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Resources

for clinicians working with people living
with low back pain

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General Information

The information provided is based on the latest scientific evidence but is general educational purposes only. It should not be used as a substitute for your clinical judgement or professional advice.


Patient Assessment

Clinicians must use their own qualifications and scope of practice to determine whether a patient’s back pain is related to ‘specific’ pathology. Where in doubt, refer patients to a suitably qualified health professional.


No Clinician-Patient Relationship

The information provided does not create a clinician-patient or formal clinical relationship.


Limitation of Liability

EVOOLVE, its directors, employees, and affiliates shall not be liable for any damages, losses, or adverse outcomes arising from the use of this information.


As Is

This information is provided ‘as is’ without any warranties, express or implied.


Updates

EVOOLVE reserves the right to update or modify this information and these disclaimers at any time without notice.


Governing Law

These disclaimers are governed by the laws of Western Australia.

There are different kinds of low back pain - 'specific' and 'non-specific'.

Specific low back pain.

Specific back pain is attributed to a disease process or serious pathology. This may include low back pain related to cancer, infection, fracture or an inflammatory process, such as spondyloarthropathy. Internal organs can also sometimes refer pain to the lower back. While these conditions are rare (about 1% of people) they require urgent medical attention.
About 5% of people have nerve compression resulting in a loss of power and sensation in the lower limb. In rare cases, this may also affect the function of the bowel or bladder. This requires urgent medical attention.

Non-specific low back pain.

For most people (90-95%) back pain is NOT attributed to a ‘specific’ disease process or serious pathology. This type of back pain is associated with sensitivity of the spinal structures that is attributable to a variety of different factors. These may include: mechanical strain, muscle tension, poor sleep, being run down, tired, stressed, tense, sad, inactive or over-active, as well as the health of the spinal structures (e.g. disc degeneration, arthritis, disc bulges with no nerve compression). These factors vary for each person thereby influencing their level of pain and disability.
Each clinician's responsibility
A clinician’s ability to determine whether a patient's back pain is related to 'specific' pathology is dependent on their qualification and scope of practice. For example, a medical doctor is trained to do this and in most parts of the world so is a physiotherapist. Anyone who works with people with low back pain and who is not qualified to make this assessment, needs to refer their patients to a qualified health professional for that assessment.

The following videos and infographics relate to people who have non-specific low back pain.

Videos

Separating Fact from Fiction

An interview with Prof. Peter O'Sullivan
Write your awesome label here.
  • What the research says
  • Problems with MRI
  • Things clinicians say that scare patients
  • Unhelpful behaviours and beliefs can drive pain and disability
  • Pain is multidimensional 
  • Fear drives behaviour

Hope for change

Dr Rangan Chatterjee interviews Prof. Peter O'Sullivan
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  • From the Feel Better Live More podcast 
  • Back facts everyone should know
  • Learn about what is healthy for your back
  • Personal pain stories
  • Lets help people develop hope

Stories of Recovery

Hear from people who have had disabling low back pain.

Learn how they restored trust in their back and built confidence to take control of their life.

Joe's journey
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  • Firefighter with active hobbies
  • "My doctor said I have the back of a 60yo"
  • Avoiding activity and good posture didn't help
  • Lost hope
Ann's journey
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  • Retired grandmother
  • Tried many interventions with many clinicians and was told to give up being active
  • MRI - bulging discs and degeneration
  • "I was so stiff, so tense and so frightened...I became less confident with everything, and depressed"
Jon's journey
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  • Australian Aboriginal man and basketballer
  • Couldn't exercise for his mental health
  • "I couldn't contribute at home or work"
  • After side-effects from medication, underwent surgery, but the pain remained
Alison's journey
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  • CFO and triathlete
  • Quit job and stopped training
  • Surgeon couldn't see anything wrong on MRI, in fact it was 'better' than most
  • "I was broken and in a dark place"
Sam's journey
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  • Mum and nurse
  • At 20 was told - "you'll be in a wheelchair by 40"
  • Chronic fatigue, disempowered, confused, depressed
  • Avoided playing with kids and living in a state of fear
Jack's journey
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  • Quit manual job and football
  • Was told "you have the back of a 70 year old"
  • Felt that back was "in pieces"
  • Very guarded and protective
Becky's journey
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  • Widespread low back to neck pain after crashing bicycle
  • Post-traumatic stress response
  • Ongoing pain despite going to doctors, physio, Pilates, acupuncture and trying stand up desk and different chairs
  • Was told - "you need to brace your core"

Infographics

Co-designed by researchers and clinicians in partnership with people living with back pain, these infographics summarise the evidence about the most common questions asked by people with low back pain.

For further information on common back facts, click here to see the videos in  
'Resources for with Low Back Pain'.

"Becoming Confidently Competent" outlines the clinician training journey to becoming a certified Cognitive Functional Therapy practitioner.

Literature

Best Practice Guidelines for Musculoskeletal Pain

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review

Ivan Lin, Louise Wiles, Rob Waller, Roger Goucke, Yusuf Nagree, Michael Gibberd, Leon Straker, Chris Maher, Peter O’Sullivan
British Journal of Sports Medicine, 2019, https://doi.org/10.1136/bjsports-2018-099878
This paper was written by physiotherapists, emergency and pain doctors, and low back pain research academics about what guidelines indicate is best practice for musculoskeletal pain.

This paper reviewed high-quality guidelines for managing common musculoskeletal pain conditions such as back, neck, knee, hip, and shoulder pain. It identified 11 key recommendations to ensure patients receive the best possible care.


The 11 key recommendations:


Provide Patient-Centered Care: Ensure treatment is individualised, incorporating shared decision-making and effective communication to align with the patient’s values, preferences, and unique circumstances.
Screen for Red Flags:
Identify serious pathology (e.g., fractures, malignancies, infections, cauda equina syndrome) before initiating routine musculoskeletal pain management.
Assess Psychosocial Factors: Evaluate psychological and social contributors to pain, such as depression, anxiety, worry, and fear-avoidance behaviors, as they can impact prognosis and treatment outcomes.
Use Imaging Selectively:
Avoid routine imaging unless there are red flag indications, persistent symptoms despite conservative management, or imaging is expected to influence treatment decisions.
Conduct a Comprehensive Physical Examination:
Assess movement, strength, neurological function, and pain responses to classify the condition appropriately and guide treatment planning.
Monitor Patient Progress with Validated Measures:
Use standardised outcome measures to track functional improvement, pain levels, and overall patient well-being over time.
Educate Patients About Their Condition:
Provide clear, evidence-based education to enhance self-management, address misconceptions, and improve adherence to active treatments.
Prioritise Physical Activity and Exercise-Based Interventions: Encourage graded physical activity and structured exercise therapy as core treatment strategies, tailored to patient capacity and goals.
Use Manual Therapy as an Adjunct, Not a Standalone Treatment:
If utilised, manual therapy (e.g., spinal manipulation, mobilisation, soft tissue techniques) should be integrated with active rehabilitation approaches.
Prioritise Non-Surgical Management:
Unless there is a clear indication for surgery, emphasise conservative interventions such as exercise, physical therapy, and pain education before considering surgical referral.
Facilitate Work Participation and Return to Function:
Support strategies that promote work engagement or return to activity, including workplace modifications, graded exposure, and vocational rehabilitation when needed.

Identifying Serious Spinal Pathology

International Framework for Red Flags for Potential Serious Spinal Pathologies

Laura Finucane, Aron Downie, Christopher Mercer, Susan Greenhalgh, William Boissonnault, Annelies Pool-Goudzwaard, Jason Beneciuk, Rachel Leech, and James Selfe.
Journal of Orthopaedic and Sports Physical Therapy, 2020, https://doi.org/10.2519/jospt.2020.9971
Members of The International Federation of Orthopaedic
Manipulative Physical Therapists (IFOMPT) developed framework for the early identification of serious spinal pathology.

The framework provides a clear clinical reasoning pathway for:
  • Determining the level of clinical concern
  • Clinical decision making
  • Considering appropriate pathways for urgent referral
We recommend you review the information below, and also the case studies that are provided within the open access paper.
Red Flags
Red flags are indicators (signs or symptoms) of potential serious spinal pathology (e.g. cancer/malignancy, fracture, infection, visceral disease, cauda equina syndrome, inflammatory disease). Individual red flags have limited diagnostic accuracy and should not be used in isolation. Concern is raised through establishing combinations of red flags, assessed within the context of a thorough history and physical examination.

As there are total of 163 red flags that have been identified across the literature we recommend clinicians become familiar with red flags described within Finucane et al. (2020), and the Australian Low Back Pain Clinical Care Standard Full Publication (pages 19 and 29).

Decision Tool for Early Identification of Serious Spinal Pathology

Press (+) to expand each section

Person-centred care extends into the management of serious spinal pathology
Managing patients with potential serious spinal pathology requires a collaborative approach to reduce anxiety and ensure informed decision-making. Clinicians should clearly explain treatment options, risks, benefits, and supporting evidence while considering the patient’s goals, values, and circumstances.

