP is a common condition that can be acute or persistent, presenting as a dull ache, sharp pain, or radiating discomfort, especially to the legs. Most cases respond well to conservative care, though some may result from serious underlying pathologies that require medical attention.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Low Back Pain Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent

Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
Key Aspects:
- Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
- Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time.
- Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
- Patient understanding and agreement:
  - Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
  - Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
  - Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
- Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.

3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic information: Age, gender, sex, race/ethnicity.
Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
Body systems review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, and history: Past medical conditions, medications (including opioids, oral contraception, etc.), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.
Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
Flag considerations: Identify red, orange, and yellow flags for potential referrals.

Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

Pain: Use pain scales (e.g., NRS) and diagrams.
Function and participation: Evaluate impact on daily activities (PSFS, WHODAS, ODI, RMDQ)
Recovery: Use self-rated recovery scales.
Quality of life: Assess using tools such as SF-12.
Work/school status: Monitor return to activities.
Sleep quality: Assess using tools such as PSQI.
Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
Patient feedback: Gather and integrate patient experience and satisfaction.

4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

Cauda equina syndrome: Severe back pain, saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs, progressive lower limb weakness, decreased perineal sensation, reduced anal sphincter tone.
Spinal infection: Severe, localized LBP with systemic symptoms (e.g., fever, chills), possible swelling/redness/tenderness, recent infection/surgery, TB history, immunosuppression, IV drug use, poor living conditions, potential neurological deficits.
Traumatic spinal fracture: Sudden onset of severe, localized pain and tenderness following trauma.

ACTION: Refer to appropriate medical provider:

Non-traumatic spinal fracture: Sudden, localized pain/tenderness following minor trauma or spontaneous in individuals with osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture/cancer.
Spinal malignancy: Severe, progressive localized back pain radiating to chest/abdomen; worse at night, not relieved by rest; history of cancer; constitutional symptoms (e.g., fatigue, weight loss), localized tenderness, potential neurological deficits.
Inflammatory arthritides (e.g., ankylosing spondylitis): LBP potentially radiating to buttocks/thighs, improves with activity, worse at night, morning stiffness > 1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), reduced spinal mobility, positive Schober’s test, joint tenderness, inflammatory signs (e.g., uveitis, psoriasis).
Referred pain from abdominal/pelvic visceral conditions (e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis): Abdominal pain, GI or urinary symptoms, systemic signs (e.g., fever, weight loss), abdominal/pelvic tenderness, palpable mass, specific findings (e.g., Murphy’s sign for kidney stones, Cullen’s sign for pancreatitis).
Non-musculoskeletalperipheral neuropathy (e.g., diabetic neuropathy, Guillain-Barré syndrome): Typically, does not present with LBP but can be a key differential for radicular pain/radiculopathy. Symptoms include burning, tingling, or numbness in a bilateral stocking-like distribution in the lower extremities, with sensory loss, reduced reflexes, muscle weakness, balance difficulties.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.
Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

Triage: Ensure primary management by medical/psychiatric providers.
Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
Social: Lack of family/social support, limited connections.
Socioeconomic: Employment status, financial stress, litigation/compensation.
Environmental/cultural: Social inequality, unsafe/unsupportive environments.
Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers:

Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).
Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

7. Physical Examination

Observation: Evaluate abnormalities, asymmetries, posture, balance, gait, movements, facial expressions.
Range of motion (ROM): Assess active, passive, and resisted lumbar spine ROM in flexion, extension, lateral flexion, and rotation. Note regional or segmental hypo-/hypermobility and aberrant movements.
Palpation: Examine for tenderness, swelling, tightness, or temperature changes in bones, joints, and soft tissues of the lumbar region.
Neurological examination:
- Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
  - L2: Hip flexors (hip flexion)
  - L3: Quadriceps (knee extension)
  - L4: Tibialis anterior (foot dorsiflexion)
  - L5: Extensor hallucis longus (big toe extension)
  - S1: Gastrocnemius (plantar flexion)
  - S2: Hamstrings (knee flexion)
- Sensory testing: Assess for sensory deficits in dermatomal distributions:
  - L3: Medial thigh at the knee
  - L4: Medial calf
  - L5: Top of foot and toes
  - S1: Lateral foot and little toe
- Reflex testing: Assess for asymmetry, diminished/absent reflexes:
  - L4: Patellar reflex
  - L5: Medial hamstring reflex
  - S1: Achilles reflex
- Upper motor neuron signs: Asses for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate central nervous system disorders (e.g., myelopathy, multiple sclerosis, stroke).
- Lower motor neuron signs: Assess muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate systemic neurological conditions (e.g., radiculopathy, peripheral neuropathy, ALS).
Special/Orthopedic Tests: Perform as clinically indicated.
Advanced Diagnostics: Radiography is generally not recommended without red flags or specific individual factors (e.g., contraindications to treatment).

