In short, most likely not. As you’ve already learnt, most cases of LBP get better by themselves (with or without treatment). Add to this the fact that only about 1 in 100 cases of lower back pain are serious1, and it’s pretty obvious why in most cases you won’t need to see a health professional.
However, as unlikely as it may be, how are you supposed to know if your LBP is caused by something serious?
‘Red flags’ are risk factors used by health professionals to help them screen for underlying pathology (e.g. infection, cancer, vertebral fractures etc.). The more of these risk factors a person has, the more likely their LBP is caused by something serious.
If a health professional suspects an underlying pathology, they will likely ask further questions related to these red flags, trying to minimise its likelihood. For example, a 50-year-old woman with chronic asthma presents with first-time (severe) LBP. Being female and possibly post-menopausal, combined with the severity of the LBP and the fact it’s the first time she’s experienced it, together mean there is a higher than normal chance that vertebral fracture is the cause of her LBP. Therefore, the health professional will likely ask about previous bone scans, info about medication(s), when or if she’s gone through menopause, and if she’s experienced any significant trauma recently (e.g falls) etc. (the list goes on). Answers to all of these questions could potentially be red flags for vertebral fractures. However, if the responses are all favourable, then it’s much less likely to be the cause of her LBP. If a health professional is unable to rule out a red flag beyond a reasonable doubt, they may decide to wait and see how the person responds to treatment (delaying the diagnosis of a serious cause of LBP for a moderate period of time is unlikely to cause significant harm2) , or, refer them immediately for further investigation (in rare cases it can be a medical emergency).
Below is a list of some of the most common red flags associated with LBP. Each of them are associated with at least one serious pathology and were adapted from the New Zealand (2004)3, European (2006)4 and Canadian (2017)5 LBP guidelines.
• New onset of LBP when you’re more than 55 years old (especially over 65)
• Recent history of significant trauma
• Severe worsening pain, especially at night or when lying down
• Past medical history of cancer
• Prolonged use of corticosteroids (common anti-inflammatory drugs used for many chronic inflammatory conditions such as asthma, skin conditions, arthritides etc.)
• Drug abuse, immunosuppression, HIV
• Unexplained weight loss
• Widespread neurological symptoms (i.e. pins and needles, altered sensation, numbness, weakness in lower limbs/gait disturbances)
• Sudden or progressive onset of loss of bowel and bladder function, saddle anaesthesia (numbness in the ‘saddle region’), pain down one/both of your legs
If you have LBP AND any of the above characteristics, there is an increased risk that your LBP is caused by something serious. However, before you start worrying, remember that rare things present rarely! One LBP expert made the observation that two medical conditions that are screened for using these red flags (cauda equina and spinal infections) are so rare that most primary healthcare practitioners will be lucky to see one case in their entire careers!2 In addition, individual red flags used in isolation may not be that reliable.6 Henschke et al. (2009) looked at the prevalence of serious spinal pathology in people presenting with acute LBP.1 Of the 1172 patients that were assessed, only 11 of these were confirmed as having serious spinal pathology (0.9%). This consisted of 8 cases of fracture, 2 cases of inflammatory arthritides and 1 case of cauda equina (with no cases of infection or cancer). But here’s the punch line. Despite this low amount of serious pathology, over 80% of the patients had at least one red flag. This high false-positive rate for some red flags, combined with the fact that all 11 serious pathologies presented with multiple red flags, suggests that no red flag should be used in isolation. Other recent studies have also called into question the current usefulness of red flags in the clinical setting.2,7–10 One study reported that red flags were more closely associated with prognosis rather than diagnosis7, whereas another labelled them as ‘outdated’ and blamed this for an overuse of imaging.9
In any case, the odds are seriously good that you simply have ‘regular’ LBP, without any cause for alarm. However, if after reading this section you’re still feeling worried, it’s worth seeking professional advice, to give yourself some peace of mind!
So, now that you’re (hopefully) confident there’s nothing serious causing your LBP, does that mean you should not see a health professional (or get treatment)? Not necessarily. Just because you don’t need to see a health professional, doesn’t mean you shouldn’t. Wait, what!? Perhaps a better question would be ‘Would you benefit from seeing a health professional?’. These two questions are actually quite distinct, and therefore may have different answers.
Below is a very basic list of ‘Pros’ and ‘Cons’ when it comes to getting treatment (seeing a health professional):
• Reassurance (especially beneficial to ‘Type A’ personalities – you know who you are!)
• May provide pain relief
• May lead to a faster/better overall recovery (especially in certain circumstances – see below)
• Nearly all major treatments for LBP are very safe (rarely create major adverse effects)
• There’s no guarantee it will help. The effectiveness of most treatments for LBP offered by health professionals are either not at all or only weakly supported by evidence
• Cost of treatment
• Possibility of minor adverse effects (most often muscle soreness)
In my opinion there are a few major factors that should influence your decision to see a health professional. These can be summed up in the following three questions:
1. Have you experienced anything like this before? (Comparable levels of pain/disability/other symptoms)
2. How much fear or uncertainty are you experiencing regarding your LBP? (Do you find yourself constantly worrying about your pain and/or have poor expectations of your recovery?)
