Recommendations for Low Back Pain: The CLIP Project Part 2

From The CLIP Project Part 1, the assessment of patients with back pain should have achieved the following:

  1. Triage patients as those with : (a) probable serious pathology; (b) neurologic/ radicular involvement or (c) non specific low back pain.

  2. Determine the extent/ probability of returning to work

  3. Identifying barriers that would prevent return to work.

For patients in whom a serious pathology is suspected, imaging modalities such as MRI or CT Scan should be considered. And referral to a specialist should likewise be contemplated. This is to expedite diagnosis (infection, fracture, trauma, malignancy, cauda equine syndrome) and eventual definitive management.

For low back pain patients with neurologic involvement, imaging modalities are not immediately warranted unless there are red flag signs present. An MRI of the spine may be ordered when surgical intervention is already being contemplated (such as for herniated disc) or when a non-invasive intervention warrants the exclusion of a particular pathology.

For patients with non-specific low back pain (which constitute a majority of the cases seen in practice), the following recommendations were made:

  1. Reassure the patient with back pain by (a) providing essential, coherent, accessible and valid information about his condition and (b) correcting beliefs

  2. Encourage and guide the patient to continue or to resume usual activities

  3. Implement a treatment plan of proven efficacy

Recommendation #1 of treatment is a very important but often neglected aspect of patient care.  Educating the patient about the diagnosis IS part of the treatment and this would also encourage patients to comply with the management plan. Patients may also have misconceptions and wrong beliefs about their condition that may, in fact, serve as barriers to recovery. These have been referred to in literature as YELLOW FLAGS in back pain – when present, they serve as independent predictors of chronic pain and/or disability. These include:

  • The belief that back pain is harmful and potentially severely disabling (i.e. CATASTROPHIZING)

  • Fear and avoidance of activity or movement that is believed to aggravate back pain (i.e. KINESIOPHOBIA)

  • Tendency for low mood and withdrawal for social interaction

  • Expectation that passive rather than active treatment will resolve back pain

As you can see, these yellow flags could only be identified by exploring beyond what we usually ask and observe when evaluating patients with back pain.

A previous practice was to advise complete bed rest for patients with back pain. However, as evidence has shown, a relative bed rest is best – that is, to minimize the activities that tend to aggravate back pain but the patient should continue with his usual activities.

As for treatment of proven efficacy, the following slides summarizes these:




From the above slides, non-pharmacologic interventions play a more important role in treating back pain >4 weeks. Pharmacologic interventions, on the other hand, have a greater impact when treating acute back pain and when controlling exacerbations of back pain during the sub-acute or the chronic phase. It is also important to note, that for patients with chronic back pain a multidisciplinary approach – consisting of pharmacologic, rehabilitative and/or CAMs – is more effective than any single treatment approach.


Author: Sids Manahan MD 🇵🇭

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

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