8. Clinical Presentations for LBP

Common LBP Disorders (including non-specific LBP, mechanical LBP, lumbar or lumbo-sacral strain/sprain, sacroiliac joint dysfunction, myofascial pain syndrome, facet joint irritation, osteoarthritis)

Accounts for 90% of LBP cases.
Pain dominant between the costal margin and inferior gluteal folds, with or without leg pain.
Pain can be sharp, dull, shooting, or aching, often worsened by specific movements and associated with muscle stiffness or spasms.
Pain is reproducible with testing; typically, no neurological deficits.

LBP with Radicular Pain/Radiculopathy (from disc protrusion/herniation)

Common, especially in younger adults.
LBP radiating down the leg in a dermatomal pattern, with symptoms like sharp, shooting, or burning pain, numbness, tingling, and weakness.
Positive straight leg raise test, sensory deficits, muscle weakness, altered reflexes.

Deep Gluteal Syndrome (e.g., piriformis syndrome)

Tenderness in the gluteal region with sciatic nerve irritation signs, without a nerve root pattern; typically no neurological deficits unless severe compression occurs.
Less common than lumbar radiculopathy; often affects individuals with prolonged sitting or repetitive hip movements.
Buttock and posterior leg pain, potentially radiating to the foot; worsens with sitting, stair climbing, or squatting.

9. Treatment Considerations for LBP

Applicable to common LBP disorders, LBP with radicular pain/radiculopathy from disc pathology, deep gluteal pain.

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. Management plans should be tailored to the individual’s needs, goals, and preferences, taking into account clinical presentation, response to care, and contextual factors.

Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most relevant components based on the clinical context.

This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.

While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.

Education and Self-Management (NICE, 2016; Qaseem et al., 2017; WHO, 2023; Zaina et al., 2023)
- Education & reassurance: Emphasize LBP’s often self-limiting nature. Use tailored, evidence-based information in various formats (written, digital, visual) to empower individuals. Limited evidence suggests no single superior type of education for improving patient outcomes, but consistent reinforcement improves understanding and engagement.
- Self-care: Encourage regular exercise, nutrition, sleep hygiene, stress management, weight maintenance, and avoidance of smoking/substance abuse. Employ SMART goals and Brief Action Planning for sustained engagement.
- Daily activities: Promote continued movement and discourage prolonged bed rest to enhance recovery and prevent functional decline.
- Social & work engagement: Encourage participation using pacing strategies and workplace accommodations to support social functioning and productivity.
- Mobility devices: Recommend assistive devices (e.g., walkers, canes) to enhance safety and independence as needed.
Exercise Therapy (Bussières et al., 2018; NICE, 2016; Wong et al., 2017; WHO, 2023; Zaina et al., 2023)
- Develop individualized programs focused on improving strength, mobility, and aerobic fitness, tailored to patient needs and preferences. Exercise has demonstrated benefits in reducing pain, improving functional capacity, and enhancing quality of life. No single exercise type is shown to be superior, so programs should align with patient capabilities and goals. Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.
Manual Therapy (Bussières et al., 2018; NICE, 2016; Wong et al., 2017; WHO, 2023; Zaina et al., 2023)
- As part of the management plan, consider incorporating spinal manipulation, mobilization, or soft tissue techniques to reduce pain and improve function.
Psychosocial and Psychological Support (Côté et al., 2015; Qaseem et al., 2017; WHO, 2023)
- Address barriers: Screen for psychosocial barriers (e.g., fear of movement, low recovery expectations, anxiety) using tools (e.g., FABQ, PHQ-9, GAD-7, ORT, PCS). Addressing psychosocial factors improves overall treatment outcomes and engagement. Provide education and strategies within the scope of care to support recovery (e.g., stress management, self-efficacy building, social/occupational engagement) [see Sections 5 and 6].
- Resources & instruction: Offer resources (e.g., online tools, written materials, mindfulness programs). Refer to mind-body practitioners (e.g., yoga, meditation, tai chi) for further support when conservative care is insufficient.
- Medical/mental health referral: Refer people with severe, persistent, or impairing symptoms to qualified medical/mental health providers or community support services to address psychological and social barriers to recovery [see Sections 5 and 6].
Medication (Qaseem et al., 2017; WHO, 2023)
- Short-term relief: Consult a medical provider. Options may include short-term use of analgesics, NSAIDs, or muscle relaxants. Long-term opioid use is discouraged due to dependency risk.
Multimodal Biopsychosocial Care (Côté et al., 2015; WHO, 2023; Zaina et al., 2023)
- Integrate physical, psychological, and social interventions tailored to individual needs, particularly for persistent LBP, to support function, work, and community engagement through predominantly non-pharmacologic care.