3. How well can you move? (Mainly applicable after the first 2-3 days)
If your answers to the above questions are something like this:
1. Yeah, I’ve had an episode like this before.
2. I’m not worried. I know it will go away by itself.
3. It’s still quite sore but already I can tell it’s better than it was a day or two ago.
Then I would suggest you really don’t need to see a health professional for your LBP. It wouldn’t hurt if you did (apart from your wallet), but you probably don’t stand to gain as much. Just keep moving!
However, if your answers are more like this:
1. No, I haven’t experienced anything like this before.
2. This pain is stressing me out. I’m worried I might not recover fully.
3. I still have a great deal of difficulty moving a few days after onset (no significant improvement).
Then I would strongly suggest that you see a health professional for your LBP. Why? Because LBP can be really scary, and this is no truer then when you haven’t experienced anything like it before. And while it is normal to feel worried if you’re in a large amount of pain and can barely move, for various reasons (whether circumstantial or due to certain inherent qualities), some people will worry more than others. People like this may be prone to unhelpful thought patterns/behaviours when it comes to their LBP (e.g. catastrophising, pain avoidance etc.). It is well established that these psychosocial risk factors (also called ‘yellow flags’) can delay the recovery from an episode of LBP, and worsen its prognosis (increase the chance of it becoming chronic).11–15 Fortunately, two of the best remedies for these are also some of the easiest: reassurance and quality advice from a professional (both of which come under the umbrella of ‘education’). Education is actually considered an important form of treatment in itself.16 And while you don’t have to see a health professional for this (you are in fact treating yourself just by reading this website!), in some cases these people require more than just education and therefore would benefit from seeing professionals who specialise in addressing these psychosocial factors (e.g. psychologists). This will be covered further in the ‘What are my treatment options’ page.
The other important factor when it comes to deciding whether you should see a health professional for your LBP, is how well you can move (level of disability). If pain is stopping you from moving, it’s also slowing your recovery. This is reflected in a recent LBP clinical guideline which states that people who are not improving, or whose LBP is exacerbated by physical activity and exercise, should be referred to a spinal care specialist (e.g. physical therapist, chiropractor etc.).5 In other words, patients who aren’t able to follow the basic recovery plan (self-care => keeping active) are the ones who most likely need some form of intervention. I would like to mention here that the level of progress also needs to be taken into consideration. Even if you can’t move well after a few days, provided you’re still experiencing significant improvements, you’re probably doing just fine. Progress is important. In contrast, someone who has only a moderate level of disability, but hasn’t improved in a week, probably needs to see a health professional. Remember that the idea of treatment in these circumstances is to allow you to return to your normal activities as quickly as possible, which should lead to better overall outcomes. This is largely how I view my role as a manual therapist – I make people feel better by providing reassurance and helping them move better.
Ultimately whether you decide to see a health professional will depend on your own set of circumstances, your answers to the above considerations, and personal preferences. In general, people who have greater levels of pain, disability and psychosocial risk factors need treatment more than those who don’t (sounds pretty simple when you put it like that!).
• It’s unlikely you will need to see a health professional for your LBP (however this doesn’t mean you won’t benefit from it).
• ‘Red flags’ are risk factors for serious underlying medical conditions causing your LBP (e.g. infection, cancer, vertebral fractures etc.). The more red flags you have, the more likely there is a serious cause of your LBP.
• Don’t panic! Common things happen commonly. An American professor put it best, “When you hear hoofbeats, think of horses not zebras.” In other words, you’re far more likely to have ‘regular’ LBP than anything ‘nasty’.
• If you’re still worried, seek professional advice (to put your mind at ease).
• You stand to benefit more from treatment when your pain is either not improving, or is exacerbated by physical activity and exercise.
• Psychosocial risk factors (e.g. catastrophising, high work demands, poor expectations of recovery etc.) are also known as ‘yellow flags’ and can delay the recovery of an episode of LBP, increasing the chance of it becoming chronic.
• Education is an important treatment in itself and can be as simple as reading this website!
• The major goal of treatment in LBP is helping you return to your normal activities as quickly as possible.
• As a general rule, people who have greater levels of pain, disability and psychosocial risk factors need treatment more than those who don’t.
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2. Underwood M. Diagnosing acute nonspecific low back pain: Time to lower the red flags? Arthritis Rheum. 2009;60(10):2855-2857. doi:10.1002/art.24858.
3. Panel E. New Zealand Acute Low Back Pain Guide.; 2004.
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