Clinical Practice Guidelines

Learning objective 1: Improve your knowledge of current clinical practice guidelines for managing LBP.


As previously highlighted, LBP is the most burdensome nonfatal condition world wide and is the second most common symptom seen by primary care physicians [1],[2]. Despite an intensive focus among researchers and clinicians, disability levels among individuals with LBP have remained relatively unchanged in the last decade [2].

Comprehensive clinical practice guidelines exist to aide health professionals in managing this highly prevalent musculoskeletal disorder. However, it is apparent that these guidelines are underutilized. The following sections provide summaries of the most recent management guidelines for LBP.

This review presents the most current recommendations and evidence based management of LBP in primary care [3]. It is based on recommendations from two new guidelines;

1. The UK National Institute for Health and Care Excellence clinical guideline for low-back pain and sciatica published in 2016

2. A clinical practice guideline from the American College of Physicians published in 2017

As a stand alone resource, it will enable clinicians to be more effective in the diagnosis and management of LBP in primary care. The emphasis of the recommendations are on cases of  nonspecific LBP, radicular pain and neurogenic claudication, as these conditions comprise more than 95% of LBP [4].

The review includes a flowchart to guide clinicians in diagnostic triaging and management of low-back pain according to the current clinical practice guidelines.

The key recommendations of the review are summarized below.

The National Institute for Health and Care Excellence (NICE) provide the most recent evidence-based recommendations for managing LBP and sciatica [5].

Low back pain and sciatica: summary of NICE guidance 2017

It is important to note that the NICE guidelines are based on systematic reviews with explicit consideration of the cost and effectiveness of interventions and the relevance of interventions to primary and community care settings.

Tousignant-Laflamme, Martel, Joshi and Cook (2017) propose a holistic model for managing the multitude of domains potentiating pain and disability in LBP [1].

In the paper “Rehabilitation Management of low back pain- it’s time to pull it all together“, the authors put forward 5 domains that clinicians should consider as potential drivers of pain and disability in an individual with LBP. The domains align with the International Classification of Functioning, Disability and Health and encourage clinicians to adopt a biopsychosocial management approach. A brief summary of these domains and their definitions is depicted below.

It is evident however that the difficulty lies in translating this knowledge into everyday clinical practice. To assist clinicians with identifying and acting on the priorities contributing to a LBP presentation, a simple form can be used in conjunction with validated diagnostic screening tools. The form allows therapists to quickly rate the relative contributions of different domains resulting in a radar graph which provides a visual guide for management based on the dominate domain(s) contributing to an individuals symptoms.

Domain 1 – Nociceptive Drivers of Pain

Categories Operational definition & criterion
Category A – Responders to CSFit into at least one of the three classification systems (CS) below:

1. Symptom modulation approach (specific mechanical pattern of pain i.e. centralization phenomenon)
2. Movement control approach (motor control issues driving pain)
3. Mobility dysfunction(s) driving pain (i.e. hypomobility)
Category B – Non-responders to CS1. Do not show signs/symptoms allowing to be classified into one of the 3 main classifications systems above
2. Are likely to respond to non-specific exercise

Domain 2 – Nervous System Function Disorders (NSDs)

Categories Operational definition & criterion
Category A – Peripheral or central NSDs1. Peripheral or central nervous system dysfunction, lesion or disease driving pain
2. Specific characteristics of neuropathic pain i.e. tingling, burning, shooting pain
Category B – Nervous system hypersensitivity 1. Evidence of mechanosensitivity, hyperalgesia, allodynia, evidence of widespread pain location, or disproportional pain intensity
2. Peripheral, spinal or supra-spinal hypersensitivity

Domain 3 – Comorbidity Drivers

Categories Operational definition & criterion
Category A – Physical comorbidities • Multiple painful musculoskeletal conditions
• Presence of specific co-occurring pathologies, such as chronic fatigue, irritable bowel syndrome, migraines
• Non-painful physical comorbidities, such as cardiac disease and high BMI
Category B – Mental health comorbidities1. Disorders of the standard classification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
2. The presence of mental disorders or psychiatric comorbidities

Domain 4 – Cognitive/Emotional Drivers of Pain

Categories Operational definition & criterion
Category A – Maladaptive cognition• Presence of maladaptive cognitive strategies i.e. pain catastrophizing, pain-related fears, fear of movement, negative perception of pain/disability/illness, poor pain self-efficacy and negative mood
Category B – Maladaptive behaviours • Communicative pain behaviours such as facial and/or verbal pain expressions
• Guarding pain behaviours such as actively or subconsciously bracing, stiffening, holding or rubbing the back when performing an activity
• Completely avoiding performing tasks

Domain 5 – Contextual Drivers of Pain

Categories Operational definition & criterion
Category A – Occupation related contextual drivers a) Negative patient expectations about return to work, job satisfaction, perception of heavy work and high job stress
b) Factual environmental factors such as occupational demands (ie, sedentary versus heavy work), job flexibility (ie, availability of modified work), employer’s policies regarding return to work
Category B – Social environment contextual drivers • Attitudes of the patient’s employer, family members, and health care professionals
• Limited access to care and rehabilitation
• Guarding pain behaviours such as actively or subconsciously bracing, stiffening, holding or rubbing the back when performing an activity
• Completely avoiding performing tasks

Oliveira et al, 2018 conducted a recent review of their recommendations regarding the diagnosis, treatment and management of non-specific low back pain in primary care [6].

15 clinical practice guidelines on the assessment and management of nonspecific LBP were reviewed and summarized.

The key recommendations consistently endorsed among the guidelines are summarized below.


  1. Tousignant-Laflamme, Y., Martel, M. O., Joshi, A. B., & Cook, C. E. (2017). Rehabilitation management of low back pain – it’s time to pull it all together! Journal of Pain Research, 10, 2373-2385. doi:10.2147/JPR.S146485
  2. Vos, T., Allen, C., Arora, M., Barber, R. M., Bhutta, Z. A., Brown, A., . . . Murray, C. J. L. (2016). Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1545-1602. doi:10.1016/S0140-6736(16)31678-6
  3. Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Diagnosis and management of low-back pain in primary care. Cmaj, 189(45), E1386-e1395. doi:10.1503/cmaj.170527
  4. Deyo, R. A., & Weinstein, J. N. (2001). Low back pain. N Engl J Med, 344(5), 363-370. doi:10.1056/nejm200102013440508
  5. Bernstein, I. A., Malik, Q., Carville, S., & Ward, S. (2017). Low back pain and sciatica: summary of NICE guidance. BMJ, 356, i6748.
  6. Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C.-W. C., Chenot, J.-F., . . . Koes, B. W. (2018). Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European Spine Journal. doi:10.1007/s00586-018-5673-2