The first qualified practitioner with the ability to do a full assessment (i.e., history, physical and neurological red flags, and psychosocial yellow flags) should assess the patient and undertake diagnostic triage (see Appendix E for summary of red and yellow flags, and the companion documents Clinical Assessment for Psychosocial Yellow Flags and Management of Psychosocial Yellow Flags -see complete list of companion materials). If serious spinal pathology is excluded, manage as non-specific low back pain.#
 Consider a diagnosis of ankylosing spondylitis, particularly in younger adults who, in the absence of injury, present with a history of needing to get out of bed at night and reduced side bending.

# SR (G1)
Emergent Cases  Refer patient with red flags (see Appendix E for red flag definitions) indicating a high likelihood of serious underlying pathology for immediate evaluation and treatment to an appropriate resource depending on what is available in your region (e.g., emergency room, relevant specialist).
The presence of Cauda Equina Syndrome is considered to be a surgical emergency.

# EO (GUC)
Cases Requiring Urgent Evaluation  Schedule an urgent appointment with a physician if any of the red flags are present (see Appendix E for red flag definitions).
EO (G2a,b) Evaluate for Fracture  Order AP and lateral plain film imaging for low back pain when compression or other fracture is suspected.
Oblique x-rays should not be done in this circumstance.

# SR (G2c) + EO (GUC)
Imaging to Rule Out Underlying Pathology in the Absence of Radiculopathy  Only order imaging to clarify anatomy where the results will direct treatment.
Imaging is typically not useful except for the following indications:  Progressively severe pain and debility despite non-interventional therapy  Severe or incapacitating back or leg pain (e.g., requiring hospitalization, precluding walking, or significantly limiting the activities of daily living)
 Clinical or radiological suspicion of neoplasm (e.g., lytic or sclerotic lesion on plain radiographs, history of cancer, unexplained weight loss, or systemic symptoms)
 Clinical or radiological suspicion of infection (e.g., endplate destruction of plain radiographs, history of drug or alcohol abuse, or systemic symptoms)
 When there are indications for surgical intervention or therapeutic injection in the presence of moderate to severe low back pain or radicular pain that is unresponsive to non-interventional therapy  CT indications:
 MRI is contraindicated  Primary bone tumors (detect or characterize)
 Trauma (rule out or characterize fracture, evaluate for healing)
Imaging to Rule out Underlying Pathology in the Presence of Radiculopathy  Consider referral for MRI if the patient has radiculopathy (leg-dominant pain) that persists after six weeks of non-interventional treatment.
Continue non-interventional treatment when clinical and imaging findings correlate, and monitor for functional improvement as non-surgical recovery is still likely, unless symptoms progress or red flags prompt surgical referral.

#  MRI indications:
 Major or progressive neurologic deficit (e.g., foot drop or functionally limiting weakness such as hip flexion or knee extension)  Progressively severe pain and debility despite non-interventional therapy  Severe or incapacitating back or leg pain (e.g., requiring hospitalization, precluding walking, or significantly limiting the activities of daily living)
 Clinical or radiological suspicion of neoplasm (e.g., lytic or sclerotic lesion on plain radiographs, history of cancer, unexplained weight loss, or systemic symptoms)
 Clinical or radiological suspicion of infection (e.g., endplate destruction of plain radiographs, history of drug or alcohol abuse, or systemic symptoms)
 When there are indications for surgical intervention or therapeutic injection in the presence of moderate to severe low back pain or radicular pain that is unresponsive to non-interventional therapy  CT indications:
 MRI is contraindicated  Primary bone tumors (detect or characterize)
 Trauma (rule out or characterize fracture, evaluate for healing)
Referral to a Spinal Care Specialist  Refer patient with disabling back or leg pain, or significant limitation of function including job-related activities, within two to six weeks to a spinal care specialist such as a physical therapist, chiropractor, osteopathic physician, or physician who specializes in musculoskeletal medicine.

# EO (G2)
Referral for Inflammatory Disease  Order a CRP and/or an ESR blood test if inflammatory disease is suspected based on patient presentation. Patients with inflammatory disease should be referred to a rheumatologist.

