Low Back Pain

Improving the quality of treatment can make a life-changing difference to patients suffering from low back pain. The Clinically Organized Relevant Exam (CORE) Back Tool and Toolkit guides providers to recognize common mechanical back pain syndromes and screen for conditions where management may include investigations, referral and specific medications.
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CORE Back Tool
Low Back Pain Tool
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The Centre for Effective Practice (CEP) has developed tools and education modules to help primary care physicians and nurse practitioners better manage patients who suffer from low back pain. This work builds from the Ministry of Health and Long-Term Care (MOHLTC) Low Back Pain Strategy, which began in 2012. The goal of this initiative was to reduce the number of unnecessary diagnostic tests, improve wait times, and enhance patient care. To read more about the provincial strategy click here.

What’s new with CORE Back 2016?

Feedback from primary care providers about the CORE Back Tool 2012 informed revisions to the 2016 Update. Providers told us they wanted more information about the evidence, an expansion of the initial management options, more clearly integrated patient key messages, and improvements to the overall information flow to align with their decision-making processes. CORE Back Tool 2016 contains these new features:

  • New cover page with teaching pearls to support those using the CORE Back Tool for education and/or to support new users.
  • Integration of identification of the mechanical patterns for low back pain into patient history questions.
  • Revised psychosocial yellow flags section includes questions and hints for providers to help identify patients who are at higher risk for chronic problems.
  • Patient key messages integrated throughout the tool.
  • New Management Matrix with suggestions for initial office management based on the patterns of low back pain.

Low Back Pain online course

To supplement the CORE Back Tool, we developed a Primary Care Focus on Low Back Pain online course, which is free and available to all health care providers across Canada. Our clinical leads, Drs. Julia Alleyne and Hamilton Hall, co-authored this course which is intended to improve patient outcomes, decrease unnecessary resource utilization and increase capacity to manage low back patients in comprehensive care.

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Project Overview

The Centre for Effective Practice (CEP) developed tools and education modules to help primary care physicians and nurse practitioners better manage patients who suffer from low back pain. This work builds from the Ministry of Health and Long-Term Care (MOHLTC) Low Back Pain Strategy, which began in 2012. The Strategy included an amendment to the schedule of benefits, a provincial pilot program and provider education. The goal of this initiative was to reduce the number of unnecessary diagnostic tests, improve wait times, and enhance patient care. To read more about the provincial strategy click here.

Development Process

CEP was engaged to develop and deliver the provincial provider education that included the original CORE Back Tool, 2012. To read more about the provider education click here.

In 2015/16, Centre for Effective Practice invested funds to update the CORE Back Tool to reflect provider feedback and recent evidence.

The CORE Back Tool 2016 Update was developed using Centre for Effective Practice’s integrated knowledge translation approach. The development process included an evidence review, expanded references and integration of expert input for areas where there is a lack of evidence but where primary care providers need a recommended approach. CEP ensures that health care providers are engaged throughout the tool development process, using a User Centered Design methodology to test the usability of tools from a provider perspective.

Engaging Providers in the Update

The CEP team led a number of activities to include the experience of providers who had used the Tool in the CORE Back Tool 2016 Update. We gathered input from:

  • Review of evaluation data from our online Primary Care Focus on Low Back Pain course on the CORE Back Tool (over 5000 providers participated in the online course)
  • Results from a survey of primary care providers on the usability of the CORE Back Tool 2012 version
  • Heuristics evaluation to improve flow of information
  • One-on-one user centered interviews with primary care providers
  • Engagement with our Clinical Working Group

The findings from these activities build on the extensive provider engagement activities used to develop the first CORE Back Tool, which included three focus groups with Family Physicians and Nurse Practitioners from across Ontario.

Participants in the 2012 and 2016 projects were recruited through CEP’s quarterly updates.

Endorsements

Through individual participation in the development process, the Canadian Spine Society (CSS) and the Nurse Practitioners’ Association of Ontario (NPAO) provided endorsements for the CORE Back Tool 2016.

CEP is pleased to have an organization-level endorsement from the College of Family Physicians of Canada (CFPC).

If you would like to be engaged in and/or endorse the CORE Back Tool or if you are interested in collaborating, modifying or using the toolkit for commercial purposes, contact us at info@effectivepractice.org

Meet Our Team

 The Centre for Effective Practice team worked with a clinical lead and clinical working group and enlisted expert input for the 2016 Update.

Clinical Lead

JuliaAlleynebiopic

Julia Alleyne, MD, CAC (SEM), FCFP
Dr. Julia Alleyne is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. In addition, she trained as a physiotherapist and maintained an active license for 30 years. She is appointed at the University of Toronto, Department of Family and Community Medicine as an associate clinical professor.

In 2009, she completed her Masters with a focus in Health Professions Education. Since that time, she has been active as an educational curriculum consultant including the clinical lead for Ontario’s Low Back Pain Strategy and program designer for the MSK Initiative in British Columbia. In 2013, she was appointed as the first Family Physician to be chair of Bone and Joint Canada.