10. Risk and Prognostic Factors for LBP

Common Risk Factors:(Hincapié et al., 2024; Parreira et al., 2018)
- Individual (e.g., older age, male, previous LBP), poor general health (e.g., smoking, chronic illness, sleep problems, other pain, frequently tired), physical stress on spine (e.g., vibration, prolonged standing/walking, frequent bending forward/backward, prolonged driving, flexed posture), psychological stress (e.g., depression, stress).
- Lumbar disc herniation with radiculopathy: Middle-age (30–50 years), smoking, higher BMI, presence of cardiovascular risk factors (in women), greater cumulative occupational lumbar load by forward bending postures and manual materials handling.
Prognosis: (Dunn et al., 2011; Nieminen et al., 2021; Otero-Ketterer, et al. 2022; Stevans et al., 2021; Wallwork et al., 2024)
- Most individuals with LBP recover, though recurrences are common.
- Common negative prognostic indicators include: High initial pain intensity, severe disability, psychological factors (e.g., fear-avoidance behaviors, anxiety, depression, high pain catastrophizing), poor coping strategies, negative recovery expectations, poor self-rated health, work-related factors (e.g., high physical demands, difficult positions, physical work, job dissatisfaction, unemployment), low social support, smoking, obesity, and previous LBP episodes.

11. Ongoing Follow-up

Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.

12. Criteria for Discharge

Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

Exercise Videos

The low back pain videos are based on the recommendations from the Clinical Practice Guideline for the Treatment of Low Back Pain Pain.

Low back mobility exercises (level 1)

Patient form for low back mobility exercises: level 1 (pdf)Download

Child’s pose / Prayer stretch

Cat stretch

Spinal rotation

Pelvic tilts

Low back strengthening & motor control exercises (level 2a)

Patient form for low back strengthening & motor control exercises: level 2a (pdf)Download

Multifidi activation

Transverse abdominis activation

Bird-dog

Supine bridge

Low back stretching exercises (level 2b)

Patient form for low back strengthening exercises: level 2b (pdf)Download

Quadriceps stretch

CFigure 4 stretching

Hip flexor stretching

Hamstring stretch

Low back strengthening exercises (level 3)

Patient form for low back strengthening exercises: level 3 (pdf)Download

Side plank

Modified curl up

Yoga exercises for low back pain

This series of yoga videos for low back pain, created by the Canadian Chiropractic Guideline Initiative (CCGI) in 2017, is based on recent clinical practice guidelines for the management of low back pain. The videos are presented by Dr. David Whitty DC, a trained yoga instructor, filmed and edited by Mountain Man Media and directed by: Monica Slanik.

Low Back Pain