# EO (GUC)
Laboratory Testing  Order the appropriate blood tests if cancer or infection is suspected.
In the absence of red flags, no laboratory tests are recommended. be on optimizing function and de-emphasizing pain.

# EO (G2)
Refer patients whose pain is exacerbated by physical activity and exercise to a spinal care specialist such as a physical therapist, chiropractor, osteopathic physician, or physician who specializes in musculoskeletal medicine for individualized advice.
Patients should limit/pace any activity or exercise that causes spread of symptoms (peripheralization). Self-treating with an exercise program not specifically designed for the patient may aggravate symptoms.

# Return to Work
 Encourage early return to work.
Refer workers with low back pain beyond six weeks to a comprehensive return-to-work rehabilitation program. Effective programs are typically multidisciplinary and involve case management, education about keeping active, psychological or behavioural treatment, and participation in an exercise program.
Working despite some residual discomfort poses no threat and will not harm patients.

# SR (G1, G2)
Heat or Cold Packs  Recommend superficial heat (application of heating pads or heated blankets) for the short-term relief of acute low back pain.

# SR (G1, G2)
Clinical experience supports a role for superficial cold packs and alternating heat and cold as per patient preference.
Heat or cold should not be applied directly to the skin, and not for longer than 15 to 20 minutes. Use with care if lack of protective sensation.

# EO (GUC)
Analgesia  Prescribe medication, if necessary, for pain relief preferably to be taken at regular intervals. First choice acetaminophen; second choice NSAIDs.
Only consider adding a short course of muscle relaxant (benzodiazepines, cyclobenzaprine, or antispasticity drugs) on its own, or added to NSAIDs, if acetaminophen or NSAIDs have failed to reduce pain. There is evidence that functional restoration with a cognitive-behavioural component reduces work absenteeism.

# Serious adverse effects of

# SR (G1)
Bed Rest X DO NOT prescribe bed rest as a treatment.
If the patient must rest, bed rest should be limited to no more than two days. Prolonged bed rest for more than four days is not recommended for acute low back problems. Bed rest for longer than two days increases the amount of sick leave compared with early resumption of normal activity in acute low back pain.
There is evidence that prolonged bed rest is harmful.

# SR (G2, G4, G7)
Evidence ? There is inconclusive evidence to recommend for or against epidural steroid injections in the presence of radiculopathy.
Image-guided epidural steroid injections may be helpful for some patients with lumbar radicular pain for longer than six weeks who have not responded to non-interventional treatments.
Clinical experience suggests that patients who have responded favourably (improved function and pain relief) to an epidural steroid injection may benefit from a follow-up injection after three months.

# Diagnostic Imaging
 Lumbar spine x-rays may be required for correlation prior to more sophisticated diagnostic imaging, for example prior to an MRI scan. In this case, the views should be limited to standing AP and lateral in order to achieve better assessment of stability and stenosis. CT scans are best limited to suspected fractures or contraindication to MRI. X-rays of the lumbar spine are very poor indicators of serious pathology. Hence, in the absence of clinical red flags spinal x-rays are not encouraged. More specific and appropriate diagnostic imaging should be performed on the basis of the pathology being sought (e.g., DEXA scan for bone density and bone scan for tumours and inflammatory diseases).
In the absence of red flags, radiculopathy, or neurogenic claudication, MRI scanning is generally of limited value.
Oblique view x-rays are not recommended; they add only minimal information in a small percentage of cases and more than double the patient's exposure to radiation.

# EO (GUC)
Exercise and Therapeutic Exercise  Recommend exercise and therapeutic exercise.
Encourage patient to initiate gentle exercise and to gradually increase the exercise level within his/her pain tolerance. Sophisticated equipment is not necessary.
Other options may include unsupervised walking and group exercise programs, such as those offered by chronic disease management programs. The peer support of group exercise is likely to result in better outcomes, giving patients improved confidence and empowering them to manage with less medical intervention.
When exercise exacerbates the patient's pain, the exercise program should be assessed by a qualified physical therapist or exercise specialist.
If exercise persistently exacerbates their pain, patients should be further assessed by a physician to determine if further investigation, medication, treatment, or consultation is required.
Some studies reported mild negative reactions to exercise programs, such as increased low back pain and muscle soreness in some patients.

