Recommendations for Low Back Pain: The CLIP Project Part 1

Low back pain is second only to the common cold as the most common affliction affecting man. Lifetime prevalence has been reported at 80% – meaning 8 of 10 individuals would have experienced back pain at any point in their life. Annual and point prevalence have been documented as high as 60% and 40%, respectively. Annual incidence rates range from 15-20%.

However, it is only the 5th most common complaint of patients in primary care – meaning a significant number of individuals experiencing low back pain have self-limiting episodes that would not warrant medical attention. Therefore, when a patient does consult for this complaint – there is significant pain, limitation of activity and disability accompanying the experience.

Differential diagnoses for any patient with low back pain include degenerative disc disease, herniation, disc tears, spinal stenosis, fractures, spondylolisthesis, spondyloarthropathies, infections, malignancy and psychosocial problems. However, in 85% no apparent cause for the low back pain could be identified – this is referred to as idiopathic low back pain. Serious pathologies – i.e. infection, malignancy, fractures, spinal stenosis/ cauda equina syndrome – account for <2-3% of all cases of low back pain. Therefore, generally most cases of low back pain carry a favorable prognosis – i.e. not fatal or life-threatening.

But it is important to note, that only a third of all cases of low back pain would last 12 weeks) low back pain which may cause disability and carries a significant economic burden.

The CLIP (Clinics on Low Back Pain in Interdisciplinary Practice) Project was created to review the evidence on the management (evaluation and treatment) of low back pain in order to prevent persistent disability.  Below are some of their recommendations for assessing low back pain.

  1. To detect serious pathology requiring immediate or specialized treatment, the clinical examination should triage the patient to the following types:

    • Back pain with suspected serious pathology (defined by the presence of red flags for infection, malignancy, fracture, CES). General characteristics include:

      • History of trauma

      • Constant, progressive, non-mechanical pain

      • Thoracic or abdominal pain

      • Pain at night not eased by lying in prone position

      • History of suspected cancer, HIV or pathologies causing low back pain

      • Chronic steroid consumption

      • Unexplained weight loss, chills or fever

      • Significant and persistent limitation of lumbar flexion

      • Loss of sensation in the perineum (saddle anesthesia)

      • Recent onset of incontinence

    • Back pain with neurologic involvement

      • Symptoms include pain radiating below the knee (which may be as intense or more intense than the back pain), pain radiating to the foot and toes, and, numbness + paresthesias in the painful area

      • Signs include positive test for radicular irritation (i.e. straight leg raising), motor, sensory and reflex signs supporting nerve root involvement

    • Non-specific back pain

      • Lumbar/ lumbosacral pain with no neurologic involvement

      • Mechanical pain varying over time and with physical activity

      • Patient’s general health is good

  • Imaging studies (radiographs, CT and MRI) are rarely indicated for patients with non-specific low back pain

  • The doctor should assess the patient’s perceived disability and the probability of return to usual activities either at the fourth week or on initial consultation if the patient has long-standing low back pain.

    • The probability of return to work decreases with length of disability due to low back pain.

    • Tools that could be used include the Symptom Checklist Back Pain Prediction Model (SCL BPPM) and the Recherche sur les Affections Musculo-Squelettiques (RAMS) Questionnaire

  • When the probability of returning to usual activities is low, the clinician should identify barriers preventing return to usual activities. The following are some of these barriers

    • Intensity of pain

    • Perceived disability

    • Symptoms (with no signs) of neuropathic pain

    • Fears and beliefs (Kinesiophobia)

    • Patient projection regarding return to work

    • Catastrophizing

    • Absence from any type of work

The next post reviews the CLIP recommendations on the therapeutic approach to low back pain.


Author: Sids Manahan MD 🇵🇭

Rheumatology. Internal Medicine. Educating Patients and Colleagues. Curating Rheumatology. Bloggero-Wanabe.

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