Cognitive Functional Therapy and other
 Patient-centred Care Research

Below is a collection of open access academic research.
Click your paper of interest to be taken to a clinical summary and link to the full paper.

Cognitive Functional Therapy:

An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain


Peter O'Sullivan et al. 2018

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

JP Caneiro et al. 2021

Patient-centered consultations for persons with musculoskeletal conditions



Joletta Belton et al. 2022

A Prospective Qualitative Inquiry of Patient Experiences of Cognitive Functional Therapy for Chronic Low Back Pain During the RESTORE Trial




Nardia-Rose Klem et al. 2024

The "future" pain clinician: Competencies needed to provide psychologically informed care





Steven Linton et al. 2024

Cognitive Functional Therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial

Peter Kent et al. 2022

The Australian Low Back Pain Clinical Care Standard

In 2022, the Australian Low Back Pain Clinical Care Standard was released, providing 8 quality statements describing the standard of care people should receive when presenting with a new acute episode of low back pain. 
The Clinical Care Standard was developed due to growing personal and societal costs of low back pain in Australia and marked variation in the use of medical imaging, opioid prescription and spinal surgery. The 8 quality statements were derived from high-quality research and guideline evidence by expert clinicians, researchers and health care service stakeholders.

International Low Back Pain Clinical Guidelines

  • Screening for serious pathology / red flags
  • Appropriate referral for medical imaging (i.e. eliminating routine referrals)
  • Psychological therapy (e.g. cognitive behavioural therapy)
  • Provide patient education
  • Movement and exercise
National Institute for Health and Care Excellence (UK)
American College of Physicians (USA)
World Health Organisation

Conducting a Patient-Centred Consultation

Patient-centered consultations for persons with musculoskeletal conditions

Joletta Belton, Hollie Birkinshaw & Tamar Pincus
Chiropractic & Manual Therapies, Volume 30, Issue 53, 2022, https://doi.org/10.1186/s12998-022-00466-w
This paper was written by a person with a lived experience of persistent pain and academics for clinicians to help them understand helpful and unhelpful reassurance strategies during a consultation.

Abstract:
Consultations between practitioners and patients are more than a hypothesis-chasing exploration, especially when uncertainty about etiology and prognosis are high. In this article we describe a single individual's account of their lived experience of pain and long journey of consultations. This personal account includes challenges as well as opportunities, and ultimately led to self-awareness, clarity, and living well with pain. We follow each section of this narrative with a short description of the emerging scientific evidence informing on specific aspects of the consultation. Using this novel structure, we portray a framework for understanding consultations for persistent musculoskeletal pain from a position of patient-centered research to inform practice.

Adapted from "Patient‑centered consultations for persons with musculoskeletal conditions. By Belton et al., 2022, Chiropractic & Manual Therapies, 30(53). (https://doi.org/10.1186/s12998-022-00466-w). Copyright 2022 by the authors (Creative Commons).

Effective Data Collection

  • Let patients tell their narrative
  • Explore impact of pain on life
  • Elicit emotions and beliefs
  • Ask open ended questions
  • Allow patients to tell their story
  • Check if you understand what matters to them
  • Check if you need to know anything else
  • Try to avoid chasing hypotheses while people are talking
  • Explore the whole person. Don't avoid emotions, concerns and problems that are beyond your perceived scope
  • Listen, avoid interrupting 
  • Respond empathetically
  • Show that you are attentive
  • Indicate that it is important
  • Ask open ended questions
  • Allow patients to tell their story
  • Check if you understand what matters to them
  • Recognise suffering and distress
  • Indicate that you believe all aspects of the narrative
  • Indicate that distress is understandable
  • Be clear and explicit about the fact that you believe the patient
  • Acknowledge the pain and suffering
  • Explicitly indicate that distress is completely normal under the circumstances
  • Where possible, describe possible causes
  • Discuss likely prognosis
  • Discuss / agree about possible interventions
  • Discuss prognosis, treatment options and likely obstacles
  • Use simple language and avoid jargon
  • Make sure the conversation flows both ways
  • Discuss prognosis, treatment options and likely obstacles

Avoid Generic Reassurance

Especially with patients who have:
  • Seen many clinicians
  • Trialed many interventions
  • A long history of pain and suffering
  • Avoid telling patients that everything will be alright unless you really know this is the case
  • Recognise that telling patients nothing is wrong is not always reassuring

Share

Share with patients and their support network
Reinforce key messages you provided in the clinic with key information related to their pain story.
Share with your colleagues
Let your colleagues know about these resources if you find them helpful.