# SR (G6, G11)
Therapeutic Aquatic Exercise  Recommend therapeutic aquatic exercise for chronic low back pain.

# SR (IHE Database)
Clinical Practice Guideline Yoga Therapy  There is some evidence that Viniyoga and Iyengar types of yoga can be helpful in the treatment of chronic low back pain.
No evidence was found to recommend other types of yoga.
It is important to find an instructor who has experience in working with individuals who have low back pain to avoid further injury.

# SR (IHE Database)
Education  Provide brief education to optimize function.
Brief education is defined as review of clinical examination results, provision of low back pain information and advice to stay active, and reduction of fear and catastrophizing.

# SR (G11)
Self-Management Programs  Recommend, if available, a structured community-based self-management group program for a patient interested in learning pain coping skills. These programs are offered through chronic disease management and chronic pain programs. Self-management programs focus on teaching core skills, such as self-monitoring of symptoms, to determine likely causal factors in pain exacerbations or ameliorations, activity pacing, relaxation techniques, communication skills, and modification of negative 'self-talk' or catastrophizing. These programs use goal setting and 'homework assignments' to encourage participants' self confidence in their ability to successfully manage their pain and increase their day-to-day functioning.
Most community-based programs also include exercise and activity programming, which are also recommended.
Where structured group programs are not available, refer to a trained professional for individual self-management counselling.

# G (G6)
Manual Therapy -Massage Therapy  Recommend massage therapy as an adjunct to a broader active rehabilitation program.

# SR (G6)
Acupuncture  Recommend acupuncture as a short-term therapy or as an adjunct to a broader active rehabilitation program.
No serious adverse events were reported in the clinical trials. The incidence of minor adverse events was 5%.

# SR (G6, G11)
Clinical Practice Guideline back pain and stiffness following injections. Some patients had severe headaches suggestive of lumbar puncture, but no serious or permanent adverse events were reported.

# Transcutaneous Electrical Nerve Stimulation (TENS) as an Adjunct Treatment
? TENS may be useful as an adjunct in select patients for pain control to reduce the need for medications. A short trial (two to three treatments) using different stimulation parameters should be sufficient to determine if the patient will respond to this modality.
Skin irritation is a common adverse event.

# EO (G6)
? There is insufficient evidence to recommend for or against the use of therapeutic ultrasound for chronic low back pain.
Based on expert opinion, this modality is overused relative to any potential therapeutic benefit.

# SR (IHE Database) Epidural Steroid Injections
? There is inconclusive evidence to recommend for or against epidural steroid injections.
For patients with leg pain, image-guided epidural steroid injections may be effective in providing short-term and occasional long-term pain relief.
Clinical experience suggests that patients who have responded favourably (improved function and pain relief) to an epidural steroid injection may benefit from a follow-up injection after three months.

# Therapeutic Sacroiliac Joint Interventions
? There is insufficient evidence to recommend for or against intra-articular sacroiliac injections.

# EO (GUC)
STarT Back Screening Tool ? There is insufficient evidence to recommend for or against using the STarT back screening tool and its associated system of stratified care for chronic low back pain.
Note that this tool has been designed to accommodate a specific program delivery model.

# EO (GUC)
Clinically Organized Relevant Exam (CORE) Back Screening Tool ? There is inconclusive evidence to recommend for or against using the CORE back tool for chronic low back pain.
Note that this tool has been designed to accommodate a specific program delivery model.

# SR (IHE Database)
Opioids ? Evidence is lacking for long-term use of opioids for chronic low back pain. However, there is some evidence of the benefit of opioids for short-term pain and function improvements.
Long-term use of opioids should only follow an unsuccessful trial of nonopioid analgesics. In severe chronic pain, strong opioids require careful consideration.
Long-acting opioids are preferred as they can establish a steady state blood and tissue level that may minimize the patient's experience of unsteady dosing (cyclical improvement and/or withdrawal) from short-acting opioids. Any use of opioids over the long term will lead to physical dependence.
Avoid escalating doses above 50 mg/day if initiating, and above 90 mg/day oral morphine equivalent for ongoing use.
Careful attention to incremental improvements in pain or function is required to justify ongoing use of opioids. Because little is known about the long-term effects of therapy it should be monitored carefully.
A history of addiction is a relative contraindication. Consultation with an addictions specialist may be helpful in these cases.

