| PMC full text: | Published online 2010 Jul 3. doi: 10.1007/s00586-010-1502-y
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Table 1
Clinical guidelines recommendations regarding diagnosis of low back pain
| Country | Patient population | Diagnostic classification | Physical examination | Imaging | Psychosocial factors |
|---|---|---|---|---|---|
| Australia (2003) | Acute (<3 months) | Non-specific low back pain (divided into acute, subacute and chronic) Specific low back pain | Conduct physical examination to assess for the presence of serious conditions Neurological examination in case it is suspected. (Physical examination such as inspection, range of motion and posture may have low reliability and validity and should be used with caution) | Not recommended unless alerting features of serious conditions are present | Yellow flags associated with the progression from acute to chronic should be assessed early to facilitate intervention |
| Austria (2007) | Acute (0–6 week), subacute (6–12 week) chronic (>12 week), and recurrent | Non-specific LBP Specific LBP (based on list of red flags) Including high-grade spondylolisthesis, facet arthrosis, severe degenerative disc disease | Inspection, palpation, range of motion testing of lumbar spine, neurological screening (strength, reflexes, sensibility, SLR) | Not useful in the first 4 weeks of an episode After 4–6 weeks may be indicated in search for a specific cause | Evaluate psychosocial factors in patients who do not show improvement over time (with recommended treatment) and in patients with recurrent LBP |
| Canada (2007) | Acute, subacute and persistent | Simple back pain Back pain with neurological involvement Back Pain with suspected serious pathologies All divided into acute, subacute and persistent | Physical examination in patients with back pain and neurological involvement includes SLR, motor, sensitivity, reflex signs | Not recommended for simple low back pain but recommended for pain with neurological involvement and suspected serious pathology. MRI and CT scans recommended if surgery is in question | Assess patients’ perceived disability and probability to return to usual activity after 4 weeks of disability or at first consultation if patient has a history of long-lasting back-related disability (Symptom Check List Back Pain Prediction Model) |
| Europe (2006) | Acute (<6 weeks) and subacute (6–12 weeks) LBP | Serious spinal pathology Nerve root pain/radicular pain Non-specific low back pain | Physical assessment including neurological screening when appropriate | Diagnostic imaging tests (including X-rays, CT and MRI) are not routinely indicated for non-specific low back pain | Assess for psychosocial factors and review them in detail if there is no improvement |
| Europe (2006) | Chronic LBP (>12 weeks) | Specific spinal pathology Nerve root pain/radicular pain Non-specific low back pain | Diagnostic triage, neuro-screening ‘We cannot recommend spinal palpatory and range of motion tests in the diagnosis of chronic low back pain’ | No radiographic imaging MRI in case of red flags X-ray in case of suspected structural deformities | ‘We recommend the assessment of prognostic factors (yellow flags) in patients with chronic low back pain’ |
| Finland (2008) | Acute, subacute and chronic LBP | Non-specific LBP Nerve root dysfunction (sciatic syndrome, intermittent claudication) Possible serious or specific disease | Inspection, palpation, spinal mobility (flexion), SLR-test, strength, reflexes | No imaging in first 6 weeks Plain lumbar X-ray is basic investigation before other imaging studies MRI is first-line imaging investigation if special examinations are needed | A list of psychosocial factors (yellow flags) is included in the guideline Assess illness behaviour, depression in subacute LBP |
| France (2000) | Acute low back pain <3 months Chronic “uncomplicated” low back pain >3 months | Acute & Chronic: Non-specific low back pain So-called symptomatic acute low back pain with or without sciatica (fracture, neoplasm, infection, inflammatory disease) Diagnostic and therapeutic emergencies (hyperalgesic sciatica, paralysing sciatica, cauda equina syndrome) | Acute: To rule out “so-called symptomatic acute low back pain” or emergencies Rating of muscle strength Chronic: Musculoskeletal and neurological examination to identify specific cause Assessment of function, anxiety and/or depression using validated measure | Acute: Not to be ordered in the first 7 weeks except when the treatment selected (manipulation, infiltration) requires formal elimination of specific form of low back pain Chronic: X-rays not repeated. CT/MRI only in exceptional circumstances | Acute and Chronic: Recommended to assess psychosocial factors |
