Information for Healthcare Services – Low Back Pain Clinical Care Standard

What the standard says

The assessment of a patient with a new presentation of low back pain symptoms, with or without leg pain or other neurological symptoms, focuses on screening for specific and/or serious pathology and consideration of psychosocial factors. It includes a targeted history and physical examination, with a focused neurological examination when appropriate. Arrangements are made for follow-up based on an evidence-based low back pain pathway.

What this means for you

Ensure the use of an evidence-based low back pain pathway that guides appropriate assessment, investigation, referral, management and counselling of patients who present with low back pain symptoms, based on their history and physical examination. The pathway should incorporate screening for specific and/or serious pathology, allow the use of validated tools to aid assessment early in an episode of low back pain and monitoring at subsequent visits40, and allow referral to specialists if needed – for example:

• Brief Pain Inventory (short form)
• Clinically Organized Relevant Exam (CORE) Back Tool

Ensure that clinicians have current training in the clinical assessment of back pain and, when relevant, in the use of validated tools.

Related resources

Evidence-based pathways to guide assessment:

• New South Wales Agency for Clinical Innovation Management of People with Low Back Pain: Model of care – provides guidance on the care to be provided to patients who present to their general practitioner or the emergency department with low back pain
• Emergency Care Institute New South Wales Acute Low Back Pain – provides guidance on the care to be provided to patients who present to the emergency department with acute low back pain
• Queensland Health clinical prioritisation criteria Spine (Orthopaedics) – provides guidance to assist with the clinical assessment and referral of people with low back pain to specialist services according to clinical urgency.

What the standard says

Early in each new presentation, a patient with low back pain, with or without leg pain or other neurological symptoms, is screened and assessed for psychosocial factors that may affect their recovery. This includes assessing their understanding of, and concerns about, diagnosis and pain, and the impact of pain on their life. The assessment is repeated at subsequent visits to measure progress.

What this means for you

Provide clinicians with training and skills to support them in managing patients with low
back pain, including biopsychosocial pain management.

Provide access to assessment tools that include screening for psychosocial barriers to
recovery in patients with low back pain, such as the STarT Back Screening Tool, or the short
form Örebro Musculoskeletal Pain Screening Questionnaire. Ensure that systems and
processes are in place to distribute and score risk assessment tools, and that clinicians are
trained in their use.

Related resources

Risk assessment tools to identify patients at risk of poor functional outcomes:

• See the STarT Back website for further guidance on using the risk assessment tool, including an Online STarT Back Calculator and downloadable screening tool
• The Örebro Musculoskeletal Pain Screening Questionnaire (10-item version) is available on the Western Australian Department of Health PainHealth website or on the OrthoToolKit website, and a downloadable version with scoring instructions is available on the Central and Eastern Sydney Primary Health Network website.

What the standard says

Expectations of imaging and its limited role in diagnosing low back pain are discussed with a patient. Early and appropriate referral for imaging occurs when there are signs or symptoms of specific and/or serious pathology. The likelihood and significance of incidental findings are reported and discussed with the patient.

What this means for you

Ensure that policies, processes and pathways are in place for appropriate assessment of low back pain, with or without leg pain, that describe indications for imaging patients with alerting features for serious underlying pathology and when imaging is not needed.

Support clinicians to provide advice about the limited role of imaging and make information resources – such as those produced by the Commission and NPS MedicineWise – available to provide to patients.

Ensure that systems are in place to monitor the appropriateness of imaging requests for low back pain as part of quality improvement processes. Consider use of a template for reporting of imaging results that includes epidemiological reporting of common imaging findings to help clinicians and patients understand the probability and significance of incidental findings.

What the standard says

A patient with low back pain is provided with information about their condition and receives targeted advice to increase their understanding, and address their concerns and expectations. The potential benefits, risks and costs of medicines and other treatment options are discussed, and the patient is supported to ask questions and share in decisions about their care.

What this means for you

Ensure that clinicians have the knowledge, information and relevant training to provide information about the nature of low back pain and to support shared decision making. Ensure that patient educational materials are available – including on the potential benefits, risks and costs of treatment options – to support the patient to be engaged in their care and to participate in decision-making.

What the standard says

A patient with low back pain is encouraged to stay active and continue, or return to, usual activity, including work, as soon as possible or feasible. Self-management strategies are discussed. The patient and clinician develop a plan together that includes practical advice to maximise function, and limit the impact of pain and other symptoms on daily life. The plan addresses individual needs and preferences.

What this means for you

Ensure that clinicians have the knowledge, information and relevant training to support people with low back pain to self-manage their condition in line with current guidelines.

Ensure that pathways are in place so that patients with low back pain receive advice and encouragement to remain as active as possible.

Ensure that appropriate services and referral pathways are available to support physical activity programs and interventions.

What the standard says

A patient with low back pain is offered physical and/or psychological interventions based on their clinical and psychosocial assessment findings. Therapy is targeted at overcoming identified barriers to recovery.

What this means for you

Ensure that systems, processes and appropriate resources are in place so that adults with low back pain can access the physical and psychosocial clinical services they need. Identify where access issues are likely barriers to appropriate treatment and develop strategies to address them (such as telehealth).

What the standard says

A patient is advised that the goal of pain medicines is to enable physical activity, not to eliminate pain. If a medicine is prescribed, it is in accordance with the current Therapeutic Guidelines, with ongoing review of benefit and clear stopping goals. Anticonvulsants, benzodiazepines and antidepressants are avoided, because their risks often outweigh potential benefits, and there is evidence of limited effectiveness. Opioid analgesics are considered only in carefully selected patients, at the lowest dose for the shortest duration possible.

What this means for you

Ensure that systems, processes and resources are in place to support clinicians to provide information to patients about their treatment. Ensure that patients have access to medicines advice, including information on the risks and benefits of pain medicines. Provide clinicians with access to current Therapeutic Guidelines and monitor appropriate adherence.

Policies should limit prescribing of opioid analgesics for low back pain to immediate-release formulations for a limited duration. Ensure that information is provided to manage patient expectations about ongoing opioid analgesic treatment. In the emergency department setting, durations of therapy should be explained to the patient. This information should also be included in the discharge summary, along with a description of the advice and the limited dose and quantity given to the patient, with the goal of avoiding prolonged use, in accordance with the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, (see Quality statement 9 – Transfer of care).

What the standard says

A patient with persisting or worsening symptoms, signs or function is reassessed at an early stage to determine the barriers to improvement. Referral for a multidisciplinary approach is considered. Specialist medical or surgical review is indicated for severe or progressive back or leg pain that is unresponsive to other therapy, progressive neurological deficits, or other signs of specific and/or serious pathology.

What this means for you

Ensure that systems, processes and resources are in place to support clinicians to monitor the symptoms, function and psychosocial wellbeing of patients with low back pain. Protocols should describe appropriate referral pathways and support timely access, including for patients with persisting and worsening pain with signs of serious pathology.

For services providing one component of multidisciplinary care, ensure that systems are in place to facilitate effective shared care across multiple healthcare providers, including mechanisms for regular communication among providers to facilitate the delivery of consistent information to the patient.

At a healthcare service level, assess whether multidisciplinary pain clinics and specialised spinal surgical services are meeting the needs of their populations. Consider quality improvement activities to assess effectiveness and improve access to care.