SPINE Course Materials Spine Pathway PDF

Saskatchewan Spine Pathway
Low Back Pain

Assessment and Management
COURSE BINDER
This course was developed for primary care providers including physicians,
nurses, physical therapists and chiropractors. The course is designed to
build on providers’ assessment and management skills when working
with patients with low back pain. Participants will gain an understanding
of how to use Spine Pathway tools and processes in clinical practice to
improve patient outcomes.
Revised April 2018

Low Back Pain Assessment and Management
TABLE OF CONTENTS
Part 1: Live Presentation
 Presentation Slides April 2018

 Patient scenarios
Part 2: Saskatchewan Spine Pathway Tools
 Spine Pathway Triage Algorithm

 Spine Pathway Clinic – Primary Care Practitioner Assessment and Referral form
Part 3: Patterns of Pain Approach
 Managing Low Back Pain: A Different Approach

 Quick Reference Triage Algorithm
Part 4: Pattern-Specific Treatment Algorithms & Patient Exercise Hand-outs
 Pattern 1: Back Dominant Pain Aggravated by Flexion

 Pattern 2: Back Dominant Pain Aggravated by Extension
 Pattern 3: Constant Leg Dominant Pain
 Pattern 4: Intermittent Leg Dominant Pain
 Pattern 5: Pain Disorder (no patient hand-out)
 General Recommendations for Maintaining a Health Back
Additional resources:
 Low Back Pain Assessment & Management On-line Course (no charge)
www.spinepathwaysk.ca
 Spine Pathway provider web pages www.sasksurgery.ca/provider/spine.html
 A list of helpful resources for managing chronic pain, compiled by the Saskatchewan Pain
Society (SaskPain) http://www.saskpain.ca/index.php/resources
 LiveWell with Chronic Pain (LWCP) www.saskatchewan.ca/residents/health/diseases-and-

conditions/chronic-pain peer-led, community based self-management program
 Online Therapy Unit - www.onlinetherapyuser.ca free online cognitive behavior therapy

teaches people with chronic pain how to better manage pain, anxiety and depression.
PART 1: LIVE PRESENTATION
 Presentation slides
 Patient scenarios for discussion
3/13/2018
Live Training Course:
Assessment and Management of
Lower Back and Leg Pain
Acknowledgements
To the Spine Training Implementation Team (consisting of Dr.
Daryl Fourney, Dr. Joseph Buwembo, Dr. Allan Woo, Dr. Martin
Heroux, Lee Gallais, John Berzolla, John Murphy, Daniel Myers,
Lilyans Zelada, Terra Hayes, Barbara Neumann, Darlene Newton,
Terry Blackmore and Vance Sanderson for their ongoing
commitment to the development and support of the
The Saskatchewan Spine Pathway would also like to acknowledge
Dr. Daryl Fourney and Dr. Hamilton Hall for developing the live
presentation materials used in today’s session
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Current Practice Pre‐test
Case History
A 49 year‐old psychiatrist gives a two month history of low back pain. There
was a gradual onset following a slip and fall outside his office. His pain is
most intense in the right buttock and over the right greater trochanter. When
severe it can radiate down the right leg into the right foot. The pain is
constant. Symptoms are sufficient to interfere with his work and he is
considering initiating a disability plan so that he can stay home. The pain is
aggravated by sitting and any attempt at lifting. There is slight improvement
with short periods of walking. When it is present, the right leg pain disturbs
his sleep. He complains of constipation. He has already had a course of
lumbar facet injections, which produced no improvement.
www.sasksurgery.ca
Physical Examination
Reduced ranges of lumbar flexion and lumbar extension. Extension is more
painful than bending forward both when standing and when lying down.
Straight leg raising on the right is limited to 60 degrees by the buttock pain. It
does not reproduce the right leg pain. Straight leg raising on the left past 80
degrees produces right‐sided back pain. There is an absent left ankle reflex.
Power testing is normal except for standing plantar flexion which is limited by
increasing back pain. The plantar responses are down‐going and there is no
change in saddle sensation.
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Suggestions?
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Introduction to the
PART ONE: INTRODUCTION
PART TWO: HISTORY TAKING
PART THREE: THE PHYSICAL EXAM
PART FOUR: MECHANICAL PATTERNS OF PAIN
PART FIVE: PAIN CONTROL STRATEGIES AND
TREATMENT FOR LOWER BACK PAIN
PART SIX: RED FLAGS
CONCLUSION
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Course Objectives:
Following completion of the course you will be able to:
• Obtain a relevant history and physical exam
• Recognize patterns of low back and leg pain
• Identify serious pathology
• Initiate appropriate primary care
• Identify patients for surgical referral
• Determine the appropriate use of medical imaging
• Understand your role in the provincial spine pathway
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PART ONE: INTRODUCTION
In this section of the course, you will learn about
the development of the Saskatchewan Spine
Pathway, including:
• how you can improve the patient and care
provider experience,
• the clinical basis for the pathway, and
• the purpose and organization of the
Saskatchewan Spine Care Assessment Clinic
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What were the issues?
• Wait times for Spine Surgeon Consultation
• Wait times and overutilization of MRI
• Lack of adherence to Clinical Practice Guidelines
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Referral to Spine Surgeon
• 75‐85% of patients referred to surgeons for LBP not candidates for surgery
Wait times: In Canada, the wait time to
see the spine surgeon may be longer than
the wait for spine surgery
Average wait to see spine surgeon
(excluding Quebec): 6.5 months
Saskatchewan: 8.5 months
Reality is probably far worse as some
refuse new referrals or consider referrals
“inappropriate” and are never seen
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Over‐Utilization of MRI
• Lumbar spine MRI accounts for about 1/3 of total
MRI utilization
• 44.3% appropriate; 27.2% uncertain value; 28.5%
inappropriate
• Appropriate MRI Lumbar Spine
– Neurosurgeons 75.7%
– Other specialties 58.1%
– Family physician 33.9%
Emery DJ et al. JAMA Intern Med:1-3, 2013
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“Inappropriate” focus
on the imaging study
• Many spine surgeons require an MRI or CT scan to be
completed before a referral is considered
• Problem: Up to 90% false positive rate of these studies
• “Abnormalities” found may increase patient demand to seek
a surgical “fix”
You JJ et al. Can Assoc Radiol J.2008;59(3):135–43.
In over 80% of cases, MRI will not establish the cause of pain
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Clinical Practice Guidelines
Although evidence‐based guidelines for the
management of back and leg pain have been
developed and promoted, they have had little
effect on practice patterns
Bishop PB & Wing PC. Spine J. 2006;6(3):282-8.

Bishop PB & Wing PC. Spine J. 2003;3(6):442-50 .
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MRI and CT Appropriateness Checklists
• MRI and CT L‐spine Checklists further address the
inappropriate use of medical imaging for low back pain
• The checklist is based on literature, best practice guidelines
and expert consensus
When utilizing the spine pathway algorithm there is no
need to refer for imaging
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• Launched in 2011 as part of Saskatchewan Surgical Initiative
• Improves the assessment and management of patients with
lower back pain and ensures timely access to appropriate care
• Developed over 3 years by a multidisciplinary team of
Neurosurgeons, Orthopaedic Surgeons, Family Physicians and
Physiotherapists
• Developed a simple, consistent process for the diagnosis and
treatment of lower back pain
Over 80% of back pain is mechanical and can be managed
effectively at the primary care level without referral for
diagnostics or surgical consult.
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Pathway includes:
• Online and live training sessions for primary care providers
• Provider and patient education materials
• Standardized referral forms
• Algorithm for categorizing conditions with associated
treatment protocols
• Rapid and thorough process of diagnosis and treatment
for patients
• Expedited referral to advanced diagnostics and surgical
consultation when required
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Pattern
Primary Spine
Diagnosis Surgical
Care Pathway
and Consultation
Provider Clinic
Treatment
If a patient has RED FLAGS, emergency referral to a
spine surgeon may be necessary.
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Spine
Pathway
Triage
Algorithm
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Methods shown to improve
appropriateness of referrals
• Educational programs targeting primary care
• Standardized referral forms
• Screening clinics
Klein BJ, et al. Spine. 2000; 25(6):738-40.

