Number 443, pp. 147–155
                                                                                                   © 2006 Lippincott Williams & Wilkins

                            Triage for Nonspecific Lower-back Pain
                               Sherri Weiser, PhD*; and M. Rossignol, MD, MSc, FRCPC†

Unremitting lower-back pain has long been a costly and per-                         specific lower-back pain totaled almost 15 million, making
sonally devastating problem in society. Guidelines for the                          it the fifth highest reason for a doctor’s visit.13 Only 10%
treatment of lower-back pain have provided evidence-based                           of these patients will have pain that persists longer than six
recommendations to help identify patients who will benefit                          weeks. However, this minority consumes eighty percent of
from specific types of treatment in an effort to reduce costs
                                                                                    back–pain-related costs.14
and human suffering. However, there is little evidence that
these guidelines are being applied in the daily practice of
                                                                                        Evidence-based guidelines for the treatment of lower-
health care providers. Practical information is required to                         back pain have been developed to provide a uniform al-
assist health care providers in triaging patients for specific                      gorithm for identifying patients that will benefit from spe-
treatments so that interventions can be targeted only to those                      cific diagnostic tests and treatments.2,3 A review of guide-
who need them. In this way, iatrogenic complications and                            lines developed in 11 different countries concludes that
unnecessary costs can be contained. This chapter provides                           their recommendations are quite similar.23 By targeting
information on how to triage the patient with nonspecific                           treatment only to those patients who need it, iatrogenic
lower-back pain for optimal care. The recommendations are                           complications and unnecessary costs can be minimized.
supported by evidence-based guidelines, and when these are                              Although treatment guidelines are a giant step forward
not available, best practice principles. Because appropriate                        the few investigations into the practical application of
treatment varies depending on the length of time a patient is
                                                                                    these guidelines suggest they are not being followed
suffering from lower-back pain, the chapter is divided into
recommendations for acute, subacute, chronic and recurrent
                                                                                    closely.6,7,11,18 Because they offer information only if
phases of lower-back pain.                                                          there is reasonable empirical evidence to endorse a par-
                                                                                    ticular treatment or procedure, there are gaps associated
Level of Evidence: Level V (expert opinion). See the Guide-                         with many of the recommendations, leaving them open to
lines for Authors for a complete description of the levels of                       interpretation. For example, there are ambiguities about
                                                                                    exactly which psychological and social factors should be
                                                                                    assessed and when this should be done. In addition, exer-
                                                                                    cises are recommended, but no specific suggestions are
Lower-back-pain–related costs and disability remains a
                                                                                    provided as to which ones should be used, at what inten-
growing problem in western cultures, despite efforts to
                                                                                    sity and for how long. These limitations open the door for
address the problem. Although specific lower-back pain
                                                                                    different interpretations of the guidelines and may be one
that is characterized by fracture, tumor, infection, cauda
                                                                                    reason why there is insufficient adherence to their recom-
equina syndrome, or systemic disease is a more serious
medical condition, nonspecific lower-back pain comprises
                                                                                        In order to triage patients with lower-back pain success-
the majority of complaints.3 In 1990, office visits for non-
                                                                                    fully for treatment, it is necessary to delineate a consistent
                                                                                    way of identifying patients who may be at risk for delayed
From the *Departments of Orthopaedic and Environmental Health Sciences,             recovery. When high quality, empirically-based evidence
School of Medicine, New York University, New York, NY; and the †De-
partment of Epidemiology, Biostatistics and Occupational Health and Mon-            is not available, health care providers must rely on best
treal Department of Public Health, McGill University, Montreal, Canada.             practice procedures to guide treatment. We combine
Each author certifies that he or she has no commercial association (eg,             guideline recommendations with best-practice approaches
consultancies, stock ownership, equity interest, patient/licensing arrange-
ments, etc.) that might pose a conflict of interest in connection with the          to provide practical information about how to triage pa-
submitted article.                                                                  tients with lower-back pain and obtain optimal results.
Correspondence to: Sherri Weiser, PhD, Research Assistant Professor, De-
partments of Orthopaedic and Environmental Health Sciences, School of               What is Triage?
Medicine, New York University, 63 Downing Street, New York, NY 10014.
Phone: 212-255-6690; Fax: 212-255-6754; E-mail:                       Triage may be described as “sorting and allocating aid on
DOI: 10.1097/                                             the basis of need for or likely benefit from medical treat-


   Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics
148    Weiser and Rossignol                                                                             and Related Research

ment.”29 In the case of nonspecific lower-back pain, the           The potential of iatrogenic damage exists when physi-
assumption is that pain will progress according to the natu-    cians prescribe unnecessary treatment and diagnostic tests.
ral history of lower-back pain unless certain signs or          For example, prescription medications can cause side ef-
symptoms associated with poor outcome are present. If           fects or become habit forming. Also, xrays or magnetic
present, these signals represent the possibility of delayed     resonance imaging (MRI) tests may reveal common ab-
recovery or chronicity and the need for specific interven-      normalities that do not alarm the physician but can be a
tions.                                                          great cause of concern for the patient. Abenhaim et al1
   The terms “triage” and “screening” sometimes have            speculate that one reason that a specific diagnosis for
been used interchangeably when referring to the identifi-       lower-back pain results in chronicity is the label itself,
cation of patients with acute nonspecific lower-back pain       regardless of the presence or absence of a physical lesion.
whose pain is likely to become chronic. However, screen-
                                                                Phases of Nonspecific Lower-back Pain
ing usually is defined as “the examination of a group of
usually asymptomatic individuals to detect those with a         Phases of nonspecific lower-back pain are defined by the
high probability of having or developing a given dis-           time from the onset of the current episode of pain. The
ease.”35 The goal of clinical screening is to identify indi-    distinct phases have predictive value in that there is a
viduals who may be at risk of developing lower-back pain.       relationship between the duration of pain and a patient’s
Although authors of some studies indicate that certain psy-     prognosis. For the outcome of “return to work” for ex-
chosocial factors can identify healthy individuals at risk      ample, an individual who has been out of work fewer than
for nonspecific lower-back pain, the effect is small.23 Cur-    3 months has better than a 90% chance of returning. At 1
rently, there is no evidence that clinical screening for the    year out of work the odds decrease substantially, and at
risk of nonspecific lower-back pain is of any value. Con-       two years, there is almost no chance of a patient returning
currently, efforts at primary prevention that target clinical   to work. Because the patient profile is different in each
factors largely have been unsuccessful.31                       phase, the goal of triage may vary. Therefore, each phase
   The goal of triage is to maximize the benefits of treat-     will be discussed separately.
ment and to minimize unnecessary costs and suffering               We will address triage of nonspecific lower-back pain
associated with undertreating or overtreating a patient with    in four phases; acute, subacute, chronic, and recurrent. The
nonspecific lower-back pain. There are a number of physi-       acute phase refers to a patient with pain up to 4 weeks after
cal, psychological, and social factors that have shown          onset. The subacute phase refers to a patient with pain 4 to
strong and consistent relationships with outcome. These         12 weeks after onset, and the chronic phase indicates a
factors can be used to target likely candidates for delayed     patient with pain for more than 3 months. Recurrent lower-
recovery. In addition, there is evidence to support special-    back pain may be defined as pain that recurs 3 months
ized treatments for patients at risk for chronic pain.12 We     after the resolution of the previous episode. This is con-
will use the term “triage” to refer to the identification of    sidered a distinct episode and is different from unrelenting
patients who may benefit from specific treatment goals.         chronic pain.32
                                                                Types of Triage
Why is triage important?                                        Three types of triage will be considered in each phase;
The natural history of nonspecific lower-back pain shows        medical, psychological, and physical work environment.
an excellent prognosis. Eighty to ninety percent of all pa-     Medical triage includes physical symptoms, pathologies
tients will improve in the first 2 weeks with no treatment      and function of the patient. Psychological triage includes
at all. Up to 90% of patients will recover in the first month   psychopathology, psychological states, and individual per-
and the pain will impede fewer than 5% of patients 3            ceptions sometimes referred to as psychosocial factors.
months latter. However, the small percentage of patients        Triage based on the physical work environment indicates
whose pain becomes chronic comprises the majority of all        physical demands or conditions that the patient confronts
costs and suffering related to nonspecific lower-back           on the job. In all cases, the strength of evidence for triag-
pain.39 Some of these problems may be eliminated by             ing patients will be presented based on high quality ran-
triage.                                                         domized controlled studies and systematic reviews. When
    Triage based on recognized medical, psychological, and      no direct evidence is available, the concept of “best prac-
workplace risk factors for chronicity can help to direct        tice” will guide recommendations.
treatment is a way that maximizes the results. In this way
patients would receive only the treatment they need to          Acute Phase
recover. This is imperative because the consequences of         The general objective of triage for the patient with lower-
undertreating or overtreating a patient can be disastrous.      back pain in the acute phase is to rule out conditions that

