Early management of persistent non-specific low back pain: summary of NICE guidance 2009


Pain diagram for patients



The red flags define the extent of examination

  • Age under 20 or over 55
  • Non-mechanical pain (capsular pattern)
  • (Thoracic pain)
  • Ca, steroids HIV or other significant past history
  • Unwell, wt loss
  • Widespread neurology eg bilateral leg signs
  • Structural deformity
  • Persistent night pain
  • Saddle anaesthesia/sphincter disturbance

Can use time as a tool. If no sensory symptoms, not worthwhile looking for sensory signs. remember though that examination may be a therapeutic procedure.


  • Inspection
  • Palpation
  • Percussion


C7/T1 Prominent
T7/T8 Lower border of scapula
L4 body Iliac crests
S2 Dimples at PSIS
Tip coccyx Ischeal tuberosities

Patterns of stiffness

Capsular pattern: stiffness in all directions (acute pain, arthritis, inflammatory, destructive).
Non-capsular pattern: stiffness in one direction (mechanical). Dysfunction = stress x vulnerability

  Reversible Not reversible
Pathological ? X
Structural ? X
Functional ? X


  • review diagnostic triage
    • nerve root problem
      serious spinal pathology
  • ESR and plain X-ray


  • attitudes and beliefs about back pain
    • fear avoidance beliefs about activity and work
    • personal responsibility for pain and rehabilitation
  • psychological distress and depressive symptoms
  • illness behaviour


  • family
    • attitudes and beliefs about the problem
    • reinforcement of disability behaviour
  • work
    • physical demands of job
    • job satisfaction
    • other health problems causing time off or job loss
    • non-health problems causing time off or job loss

Waddell tests for functional backpain

  • Tenderness to touch
  • Simulated axial loading
  • Distraction tests
  • Non-anatomical regional disturbance
  • Over-reaction

Diagnostic Triage including 'Red Flags'


Simple backache

Nerve root pain

RED FLAGS for Possible Serious Spinal Pathology

Risk factors for chronicity

The whole examination



Root signs:


Root signs:

Inappropriate signs

This is "pain behaviour"


NICE referral guidelines

Early management of persistent non-specific low back pain: summary of NICE guidance 2009