# BACKGROUND INTRODUCTION
This guideline has been adapted from eleven "seed" guidelines for prevention and treatment of acute, subacute, and chronic low back pain published between 2003 and 2014 (referenced as G1 through G11; see Seed Guideline References).
When considering recommended interventions it is important to take into account the patient's expectations and preferences, but do not use his/her expectations and preferences to predict response to treatments. Discrepancies between patient expectations and preferences and evidenceinformed practice could reflect a lack of awareness. This presents an opportunity for dialogue, mutual decision-making, and utilizing educational resources.
The most common type of low back pain is called 'non-specific low back pain' and accounts for approximately 90% of cases in primary care settings.  Less than 2% of people with low back pain have potentially serious spine conditions that will require surgery or medical intervention. 6,7 Up to 84% of people in developed countries will experience at least one episode of low back pain during their lifetime, with up to 23% of the adult population suffering from back pain at any given time. 8 Back pain is usually self-limiting and resolves within two to six weeks, but symptoms may linger for up to two months. 5, A small minority of patients (2% to 7%) will develop chronic low back pain. 5,9 Given that low back pain is common and predominantly benign, it is helpful to think of it as a condition of life rather than a medical problem that always requires investigation and intervention.
The initial aim of the primary care practitioner is to identify the small proportion of patients with serious pathology or barriers to recovery by recognizing the clinical "red flags" and "yellow flags". The vast majority of patients with non-specific low back pain need to be reassured about the very low Clinical Practice Guideline Page 22 of 49 Background risk of a serious disorder being present, educated about the natural history of low back pain, and encouraged to self-manage whenever possible.
The role of the primary care practitioner is to normalize the patient's experience in line with the expected course of recovery, while explaining that recurrences are common. At least 25% of patients will experience further episodes within a year, and over three quarters will have a recurrence at some point in their lives. 5,8,9,12,13 Many patients who understand the benign and common nature of their complaint and who have access to appropriate self-management techniques are able to manage future recurrences on their own. Nonetheless, there will be instances where patients will need to have their low back pain managed in primary care because of severity, disability, or uncertainty. When indicated, patients can be given pain relieving medications, informed about the various therapeutic modalities for which there is some positive evidence, and referred to specialty care in the minority of cases in which it is required.
A precise anatomical diagnosis is not required to determine an effective treatment plan for nonspecific low back pain. Imaging can lead to unnecessary costs and inferior patient outcomes. Finding irrelevant anatomic abnormalities can lead to diagnostic confusion and patient anxiety, as well as to unnecessary additional expense. In the absence of "red flags", x-rays and advanced imaging are only indicated when the results will inform a treatment plan that includes surgery or another interventional therapy. Imaging findings alone rarely lead to a change in treatment plan, and there is some evidence that imaging in the absence of red flags does not reassure patients. 14,15 When imaging is ordered, the results need to be explained to the patient in a way that normalizes the findings and does not attribute them to the cause of pain, except when the results will lead to a change in treatment or when "red flags" such as fracture, infection, or neoplasm are present. This applies regardless of whether nerve root compression radiculopathy is present or not as the initial management pathway is the same. Imaging can usually be deferred until the patient's clinical response to conservative treatment has been determined, except in cases of severe or progressive radicular pain when more urgent investigation and interventional management may be needed.
Exercise and activity have a positive role in the treatment of low back pain, but current evidence does not support detailed recommendations on the duration, frequency, and specific type of exercises. However, it is reasonable to consider specific exercises provided by a qualified examiner that are tailored to patients' needs and interests.
Many experts consider active rehabilitation to be preferable to passive treatment, particularly when patients have not responded to a brief trial of passive therapies. Active rehabilitation includes: Some of the rehabilitation interventions currently undergoing active research are listed in this guideline as Do Not Know recommendations to reflect the fact that there is as yet insufficient or inconclusive evidence of their efficacy in treating low back pain.
Rapport and the development of an effective therapeutic alliance can have a significant impact on patient engagement. Providers have the opportunity to enhance patient wellbeing by encouraging self-management, adaptation to physical limitations, and return to highly valued activities including work and exercise as early as tolerated. Patient information pamphlets, booklets, and videos can be effective tools for enhancing patients' understanding and acceptance of back pain and its commonly transient nature, as well as strategies for minimizing the chance of future recurrence.
While there have been some studies of medications used specifically for low back pain, in many cases the probable effectiveness has to be inferred from more general studies of the management of painful conditions generally, either acute or chronic.
When it is possible to differentiate pain as having nociceptive, neuropathic, inflammatory, infectious or malignant qualities then appropriate medication selection will naturally follow. In non-malignant low back pain, most pain is nociceptive or neuropathic in nature. Medications for either classification can be selected in a step-wise fashion as summarized in the Medication Table (Appendix F). Any medication should be tapered and withdrawn if it is clearly not improving pain or function. It is also important for patients to understand that successful use of medications may not bring complete pain relief. With chronic pain, a reduction of pain by 30 or 40% may be considered a success with no further gains to be made by increasing the medication dosing.
The use of opiates in chronic low back pain remains controversial due to the lack of adequate research demonstrating long-term efficacy in this population.