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Number 443
February 2006                                                                         Triage for Nonspecific Lower-back Pain   149

can affect the prognosis early on. The most important goal          tional or maladaptive beliefs held by the patient by repeat-
is to identify specific serious conditions, or red flags, that      ing accurate and optimistic messages. One study found
require urgent treatment. The reciprocal goal is to avoid a         that introducing information aimed at reducing psycho-
course of treatment in those patients for whom treatment is         logical distress in the acute stage decreased work ab-
unnecessary.                                                        sence.36 Second, individuals who have these characteris-
    The identification of serious urgent conditions has been        tics automatically should be considered at risk and should
recognized universally as an important goal in the initial          be referred for psychological evaluation immediately if
treatment of a patient with lower-back pain.23 Even if they         they have not improved at the 4-week mark.
are rare, these conditions are easy to identify in primary             Authors of several studies show that these factors, when
care by questioning the patient and require no special test         identified in the acute phase, predict future disability. For
at the initial triage. Carter et al4 classified patients in their   example, Nordin et al30 found that the extent of functional
guidelines for the treatment of lower-back pain in three            disability expressed by the subject as measured using the
categories based on initial triage (Appendix 1). The par-           Oswestry Disability Index near the onset of the back pain
ticular interest in this classification is not only to identify     episode predicted sickness absence from work 4 weeks
red flags (Category C) but also to distinguish patients with        after injury. Pincus et al33 found evidence that certain
nerve root pain (Category B) from those with simple me-             variables such as distress and somatization assessed in the
chanical pain (Category A), patients in the former group            acute stage predict chronicity, however, other variables
being expected to recover more slowly than the latter. The          such as coping strategy showed weak or no predictive
systematic search for nonorganic signs at the physical ex-          value.
amination will help the clinician make the distinction be-             At this stage, best practice dictates an informal assess-
tween categories B and C.39                                         ment of psychological and psychosocial risk factors. For-
    The recommended treatment of patients with red flags
                                                                    mal assessment by a psychologist or counselor or standard
(Category C) is the urgent investigation of a serious pa-
                                                                    questionnaires can be off putting at this juncture as pa-
thology such as cancer, infection, fracture, or neurologic
                                                                    tients are likely to assume that the physician believes that
compromise from disc displacement. In the absence of red
                                                                    the pain is not organically based and therefore, not “real.”
flag, patients with nerve root pain (Category B) will be
                                                                    Also, while certain factors such as distress, fear of activity,
observed closely by their physician for the persistence or
                                                                    and negative perceptions of work and its impact on pain
worsening of neurologic signs and symptoms. If deficits
are progressive or severe, emergent intervention is re-             have been linked repeatedly to poor outcomes at later
quired. Minor neurologic signs and symptoms usually re-             stages of nonspecific lower-back pain there is less evi-
solve without specific intervention.                                dence about what psychological factors should be identi-
    There is strong evidence that imaging techniques                fied in the acute phase of lower-back pain.40,41 A modi-
should be avoided if no red flag is suspected.19,38 Special-        cum of distress in the form of anxiety, fear, and anger are
ized tests should be ordered only when systemic pathology           normal reactions to severe pain. This should be explained
is suspected or surgery is considered. The increasing so-           to patients so that they are comfortable sharing their reac-
phistication of imaging technology has lead to a rise in the        tions to pain. Patients also may be questioned about con-
number of false-positive tests. Even though these findings          cerns they have about their job and returning to work. If
are innocuous from a medical standpoint, they can have              distress is noted, efforts should be made to emphasize the
deleterious effects on patients. Erroneous beliefs about the        patient’s excellent diagnosis. If the patient remains ex-
seriousness of back pain are difficult to change and may            tremely distressed about pain or functional limitations and
lead to behaviors, such as activity restriction, that can           expresses negative work attitudes despite these reassur-
worsen pain. In fact, a false-positive test can worsen the          ances, these issues should be reevaluated at the next visit.
prognosis and represents the most frequent adverse effect           At followup, if the patient has not improved at all, has
of triage in the acute phase of lower-back pain.1                   failed to follow recommendations, or displays extreme
    There is weak evidence for a formal psychological and           signs of stress, an early psychological consultation should
psychosocial assessment in the acute phase of nonspecific           be discussed.
lower-back pain. However, some authors recommend                       In the acute phase of lower-back pain, the clinician
screening for these factors as early as two weeks after             should question the patient on previous history of chronic
onset of pain.34 This is because of the strong relationship         lower-back pain or recurring lower-back pain. A short oc-
between these factors and outcome at later stages. It seems         cupational history including the job title, a description of
logical to flag these warning signs as early as possible.           the working environment, and working schedule is valu-
    The purpose of gathering such information at this stage         able information to foresee potential difficulties and to
is twofold. First, the physician can attempt to dispel irra-        reduce delays in returning to work in the eventuality that

