Low Back Pain

• 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 rather than assume how cultural, family, community, Indigenous or other healing practices should be included (Public Health Agency of Canada 2018; Government of Canada 2023).
  
• Patient and contextual information: 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.
    
• Relevant systems review: 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).
  
• Beliefs, expectations, and goals: the patient’s understanding and concerns, recovery expectations, confidence, previous experiences of care, preferences, cultural approaches, and what meaningful improvement would look like.
  
• Flag considerations: obtain the history needed to identify the Red, Orange and Yellow Flag features described in their dedicated sections. Reassess relevant features if the presentation changes.

​​Baseline outcomes:

Choose a small set that reflects the patient’s goals and is likely to inform care; repeat the same measures at agreed reassessment points. Examples include:

• pain impact or interference, with intensity recorded when useful;
• patient-specific function, using the Patient-Specific Functional Scale or another measure suited to the patient’s goals;
• broader functioning and participation, using WHODAS 2.0 when it is useful;
• quality of life, using the patient’s own rating or a relevant measure such as WHOQOL-BREF;
• work, school, caregiving or other role participation, along with the patient’s own assessment of change or recovery;
• sleep, mood or other concerns when they are relevant to care; and
• goals that are meaningful to the patient, specific enough to follow, realistic in the patient’s circumstances and revised when needs or priorities change.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• 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 and general assessment: 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.
  
• Neurological examination: 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.
  
• Functional assessment: 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 only 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.
  
• Imaging: imaging is generally not needed as a routine part of the examination. Consider 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 (Choosing Wisely Canada 2026; NICE 2020; Oliveira et al. 2026a).
  
• 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 or primary LBP: 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 or radiculopathy: radicular pain follows a nerve-root distribution; radiculopathy refers to objective motor, sensory or reflex impairment and may occur with or without prominent pain. The clinical profile is based on the history, neurologic examination and provocation tests together. 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. Consider vascular claudication and peripheral neuropathy in the differential.
  
• Persistent or recurrent LBP: not a separate pain source. Revisit the differential and consider 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.

Evidence, clinical findings, patient goals and preferences should inform a shared plan that can be adjusted over time. Consider the clinical presentation, symptom course, other health conditions, risks, culture, access and response to previous care. Agree on what will be monitored and when the plan will be reviewed (Oliveira et al. 2026a; WHO 2023).

Care and rehabilitation plan

• Education and communication: validate the person’s experience; explain findings, uncertainty and prognosis in plain language that does not create unnecessary fear; correct misinformation without blame; and support confidence in movement and recovery without promising a particular outcome.

• Self-management: agree on strategies the patient can realistically use between visits, including ways to respond to symptom changes and continue progress toward meaningful activities.
  
• Physical activity and exercise: support continued or gradually resumed movement and valued activities as tolerated. Exercise may include aerobic, strengthening, mobility, motor control, mindful movement, aquatic, walking or other forms according to goals, preferences, ability, access and response. Use pacing or gradual progression when helpful and adjust the type, amount and challenge collaboratively.
  
• Participation and roles: support work, school, caregiving, recreation and community participation, including temporary pacing, task modification or accommodations when useful.
  
• Broader health context: address sleep, stress, nutrition, smoking or substance use only when relevant to the patient’s priorities and care; avoid blame or implying that one factor fully explains the pain.

Other care options

• Manual therapy and soft tissue care: spinal manipulation, mobilization, massage or related techniques may be included when acceptable, clinically appropriate and within scope. Obtain informed consent, identify the intended purpose, evaluate the response and use these options as part of the overall plan when appropriate (Bussières et al. 2018; Bronfort et al. 2026).
  
• Other care and cultural practices: heat, acupuncture, relaxation or breathing practices, supports, ergonomic changes, traditional or Indigenous healing approaches, spiritual practices and community supports may be considered according to the patient’s preferences. Discuss benefits, harms and uncertainty; consider interactions, cost and access; coordinate with the patient’s chosen practitioners when appropriate; and monitor outcomes that matter to the patient.
  
• Psychologically informed care: when fear, distress, mood, trauma or coping is affecting recovery, use supportive communication and behavioural strategies within competence and with the patient’s agreement, or coordinate with an appropriate mental health professional.
  
• Interdisciplinary care: consider coordinated physical, psychological, occupational, medical or social support for persistent disabling LBP, complex comorbidity, substantial participation restrictions or barriers that one clinician cannot address (WHO 2023).
  
• Medication decisions: review current use, intended benefit, contraindications, interactions and adverse effects. When medication is being considered or reviewed, coordinate with an authorized prescriber or pharmacist and use current guidance (NICE 2020; Oliveira et al. 2026a; WHO 2023).

Monitoring and reassessment

• Agree on a reassessment point based on symptom course, risk, goals, the option being tried and access to care rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, functioning, participation, adverse effects, treatment burden, confidence and progress toward goals.
• Continue what is useful and acceptable; adapt or stop what is not; and reconsider the clinical impression, barriers, referral or co-management when progress differs from what was anticipated. Arrange further assessment for new or worsening red flags.

• Expected course: prognosis is individual. Many people with recent LBP improve most during the first six weeks, while persistent LBP often changes more slowly and varies widely. Research on groups cannot predict a particular person’s course, and recurrence or residual symptoms are common (Wallwork et al. 2024).
  
• Factors associated with a less favourable course: 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).
  
• Potential supports for recovery: 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.
  
• Discussing prognosis: 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.