| Germany (2007) | Acute, subacute, chronic/recurrent LBP | Non-specific LBP Radicular pain Specific LBP (based on red flags) Patients at risk for chronicity (based on yellow flags) | Inspection, palpation, neurological screening; reflexes, SLR/Lasegue, sensibility, strength Further investigation (e.g. lab testing) is based on red flags | X-ray not useful in acute non-specific LBP CT, MRI only in cases with suspected radicular pain, or stenosis, or specific pathology such as tumours After 6 weeks persistent pain X-ray may be indicated or after 6–8 weeks an MRI | Evaluate risk factors for chronicity (yellow flags); including biological, psychological, occupational, lifestyle, and iatrogenic factors |
| Italy (2006) | Acute, subacute and chronic LBP | Non-specific LBP Specific LBP Sciatica | Pain/functional limitation on trunk movement Palpation Postural evaluation Neurological exam is recommended (SLR, sensibility) | Useless for non-specific acute LBP Option after 4–6 weeks if surgery is indicated (sciatica) | Screening after 2 weeks: yellow flags, Waddell test (for pain behaviour) |
| New Zealand (2004) | Acute LBP (<3 months) | Non-specific LBP Specific pathologic change | Neurological screening Establish degree of functional limitation caused by the pain | Investigations in first 4–6 weeks do not provide clinical benefit unless Red Flags present There are risks associated with unnecessary radiology | Screen for yellow flags with the Acute Low Back Pain Screening Questionnaire, and if at risk, clinical assessment |
| Norway (2007) | Acute and subacute (<3 months) Chronic (>3 months) | Non-specific LBP Radicular pain Serious pathologies/acute neurological conditions (Cauda equina syndrome) | Inspection, posture, deformity, Spinal mobility, including finger-to-floor distance, Neurological screening (SLR/Lasegue) if radicular pain is suspected | Not recommended in acute, subacute chronic LBP and radicular pain in the absence of red flags, Recommended in case of red flag First choice is MRI | A list of yellow flags is presented as risk factors for chronicity, sick leave |
| Spain (2005) | Non-specific acute, subacute and chronic | Specific spinal pathology Nerve root pain/radicular pain Non-specific low back pain | Clinical history, red flags. Do not recommend palpation and tests of intervertebral mobility | Not useful in non-specific LBP; X-rays, CT and MRI use only in case of red flags | Assess psychological factors in 2–6 weeks after treatment if not improving. Assess physiological factors as prognostic factor only |
| The Netherlands (2003) | Acute (0–12 week) and chronic (>12 week) LBP | Non-specific LBP Specific LBP (based on a list of red flags) | SLR-test, neurological inspection; loss of motor control, sensibility, miction. Palpation of spine, Inspection of lumbar kyphosis or flattened lumbar lordosis | Not useful in non-specific acute LBP | Assessment of psychosocial factors (yellow flags) is recommended. These include emotional reaction, cognitions and behaviour |
| United Kingdom (2008) | Acute <6 weeks, sub acute 6–12 weeks, chronic >3 months | Non-specific low back pain: Mechanical low back pain Inflammatory low back pain and stiffness Serious pathology | Rule out serious pathology (identify red flags) Confirm pain is in the lower back, is mechanical, not inflammatory | Does not inform management of non-specific low back pain but may be indicated to rule in/out serious pathologies | Recognise and manage psychosocial barriers (yellow flags) to recovery |
| United States (2007) | Acute and chronic LBP | Non-specific LBP LBP due to specific causes LBP-Radiculopathy/Spinal Stenosis | Neurological screening (including SLR, strength, reflexes, sensory symptoms) | Only where progressive neurological or serious pathology is suspected Discouraged for non-specific LBP Recommended for radiculopathy or spinal stenosis only if patients are potential candidates for further intervention | Assessment of psychosocial risk factors strongly recommended |
| Most apparent changes since 2001 | |||||
| Addition of guidelines from countries such as Austria, Canada, France, Italy, Norway, Spain and a unified one from Europe | More countries (UK, US) now include recommendations for chronic LBP in addition to acute LBP. Germany now includes subacute and recurrent LBP | Almost no change in diagnostic classifications used in the guidelines | Almost no change in recommended types of physical examination | In some guidelines (Finland, Germany) now more explicit statements regarding the use of CT and MRI | In a few guidelines (Netherlands, US) the measurement of yellow flags are now more strongly recommended. In Germany the assessments is now recommended at a much earlier stage |