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Clinical Orthopaedics
150    Weiser and Rossignol                                                                                and Related Research

a patient’s absence at work would go beyond the acute                Kendall outlined “yellow flags.”21 These are psycho-
phase of back pain.37                                            logical and social factors for which there is moderate to
                                                                 strong evidence of an association with outcome. These are
Subacute Phase                                                   the presence of a belief that back pain is harmful or po-
                                                                 tentially severely disabling, fear-avoidance behavior and
Because the majority of patients with nonspecific lower-         reduced activity levels, tendency to low mood, withdrawal
back pain recover within the first 4 weeks, the subacute         from social interaction, and high expectations of passive
phase of nonspecific lower-back pain is a critical juncture.     treatment(s) rather than a belief that active participation
There is strong evidence that pain lasting more than four        will help.22 Work perceptions include dissatisfaction with
weeks is a risk factor for disability; the likelihood of chro-   the job or workplace, work stress, and the belief that work
nicity increases considerably at this time. Therefore the        will exacerbate pain. There is strong evidence that these
goal of triage in this phase is to prevent chronicity. This is   factors are modestly related to poor occupational outcome
accomplished by improving function and removing or               and also should be assessed.40
modifying psychological, social, and environmental barri-            In order to triage effectively, it is important to under-
ers to recovery whenever possible.                               stand the specific beliefs and concerns that prevent recov-
   Even at this phase, a majority of patients will improve       ery. Best practice indicates that the clinical interview is the
and return to normal function with evidence-based inter-         gold standard for triaging patients in this stage. A com-
ventions such as injections and active physical therapy.         prehensive interview conducted by a psychological expert
Therefore, it particularly is important at this point to iden-   is the best option. Patients often will respond well to this
tify those patients with the highest risk of developing          referral if it is explained to them that they can learn ways
chronic pain through careful medical and psychological           of coping with pain and handling the stress of nonspecific
evaluation.                                                      lower-back pain by speaking with an expert in the field of
   The objective of medical triage in the subacute phase is
to identify patients with lower-back pain whose conditions
                                                                     Numerous valid and reliable self-report screening ques-
have not improved or have worsened after 4 weeks of the
                                                                 tionnaires exist to assess distress, pain beliefs and social
onset of pain. Research on the prognostic value of a stag-
                                                                 perceptions. Most are excellent research tools and provide
nant or worsening functional score after the first 4 weeks
                                                                 insight into the patient’s experience. Some recommend
of onset of pain has shown consistent associations with a
                                                                 clinical cutoff scores that have been associated with chro-
reduced probability of returning to work during the sub-
acute phase.32                                                   nicity such as the Oswestry Disability Questionnaire9, the
   Several tools have been validated for the clinical evalu-     Distress and Risk Assessment Method (DRAM)28, and the
ation of the functional status of patients with lower-back       Acute Low Back Pain Screening Questionnaire26. How-
pain.5 As an example, Appendix 2 shows the Quebec Back           ever, these tools should never be used in isolation to di-
Pain Disability Scale that has been used widely. Scores are      agnose or to treat a patient. They provide only partial
based on a total of 100 points. On average, the score            information. They are best used to confirm impressions
should improve by at least 10 to 20 points during the acute      obtained during a clinical interview or to guide referral to
phase of lower-back pain. In the subacute phase, a patient       a specialist.
with a score that has not improved by at least 10 points for         If a referral to an expert is impractical or not acceptable
a period of 4 weeks is at high risk of developing chronic        to the patient, the healthcare provider can ask several key
pain. The clinician should intensify the search for specific     questions. In addition to assessing the risk factors men-
barriers facing the patient in his or her return to work and     tioned above, the information obtained can provide spe-
to normal activity. Another possibility is the patient who       cific target areas for treatment. Based on the work of Ken-
improves slowly but steadily. In that case, the clinician can    dall et al,21 Waddell and Burton40 and others, a brief series
help by referring that patient to a supervised exercise pro-     of questions is suggested that the physician can use to
gram.                                                            determine if referral to a psychological specialist is nec-
   There is good evidence that psychosocial factors sub-         essary (Appendix 3).
stantially affect the transition from acute to chronic pain.33       A referral to a psychological professional is warranted
In addition there is moderate evidence that multidisci-          if the patient exhibits any of the warning signs for delayed
plinary interventions addressing these factors are superior      recovery. In addition, best practice dictates that several
to alternative treatments at this stage.20 Therefore, a psy-     other observations may indicate a poor prognosis and re-
chosocial evaluation is recommended for all patients who         quire specialized treatment: (1) if the patient fails to im-
are not expected to regain normal function 4 weeks after         prove in the expected amount of time; (2) if the patient
pain onset.34                                                    fails to comply with recommended treatment; (3) if the