# COMPANION MATERIALS
All materials and/or links are available at:   The GDG accepted the original recommendation, which provided a prescriptive direction not to perform the action, used the term "ineffective" to describe it, or stated that the evidence does "not support" it  The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, which did not support the action  A supplementary literature search found at least one systematic review presenting consistent evidence that did not support the action

# Do Not Know ?
- The GDG accepted the original recommendation, which did not recommend for or against the action or stated that there was "no evidence," "insufficient or conflicting evidence," or "no good evidence" to support its use  The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, which was equivocal with respect to supporting the action  A supplementary literature search found either no systematic reviews ('insufficient evidence to recommend for or against") or at least one systematic review presenting conflicting or equivocal results or stating that the evidence in relation to the action was "limited," "inconclusive," "inconsistent," or "insufficient" ("inconclusive evidence to recommend for or against")

# EVIDENCE SOURCE LEGEND
Systemic Review = SR Randomized Control Trial = RCT Non-Randomized Comparative Study = NRCS Case Series = CS Guideline = G Expert Opinion = EO Guideline Development Committee = GDC Guideline Update Committee = GUC
The following evidence sources were considered:
- Systematic review (SR): as cited by the seed guideline(s) or identified from a supplementary literature search required by the Guideline Development Group (GDG) or Guideline Update Committee (GUC). The literature search spanned from January 1996 to August 2007 for the first edition of this guideline, from January 2002 to December 2010 for the second edition, and from January 2010 to April 2014 for the third edition. For evidence cited by the seed guideline(s), only the highest level of evidence was listed. For example, when the evidence cited by a seed guideline was from SRs and studies of other design (i.e., RCT, NRCS, CS, or G) only SR is listed as the source. When no SR was referenced in the seed guideline, the evidence source was indicated in the following order: RCT, NRCS, CS, G, EO. The same classification for the evidence source was applied when multiple seed guidelines were used to inform one recommendation.
Each recommendation in the Alberta guideline came from one or more seed guidelines or was created by the GDG or GUC, based on their collective professional opinion and an analysis of relevant evidence. The GDG constructed the first edition of the Alberta guideline. Subsequent editions were constructed by the GUC.

# APPENDIX C -GLOSSARY
(Adapted from 5, 21-44, G1, G5, G10, G11)
An intervention consisting of the insertion of needles at specific acupuncture points.

# Acute and subacute low back pain
Pain present for less than three months.

# Back schools
An intervention consisting of education and a skills program, including exercise therapy, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist.

# Behavioural treatment (BT) & Cognitive behavioural treatment (CBT)
BT: There are three behavioural treatment approaches: operant, cognitive, and respondent. Each of these focuses on the modification of one of the three response systems that characterize emotional experiences: behaviour, cognition, and physiological reactivity. CBT: A range of therapies based on psychological models of human cognition, learning and behaviour that are usually taught as a "package" and are intended to provide patients with a variety of skills for managing their pain.

# Brief education in a clinical setting
Brief education in clinical setting is defined as review of the patient's clinical examination results, provision of low back pain information and advice to stay active, and reduction of fear and catastrophizing.
Exaggerating the potential or real consequences of an event and becoming fearful of these consequences.

# Chronic low back pain
Pain present for more than three months.

# Craniosacral therapy
An alternative treatment approach that involves applying a gentle manual force to address somatic dysfunctions of the head and body, with the aim of releasing restrictions around the spinal cord and brain and restoring body function.

# Electrodiagnostic studies
Studies performed in the electromyography (EMG) laboratory, including nerve conduction studies, F-waves, somatosensory evoked potentials, and EMG.

# Electromyography (EMG)
The recording of electrical activity generated in skeletal muscle for diagnostic purposes. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram.
Therapeutic exercises are prescribed according to the results of an individual patient assessment. Recommendations are based on the specific impairments identified. Supervised exercise programs and formal home exercise regimens range from programs aimed at general physical fitness or aerobic exercise to programs aimed at muscle strengthening, flexibility, stretching, or different combinations of these elements.

# Facet joint injection
Injection of local anesthetic, with or without corticosteroid medication, into one or more of the small joints along the sides of each vertebrae to diagnose or treat low back pain associated with facet joint dysfunction.
See also the companion document Radiological Diagnostic and Therapeutic Interventions Directed to Lumbar Spine Pathology.

# Functional restoration (also called physical conditioning, work hardening, or work conditioning)
An intervention that involves simulated or actual work tests in a supervised environment in order to enhance job performance skills and improve strength, endurance, flexibility, and cardiovascular fitness in injured workers.

# Interdisciplinary rehabilitation (also called multidisciplinary therapy)
A biopsychosocial intervention that combines and coordinates physical, vocational, and behavioural components and is provided by multiple health care professionals with different clinical backgrounds.
The intensity and content of interdisciplinary therapy varies widely.

# Interferential current therapy
The superficial application of a medium-frequency alternating current modulated to produce low frequencies up to 150 Hz. It is thought to increase blood flow to tissues and provide pain relief and is considered more comfortable for patients than transcutaneous electrical nerve stimulation.

# Intramuscular stimulation
Uses very thin needles to 'dry needle' affected areas without the injection of any substance. IMS differs from acupuncture in its application because needle insertion is indicated by physical signs as opposed to the predetermined meridians of acupuncture. IMS is based on known scientific, neurophysiological principles.

# Low-level laser therapy
The superficial application of lasers at wavelengths between 632 and 904 nm to the skin in order to apply electromagnetic energy to soft tissue. Optimal treatment parameters (wavelength, dosage, doseintensity, and type of laser) are uncertain.

# Lumbar disc herniation with radiculopathy
Localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in pain, weakness or numbness in a myotomal or dermatomal distribution.

# Lumbar discography
Procedure that is used to characterize the pathoanatomy and architecture of the intervertebral disc and to determine if the intervertebral disc is a source of chronic low back pain.

# Lumbar supports
External devices designed to reduce spinal mobility.

# Manual therapy
Manual therapy (MT) is an umbrella term that has increasingly been adopted to encompass various forms of hands-on treatment, including both manipulation and mobilization (see spinal manipulative therapy and spinal mobilization).
Manual therapy as a treatment option in the management of pain is an intervention that is practised by a variety of healthcare professionals including physiotherapists, osteopaths, and chiropractors. Philosophical differences exist both within and between the various professions regarding the possible mechanisms of action of manual therapy.
Soft tissue manipulation using the hands or a mechanical device through a variety of specific methods. The pressure and intensity used in different massage techniques vary widely.

# Medial branch block
An injection of local anesthetic, with or without corticosteroid medication, in the area of the medial branch of the posterior primary ramus, the primary nerve innervating the intervertebral facet joint, to diagnose or treat back pain.
The skill of non-judgmentally observing emotions, sensations, or cognitions (moment-to-moment awareness). It is learned through meditation exercises that have been adapted from Buddhist traditions.

# Motorized traction
An intervention involving drawing or pulling in order to stretch the lumbar spine. Various methods are used, usually involving a harness around the lower rib cage and the iliac crest, with the pulling action done by using free weights and a pulley, motorized equipment, inversion techniques, or an overhead harness.
Magnetic resonance imaging; an imaging technique used to image internal structures of the body, particularly the soft tissues without use of radiation.

# Multidisciplinary therapy (multidisciplinary treatment programs)
See Interdisciplinary rehabilitation.

# Nonspecific low back pain
Pain occurring primarily in the back with no signs of a serious underlying condition (such as cancer, infection, or Cauda Equina Syndrome), spinal stenosis or radiculopathy, or another specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis). Degenerative changes on lumbar imaging are usually considered nonspecific, as they correlate poorly with symptoms.

# Osteopathic physician
The training of osteopathic physicians incorporates the diagnosis, treatment, prevention and rehabilitation of musculoskeletal conditions. Osteopathic manual therapy, including manipulation, can be an important part of treatment.

# Physiotherapy provided operant conditioning
Operant conditioning is defined as a time contingent, graduated increase in activity including goal setting and the education and reinforcement of positive pain behaviours with the ultimate aim of decreasing disability and increasing function.

# Prevention of occurrence of low back pain
Reduction of the incidence (first-time onset) of low back pain or the risk of new cases appearing, i.e., primary prevention.

# Prevention of recurrence of low back pain
Reduction of the occurrence of a new episode of low back pain after a symptom-free period in patients who have previously experienced low back pain, i.e., secondary prevention.

# Progressive (muscle) relaxation
A technique that involves the deliberate tensing and relaxation of muscles to facilitate the recognition and release of muscle tension.
Injections of irritant solutions to strengthen lumbosacral ligaments.
Proton pump inhibitor A type of drug that reduces the production of acid in the stomach, and is used to treat indigestion and stomach ulcers.
Dysfunction of a nerve root associated with pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution. The most common symptom of lumbar radiculopathy is sciatica.

# Radiofrequency neurotomy
Application of a high-frequency electrical current via an electrode to spinal nerves to destroy nerve function and interrupt pain signals to the brain. Also known as radiofrequency ablation. Physical examination findings predictive of facet joint origin for low back pain:
While published research suggests a significant degree of inter-examiner variability in interpreting physical examination findings, the following are considered by the authors to be suggestive of a facet joint origin for low back pain. Within the limitations noted above, such patients may be considered for referral for facet joint blocks as a confirmatory test:
- Pain is often of rapid onset  Pain is unilateral or bilateral at or above the belt-line. If radiation to the leg is present it tends to be to the buttocks or lateral thigh and rarely below the knee  Pain tends to be worse with low back extension, and may be relieved with flexion or sitting  Pain may be provoked with palpation over the paravertebral tissues in the area of the facet joints lateral to the midline, and often under several layers of muscle that may also be pain generators  Pain may be provoked by "facet joint loading maneuvers" on physical examination, for example: while standing with feet pointing ahead at shoulder distance apart, the patient is asked to look over one shoulder, followed by trunk rotation to the same side, then lumbar extension. The resulting lumbar extension in combination with side-bending and rotation will cause facet joint loading on the same side. The examiner may need to help stabilize the patient to prevent a loss of balance Similarly, the following findings are considered by the authors to be suggestive of a sacroiliac joint origin for low back pain:
- Pain is localized in the lower back and buttock area, usually unilaterally and just below the belt line  The patient points to the sacroiliac joint as the area of maximal pain  Pain may be aggravated by either flexion or extension, but the patient points to the same point as the pain generator  "Do" category -indicates that the action should be undertaken;  "Do Not Do" category -indicates that the action should not be undertaken; ? "Do Not Know" category -indicates that there was either insufficient evidence or a lack of conclusive evidence to make a definitive decision regarding the action.  "Do" for clarifying anatomy and directing treatment decisions and "Do Not Do" when results are not going to affect treatment decisions.

# Appendix B -Evidence Source

# APPENDIX B -EVIDENCE SOURCE
The Evidence Source provides information on the "seed" guideline(s) that were used to develop the Alberta guideline recommendations and the design of the studies referenced by the seed guideline(s) in support of their recommendations. Appendix C -Glossary Appendix C -Glossary Appendix C -Glossary See also the companion document Radiological Diagnostic and Therapeutic Interventions Directed to Lumbar Spine Pathology.

# Red flags
Clinical (i.e. physical) features that may alert to the presence of serious but relatively uncommon conditions or diseases requiring evaluation. Such conditions include tumours, infection, fractures, and neurological damage/ disease.

# Respondent therapy using EMG biofeedback
A therapy aimed at modifying physiological response to pain by reducing muscular tension. It is based on the idea of a pain-tension cycle, where pain is viewed as both a cause and a result of muscular tension. Respondent therapy attempts to interrupt this cycle by using a tension-incompatible reaction, such as relaxation. EMG biofeedback is frequently used to reduce the assumed muscular tension, relieve anxiety, and subsequently pain (see separate glossary entry).

# Sacroiliac joint block
An injection of local anesthetic, with or without corticosteroid medication, into the sacroiliac joint to diagnose or treat low back pain associated with sacroiliac joint dysfunction. See also the companion document Radiological Diagnostic and Therapeutic Interventions Directed to Lumbar Spine Pathology.
Pain that radiates along the path of the sciatic nerve, which runs from the lower back, through the buttock, and down the back of the leg. Sciatica can be caused by irritation or compression of the sciatic nerve.

# Selective nerve root block (SNRB)
An injection of local anesthetic, with or without other substances such as corticosteroid medication, along a specific nerve root that exits from the spinal cord to diagnose or treat nerve root pain in the back. Also known as selective transforaminal epidural injection. See also the companion document Radiological Diagnostic and Therapeutic Interventions Directed to Lumbar Spine Pathology.

# Shock-wave treatment
Application of low-frequency sound waves (10, 50, 100, or 250 Hz) to the skin, causing an oscillatory pressure in the underlying soft tissue. Also commonly known as "vibrotherapy".
Short-wave diathermy Therapeutic elevation of the temperature of deep tissues by application of short-wave electromagnetic radiation with a frequency range from 10-100 MHz.

# Spa therapy
An intervention involving several interventions, including mineral water bathing, usually with heated water, and other interventions such as massage and exercise, typically while staying at a spa resort.

# Spinal care specialist
A physical therapist, chiropractor, osteopathic physician, or physician who specializes in musculoskeletal medicine.

# Spinal manipulative therapy
Application of high-velocity, low-amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion. This may be accompanied by an audible 'crack' or 'pop'.

# Spinal mobilization
Application of manual force to the spinal joints within the passive range of joint motion that does not involve a thrust.

# Spinal stenosis
A condition in which there is diminished space available for the neural and vascular elements in the lumbar spine, secondary to degenerative changes in the spinal canal. When symptomatic, this causes a variable clinical syndrome of gluteal and/or lower extremity pain and/or fatigue, which may occur with or without back pain. Appendix C -Glossary
See also the companion document Radiological Diagnostic and Therapeutic Interventions Directed to Lumbar Spine Pathology.
Transcutaneous electrical nerve stimulation; use of a small, batteryoperated device to provide continuous electrical impulses via surface electrodes, with the goal of providing symptomatic relief by modifying pain perception.

# Therapeutic aquatic exercise
Active exercise in warm water; such as aqua-aerobics and aquajogging.

# Therapeutic ultrasound
The use of, externally applied sound waves to generate heat within specific parts of the body.
Trigger point injection An injection of fluid directly into a hyperirritable area of muscle or soft tissue (trigger point) that is tender when compressed and can give rise to referred pain. Also known as direct wet needling.

# Touch therapies
Touch therapies are defined as energy based complementary therapies including healing touch, therapeutic touch, and Reiki.

# Yellow flags
Psychosocial and sociological factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain.
An intervention distinguished from traditional exercise therapy by the use of specific body positions, breathing techniques, and an emphasis on mental focus.

# GUIDELINE COMMITTEE
The committee consisted of representatives of anesthesia, diagnostic radiology, family medicine, general practice, internal medicine, kinesiology, orthopedic surgery, pharmacy, physical medicinerehabilitation, physiotherapy, psychology, occupational therapy.