Harrington JT, et al. Jt Comm J Qual Improv. 2001; 27(12):651-63.
Grimshaw JM,et al. Cochrane Database of Syst Rev. 2005; (3): CD005471
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Spine Pathway Live Training
• Medical education has been offered by the
Saskatchewan Spine Pathway since 2010
• From 2010 to Sept 2017 over 800 health
care providers attended live spine training
sessions.
Practitioner Total
Family Physician 391
Family Medicine Resident 268
Physical Therapist 84
Nurse Practitioner 67
Chiropractor 33
Grand Total 862
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Spine Pathway On‐line Training
• From 2010 – February 2018 over 1600 health care providers
registered for the on‐line spine training sessions and over 700
completed the course.
Total Total %
Practitioner Register Complete Complete
Physician 595 221 37%
Family Medicine Resident 274 78 28%
Physical Therapist 322 217 67%
Nurse Practitioner 138 70 51%
Chiropractor 137 91 66%
Other 117 25 21%
Exercise Therapist 19 11 58%
Nurse 25 7 28%
Grand Total 1628 721 44%
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PART TWO: HISTORY TAKING
In this section of the course, you will
learn how to:
• take an appropriate patient history
• establish a pain pattern
• what essential questions to ask
• how to obtain accurate answers from
patients
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Spine
Pathway
Assessment
and Referral
Form
www.sasksurgery.ca
Important questions in the
mechanical back pain history:
• Where do you hurt?
• Where is your pain the worst?
• Where does your pain go?
• How are you feeling?
• What brought you here today?
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The most important question in
the mechanical back pain history:
• Where do you hurt?
• Is it back or leg dominant?
• Where does your pain go?
• How are you feeling?
• What brought you here today?
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The other most important
question in the mechanical back
pain history:
• Is your pain constant or intermittent?
This question must be asked in several parts.
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Part A
Is there ever a time when you are in your
best position or at the best time of your
day when your pain stops ‐‐ and I know it
comes right back but is there a moment
or two when the pain is gone?
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Part B
When your pain stops does it stop
completely? Is it all gone? Are you
completely without your pain?
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When the pain is
constant consider:
• Malignancy
• Systemic conditions
• Pain disorder
• Constant mechanical pain
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Other questions
• Where is your pain the worst?
• Is your pain constant or intermittent?
• Aggravating movements/positions?
• Relieving movements/positions?
• Have you had this same pain before?
• Have you had treatment before?
• Have you ever had spine surgery?
• What can’t you do now that you could do
before you got the pain?
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• History takes precedence over physical
examination
• but the physical examination must support
the history.
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PART THREE: THE PHYSICAL EXAM
In this section of the course, you will learn how
to conduct the physical examination for back
pain patients, including:
• the standard physical examination
• important elements of spinal movement
• proper interpretation of the straight leg raise
• appropriate neurological testing
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• Observation
• Movement
– Flexion
– Extension
• Nerve root irritation tests
– Straight leg raising
– Femoral stretch test
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Straight Leg Raising
• Reproduction of typical leg pain
• Back pain is not relevant
• At any degree of leg elevation
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• Nerve root conduction tests
– L5 Ankle dorsiflexion
Great toe extension
– S1 Great toe flexion
Ankle reflex
• Plantar reflex
• Saddle sensation
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Back pain patterns: The axioms
• History takes precedence.
• Back dominant patterns are mutually exclusive.
• Leg dominant patterns can co‐exist.
• Leg pain takes precedence over back pain.
• Mechanical pain takes precedence over pain
disorder.
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PART FOUR: MECHANICAL
PATTERNS OF PAIN
In this section of the course, you will:
• Learn the difference between a syndrome and a disease
• Recognize the four mechanical patterns of back pain
• Learn to identify the characteristics of the two patterns
of back dominant and leg dominant pain
• Learn to identify patients at risk of developing a pain
disorder syndrome.
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Spine
Pathway
Quick
Reference
Triage
Algorithm
Patterns of
Low Back
Pain
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Pattern 1: Back Dominant Pain
Aggravated by Flexion
History
• Back dominant pain
– Back
– Buttock
– Greater trochanter
– Groin
• Worse with flexion
• Constant or Intermittent
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• Back dominant pain • Back dominant pain
• Worse on flexion • Worse on flexion
• Better with unloaded • Worse with extension
extension loaded/unloaded
= Pattern 1 Fast Responder = Pattern 1 Slow Responder
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Pattern 2: Back Dominant Pain
Aggravated by Extension
History:
• Worse with extension
• Never worse with flexion
• Always intermittent
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• Worse with extension
• No effect or better with flexion
• Neurological examination normal or
non‐contributory
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Pattern 3: Constant Leg Dominant Pain
History:
• Leg dominant pain ‐‐ below the gluteal fold
• Affected by back movement/position
• Constant
Physical Examination:
• Positive irritative test
– and/or conduction loss
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Pattern 4: Intermittent Leg Dominant Pain
History:
• Leg dominant pain
• Worse with activity in extension
• Better with rest and flexion
• Always intermittent
• Negative irritative tests
• Possible conduction loss
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Vascular vs. Neurogenic claudication
Vascular Neurogenic (AKA “pseudoclaudication”)
• Reliably produced • May also have radicular pain or
with same amount of numbness (dermatomal
exercise (decreases as distribution)
disease progresses) • Somewhat more variable
• Relief almost symptoms day to day
immediate at rest— • Relief slower, characteristically
not dependent on with flexion L‐spine (e.g.
posture pushing grocery cart). Standing
• Foot pallor on at rest usually not sufficient.
elevation, reduced • Normal pulses / skin temp
pulses, cool skin temp
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Case 1: History
A 49 year‐old psychiatrist gives a two month history of low back pain. There
was a gradual onset following a slip and fall outside his office. His pain is
most intense in the right buttock and over the right greater trochanter. When
severe it can radiate down the right leg into the right foot. The pain is
constant. Symptoms are sufficient to interfere with his work and he is
considering initiating a disability plan so that he can stay home. The pain is
aggravated by sitting and any attempt at lifting. There is slight improvement
with short periods of walking. When it is present, the right leg pain disturbs
his sleep. He complains of constipation. He has already had a course of
lumbar facet injections, which produced no improvement. He is scheduled for
an MRI and has already arranged to see a spine surgeon as soon as the results
are available.
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Case 1: Physical Examination
Reduced ranges of lumbar flexion and lumbar extension. Extension is more
painful than bending forward both when standing and when lying down.
Straight leg raising on the right is limited to 60 degrees by the buttock pain. It
does not reproduce the right leg pain. Straight leg raising on the left past 80
degrees produces right‐sided back pain. There is an absent left ankle reflex.
Power testing is normal except for standing planter flexion which is limited by
increasing back pain. The plantar responses are down‐going and there is no
change in saddle sensation.
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Case 2: History
A 60 year‐old chef has a chief complaint of left posterior thigh pain after
walking for more than 15 minutes. This is making it difficult for her to
continue to work in the kitchen of an exclusive Italian restaurant. She has
suffered constant low back pain for about ten years which has not responded
to chiropractic manipulation, physiotherapy modalities or massage therapy.
The leg pain began three years ago after she was involved in a rear end
collision and is getting progressively worse. To continue working she must sit
down frequently and draw up her left knee, which gives total but only short
term relief from her leg complaints.
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Repetitive flexion in standing increases the back pain but does not produce
pain in the thigh. Her symptoms don’t change with repeated standing
extensions. Straight leg raising on the left at 90 degrees causes back pain only.
Motor power is 4/5 in the left ankle dorsiflexiors and left EHL. The remaining
motor, reflex and sensory tests are unremarkable. There are no upper motor
findings.
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Case 3: History
A 48‐year‐old contractor reports four months of pain across the low back at
the top of the pelvis, more severe on the right side. His symptoms began
while he was installing ceiling tile and were severe enough to make him stop.
He describes his pain as constant but is aware that there are brief periods of
complete pain relief when he lies in a fetal position. The pain returns as soon
as he moves. He prefers to sit slumped forward rather than to stand. There is
occasional pain radiation into the right leg to just below the knee.
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On examination in standing there is no change in the back pain with repeated
flexion while a single extension reproduces it immediately. Both passive
prone lumbar extension and supine passive right straight leg raising produce
the typical back pain. The remaining neurological examination is normal.
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Case 4: History
A 28 year‐old construction worker presents three weeks post injury. He
describes the sudden onset of back and right knee pain while walking up a
ramp carrying a bag of cement. There was a sharp jab of back pain but he did
not lose his balance. The pain intensified and by the following day it was bad
enough to prevent him from going to work. He has been off the job since. He
reports that the back pain is constant. The pain in the knee has diminished
and become intermittent. Sleeping is not a problem once he can find a fairly
comfortable position although his symptoms are worse in the morning when
he first gets out of bed. They increase in severity again in the evening. He
has difficulty sitting and bending to put on his shoes. Using a lumbar roll
offers some relief. Bowel and bladder function are normal.
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During the physical examination the patient reports increased back pain with
repeated flexion in standing. He notes no change with standing extension but
records a decrease in back pain following five prone passive extensions.
Straight leg raising is normal bilaterally. Power, reflexes and sensation are
unremarkable. The plantar responses are down‐going. Examination of the
right knee reveals no abnormalities. There are two non‐organic findings,
acetabular rotation and cogwheel release of the right ankle dorsiflexiors
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Case 5: History
A 41 year‐old airline pilot has a five month history of left low back pain
radiating from the top of the left buttock into the left flank. He first noticed
the pain after finishing a trans‐Atlantic flight and it has gradually gotten
worse. Although the symptoms do vary in intensity he has not been
completely pain free at any time in the past few months. His pain has
stopped him from coaching his son’s hockey team and has limited his
activities around the house. He has started using a laxative to combat
increasing constipation.
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All back movements are significantly restricted. Both flexion and extension
while standing reproduce his left sided back pain. The pain prevents him
from performing a single passive prone extension. Lying in a supine knees‐to‐
chest position with his legs up on a chair gives some relief. Straight leg raising
is about 70 degrees bilaterally with the production of typical pain. Motor
testing is hampered by the spinal stiffness and back pain. There seems to be
a generalized weakness in both lower limbs. Reflexes are brisk and
symmetrical. The plantar reflex is down‐going. Sensation, including the
saddle area, is normal.
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PART FIVE: PAIN CONTROL
STRATEGIES AND TREATMENT FOR
LOWER BACK PAIN
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Self‐treatment for mechanical
low back pain
• Patient education
• Postural correction
• Direction‐specific exercise
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Pattern 1: General self treatment principles
Postural correction Direction‐specific
• Lumbar roll and night roll repetitive movement
• Unloaded prone passive
extensions
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Spine
Pathway
Pattern 1
Treatment
Algorithm
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Pattern 2: General self treatment principles
Postural correction Direction‐specific
• Seated flexion repetitive movement
• Trunk flexion stretch
(sustained flexion)
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Spine
Pathway
Pattern 2 Treatment Algorithm
Pattern 2
Treatment
Algorithm
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Pattern 3 AND Pattern 1 Slow Responder
General self treatment principles
Scheduled rest
• P1…Knees to chest
• P3…Z‐lie
• P1, P3…Prone over
pillows
Gradually progress towards
regaining extension
Harte, Arch Phys Med, 2003
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Spine
Pathway
Pattern 3
Treatment
Algorithm
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Pattern 3: Patient Education
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Pattern 2 AND Pattern 4
They achieve pain control quickly.
• Flexion in supine lying
• Flexion in sitting
• Flexion in standing (step)
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Pattern 4 General self treatment principles
Improved postural control
• Abdominal
strengthening
• Core strengthening
• Pelvic tilt
Gradual improvement
Long term commitment
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Spine
Pathway
Pattern 4
Treatment
Algorithm
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• Mechanical pain responds quickly
• Early recheck
o Location of the pain
o Intensity of the pain
o Frequency of the pain‐free periods
o Effect of the recommended treatment
• Avoid information overload
• One activity done well is better than two activities done
poorly
• The goal is control (not cure)
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Why do they fail?
• Didn’t do it
• Did it wrong
• Did something else
• You got the wrong pattern
Should respond predictably
“If it is not a pattern, it is a disease.”
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PART SIX: RED FLAGS
When is the surgeon interested in seeing a patient with
back pain? In this section of the course, you will learn:
• How to identify red flags that require urgent referral
to a specialist
• How to identify patients that can benefit from spine
surgery
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Red flags in any patient with back pain
• Cancer or infection
– Young patient (<20) with back pain
– Any history of cancer (even distant)
– Unexplained weight loss
– Immunosuppression (steroids, transplant, HIV)
– IV drug use
– Fever / chills
• Fracture
– History of significant trauma
– Mild trauma in patient with osteoporosis or chronic steroid use
• Neurological
– Acute urinary retention or overflow incontinence
– Fecal incontinence or loss of anal sphincter tone
– Saddle anesthesia
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Prevalence of and screening for serious spinal
pathology in patients presenting to primary care
settings with acute low back pain
In patients presenting to a primary care provider with back pain,
previously undiagnosed serious pathology is rare. The most
common serious pathology observed was vertebral fracture.
Approximately half of the cases of serious pathology were
identified at the initial consultation. Some red flags have very
high false‐positive rates, indicating that, when used in isolation,
they have little diagnostic value in the primary care setting.
Arthritis & Rheumatism 2009
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Every patient with new onset back pain
• PMHx:
– “Have you ever had any cancers or tumors?”
• SHx:
– IV drug use?
• ROS:
– Unexplained weight loss
– Fever/chills
– Change in bowel or bladder function
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Best safety check: Start with patterns!
• If there is a pattern and it
responds as it should,
you have your solution.
• If there is no pattern or it
doesn‘t respond, that is
the time to start looking.
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Red Flags
in the
Spine
Pathway
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Back (+/‐ Leg) Pain
Who needs to see the surgeon?
• Anybody with “red flags”
• Pattern 4
• Pattern 3 that has failed conservative management
What about back‐dominant pain?
• In the absence of “red flags,” most back‐dominant
pain is mechanical and treatment is nonsurgical
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Confounders for surgical
indications (examples)
• Illness behavior (chronic pain patient)
• Medically inappropriate (frail, elderly)
• Secondary gain issues (ongoing litigation, unsettled
insurance claim)
• Pain just isn’t that bad
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Surgery rationale: Pattern 4
What is Lumbar Stenosis?
• Not a disease, but a radiologic
finding (often asymptomatic)
• Caused by facet hypertrophy,
thickening of liagmentum
flavum
• May be exacerbated by disc
bulging or spondylolisthesis
• Can be superimposed on
congenital narrowing of spinal
canal
• Most common level L4/5
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Natural history of
neurogenic claudication
• If untreated, symptoms progress in 20‐ 40% , remain the
same in 40%, improve somewhat in 20%
• Main components of non‐operative treatment are:
– mechanical self‐treatment,
– NSAIDs +/‐ epidural corticosteroid injections
• Most patients treated with decompressive surgery.
Why?
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Surgery is superior for
neurogenic claudication
“…patients who underwent surgery showed
significantly more improvement in all primary
outcomes than did patients who were treated
non‐surgically.”
Weinstein, James N., Tor D. Tosteson, Jon D. Lurie, Anna NA Tosteson,
Emily Blood, Brett Hanscom, Harry Herkowitz et al. "Surgical versus
nonsurgical therapy for lumbar spinal stenosis." New England Journal of
Medicine 358, no. 8 (2008): 794‐810.
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“Improvement in self‐reported quality of life (SF‐36
PCS and MCS scores) was comparable after surgery
for spinal stenosis vs hip and knee arthroplasty at 1
and 2‐years postop.”
Rampersaud, Y. Raja, Bheesma Ravi, Stephen J. Lewis, Venessa
Stas, Ronald Barron, Roderick Davey, and Nizar Mahomed.
"Assessment of health‐related quality of life after surgical
treatment of focal symptomatic spinal stenosis compared with
osteoarthritis of the hip or knee." The Spine Journal 8, no. 2
(2008): 296‐304.
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Techniques – lumbar decompressive
laminectomy / laminotomy
Fusion sometimes
necessary too if
spondylolisthesis
plus stenosis: this is
where there is some
disagreement
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Surgical rationale: Pattern 3
Sciatica due to lumbar disc herniation
• 80‐90% of patients get better on
their own
• Standard therapy =
– Education, self‐treatment for
Pattern 3
– NSAIDs +/‐ muscle relaxants
www.sasksurgery.ca
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When to consult a surgeon
for Pattern 3
• Consider a referral to a spine surgeon if:
– Persistent sciatica beyond 6 weeks
– Pain is severe enough that patient is willing to
consider surgery
• Early referral to spine surgeon if: “red flags” (e.g.,
cauda equina syndrome) – rare
• No need for MRI unless red flag or planning surgery
www.sasksurgery.ca
www.sasksurgery.ca
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www.sasksurgery.ca
Surgical treatment appropriate for:
• Pattern 4
• Pattern 3 that has failed conservative
management
What about back‐dominant pain that has failed
non‐operative care?
• This is where the guidelines start to differ
because the benefits of surgery are far less clear
www.sasksurgery.ca
45
3/13/2018
CONCLUSION
www.sasksurgery.ca
Summary
1) RED FLAGS = contact spine surgeon on call
2) Pattern 1‐4: Use treatment algorithms. If
fails to respond on follow‐up, refer to spine
pathway clinic
– Seen within 3 weeks
– If surgical, MRI and surgeon appt will be priority
www.sasksurgery.ca
46
3/13/2018
For more information
• More information including treatment algorithms and patient
education materials can be found at
www.sasksurgery.ca/patient/spine.html
www.sasksurgery.ca/provider/spine.html
• Print materials can be ordered (at no charge) by emailing:
SpineTraining@health.gov.sk.ca
• Spine Training Online Course: www.spinepathwaysk.ca
www.sasksurgery.ca
Course Credits
Post‐reflective assignments will be distributed via email
approximately 4‐6 weeks following the live session. Upon
completion of the post‐reflective assignment, family physicians
will receive a certificate of completion which they must submit
to The College of Family Physicians of Canada to claim their
Mainpro+ credits. Reciprocal recognition is also available
through the Saskatchewan Chiropractic Association.
47
3/13/2018
Thank you for attending the Saskatchewan Spine Pathway
Low Back Pain Assessment and
Management training course
The Spine Pathway Working Group continually strives to
improve the Saskatchewan Spine Pathway program. To do so,
we require the feedback of those physicians that have
completed this program. The post‐reflective assignment and
on‐line course evaluation are means for physicians to provide
this highly valued feedback.
48
PATIENT SCENARIO
Your patient is a 62 year old man with a chief drugs. He has no complaints referable to the
complaint of low back and bilateral leg pain. He respiratory, cardiovascular, gastrointestinal or
describes the back pain as a severe constant ache genitourinary systems. There is no history of cancer,
with occasional sudden intense jolts caused by heart trouble, diabetes or rheumatoid disease.
sudden movement. The back symptoms have been There has been no change in weight or unexplained
present for about 18 months and followed several fever. He had a left inguinal hernia repair ten years
days of frequent snow shoveling during a winter ago; there were no complications. Bowel and
storm. There is a past history of intermittent back bladder functions are normal.
pain treated with non-prescription drugs and
chiropractic adjustment. No attack lasted for more He is 5’ 11” (180 cm) tall and weighs 205 lbs. (93 kg).
than a couple of months and all subsided completely. He slouches when he stands and has a prominent
The last episode was about three years ago. abdomen. During your assessment the patient is
obviously uncomfortable and keeps changing
The current level of back pain is sufficient to limit position. Chest is clear, heart sounds are normal,
his daily activities and is interfering with his job as abdomen is soft and non-tender. Peripheral pulses
an operations manager for a large trucking are present but questionable on palpation of the
company. Sitting for more than 30 minutes right ankle and dorsum of the right foot.
increases his pain, particularly on the right side of
Hip movement is normal bilaterally with some
the low back and top of the right buttock. The pain
can become so bad that to get relief he must stand discomfort in the right groin at the limit of flexion.
up and walk around. If he moves slowly without Knee and ankle function is unremarkable.
twisting, the pain will slowly subside and can On standing and bending forward, the finger tips
disappear for a few minutes. reach just below the knees. There is typical right-
His symptoms not only disrupt his work, they are sided low back and buttock pain. The range of
having a significant impact on his recreational standing extension is very limited and produces a
sharp mid-line pain at the top of the pelvis. Side
activities. He is an avid golfer but has been forced
to greatly curtail his game. If he walks for more bending and trunk rotation are both limited with
than two or three holes his legs begin to ache and pain. Passive low back extension while lying prone
he starts to have problems with his balance. Again provoked both the buttock and back pain.
the pain is worse on the right side, particularly in Straight leg raising is 900 on the left and 700 on the
the back of the right thigh but it can radiate all the right limited by back and buttock pain. The knee
way from the right buttock to the top of the right reflexes are bilaterally normal while the ankle
foot. When the level of pain stops him from reflexes are both diminished, slightly more on the
walking, he gains relief by sitting down. The leg right than on the left. Power of dorsiflexion and
pain is usually gone within five minutes and he is planter flexion is normal in both ankles. The
able to continue the game. He has started using a Trendelenburg test is symmetrical. Resisted hip
golf cart but the poor seat and rough terrain extension is limited bilaterally by back pain. All
aggravate his back. sensory testing is normal except for an area on the
The patient’s general health is good. He is a non- dorsum of the left foot. The plantar responses are
smoker, social drinker and does not use recreational down-going.
POP Q # 1:
A 49 year-old psychiatrist gives a two month history of low back pain. There was a gradual
onset following a slip and fall outside his office. His pain is most intense in the right buttock
and over the right greater trochanter. When severe it can radiate down the right leg into the
right foot. The pain is constant. Symptoms are sufficient to interfere with his work and he is
considering initiating a disability plan so that he can stay home. The pain is aggravated by sitting
and any attempt at lifting. There is slight improvement with short periods of walking. When it
is present, the right leg pain disturbs his sleep. He complains of constipation.
He has already had a course of lumbar facet injections, which produced no improvement. He is
scheduled for an MRI and has already arranged to see a spine surgeon as soon as the results are
available.
The physical examination demonstrates reduced ranges of lumbar flexion and lumbar
extension. Extension is more painful than bending forward both when standing and when lying
down. Straight leg raising on the right is limited to 60 degrees by the buttock pain. It does not
reproduce the right leg pain. Straight leg raising on the left past 80 degrees produces right-
sided back pain. There is an absent left ankle reflex. Power testing is normal except for
standing planter flexion which is limited by increasing back pain. The plantar responses are
down-going and there is no change in saddle sensation.
What is the significant pattern of pain?
Pattern 1 fast responder
Pattern 1 slow responder
Pattern 2
Pattern 3
Pattern 4
Pattern 5
Non-spinal pain
POP Q # 2:
A 60 year-old chef has a chief complaint of left posterior thigh pain after walking for more than
15 minutes. This is making it difficult for her to continue to work in the kitchen of an exclusive
Italian restaurant. She has suffered constant low back pain for about ten years, which has not
responded to chiropractic manipulation, physiotherapy modalities or massage therapy. The leg
pain began three years ago after she was involved in a rear end collision and is getting
progressively worse. To continue working she must sit down frequently and draw up her left
knee, which gives total but only short term relief from her leg complaints.
Repetitive flexion in standing increases the back pain but does not produce pain in the back of
the thigh. Her symptoms don’t change with repeated standing extensions. Straight leg raising
on the left at 90 degrees causes back pain only. Motor power is 4/5 in the left ankle
dorsiflexiors and left EHL. The Trendelenburg test is asymmetrical. The remaining motor, reflex
and sensory tests are unremarkable. There are no upper motor findings.
Pattern 2
Pattern 3
Pattern 4
Pattern 5
Non-spinal pain
POP Q # 3:
A 48-year-old contractor reports four months of pain across the low back at the top of the
pelvis, more severe on the right side. His symptoms began while he was installing ceiling tile
and were severe enough to make him stop. He describes his pain as constant but is aware that
there are brief periods of complete pain relief when he lies in a fetal position. The pain returns
as soon as he moves. He prefers to sit slumped forward rather than to stand. There is
occasional pain radiation into the right leg to just below the knee.
On examination in standing there is no change in the back pain with repeated flexion while a
single extension reproduces it immediately. Both passive prone lumbar extensions and supine
passive right straight leg raising produce the typical back pain. The remaining neurological
examination is normal.
Pattern 2
Pattern 3
Pattern 4
Pattern 5
Non-spinal pain
POP Q # 4:
A 28 year-old construction worker presents three weeks post injury. He describes the sudden
onset of back and right knee pain while walking up a ramp carrying a bag of cement. There was
a sharp job of back pain but he did not lose his balance. The back pain intensified and by the
following day it was bad enough to prevent him from going to work. He has been off the job
since.
He reports that the back pain is constant. The pain in the knee has diminished and become
intermittent. Sleeping is not a problem once he can find a fairly comfortable position although
his symptoms are worse in the morning when he first gets out of bed. They increase in severity
again in the evening. He has difficulty sitting and bending to put on his shoes. Using a lumbar
roll offers some relief. Bowel and bladder function are normal.
During the physical examination the patient reports increased back pain with repeated flexion
in standing. He notes no change with standing extension but records a decrease in back pain
following five prone passive extensions. Straight leg raising is normal bilaterally. Power,
reflexes and sensation are unremarkable. The plantar responses are down-going.
Examination of the right knee reveals no abnormalities. There are two non-organic findings,
acetabular rotation and cogwheel release of the right ankle dorsiflexiors.
Pattern 2
Pattern 3
Pattern 4
Pattern 5
Non-spinal pain
POP Q # 5:
A 32 year- old woman who works at the checkout counter in a supermarket gives a seven week
history of pain in the left buttock and thigh. She states that about two months ago the pain
began in the left buttock but that about three weeks ago it shifted into her leg radiating as far
as her left knee. She now has pain in both areas but the posterior thigh pain is more severe.
She cannot recall any event that might have triggered the pain or the change in location. Her
symptoms are aggravated by sitting and are reduced by lying on her back. The pain has become
so intense that she has not been able to work for the past three weeks. There is a burning
discomfort involving most of the left foot.
On physical examination the patient has a marked left trunk shift. Left straight leg raising at 50
degrees produces both the left buttock and the left leg leg pain. The “Z” lie position decreases
the pain in both areas but does not eliminate it completely. There are no changes in the power
or reflexes in either leg. She can feel light touch over all of the left foot. Saddle sensation and
the plantar responses are normal.
Pattern 2
Pattern 3
Pattern 4
Pattern 5
Non-spinal pain
POP Q # 6:
A 41 year-old airline pilot has a five month history of left low back pain radiating from the top
of the left buttock into the left flank. He first noticed the pain after finishing a trans-Atlantic
flight and it has gradually gotten worse. Although the symptoms do vary in intensity he has not
been completely pain free at any time in the past few months. His pain has stopped him from
coaching his son’s hockey team and has limited his activities around the house. He has started
using a laxative to combat increasing constipation.
All back movements are significantly restricted. Both flexion and extension while standing
reproduce his left sided back pain. The pain prevents him from performing a single passive
prone extension. Lying in a supine knees-to-chest position with his legs up on a chair gives only
partial relief. Straight leg raising is limited at about 70 degrees bilaterally by the production of
the typical buttock and flank pain. Motor testing is hampered by the spinal stiffness and back
pain. There seems to be a generalized weakness in both lower limbs. Reflexes are brisk and
symmetrical. The plantar reflex is down-going. Sensation, including the saddle area, is normal.
Pattern 2
Pattern 3
Pattern 4
Pattern 5
Non-spinal pain
PART 2: SASKATCHEWAN SPINE
PATHWAY TOOLS
 Spine Pathway Triage Algorithm

 Spine Pathway Clinic – Primary Care Practitioner
Assessment and Referral form
Lower back ± leg pain
yes
Primary care
Red flags?
no
Pattern diagnosis and treatment algorithm*
Continue treatment to
Improvement? yes restore functional ROM
and resume normal activity
no
Red flags? yes

Spine pathway clinic
no
Reassessment of pattern diagnosis and treatments*
Improvement? yes
no
Patterns 1 and 2: Refer back to primary care with Pattern 4 Pattern 3 pain >6 wk
recommendations for additional mechanical treatment and
referral to surgery if symptoms persist >6 mo
Non-urgent Emergency
Imaging and surgery consultation referral
Urgent referral
referral
Saskatchewan Spine Pathway Clinic FAX to Regina: 306-766-7551
Primary Care Practitioner
Assessment and Referral Form FAX to Saskatoon: 306-655-8951
Patient Information
INITIAL ASSESSMENT: / /
Name:
FOLLOW UP ASSESSMENT: / /
HSN: - - Female Male Age:
Address: HOME ADDRESS CITY/PROVINCE
Phone: - - Alt. Phone: - -

Back Specific History
1. Where has the pain been the worst? (Check one) 6. What is the overall level of disability?
Back Dominant Leg Dominant No Limitations
2. Does the pain stop, even for a moment? Mild Limitations- able to do most activities with minor modifications
Intermittent Constant Moderate Limitations – able to do most activities with modification
Severe Limitations – unable to perform most activities
3. What are the: 7. Check if Red Flags are present:
Aggravating Factors: __________________________________________ Indicates urgent surgical referral:
Possible Cauda Equina Syndrome
Relieving Factors:____________________________________________
Loss of anal sphincter tone/fecal incontinence
4. Is there a previous history of back problems? Saddle anaesthesia about anus, perineum, or genitals
No Yes. Describe:______________________________ Urinary retention with overflow incontinence
5. Has there been previous treatment or surgery for back problems?
No Yes. Describe:______________________________
Back Specific Physical Exam
8. Movement: Produce typical pain 12. Reflex (conductive) Tests
Major Deep Tendon Reflexes
Pain produced on flexion Pain produced on extension
Patella Reflex (L4) Normal Abnormal Not Tested
9. Irritative Test: Looking to reproduce patient’s typical leg dominant pain
a. Passive Single Leg Raise Achilles Reflex (S1) Normal Abnormal Not Tested
Right Positive Negative
13. Motor (conductive) Tests
Left Positive Negative
a. L5
b. Passive Femoral Stretch Test Ankle dorsi -flexion Normal Weak Not Tested
Right Positive Negative Not Tested Hip Abductor Normal Weak Not Tested
Left Positive Negative Not Tested Extensor Hallucis Longus Normal Weak Not Tested
10. Lower Motor Function
b. SI
Saddle sensation Normal Abnormal
Flexor Hallucis Longus Normal Weak Not Tested
Rectal (as needed) Normal Abnormal
Gluteus Maximus Normal Weak Not Tested
11. Plantar Response
Flexor(normal) Extensor (positive Babinski)
Diagnosis and Treatment
Pattern 1 Pattern 2 Pattern 3 Pattern 4 + Pattern 5
Co-Morbidities:__________________________________________________________________________________________________________________
Comments:_____________________________________________________________________________________________________________________
Refer directly to surgeon if “Red Flags” are present, or to Spine Pathway clinic if “No Improvement” at follow up.
I hereby refer the above noted patient for referral to the Saskatchewan Spine Pathway Clinic and to a Spine Surgeon as appropriate.
If surgical referral indicated following Spine Pathway Clinic assessment, please refer to:
Next available surgeon Specific surgeon*: _____________________

*Please note that if specific surgeon is selected, wait time may be longer than for next available surgeon.
I am referring to: Community Rehabilitation Chiropractor Physio Therapist Other___________________

Referring Practitioners Name: __________________________________ Discipline: _______________
Practitioner’s Address: ___________________________________________________________________
Practitioner’s Signature: _________________________________________ Date: / /

SPINE CLINIC PHONE NUMBERS: (306) 766-7025 Regina, (306) 655-7644 Saskatoon
April 14, 2016
PART 3: PATTERNS OF PAIN
APPROACH
 Managing Low Back Pain: A Different Approach

 Quick Reference Triage Algorithm
Managing Low Back Pain: a different approach
Why do we need a different approach to “Distinct patterns of reliable clinical findings are
managing patients with low back pain? the only logical basis of back pain
Because the way we are doing things does not categorization and subsequent treatment.”
address the problem. It doesn’t give the Quebec Task Force 1987
patient what the patient wants: History:
 Rapid pain relief
The key to the initial treatment is identifying
 Reassurance
the correct syndrome, and identifying the
 A clear picture of what is going to happen
correct syndrome requires a precise history.
The results of our failure can be seen in the The two essential questions are:
increasing popularity of alternative options and  Where is your pain the worst? That means
the length of the waiting list to see a spine is it back or leg dominant. Pain that is
surgeon. As a triage tool for low back pain, the dominant above the gluteal fold is back-
medical paradigm doesn’t work. We can dominant pain. Pain that is dominant below
identify the specific patho-anatomic source of the gluteal fold is leg-dominant pain.
the pain in only 20% of back pain patients. Or  Is your pain constant or intermittent? That
to put it another way, we cannot give a question must be asked in two parts:
diagnosis in 80% of back pain patients and with o Is there ever a time when your pain
the medical paradigm, we need a diagnosis in stops, even though it comes back
order to treat. immediately?
Imaging the spine doesn’t help. There is no o When your pain is gone, is it totally and
correlation between the degenerative changes completely gone?
seen on plain x-ray and the presence of back Back dominant, truly intermittent pain is the
pain. CT has a 30% false positive rate. MRI has result of a benign mechanical condition. If the
a 60-80% false positive rate. Even identified pain is constant, consider malignancy, systemic
pathology has a weak connection to the clinical conditions and disease, or pain disorder. If
response to treatment. none of these are present, the pain can be
The good news is the medical paradigm doesn’t considered constant mechanical pain.
matter. Over 90% of back pain is the result of
minor alterations in spinal mechanics -- so most The remaining questions are:
back pain is mechanical. Mechanical pain is:  What are the aggravating movements or
 Related to movement positions?
 Related to position  What are the relieving movements or
positions?
 Related to a physical structure
 Have you had this same pain before?
There is another way. Distinct patterns of  What treatment have you had before?
reliable clinical findings are syndromes. A  What can’t you do now that you could do
syndrome is a constellation of signs and before you got the pain?
symptoms that appear together in a consistent
manner and respond to treatment in a
predictable fashion.
Adapted from “A Syndrome Approach to Low Back Pain” lecture by Hamilton Hall MD FRCSC Professor, Department of
Surgery, University of Toronto; Hall H, McIntosh G, Boyle C “Effectiveness of a Low Back Pain Classification System” The
Spine Journal, vol. 9, no. 8, 2009, pp. 648–657
Physical Examination: o Ankle reflex
 with the patient kneeling
The precise history must be supported by an
o Plantar flexion
accurate physical examination. The physical
 separately and together
examination is not an independent event. It is
designed to support the history and should
contain the elements that verify or refute the Two essential questions and
patient’s story. The examination includes: two essential tests:
Observation Question: Where Question: Is your pain
 General activity and behaviour is your pain the constant or
 Back specific: worst? intermittent?
o Contour
o Color Test: Plantar Test: Saddle sensation --
o Scars response -- an a lower sacral nerve
upper motor test. roots test. These are the
Movement There is never an roots that control the
 Flexion upper motor bowel and bladder
 Extension finding in low sphincters. This test is a
back pathology. reminder to always ask
Nerve root irritation tests about a change in bowel
 Straight leg raise test or bladder function.
o Passive test - the examiner lifts the leg
o Reproduction of the typical leg pain
o Reproduction of back pain is not Red Flags
relevant Every red flag listed has already been covered
o Produced at any degree of leg in the history and physical examination or will
elevation be revealed in the subsequent indicated
 Femoral stretch test treatment.
o Passive test - the examiner lifts the leg  Sphincter disturbance: bowel and bladder
o Patient prone with the knee extended  History of cancer
o Reproduction of the anterior thigh pain  Unexplained weight loss
o Back pain is common and not relevant  Immunosuppression
 Intravenous drug use
Nerve root conduction tests
 Recent onset of structural deformity
 L5
 Recent or on-going infection
o Hip abduction
 Trendelenburg test  Fever
o Ankle dorsiflexion  Night sweats
 with the patient seated, foot on floor  Non mechanical pattern of pain
 identify voluntary release  Constant pain
o Extensor hallicis longus  Widespread neurological signs or symptoms
 separately and together  Disproportionate night pain
 S1  Lack of treatment response
o Hip extension  Thoracic dominant pain
o palpate gluteus maximus muscle tone  History of infections such as tuberculosis,
o Flexor hallicis longus HIV, etc
 separately and together
2
Four Mechanical Patterns = Physical Examination:
Four Mechanical Syndromes  Back dominant pain
 Worse with extension
 No effect or better with flexion
Start with the patterns
If there is a pattern and it responds as it should,  Neurological examination is normal or non-
you have your solution. contributory
There is usually a pattern if you look. Pattern 3