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Number 443
February 2006                                                                        Triage for Nonspecific Lower-back Pain   151

patient believes stress is the main source of lower-back           require a comprehensive psychosocial evaluation.34 There
pain; and (4) if additional treatments fail.                       is strong evidence that disability caused by nonspecific
   In the subacute phase, the clinician should identify spe-       lower-back pain has more relationship to complex psycho-
cific barriers facing the patient in his or her return to work,    social factors than clinical or physical factors.40 In addi-
especially for patients who show no improvement in their           tion, there is strong evidence that patients who remain
functional status. The goal is to recommend a gradual              disabled 3 months after pain onset have an increasingly
return to work, specifying restrictions that can be managed        difficult time returning to work.31 This means, that in ad-
in the workplace. At that point, medical interventions             dition to a through physical examination, a functional and
count for less than 20% of the success for return to work;         psychosocial assessment done by a professional in the
workplace interventions account for the rest.27 Clinical           field of psychology should be mandatory.
recommendations for restrictions at work can be guided by              Information obtained in the clinical interview can be
using the grid shown in Appendix 4.                                used to triage patients into appropriate programs. Multidis-
   In the spirit of gradual return to the job, the restrictions    ciplinary treatments are recommended. However, there is
should be temporary while the functional status continues          some controversy about whether patients with chronic pain
to be monitored. Authors of one study showed that placing          can be rehabilitated to an extent that justifies such pro-
patients with nonspecific lower-back pain with heavy               grams. For example, Waddell and Burton40 have claimed
physical jobs on open-ended temporary restrictions did not         strong evidence that treatments aimed at returning patients
increase their likelihood of returning to full duty.15 There-      with chronic nonspecific lower-back pain to work are in-
fore, best practice indicates that a specific date for return      effective. Others agree, showing moderate to strong evi-
to full duty should be established at the time restrictions        dence that behavioral and/or multidisciplinary treatment
are recommended.                                                   for chronic pain is effective for pain and function, but the
   Clinicians should refrain from recommending perma-              evidence is unclear for return to work.12,38
nent partial or total disability from work. It is not possible         Unemployment is a large part of the cost of chronic
to distinguish between physical and psychosocial environ-          nonspecific lower-back pain. Therefore a poor result on
mental factors at work in a clinical assessment. Further-          this outcome should recommend against these programs
more, the “permanent disability” label is likely to result for     for patients with chronic pain. However, at least one au-
those patients with chronic pain and such a label often is         thor has shown a return-to-work rate for patients with
difficult to overcome.                                             chronic lower-back pain to be 71%.10 These conflicting
                                                                   results may be attributed to the comparison of different or
Chronic Phase                                                      mixed populations of patients with chronic nonspecific
The general objective of triage of the patient with chronic        lower-back pain. Some authors have attempted to identify
lower-back pain is to minimize delays in identifying chro-         factors that predict success in multidisciplinary treatment
nicity so that care can be adapted to the role of achieving        programs; perceived disability, psychopathology, and mo-
the best functional status while reducing suffering, health-       tivation are associated with the outcome of treat-
care consumption, and adverse reactions from medication.           ment.8,16,17 However, there is no evidence that triaging
    Medical triage for identifying the patient with chronic        patients along these dimensions leads to successful treat-
lower-back pain starts at the first medical visit. While           ment outcomes.
more then 80% of initial consultations for lower-back pain             It seems that there are at least two types of patients with
are made for ongoing pain, less than 5% of patients have           chronic nonspecific lower-back pain. Patients with chronic
chronic pain. At the initial questionnaire, if the current         nonspecific lower-back pain who have been poorly
episode of back pain already has caused considerable re-           treated, who have a job to return to, and who are motivated
striction of activities for a period of more than 12 weeks,        to get well must be differentiated from the patients who
it should be considered chronic. Among those completely            give their lives over to the pain and adopt a new identity
disabled from work, the likelihood of returning to work in         based on the role their pain allows them. Psychological
the following year remains in the order of 50%. Patients           evaluation is crucial to triage patients with chronic lower-
with chronic lower-back pain should be referred without            back pain. A comprehensive clinical interview includes
delay to specialized multidisciplinary care because the            pain history and symptoms, treatment and responses, ac-
success of this type of intervention may be inversely re-          tivity impairment, family, friends, workplace factors, pain
lated to the duration of the disability at the time of referral.   attitudes and beliefs, motivation to return to work, psy-
    There is good agreement among international guide-             chological history, and current psychological status. At
lines for the treatment of lower-back pain that all patients       this stage it is important to assess the effects of mood state
with nonspecific lower-back pain for more than 12 weeks            on recovery. Patients may also be triaged for psychotropic

