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Table 1

Clinical guidelines recommendations regarding diagnosis of low back pain

CountryPatient populationDiagnostic classificationPhysical examinationImagingPsychosocial 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 presentYellow 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 recurrentNon-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 persistentSimple 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 signsNot 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 questionAssess 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) LBPSerious spinal pathology
Nerve root pain/radicular pain
Non-specific low back pain
Physical assessment including neurological screening when appropriateDiagnostic imaging tests (including X-rays, CT and MRI) are not routinely indicated for non-specific low back painAssess 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 LBPNon-specific LBP
Nerve root dysfunction (sciatic syndrome, intermittent claudication)
Possible serious or specific disease
Inspection, palpation, spinal mobility (flexion), SLR-test, strength, reflexesNo 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)
To rule out “so-called symptomatic acute low back pain” or emergencies
Rating of muscle strength
Musculoskeletal and neurological examination to identify specific cause
Assessment of function, anxiety and/or depression using validated measure
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
X-rays not repeated. CT/MRI only in exceptional circumstances
Acute and Chronic:
Recommended to assess psychosocial factors

Germany (2007)Acute, subacute, chronic/recurrent LBPNon-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 LBPNon-specific LBP
Specific LBP
Pain/functional limitation on trunk movement
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 suspectedNot 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 chronicSpecific spinal pathology
Nerve root pain/radicular pain
Non-specific low back pain
Clinical history, red flags. Do not recommend palpation and tests of intervertebral mobilityNot useful in non-specific LBP; X-rays, CT and MRI use only in case of red flagsAssess 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) LBPNon-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 lordosisNot useful in non-specific acute LBPAssessment 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 monthsNon-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 pathologiesRecognise and manage psychosocial barriers (yellow flags) to recovery

United States (2007)Acute and chronic LBPNon-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 EuropeMore countries (UK, US) now include recommendations for chronic LBP in addition to acute LBP. Germany now includes subacute and recurrent LBPAlmost no change in diagnostic classifications used in the guidelinesAlmost no change in recommended types of physical examinationIn some guidelines (Finland, Germany) now more explicit statements regarding the use of CT and MRIIn 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