History:
If you pick the wrong pattern, there will be no  Leg dominant pain
positive treatment response. o below the gluteal fold
 Affected by back movement or position
You have time to change your diagnosis and
 Constant
start again.
If there is no pattern or if the pattern does not
 Leg dominant pain
respond to the correct treatment, that is the
time to consider Red Flags.  Affected by back movement or position
 Positive neurological findings
o irritative test
Pattern 1 o and/or conduction loss
History:
 Back dominant pain Pattern 4
o back History:
o buttock  Leg dominant pain
o coccyx  Worse with activity in extension
o greater trochanter  Better with rest in flexion
o groin  Always intermittent
 Worse with flexion
 Constant or intermittent
 Negative irritative tests
Physical Examination:  Possible conduction loss
 Back dominant pain
 Worse with flexion Pain Control Strategies
 Better with unloaded passive extension
General principles
(Pattern 1 Fast Responder)
 Education
 Worse with extension loaded or unloaded
(Pattern 1 Slow Responder)  Counter-irritation
 Neurological examination is normal or non-  Posture correction
contributory  Direction specific movement
 Medication
Pattern 2
Avoid information overload. One activity done
History:
well is better than two activities done poorly.
 Back dominant pain
The patient must do frequent sessions of any
 Worse with extension
prescribed activities on a fixed schedule during
 Never worse with flexion
the day.
 Always intermittent
3
Pattern 1 Fast Responder  Standing step flexion:
Postural correction o Stand with one foot up and push off
 While sitting with hands on the knee
o lumbar roll
 While lying Pattern 3
o night roll Postural correction
o large pillow between the knees  Scheduled rest for a set number of minutes
every hour during the day.
Direction specific movement  Specific rest positions
 In lying: o Z lie
o unloaded prone passive extensions: lock o prone over several pillows
the elbows, keep the hips on the table,
sag the back The schedule must be strictly followed. Expect
 In standing: improvement weekly. Add narcotic medication
o Lean over the back of a large chair. as required.
Pattern 4
If standing extension doesn’t work in the office,
it won’t work at home.  Improved posture control.
o abdominal strengthening
o core strengthening
Pattern 1 Slow Responder o pelvic tilt
Postural correction
 While sitting Very gradual improvement – the first three
o lumbar roll months are “an act of faith”. There must be a
 While lying long term commitment.
o night roll
o large pillow between the knees
Follow Up: Is it working?
Direction specific movement Mechanical pain responds quickly and
All Pattern 1s aim for prone passive extensions. predictably. If you don’t see progress, recheck:
Pattern 1 SRs need to start slowly.  Location of the typical pain
 Begin with unloaded flexion positions  Intensity of the typical pain
(knees to chest)  Frequency of the pain-free periods
 Progress to unloaded flexion movement  Effect of the recommended treatment
(tucks) Unresponsive Patterns 3 and 4 are usually
 Progress to unloaded extension position excellent surgical candidates.
(prone over pillows)
If a movement worked in the office it should
 Finally progress to prone passive extensions
work at home. So why is there no progress? It is
Pattern 2 possible that the patient didn’t do activities, did
Postural correction activities wrong, or did something else to bring
 While lying on the pain.
o large pillow between the knees
Remember the goal is control, not cure.
Direction specific movement Mechanical back pain is not a disease.
 Sitting flexion:
o bend forward between the knees and
push up with the arms, hands on knees
4
QUICK REFERENCE TRIAGE ALGORITHM
Patterns of Low Back Pain
DESCRIPTIVE SYMPTOMS FINDINGS ON OBJECTIVE ASSESSMENT

Pattern 1: Back dominant pain aggravated by flexion
 Low back dominant pain: felt most intensely This pattern is divided into two groups:
in the back, buttock, over the trochanter or  Fast Responders: Increased pain on flexion
in the groin and relief with lumbar extension
 Pain is always intensified by forward  Slow Responders: Increased pain on
bending or sustained flexion flexion and on extension
 Pain may be constant or intermittent The neurological examination is normal or
 No relevant neurological symptoms non-contributory
Pattern 2: Back dominant pain aggravated only by extension
 Low back dominant pain; felt most intensely The neurological examination is normal or
in the back, buttock, over the trochanter or non-contributory
in the groin
 Pain is NEVER intensified with flexion
 Pain is always intermittent
 No relevant neurological symptoms
Pattern 3: Constant leg dominant pain
 Leg dominant pain: felt most intensely below Never give exercises to a Pattern 3
the gluteal fold above or below the knee
 Pain is always constant Neurological examination must be positive for
 Neurological symptoms must be present either an irritative test or a newly acquired
focal conduction deficit.
Pattern 4: Intermittent leg dominant pain aggravated by activity
 Leg dominant pain: felt most intensely below Neurological examination at rest is normal or
the gluteal fold above or below the knee identifies an established focal conduction
 Pain is brought on by activity and relieved defect.
by rest in flexion
 Pain is always intermittent  negative irritative test
 Neurological symptoms are usually absent at  possible conduction loss
rest  straight leg raise is negative
 Generally found in patients over 50 – often  pheasant test (test pre/post dorsi flexion
associated with degenerative changes in the with resistance)
spine
Please see corresponding Treatment Algorithm (Patterns 1-5) for treatment schedules
Follow-up questions:
1. Ask the patient – Did it work?
2. Location of Pain
3. Intensity of Pain
4. Frequency of Pain periods
5. Effect of the recommended treatment
PART 4: PATTERN-SPECIFIC
TREATMENT ALGORITHMS AND
PATIENT HAND-OUTS
 Pattern 1: Back Dominant Pain Aggravated by Flexion

 Pattern 2: Back Dominant Pain Aggravated by Extension
 Pattern 3: Constant Leg Dominant Pain
 Pattern 4: Intermittent Leg Dominant Pain
 Pattern 5: Pain Disorder (no patient hand-out)
 General Recommendations for Maintaining a Health Back
Saskatchewan Low Back Pain Pathway
Primary Care Provider Treatment Algorithm
Pattern 1: Back Dominant Pain Aggravated by Flexion

Descriptive Symptoms
Low back dominant pain: felt most intensely in the back, buttock, over the trochanter or in the groin.
Pain is always intensified by forward bending or sustained flexion.
Pain may be constant or intermittent
No relevant neurological symptoms
Findings on Objective Assessment

This pattern is divided into two groups:
 Fast responders: Increased pain on flexion and relief with prone lumbar extension.
 Slow responders: Increased pain on flexion and on extension.
The neurological examination is normal or non-contributory
Initial Treatment
1. Reassure patient. Provide patient with Back Pain: Patient Information and Pattern 1: Patient Handout
2. Instruct patient to follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies
Positions:
Slow Responder: Constant Pain: Slow Responder: Intermittent Pain: Fast Responder:
“Z” lie ”Z” lie ”Z” lie
Knees to Chest Minimal lumbar support Use lumbar support when sitting
Lie prone: pillow under pelvis Lumbar night roll Place one foot on stool when
Prone Lie standing
Movement:
Slow Responder: Constant Pain: Slow Responder: Intermittent Pain: Fast Responder:
Progress to Sloppy Pushup Progress to Sloppy Pushup Sloppy Pushup is mainstay of
Avoid loaded flexion activity (Perform 10 reps every
hour as the benefits are short-
lived).
Typical Therapy Options:
Pharmacologic Therapy Non-Pharmacologic (Adjunct) Therapy
Acetaminophen Spinal Manipulation Yoga
NSAIDS Exercise Therapy Apply Ice/Heat
Massage Progressive Relaxation
Acupuncture
Schedule 1: Follow Up: One to two days after beginning therapy

1. Assess treatment response
 Assess pain medication and treatment modalities
 Assess improvement:
Better = decreased pain or pain is becoming more centralized
Worse = increased pain or pain moving down the legs
2. Has there been clinical improvement?
Significant Improvement
It is anticipated that a significant percentage of patients will have experienced considerable resolution of symptoms
within seven days.
 Provide patient with exercise and stretching information
 Encourage patient to follow back care wellness program
 If necessary, advise gradual return to work program
Limited Improvement
 Continue to treat – see Schedule 2
 Patients experiencing intermittent pain at reassessment continue to treat as Fast Responders
No Improvement
 Patients with increased pain or radiation of pain into the legs should be referred to the Multi Disciplinary Clinic
Material developed by the Saskatchewan Spine Pathway Working Group and should not be republished
without the permission of the Saskatchewan Ministry of Health.
Schedule 2: For patients with limited improvement in first week of treatment
Positions:
Slow Responder Fast Responder:
Maintain a rigid schedule of rest and movement Increase lumbar support
Use lumbar support when recumbent
Movement:
Slow Responder: Fast Responder:
In addition to initial therapies add asymmetric Improve techniques and increase frequency
movements and core stability exercises (Back Schedule Sloppy Pushup
Pain: Patient Information)
Avoid flexion
Follow Up: Two weeks after beginning Schedule 2

Has there been clinical improvement?
Improvement
Fast Responders:
 Provide patient with exercise and stretching information
 Encourage patient to follow back care wellness program
 If necessary, advice gradual return to work program
Slow Responders:
 Continue to treat following guidelines for Fast Responder: Schedule 2
No Improvement
 If patient has no improvement, refer to the Multi Disciplinary Clinic.
Material developed by the Saskatchewan Spine Pathway Working Group and should not be republished
without the permission of the Saskatchewan Ministry of Health.
Pattern #1 - Patient Education
Symptoms
✓ Pain is worst in the back, buttocks, upper thigh,
or groin but may radiate to the legs.
✓ Pain may be constant or intermittent.
✓ Pain is worse when sitting or bending forward.
✓ Pain may be eased by bending backwards.

Walking and standing are better than sitting.
❑ Knees to Chest:
Positions and Exercises • Lie on back with knees bent and feet
The following rest positions can be used at home to rest flat on the floor
your back and reduce pain. Your health care provider • Slowly, bring knees up towards chest. Bringing the
will check the boxes next to the positions and exercises legs up one at a time makes it easier.
recommended for your condition. • Wrap arms behind knees and pull toward chest.
Hold for ___ minutes every ____ hour(s).
❑ Supine Lie:
• Lie on back, knees and head resting on pillows.
Rest for ____ minutes every ____ hour(s).
❑ “Z” Lie:
• Lie with back flat on floor, head supported
by a pillow.
• Put feet on a chair with knees bent at more than a
90º angle. (May support buttocks with a pillow.)
Rest for ___ minutes every ____ hour(s).
❑ Prone Lie:
• Lie on stomach. Use three pillows to support hips.
❑ Lumbar Roll -
Sitting:
• Use a straight backed
chair and ___ cm
(__ inch) lumbar roll
to support curve of ❑ Lumbar Roll - Night:
the back. • Use lumbar night roll under mid-back when
Rest for ___ minutes sleeping to support curve of the back.
every ____ hour(s).
Other Care Information

For the first few days, you may only be able to lie on your stomach (see Prone Lie). Progress to prone extension using your
arms, at your health care provider’s recommendation.
❑ Sloppy Pushup:
• Lie on stomach with hands on either side of head.
• Keep lower body on floor and use arms to slowly raise
upper body. (Hands may need to be positioned above head
to fully extend elbows, while pelvis remains on the floor.)
• Keep back muscles relaxed.
• Perform ____ repetitions every ____ hours for ____ days.
Rest for ____ minutes every ____ hour(s).
To strengthen your back muscles, your care provider may prescribe other exercises and stretches.
Please see General Recommendations for Maintaining a Healthy Back: Patient Information.
• Your back will feel better when you walk or stand rather than sit. Schedule ____ minutes of walking every ____hour(s).
• When standing, place one foot on a stool to relieve pressure on your back.
Switch feet every 5 to 15 minutes. Maintain good posture.
• Avoid rolling your spine forward. This may put more pressure on the painful areas and increase your discomfort.
Comments
Material was developed by the Saskatchewan Spine Pathway Working Group and should not be republished without April 2010
the permission of the Saskatchewan Ministry of Health.
Pattern 2: Back Dominant Pain Aggravated by Extension

Low back dominant pain; felt most intensely in the back, buttock, over the trochanter or in the groin.
Pain is never intensified with flexion.
Pain is always intensified by extension
Pain is always intermittent.
No relevant neurological symptoms.

Increase pain on extension
Never increased pain on flexion
The neurological examination is normal or non-contributory
Initial Treatment
2. Instruct patient to follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies.
Positions: Movement:
”Z” Lie Repeated supine flexion (Knees to chest)
Supine knees to chest Repeated seated flexion (Use hands on thighs to push upper body into
Correct sitting and standing postures upright position)
Avoid extension as required
Acetaminophen Spinal Manipulation
NSAIDS Exercise Therapy
Massage
Acupuncture
Yoga
Apply Ice/Heat
Follow Up: One to two days after beginning therapy

Better = decreased pain or pain is becoming more centralized
Worse = increased pain or pain moving towards the periphery
 Movement should begin to restore within one or two days. Full function is expected in two to three weeks
 If necessary, advice gradual return to work program
Limited Improvement
 Continue treatment. Use Pattern 1: Slow Responder
 Improve techniques
 Introduce manual therapies
No Improvement
 Reconsider pattern selection
 If patient has no improvement, refer to the Multi Disciplinary Clinic
Material developed by the Saskatchewan Spine Pathway Working Group and should not be republished without the
permission of the Saskatchewan Ministry of Health.
Symptoms
✓ Pain is worst in the lower back and
may spread to buttocks or legs.
✓ Pain is always intermittent.
✓ Pain is worse when bending backward and when

standing or walking for extended periods.
✓ Pain may be eased by bending forward

or sitting.
❑ Knees to Chest:
Positions and Exercises • Lie on back with knees bent and feet
flat on the floor
The following positions and exercises can be done at
• Slowly, bring knees up towards chest. Bringing the
home to rest your back and reduce pain. Your health
legs up one at a time makes it easier.
care provider will check the boxes next to the positions
• Wrap arms behind knees and pulling toward chest.
and exercises recommended for your condition.
Hold for ___ minutes every ____ hour(s).
❑ “Z” Lie:
• Lie with back flat on floor, head supported ❑ Sitting Flexion:
by a pillow. • Sit with feet flat on the floor, about hip-width apart.
• Put feet on a chair with knees bent at more than a • Lean forward to rest stomach on lap. Allow arms
90˚ angle. (May support buttocks with a pillow.) and head to hang near feet.
Rest for ___ minutes every ____ hour(s). • With hands on knees, use arms to raise upper body.
Hold for _____ seconds. Do _____ repetitions.

Progress to these exercises at your health care provider’s recommendation.
❑ Trunk Flexion Stretch (sustained flexion):

• Kneel on hands and knees.
❑ Knees to Chest Stretch:
• Tuck in chin and arch back. • Lie on back with knees bent and feet flat on floor.
• Slowly sit back on heels, dropping shoulders • Raise one knee to chest and slowly raise the other to
towards floor. meet it. (Use hands to lift knees if necessary.)
• Place hands around knees and pull gently to chest.
Hold for ____ seconds, then relax.
Press back firmly against floor by flexing stomach
Do ____ repetitions.
muscles.
Hold for ____ seconds, then relax.
Your health care provider may recommend other exercises and stretches. Please see General Recommendations for
Maintaining a Healthy Back: Patient Information.
• When standing up, reduce unnecessary load on the spine by using your arms on your thighs to push your upper body
into an upright position.
• Avoid extension: Do not bend your back backwards. This may cause more pain.
Comments
Pattern 3: Constant Leg Dominant Pain

Leg dominant pain: felt most intensely below the gluteal fold above or below the knee.
Pain is always constant.
Neurological symptoms must be present

Neurological examination must be positive for either an irritative test or a newly acquired focal conduction deficit.
Initial Treatment
NOTE: Pattern 3 will not respond to exercise. Treatment consists of prescribed REST positions.
Track progress over six weeks (Neurological deficit beyond seven days does not happen unless it is Cauda
Equina Syndrome).
2. Instruct patient to follow appropriate treatment schedule: position, pharmacology and adjunct therapies.
Positions:
Basis of treatment is scheduled rest: 20-40 minutes every hour
“Z” lie
Prone lying on pillows
Prone lying on elbows
Rest on hands and knees
Lumbar support
Night roll

Acetaminophen Massage Progressive Relaxation
NSAIDS Acupuncture Professionally administered invasive therapies
Tramadol, Opiods Apply Ice/Heat Spinal Manipulation(if there is no inflammation)
Follow Up: One to two weeks after beginning therapy

Better = decreased leg pain
Worse = increased leg pain
 Focus on symptom reduction for up to six weeks.
 Pain should begin to resolve within four weeks
 Once leg symptoms become intermittent or pain becomes back dominant continue treatment as per Pattern 1.
No Improvement
Symptoms
✓ Pain is mainly in the legs but back pain
may be present.
✓ Pain is constant.
✓ Pain is often worse when sitting or bending,

but in the acute stage can be made worse by
❑ Prone Lie:
• Lie on stomach. Use three pillows to support hips.
any movement.
(May support hips and head with pillows.)
✓ Pain may be lessened in some rest positions. Rest for ___ minutes every ____ hour(s).
✓ The best position is the one that most reduces
the leg pain.
✓ There is no place for exercise or repeated

movements.
Positions and Exercises

The best treatment is to schedule rest periods throughout
the day. Lie down for _____ minutes each hour. Find
the rest position that best reduces leg pain. Long-term ❑ Prone Lie on Elbows:
bed rest is not recommended and can hinder recovery. • Lie face down on floor or bed.
Your health care provider may prescribe other medical • Bend elbows and relax.
therapies to decrease pain and will check the boxes next
Rest for ______ minutes every ___ hour(s).
to the positions recommended for your condition.
❑ “Z” Lie:
❑ Rest on Hands and Knees:
• Lie with back flat on floor, head supported • Kneel on hands and knees on floor or bed.
by a pillow.
• Put feet on a chair with knees bent at more than a Rest for ______ minutes every ___ hour(s).
90º angle. (May support buttocks with a pillow.)
❑ Lumbar Night Roll:

• Wrap a night roll securely around waist when
sleeping to support spine. ❑ Lumbar Support When Sitting:
• Use a straight backed chair and __ inch (__ cm)
lumbar roll to support curve of back.
Please see General Recommendations for Maintaining a Healthy Back: Patient Information for more information about
back care. Your health care provider may recommend stretches and exercises to strengthen your back and core muscles.
Comments
Pattern 4: Intermittent Leg Dominant Pain

Leg dominant pain: felt most intensely below the gluteal fold above or below the knee.
Pain is worse with activity in extension and better with rest and flexion.
Pain is always intermittent.
Neurological symptoms are usually absent at rest.
Generally found in patients over 50 – often associated with degenerative changes in the spine

There are no acute irritative findings.
Neurological examination at rest is normal or identifies an established focal conduction defect.
Initial Treatment
2. Instruct patient to follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies
Positions: Movement:
Generally relieved rapidly with rest and flexion Modification of daily routine
Pelvic tilt Regular, continued flexion-strengthening exercises is the most
Correct sitting and standing postures effective physical treatment
Increase trunk strength in the abdominal oblique and paraspinal
muscles

Acetaminophen Exercise Therapy
NSAIDS Massage
Acupuncture
Yoga
Apply Ice/Heat
Progressive Relaxation
Follow Up: Treat for one to two months before follow-up

Better = Increased walking distance
Worse = Decreased walking distance
 Treatment requires an extended period of increasing strength and range of motion
 Patient should have a quick return to work with no modification or review
Limited Improvement
 Continue with treatment
 Improve exercise techniques
 Stationary cycling in flexion
 Increase frequency of rest/exercise cycles
No Improvement
Symptoms
✓ Pain is worst in legs and can be described as
heaviness or aching.
✓ Pain is intermittent and is made worse by

activity (often walking).
✓ Pain is relieved by a change in position, usually

by bending forward.
Positions and Exercises

Pain should be relieved quickly with proper rest and
flexion. When pain occurs in your legs, sit in a chair and
❑ Pelvic Tilt
lean forward until it subsides (see Sitting Flexion). Your • Lie on back, knees bent, arms on chest or at sides.
health care provider will check the boxes next to the • Place feet flat on floor, hip-width apart, with knees
positions and exercises recommended for your condition. slightly closer together than feet.
• Tighten abdominal muscles.
• Press small of back against floor, causing front of
pelvis to tilt forward.
Hold for ____ seconds and then relax.
❑ Single Leg Abdominal Press:

• Lie on back with knees bent.
• Keep back in a neutral position and tighten
abdominal muscles.
• Lift one leg so knee and hip are at a 90˚ angle.
• Press one hand against the knee while pulling it
towards the hand. Keep elbow straight.
Hold for ____ seconds. Return to start position and
repeat with opposite leg. Do ___ repetitions.
❑ Sitting Flexion:
• Sit with feet flat on the floor, about hip-width apart.
• Lean forward to rest stomach on lap. Allow arms
and head to hang near feet.
Hold for _____ seconds. Do _____ repetitions.
❑ Partial Sit Up or Crunch:

• Lie on back with knees bent, feet flat on floor and
arms crossed over chest.
• Using lower stomach muscles, raise head and
shoulders slightly until shoulder blades are just off
floor. (You may not be able to get up this far at first.)
Hold for ___ seconds. Relax. Do ___ repetitions.

The most effective treatment of your condition is a long-term
regular exercise program, focused on increasing strength in
❑ Cat and Camel: your core muscles. Your health care provider may recommend
• Kneel on hands and knees. exercises and stretches. (See General Recommendations for
• Arch back, letting head drop slightly. Maintaining a Healthy Back: Patient Information)
• Keep abdomen and buttock muscles tightened.
Hold for ____ seconds.
Comments
• Let back sag towards floor while keeping arms
straight and weight evenly distributed between legs
and arms.
Hold for ____ seconds. Do ____ repetitions.
Pattern 5: Pain Disorder

Objective of Assessment:
 To specify the environment or situations in which Pain Disorder occurs

 To identify precursor (antecedent) factors that influence behaviour
 To identify consequent factors that influence behaviour
Assessment
Complete history as per Primary Care Provider Assessment Tool
LIFESTYLE QUESTIONNAIRE identifies possible need to ask the following questions:
1. Do you have pain that has lasted longer than three months?
Yes No
2. Does your pain keep you from doing the work, play or daily activities you want to do?
Yes No
3. Has your doctor ruled out surgery?
Yes No
IF YES, THEN CONTINUE
Subjective History
4. Do you:
Need assistance with personal care?
Blame others for your situation?*
Have constant pain?
Demand a physical diagnosis?
Have an expanding array of symptoms?
Have a high perceived level of disability?
Receive financial compensation? *
5. Have you:
Sought legal consultation (union, worker reps)?*
Have multiple medical consultations?
Had negative family/workplace/social situations? *
Had poor medication response?
Experienced sexual dysfunction?
Had sleep disturbances? *
6. Are you:
Unemployed?
Experiencing unexplained deterioration
The greater the number of positive responses, the higher the probability of a Pain Disorder.
* If all five history points are present the risk of pain disorder is 99% (Treating the Patient with Pain Disorder, The CBI
Method)
Complete physical as per Primary Care Provider Assessment Tool
Check Waddell’s Signs (More than three of four groups support a diagnosis of Pain Disorder):
Superficial and widespread tenderness or nonanatomic tenderness.
Stimulation tests: Axial loading and pain on simulated spinal rotation.
Distracted straight leg raise and double straight leg raise lower than single straight leg raise.
Non-anatomic or regional sensory changes.
Diagnosis
If assessed as Pain Disorder, refer to Multi Disciplinary Clinic. Provide assessment results with referral.

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Saskatchewan Spine Pathway

Low Back Pain

Revised April 2018

Part 1: Live Presentation

 Presentation Slides April 2018

Part 2: Saskatchewan Spine Pathway Tools

 Spine Pathway Triage Algorithm

Part 3: Patterns of Pain Approach

 Managing Low Back Pain: A Different Approach

Part 4: Pattern-Specific Treatment Algorithms & Patient Exercise Hand-outs

 Pattern 1: Back Dominant Pain Aggravated by Flexion

 Spine Pathway provider web pages www.sasksurgery.ca/provider/spine.html

 LiveWell with Chronic Pain (LWCP) www.saskatchewan.ca/residents/health/diseases-and-

 Online Therapy Unit - www.onlinetherapyuser.ca free online cognitive behavior therapy

Bishop PB & Wing PC. Spine J. 2006;6(3):282-8.

Klein BJ, et al. Spine. 2000; 25(6):738-40.

Harte, Arch Phys Med, 2003

Arthritis & Rheumatism 2009

What is the significant pattern of pain?

Pattern 1 fast responder

Pattern 1 slow responder

What is the significant pattern of pain?

Pattern 1 fast responder

Pattern 1 slow responder

What is the significant pattern of pain?

Pattern 1 fast responder

Pattern 1 slow responder

What is the significant pattern of pain?

Pattern 1 fast responder

Pattern 1 slow responder

What is the significant pattern of pain?

Pattern 1 fast responder

Pattern 1 slow responder

What is the significant pattern of pain?

Pattern 1 fast responder

Pattern 1 slow responder

 Spine Pathway Triage Algorithm

Pattern diagnosis and treatment algorithm*

Red flags? yes

Reassessment of pattern diagnosis and treatments*

Address: HOME ADDRESS CITY/PROVINCE

Phone: - - Alt. Phone: - -

Next available surgeon Specific surgeon*: _____________________

I am referring to: Community Rehabilitation Chiropractor Physio Therapist Other___________________

Practitioner’s Signature: _________________________________________ Date: / /

 Managing Low Back Pain: A Different Approach

There is usually a pattern if you look. Pattern 3

DESCRIPTIVE SYMPTOMS FINDINGS ON OBJECTIVE ASSESSMENT

 Pattern 1: Back Dominant Pain Aggravated by Flexion

Pattern 1: Back Dominant Pain Aggravated by Flexion

Findings on Objective Assessment

Schedule 1: Follow Up: One to two days after beginning therapy

2. Has there been clinical improvement?

Follow Up: Two weeks after beginning Schedule 2

✓ Pain may be constant or intermittent.

✓ Pain is worse when sitting or bending forward.

✓ Pain may be eased by bending backwards.

Other Care Information

Pattern 2: Back Dominant Pain Aggravated by Extension