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Clinical Orthopaedics
152    Weiser and Rossignol                                                                             and Related Research

medications such as antidepressants if it is suspected that     the recommendations for gradual return to work should be
distress will interfere with their participation in recom-      followed.
mended treatments.
   Triage into evidence-based rehabilitation should pro-        DISCUSSION
ceed for those patients with chronic pain. If a patient has
had evidence-based care with poor results or is not inter-      Overall, triage can be a helpful tool to guide the treatment
ested in working hard to regain a healthy lifestyle, the        of patients with nonspecific lower-back pain. However,
patient should be told that pain management is their only       there are several caveats to consider. There are varying
option. The likelihood of such patients benefiting from         degrees of evidence that medical, psychological, and oc-
multidisciplinary treatment is low.                             cupational risk factors can be helpful in predicting chro-
   Usually, patients out of work for very long periods of       nicity and determining who would be likely to benefit
time do not have a job to return to. Even though the pa-        from specific treatment strategies (Appendix 5). For in-
tient’s general attitude toward work is important in decid-     stance, empirical studies show that some psychological
ing treatment, there is no evidence that past work percep-      factors such as negative beliefs about pain are consistently
tions effect rehabilitation in individuals with chronic non-    associated with poor outcomes in the subacute phase of
specific lower-back pain. Therefore, it is not necessary to     pain. However, aggregate data is not applicable to all in-
assess risk from this standpoint. Because pain, however, is     dividuals. Therefore, clinical judgment must always
considered chronic when it lasts more than 3 months, some       supplement the results of screening tools. Also, as most
patients do have a job to return to. If this is the case,       cases of nonspecific lower-back pain resolves without in-
questions about work should be ascertained in the same          tervention, physicians should interpret psychological fac-
manner as in the subacute stage. No workplace triage is         tors with caution in the early stage of injury.
recommended to the primary care clinician during this              Until more research is done that will add to the strength
phase.                                                          of the evidence in some instances, best practice guidelines
                                                                must be followed. None of the recommendations given
Recurrent Back Pain                                             here replace the good judgment of an experienced clini-
Recurrent lower-back pain is defined as the repetition of       cian. Patients may sometimes request treatments for which
two or more episodes of disability from normal activity         there is no evidence. If the physician believes that such
over a period of 12 months that are separated by at least 3     treatments will do no harm and may provide psychological
months of normal functioning. This definition is used to        benefits to the patient, they may choose to permit them.
avoid confusion with chronic lower-back pain. The goal of       These types of decisions are based on clinical experience
triaging recurrent lower-back pain patients is to prevent       and are at the discretion of the individual physician.
further recurrences.                                               We have yet to determine the comparative value of
    Questioning the patient at the initial visit can identify   specific treatments. There are no high-quality randomized
recurrent back pain. Although no scientific evidence exists     controlled studies that have assigned patients with similar
on triaging based on recurrent back pain, its existence may     risk factors to different types of treatment. For example, do
indicate important information regarding workplace haz-         patients with poor psychological prognosticators benefit
ards or yellow flags that have been overlooked in previous      more from psychological interventions than they do from
episodes.                                                       physical ones? Do all at-risk patients require multidisci-
    Recurrent nonspecific lower-back pain can signal im-        plinary care to improve? This information would further
portant psychosocial factors that have yet to be detected.      streamline medical treatment and lead to improved out-
Despite the absence of scientific evidence for the useful-      comes.
ness of triage in these patients, it would be prudent to           There still is a good deal about nonspecific lower-back
proceed as if they were at risk and assess them as one          pain that is not understood. It remains a complex, multi-
would a patient with subacute nonspecific lower-back            faceted problem and needs to be addressed as such. Treat-
pain. If the patient has more than one recurrence that re-      ing physicians should consider medical, psychological,
sults in lost work days, a comprehensive psychosocial           and workplace factors simultaneously when evaluating a
evaluation including psychological and psychosocial fac-        patient. Ultimately however, the physician should engage
tors may be justified. Psychological treatments or mul-         the cooperation of the patient as a partner in treatment. It
tidisciplinary options should be considered immediately         is unlikely that any type of treatment will work or have a
when traditional medical care is unsuccessful.                  high compliance rate if the patient does not assume re-
    The tool proposed in Appendix 4 can help determine          sponsibility for his or her own well being.
specific workplace hazards that could explain the recur-           It has been stated that existing guidelines for lower-
rence pattern of lower-back pain. As the patient improves       back pain provide important information but have not be

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Number 443
February 2006                                                                                  Triage for Nonspecific Lower-back Pain         153