In addition, her work in the area of Back Care includes being an educational consultant for curriculum and tool development for provincial MSK initiatives in Ontario and British Columbia. She has co-authored a series of Spine related articles for Current Concepts in Care and is the co-chair for the Spine Quality Based Pathway. Dr. Alleyne has worked with the Centre for Effective Practice for a decade in the area of Primary Care Musculoskeletal tool development and education.

Clinical Working Group

For the 2016 update, we invited members from the CORE Back Tool 2012 Education Planning Committee to participate. In 2016 membership was expanded to include the following:

  • Michelle Acorn, Nurse Practitioner
  • John Axler, Family Physician
  • Craig Bauman, Chiropractor
  • Kerri Deir, Kinesiologist
  • David Dos Santos, Chiropractor
  • Dale Guenter, Family Physician
  • Bruce Hobson, Family Physician
  • Jessica Munro, Nurse Practitioner
  • Steve Radke, Family Physician
  • Hema Rajawat, Pharmacist
  • Inge Schabort, Family Physician
  • Murray Townsend, Chiropractor
  • Kathy Tripp, Nurse Practitioner
  • Xu Wang, Family Physician
  • Jennifer Young, Family Physician

Thank you to all of our members for their work!

Expert Opinion

CEP sought additional expert input for the 2016 Update on topics including: terminology, assessment, management and appropriate referrals. Expert input was provided by:

Hamilton Hall MD, FRCSC
Dr. Hamilton Hall is a Professor in the Department of Surgery at the University of Toronto and on the orthopaedic staff at the Sunnybrook Health Sciences Centre.
In 1974 Dr. Hall founded the Canadian Back Institute (CBI Health Group), now the largest rehabilitation company in Canada. Dr. Hall continues to serve as its Medical Director. He is a co-founder of the Canadian Spine Society and is presently the Society’s Executive Director.

Dr. Hamilton Hall is a member of the North American Spine Society, the Canadian Orthopaedic Association and the International Society for the Study of the Lumbar Spine. He has served on the editorial boards of Spine, The Spine Journal and The BackLetter. In addition to over 100 published articles and book chapters and 1000 invited presentations, Dr. Hamilton Hall is the author of the best-selling Back Doctor series, most recently A Consultation with the Back Doctor.

Y. Raja Rampersaud MD, FRCSC
Dr. Rampersaud is nationally and internationally recognized leader and innovator in minimally invasive spine surgery. Dr. Rampersaud has recently completed a two year term as the president of the Canadian Spine Society and has been instrumental in the development of spine care advocacy efforts across Canada. Dr. Rampersaud is leading the Interprofessional Spine Assessment and Education Centre (ISAEC) Pilot Project funded through Government of Ontario.

Supporting Material

Here are some additional resources and sources of information and links to supporting tools. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. CEP will make every effort to keep these links up to date.

To view a list of references for the CORE Back Tool click here.

Supporting Materials

The following tools are aligned with the content in the CORE Back Tool and offer additional support to providers who are treating patients with low back pain.

Low Back Pain Education
5000 providers across Canada have completed our online education modules!

Opioid Risk Tool
This tool identifies patients who may be at risk for opioid dependency so that appropriate medication management can be planned.
Available in colour or black and white

Patient Education Inventory
This tool is an inventory for primary care providers to help identify useful patient education material. It lists tools or materials that have been created for Low Back Pain patients, along with provides references and (where available) direct links
Available in colour or black and white

Personal Action Planning for Patient Self-Management
This tool provides 3 key questions for effective goal setting with patients as well as a quick guide to engage patients in defining a self-management action plan.
Available in colour or black and white

The Keele STarT Back Screening Tool
This screening tool categorizes patients by risk of persistent symptoms (low, medium or high), which allows the clinician to tailor interventions appropriately.
Available in colour or black and white

Where existing tools were used and/or modified for the CORE Back Tool, the developers and authors were contacted for permission. All supporting tools have been included in this toolkit with the permission of the developers and appropriate acknowledgement is indicated on each tool.

Additional Resources

Low Back Pain Patient Self-Management Video

The Centre for Effective Practice is excited to present a patient video on Low Back Pain created by Dr. Mike Evans (Health Design Lab) and developed in collaboration with the Government of Ontario, and the Institute for Work & Health. This video is designed to help Ontario adults with low back pain. The information is based on the evidence-informed tools and resources developed as part of the provincial Low Back Pain Strategy.

