Low Back Pain: When is it time to refer out?

by Carolyn Dolan | Follow on Twitter

Low back pain is a common condition in your clients. Know when to refer out for more specific medical attention.

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The prevalence of low back pain in the adult population is considered normal given it’s frequency.

Upwards of 50% of adults will have back pain in any one year. It can be highly variable in its natural history. Recurrence, episodes and persistent symptoms are common.

The prevalence in the adult population experiencing back pain is considered to be normal. Risk factors for developing back pain are lifestyle, biomechanical and psychosocial.

As all integrative practitioners know, many things can cause pain.

More often than not, pain is a signal that the inflammatory system is running amuck. Integrative practitioners especially, are concerned about how the pain may be a result of poor lifestyle choices (especially sugar, gluten, alcohol), potential food sensitivities, the burden of stress, lack of sleep, digestive issues and even lack of movement. All of these issues may contribute to joint and soft tissue pain, especially in the lower back.

But what happens when addressing these issues doesn’t resolve the pain?

What do you do?

It is an important distinction to make between what needs allopathic medical attention and what needs a mechanical assessment from a physical therapist.

When is it time to refer?

Although most lifestyle changes are positive for reducing pain, they often take time. Having a screening tool available to help guide you will help the patient recover their function sooner and safely.

Pain is a great teacher, we just need to practice good listening. <– Click to Tweet

During an evaluation there are “Red Flag Clues” that indicate the appropriateness of medical treatment. If the patient answers yes to these questions, then referral their MD is warranted if not emergent. These may be an indication of potential metastatic disease, medical emergency or fracture.

Allopathic imaging and care is necessary to rule out these possibilities even if naturopathic care is warranted to complement.

Here is a list of Red Flag Clues for Low Back Pain:

  • Age >55 (With increased age comes increased risk of metastatic disease. This alone is not considered a “Red Flag Clue”)
  • History of cancer
  • Unexplained weight loss
  • Constant, progressive, unrelenting, non-mechanical pain, worse at rest
  • Systemically unwell
  • Persisting severe restriction of lumbar motion
  • Widespread neurological deficit (measured by deep tendon reflexes and manual muscle testing)
  • Loss of bowel and bladder control (may be a surgical emergency to spare the nerves that control bowel and bladder function – refer to Emergency Room)
  • Numbness and tingling in the saddle area between the thighs
  • Numbness and tingling in the legs that is progressively getting worse or unchanging despite treatment
  • Systemic steroids
  • History of IV drug use
  • History of significant trauma enough to cause fracture or dislocation (x-rays will not always detect fractures and sometimes Computed Topography (CT) scan is necessary)
  • History of trivial trauma and severe pain in potential osteoporotic individual
  • No movement or positions reduces pain (usually indicates something sinister or at times can be just heightened inflammatory state as a result of poor diet and lifestyle)

Although there is no clear answer here about how many questions need a yes in order to refer out, it is safe to use clinical judgment. For certain, if there are “yes” answers to multiple Red Flag Clues, it is appropriate to recommend further evaluation by a medical doctor while the patient works on positive lifestyle changes with their integrative or naturopathic provider.

The above is uncommon, yet extremely important to be aware of and screen for. The consequence of ignoring above Red Flag Clues could have dire consequences for the patient.

Assuming the above questions have been cleared, then it is appropriate to assess lifestyle changes to see if there is any effect.

Systemic inflammation can effect pain as can mechanical inflammation. They are not mutually exclusive. Yet, how do you determine if mechanical inflammation is a component of their pain? This is where a quick screening of movement will help guide your next step to refer to a movement specialist.

In the Mechanical Diagnosis and Treatment specialty, we are trained to evaluate symptom response to movement systematically. Four specific movements are critical to clear the lumbar spine to measure change and even determine when the patient is ready for discharge. They are:

  1. Flexion in standing (touch toes)
  2. Extension in standing (bending backward with hands on lower back)
  3. Side glide left (keeping shoulder and hips parallel, slide hips side to side)
  4. Side glide right (keeping shoulder and hips parallel, slide hips side to side)
The four main movements of the low back.

The four main movements of the lumbar spine.

These four motions should be free of obstruction to movement and pain. The specific range of motion is based on the patient’s anatomy. Note that I am unable to touch my toes, but this is my normal and I have no pain. If one of these movements is limited and/or painful then a referral out to a physical therapist is appropriate to restore the mobility.

It is important to assess lower extremity symptoms of numbness, tingling and weakness if a patient has low back pain. If there is presence of distal symptoms beyond the back then physical therapy referral becomes more important with or without the movement loss.

There are many other tests, movements, and even protocols. Naturopathic medical efforts to restore a normal systemic inflammatory response are appropriate for the patient with back pain, but the resolution of symptoms will be limited if the mechanical component is not addressed.

Navigating Low Back Pain

Below is a flow chart to remember when screening those patients with Low Back Pain.


In most cases, it is always a good idea to include movement into a person’s life. However, there are times when specific movements can be more beneficial and that certain movements can be detrimental when mechanical inflammation is present.

In the end, listening to the patient’s symptoms and being sure that in the event symptoms are not getting better, it is time for collaboration. I have seen patients ignore the components of lifestyle on inflammatory pain only to continue to suffer despite the mechanical efforts and vice versa.

Movement screening is easy to do and easy to incorporate into a patient history. It will help guide integrative clinicians to refer to other conservative, safe and effective modalities to resolve back pain.

Remove. Replace. Restore.

Remove the idea that systemic inflammation works alone.

Replace with a screening tool to help guide you when a patient has mechanical inflammatory symptoms that can be improved with mechanical treatment.

Restore a healthy lumbar spine and normal mechanical and systemic inflammatory response.

Eat well. Move well. Sleep well. Soar on….. even with back pain.

About the Author
Carolyn Dolan

Carolyn Dolan PT, DPT, Cert MDT is a traditionally trained physical therapist with certification in the Mechanical Diagnosis and Treatment (MDT). Following her own health struggles she began to explore the importance of lifestyle on healing from injury or disease. She returned to school to work towards her Masters Science in Holistic Nutrition. She now uses this knowledge to integrate into her physical therapy practice and holistic health coaching practice. You can find her blog under the How to SOAR tab. Her book, Soar Into Health, about simple strategies to dramatically change your health is available online at her website and Amazon.