implemented as easily as it was hoped. Based on these                          from a multidisciplinary treatment program for chronic low back
                                                                               pain. Spine. 1997;22:990–1001.
guidelines and best practice recommendations, we have                     17. Hutten MM, Hermens HJ, Zilvold G. Differences in treatment out-
attempted to present a practical and universal approach to                     come between subgroups of patients with chronic low back pain
the care of lower-back pain. It is contended that it is pos-                   using lumbar dynamometry and psychological aspects. Clin Reha-
sible to successfully identify patients who require specific                   bil. 15:479-488.
                                                                          18. Jackson JL, Browning R. Impact of national low back pain guide-
types of care at all phases of nonspecific lower-back pain                     lines on clinical practice. South Med J. 2005;98:139–143.
through careful triage. Once this is achieved appropriate                 19. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with
care can be provided, and we may find ourselves one step                       emphasis on imaging. Ann Intern Med. 2002;137:586–597.
                                                                          20. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen
closer to a solution to the lower-back pain puzzle.                            M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilita-
                                                                               tion for subacute low back pain in working-age adults: a systematic
                                                                               review within the framework of the Cochrane Collaboration Back
Acknowledgment                                                                 Review Group. Spine. 2001;26:262–269.
The authors thank Rudi Hiebert, ScM for his assistance in the             21. Kendall NA. Psychosocial approaches to the prevention of chronic
                                                                               pain: the low back paradigm. Baill Clin Rheum. 1999;13:545–554.
preparation of this manuscript.                                           22. Kendall NAS, Linton SJ, Main CJ. Guide to Assessing Psychosocial
                                                                               Yellow Flags in Acute Low Back Pain: Risk Factors for Long Term
                                                                               Disability and Work Loss. Wellington, New Zealand: Accident Re-
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Clinical Orthopaedics
154       Weiser and Rossignol                                                                                                    and Related Research

      tation rate in diagnosing low back pain in general practice. A cri-       • Nerve irritation signs such as a reduced straight-leg rais-
      teria-based review of the literature. Spine. 1995;20:318–327.
38.   van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal
                                                                                  ing test that reproduces leg pain.
      radiographic findings and nonspecific low back pain. A systematic         • Motor, sensory, or reflex changes that are limited to one
      review of observational studies. Spine. 1997;22:427–434.                    nerve root.
39.   Waddell G. The Back Pain Revolution. Edinburgh, Scotland: Chur-
      chill Livingston; 2004.
40.   Waddell G, Burton AK. Occupational Health Guidelines for the              C. Red flags for possible serious spinal
      Management of Low Back Pain at Work Evidence Review. London:              pathology—General characteristics:
      Faculty of Occupational Medicine; 2000.
41.   Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M. Low                • Age of onset younger than 20 or older than 55 years.
      Back Pain Evidence Review. London: Royal College of General               • Violent trauma such as a fall from a height or a motor
      Practitioners; 1999.
                                                                                  vehicle crash.
                                                                                • Constant, progressive, non-mechanical pain.
APPENDIX 1. CATEGORIES OF PATIENTS                                              • Night pain not relieved in supine position.
WITH LOWER-BACK PAIN AT INITIAL TRIAGE                                          • Thoracic or abdominal pain.
                                                                                • Previous history of carcinoma, systemic steroids, drug
A. Simple back pain—General characteristics:                                      abuse, HIV.
                                                                                • Unexplained weight loss, systemically unwell.
• Age between 20 and 55 years.                                                  • Persistent severe restriction of lumbar flexion.
• Pain restricted to lumbosacral region, buttocks, and                          • Widespread neurology.
  thighs.                                                                       • Saddle anesthesia, difficulty urinating, fecal inconti-
• Pain “mechanical” in nature, ie, varies in time and with                        nence.
  physical activity.                                                            • Structural deformity.
• Good general health.
                                                                                APPENDIX 2. QUEBEC BACK PAIN DISABILITY
B. Nerve root pain—General characteristics:                                     SCALE
• Unilateral leg pain worse than lower-back pain.                               TODAY, do you find it difficult to perform the following
• Pain generally radiates to foot or toes.                                      activities because of your back? (Circle the number cor-
• Numbness or paresthesia in same distribution.                                 responding to the level of difficulty)

                                              Not Difficult          Minimally           Somewhat              Fairly            Very            Unable
                                                 at All               Difficult           Difficult           Difficult         Difficult         to Do
 1.   Get out of bed                                 0                      1                  2                  3                 4                5
 2.   Sleep through the night                        0                      1                  2                  3                 4                5
 3.   Turn over in bed                               0                      1                  2                  3                 4                5
 4.   Ride in a car                                  0                      1                  2                  3                 4                5
 6.   Sit in a chair for several hours               0                      1                  2                  3                 4                5
 7.   Climb one flight of stairs                     0                      1                  2                  3                 4                5
 8.   Walk a few blocks (300–400 m)                  0                      1                  2                  3                 4                5
 9.   Walk several miles                             0                      1                  2                  3                 4                5
10.   Reach up to high shelves                       0                      1                  2                  3                 4                5
11.   Throw a ball                                   0                      1                  2                  3                 4                5
12.   Run one block (about 100 m)                    0                      1                  2                  3                 4                5
13.   Take food out of the fridge                    0                      1                  2                  3                 4                5
14.   Make your bed                                  0                      1                  2                  3                 4                5
15.   Put on socks (pantyhose)                       0                      1                  2                  3                 4                5
16.   Bend over to clean the bathtub                 0                      1                  2                  3                 4                5
17.   Move a chair                                   0                      1                  2                  3                 4                5
18.   Pull or push heavy doors                       0                      1                  2                  3                 4                5
19.   Carry 2 bags of groceries                      0                      1                  2                  3                 4                5
20.   Lift and carry a heavy suitcase                0                      1                  2                  3                 4                5

Total score: (maximum 100)
Reprinted with permission from Kopec JA, Esdaile JM, Abrahamowicz M, Abenhaim L, Wood-Dauphinee S, Lamping DL, Williams JI. The Quebec Back Pain Disability
Scale. Measurement properties. Spine. 1995;20:341–352.

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Number 443
February 2006                                                                                    Triage for Nonspecific Lower-back Pain   155

APPENDIX 3. PSYCHOLOGICAL TRIAGE                                                   Would you be able to work TODAY if your job re-
                                                                                quired any of the following activities?
1. Do you believe that you can recover from lower-back pain?
2. What activities are you avoiding because of your
   lower-back pain? Why?                                                        APPENDIX 5. EVIDENCE SUMMARY
3. How has your mood been since you’ve had lower-back
   pain?                                                                        Acute Phase
4. How have your relationships with family, friends and
   coworkers be affected by your back pain?                                     1. There is strong evidence that prognosis is influenced by
5. What type of treatment(s) do you think will help you?                           the presence of red flags.
6. How do you feel about your job?                                              2. There is strong evidence that imaging techniques are
7. What effect if any, do you think your job will have on                          unnecessary if no red flags are present.
   your lower-back pain?                                                        3. There is moderate evidence that assigning a medical
8. When do you expect to return to work?                                           label to patients without red flags increases the risk of
9. What do you think has prevented you from getting                                chronicity.
   better?                                                                      4. There is moderate evidence that some psychosocial fac-
                                                                                   tors predict chronicity.
APPENDIX 4. BACK PAIN AND WORK ABILITY                                          5. There is weak evidence for conducting a formal psy-
This questionnaire is about the way your back pain is                              chological evaluation.
affecting your ability to perform various work-related                          6. Best practice dictates an informal assessment of the
tasks and activities. SUPPOSE, your job requires one of                            patient’s distress level, fear of movement, and work
the activities listed below. We would like to know if you                          attitudes.
would be able or unable to perform these activities today.                      7. Best practice dictates obtaining information about job
Please choose one response option for each activity (do not                        title, description, and schedule.
skip any activities), and circle the corresponding number.
                                                                                Subacute Phase
                                                                                1. There is strong evidence that a patient’s risk for chro-
                                      Probably       Probably                      nicity increases at 4 weeks.
                               Able     Able          Unable       Unable
                                                                                2. There is strong evidence that certain psychological and
 1. Frequent lifting and                                                           psychosocial factors are associated with delayed recovery.
    carrying of light
                                                                                3. There is moderate evidence that treatment should be
    weights (5–10 lbs)          0          1              2            3
 2. Frequent pulling and                                                           multidisciplinary.
    pushing with moderate                                                       4. Best practice dictates that psychological information be
    strength                    0          1              2            3
                                                                                   obtained by interview.
 3. Frequent lifting and
    carrying with heavy                                                         5. Best practice dictates identifying occupational barriers
    weights (over 40 lbs)       0          1              2            3           to returning to work.
 4. Frequent twisting and
    stretching of your back     0          1              2            3
 5. Frequent squatting and                                                      Chronic Phase
    kneeling                    0          1              2            3
 6. Bending over or                                                             1. There is strong evidence that the risk a permanent dis-
    stooping for long                                                              ability increases at 3 months.
    periods of time             0          1              2            3
 7. Standing up for                                                             2. There is strong evidence that disability is related to
    periods of 20–30                                                               psychological and psychosocial factors.
    minutes at a time           0          1              2            3        3. There is strong evidence that treatment should be mul-
 8. Standing up or walking
    continuously for                                                               tidisciplinary.
    several hours               0          1              2            3        4. Best practice dictates that motivated patients with
 9. Frequently walking up                                                          chronic pain receive work rehabilitation.
    and down stairs             0          1              2            3
10. Sitting continuously for                                                    5. Best practice dictates identifying occupational barriers
    several hours               0          1              2            3           to returning to work if the patient has a job.
Total score: (maximum 30)
Reprinted with permission from Kopec JA. Conceptualization, Development, and    Recurrent Back Pain
Evaluation of a New Self-Report Measure of Disability in People with Low Back
Pain. Montreal, Canada: Department of Epidemiology and Biostatistics, McGill
                                                                                Best practice indicates that the subacute protocol should be
University; 1994.                                                               used.

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