Additional Tools

In addition to the CORE Back Tool 2016, here are some other useful tools:

For Providers
Pharmacy Table: Acute and Subacute Low Back Pain – Pharmacological Alternatives5
Pharmacy Table: Acute and Subacute Low Back Pain – Topical and Herbal Products6
Evidence Summary for Management of Non-Specific Chronic Low Back Pain7
Opioid Manager Switching Opioids Form8

For Patients
General Recommendations for Maintaining a Healthy Back10
So Your Back Hurts11
What You Should Know About Acute Pain12
What You Should Know About Chronic Pain13
Imaging Tests for Lower Back Pain: When You Need Them – And When You Don’t14
Dr. Mike Evans Low Back Pain Patient Self-Management Video15 – watch the video above
Full references available here.

Other Relevant Initiatives

Here is some information for primary care providers about other relevant initiatives related to Low Back Pain or other Musculoskeletal (MSK) issues.

Provincial Initiatives

Government of Ontario Low Back Pain
www.ontario.ca/lowbackpain 

Interprofessional Spine Assessment and Education Clinics (ISAEC):
Ontario Pilot Project www.isaec.org
“The goal of the Inter-professional Spine Assessment and Education Clinics (ISAEC) pilot is to evaluate a new model of care in which inter-professional allied health care teams provide low back pain patients with assessment, education and evidence-based treatment plans emphasizing self-management strategies. In addition, referred patients will be provided with more streamlined access to specialists and diagnostic services when indicated. This pilot launched in Toronto, Hamilton and Thunder Bay in November 2012 and runs until the end of November 2013. The ISAEC pilot is funded by the Government of Ontario.” Source: www.isaec.org

Government of Saskatchewan
www.health.gov.sk.ca/back-pain
“Saskatchewan has implemented a spine pathway – new assessment and treatment processes for patients with low back pain. This pathway will improve the assessment of low back pain by family physicians and other health providers, so patients can quickly receive care that is appropriate for their condition. The pathway is expected to decrease wait times for specialist referrals, treatment and surgery. In June 2011, the Regina Qu’Appelle and Saskatoon Regional Health Authorities opened Saskatchewan Spine Pathway Clinics in Regina and Saskatoon. Primary care providers can now refer patients who require additional assessment and support to either clinic, using a physician referral form. At the Spine Pathway Clinics, a multi-disciplinary team of health providers will reassess patients and identify treatment options. ”

British Columbia
www.bcma.org/practice-support-program
“The Practice Support Program (PSP) provides training and support (learning modules) for physicians and their MOAs designed to improve clinical and practice management and to support enhanced delivery of patient care. The PSP began as an initiative of the General Practice Services Committee’s (GPSC), a partnership between the BCMA and Ministry of Health (MoH), and now receives additional direction, support, and funding from the Shared Care Committee and the Specialist Services Committee (also a partnership between the BCMA and MoH). The Shared Care Committee is working with the PSP in the development and delivery of learning modules with a focus on the shared care of patients between family and specialist physicians. The committee provides additional funding to the PSP for development and delivery of and specialist participation in modules with a shared care approach, which currently include:

Alberta 
www.topalbertadoctors.org
Low Back Pain Guidelines were developed by Alberta’s Towards Optimized Practice (TOP) group. They are available at the link above and include additional tools to support providers and patients in the appropriate assessment and management of Low Back Pain across acute, recurrent and chronic.

National or Pan-Canadian

Back Care Canada
www.backcarecanada.ca

Bone and Joint Canada
www.boneandjointcanada.com
“Over the last few years Bone and Joint Canada (BJC), the Canadian division of the Bone and Joint Decade, has developed partnerships across Canada with organizations committed to the management of patients presenting with musculoskeletal disorders. Working through clinical, administrative and policy leaders in each of the provinces BJC has developed a network approach to improving system performance and patient care. By working together and building on these relationships there are significant opportunities for improving the care for MSK patients across Canada through the next decade.” It supports collaboration across Canada for initiatives on topics related to its mandate including Low Back Pain.

Canadian Spine Society
www.spinecanada.ca/

CBI Health Group
www.cbi.ca

Copyright & Disclaimer

CEP fully supports the use of the CORE Back Tool by providers, educators, decision-makers and others. Please read the following information prior to use of CORE Back Tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative Commons The CORE Back Tool is a product of the Centre for Effective Practice under copyright protection with all rights reserved to the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the paragraphs pertaining to Creative Commons License and the Disclaimer are reproduced and provided that appropriate citations appear in all copies, modifications, and distributions. Use of the CORE Back Tool for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: info@effectivepractice.org).

For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@effectivepractice.org) of any use or reprinting of the tool.

Please use this citation when referencing the tool:

Reprinted with Permission from Centre for Effective Practice (February 2016). CORE Back Tool. Toronto. Centre for Effective Practice.

Disclaimer

CORE Back Tool (the “Tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations. These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Third Party Resource(s).

This Tool was developed for licensed health care professionals in Canada as a guide only and does not constitute medical or other professional advice. Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool.

Neither the Centre for Effective Practice (“CEP”), the Canadian Spine Society, the Nurse Practitioners’ Association of Ontario, The College of Family Physicians of Canada, the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in this Tool (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein.