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Lower Back Pain

Red flags


  • Begin low back pain after 50 life years;

  • Continuous pain (repositioning or movement does not lessen the pain);

  • Pain during the night (pain is not due the body's position);

  • Malaise;

  • Malignancy in the past;

  • Unexplainable body weight loss;

  • And/or high erythrocyte sedimentation rate.

Osteoporostic spine fracture

  • Recent fracture (<2 years);

  • Spine fracture in the past;

  • Age above 60 years;

  • Low body weight (<130 lbs, BMI < 20 kg/m2);

  • Elderly with hip fracture;

  • Corticosteroids use for longer period of time;

  • Local tap (palpation) or pressure pain on the spine;

  • Remarkable decrease in body length;

  • And significant thoracic kyfosis.

Spondylitis ankylopoetica

  • Begin low back pain;

  • Male;

  • Iridocyclitis (yellow eyes);

  • Unexplainable peripherally artritis or inflammatory dermondoining in past;

  • Mainly nightly pain;

  • Morning stiffness > 1 hour;

  • Less pain when laying down/movement/exercises;

  • Good reaction on NSAID's

  • And/or high erythrocyte sedimentation rate.

Spine fracture

  • Severe low back pain after trauma

Severe form of spondylolisthesis

  • Begin low back pain before age 20;

  • Pronounced and touchable process spinosus around the level L4-L5.


  • Physical symptoms;

  • Consult question;

  • Specify begin of the physical symptoms and course over time;

  • Status presens;

  • Coping;

  • And psychosocial factors.


  • Numeric (pain) rating scale: 10 is most pain imaginable; 0 is no pain;

  • Patient Specific Complaints [patiënt Specifieke Klachten]: Rate the effort of three activities it takes you to execute;

  • And Quebec Back Pain Disability Scale: evaluate functional status.

Profile 1: Natural history

A natural history means that there is an increase of activities and a decrease of pain with 3 weeks.


  • No need to worry;

  • Avoid laying in bed to lessen the pain (max. 2 days in case of severe pain);

  • Resume activities and try to keep working or make adaption so you can keep working;

  • Increase of activities will not lead to damage of the back;

  • And max. 3 physical therapy consults needed.

Profile 2: different course

A different course means that there is no increase of activities and no decrease of pain with 3 weeks.


  • Build up activities, keep working or try to resume work;

  • Increase of activities will not lead to damage of the back;

  • Use my training schedule adjusted to your wishes;

  • Consider mobilization (increase the range of movement of the joints);

  • Consider short massage or warmth therapy for pain releave;

  • And in case of absenteeism >4 weeks, contact a occupational therapist.

Profile 3: different course with dominant psychological factors

Psychological factors have a negative effect on the physical well being. Dare to talk together about psychological factors.

  • Discuss psychological factors;

  • Discuss multidisciplinary with occupational therapist in case of severe physical injury, absenteeism or conflict in workplace;

  • Start a graded activity program (a slow and steady increase of activities based on time and not based on pain;

  • In case of absenteeism match the goals of graded activity program with resumption of work;

  • Evaluate program when there is no progression within 6 weeks.

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