Clinically Organized Relevant Exam (CORE) Back Tool

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This tool will guide the family physician and/or nurse practitioner to recognize common mechanical back pain syndromes and screen for other conditions where management may include investigations, referrals and specific medications. This is a focused examination for clinical decision-making in primary care.

Click on the sections below to get started:

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History and physical examination

Review History

A patient’s history can help identify:

  • Back or leg dominant pain
  • Intermittent or constant pain
  • Associated aggravating movement
  • Non-mechanical vs. mechanical pain
  • Red flags and yellow flags

Work through questions 1–6 to evaluate the patient’s history

Red flags
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Red Flags

The acronym NIFTI can help you remember red flags.21, 22, 42, 43

Indication
  • Neurological: diffuse motor/sensory loss, progressive neurological deficits, cauda equina syndrome
  • Infection: fever, IV drug use, immune suppressed
  • Fracture: trauma, osteoporosis risk/fragility fracture
  • Tumour: hx of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue
  • Inflammation: chronic low back pain > 3 months, age of onset < 45, morning stiffness > 30 minutes, improves with exercise, disproportionate night pain
Investigation
  • Urgent MRI Indicated

 

  • X-ray and MRI
  • X-ray and may require CT scan
  • X-ray and MRI
  • Rheumatology Consultation and Guidelines
Acute Cauda Equina syndrome is a surgical emergency.23

Symptoms are:

  • Urinary retention followed by insensible urinary overflow
  • Unrecognized fecal incontinence
  • Distinct loss of saddle/perineal sensation

If there are no red flags, continue reviewing history.

 

Yellow flags
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Yellow Flags21, 22, 24

Psychosocial Risk Factors for Developing Chronicity
For those with low back pain > 6 weeks or non-responsive to treatment, consider asking:

Questions to ask
  • “Do you think your pain will improve or become worse?”
  • “Do you think you would benefit from activity, movement or exercise?”
  • “How are you emotionally coping with your back pain?”
  • “What treatments or activities do you think will help you recover?”
Look for
  • Belief that back pain is harmful or potentially severely disabling.
  • Fear and avoidance of activity or movement.
  • Tendency to low mood and withdrawal from social interaction.
  • Expectation of passive treatment(s) rather than a belief that active participation will help.

A patient with a positive yellow flag will benefit from education and reassurance to reduce risk of chronicity. If yellow flags persist, consider additional resources: Keele StarT Back 4 ; The Patient Health Questionnaire for Depression and Anxiety (PHQ-4).25

Physical examination

  • An examination refutes or supports the back pain pattern identified in history
  • Referred leg pain will have a normal neurological exam
  • Radicular (nerve) pain will have a positive straight leg raise (SLR) with reproduction of leg pain and possible abnormal neurological signs
  • Interpretation of range of motion includes the pain response to flexion and extension movements

NOTE: Bolded tests are the suggested minimum requirements of the exam.

Gait
  • Heel Walking (L4-5)
  • Toe Walking (S1)
Standing
  • Movement testing in flexion
  • Movement testing in extension
  • Trendelenburg test (L5)
  • Repeated toe raises (S1)
Sitting
  • Patellar reflex (L3-4)
  • Quadriceps power (L3-4)
  • Ankle dorsiflexion power (L4-5)
  • Great toe extension power (L5)
  • Great toe flexion power (S1)
  • Plantar response, upper motor test
Kneeling
  • Ankle reflex (S1)
Lying supine
  • Passive straight leg raise (SLR)
  • Passive hip range of motion
Lying prone
  • Femoral nerve stretch (L3-4)
  • Gluteus maximus power (S1)
  • Saddle sensation testing (S2-3-4)
  • Passive back extension (patient uses arms to elevate upper body)

Initial Management

  • Goals may include “to reduce pain” and “to increase activity”
  • Frequent movement in small doses recommended
  • Self management involves patient driven goals for motivating behaviour change like exercise, medication compliance or activity modification
  • Remember that all recovery positions and/or exercises should be customized to the individual patient. This section offers a starting point with links to additional resources

Select pattern for initial managment details

Commonly called27
  • Disc Pain
Medication5,6,7
  • Acetaminophen
  • NSAID
Recovery positions28

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Starter exercises29
  • Repeated prone lying passive extensions (i.e. hips on ground, arms straight).
  • 10 reps, 3 x day
Functional activities36
  • Encourage short frequent walking
  • Reduce sitting activities
  • Use extension roll for short duration sitting
Follow-up
  • 2–4 weeks if referred to therapy, or prescribed medication
  • PRN if given home program and relief noted in office visit
Self management37-40
  • Once pain is reduced, engage patient for self management goals
Commonly called27
  • Facet Joint Pain
Medication5,6,7
  • Acetaminophen
  • NSAID
Recovery positions28

null

Starter exercises29
  • Sitting in a chair, bend forward and stretch in flexion.
  • Use hands on knees to push trunk upright.
  • Small frequent repetitions through the day
Functional activities36
  • Encourage sitting or standing with foot stool
  • Reduce back extension and overhead reach
Follow-up
  • 2–4 weeks if referred to therapy, or prescribed medication
  • PRN if given home program and relief noted in office visit
Self management37-40
  • Self management can be initiated in 1st or 2nd session with most patients

 

Commonly called27
  • Compressed Nerve Pain
Medication5,6,7
  • May require opioids if 1st line pain meds not sufficient
Recovery positions28

null

Starter exercises29
  • “Z” lie (see image above)
  • Caution: exercise will aggravate the pain so start with pain reducing positions
Functional activities36
  • Change positions frequently from sit to stand to lie to walk
Follow-up
  • 2 weeks for pain management and neurological review
Self management37-40
  • Patient is not usually suitable for self management due to high pain levels and possible surgical intervention

 

Commonly called27
  • Symptomatic Spinal Stenosis (Neurogenic Claudication)
Medication5,6,7
  • Acetaminophen
  • NSAID
Recovery positions28

null

Starter exercises29
  • Rest in a seated or other flexed position to relieve the leg pain
Functional activities36
  • Use support with walking or standing.
  • Use frequent sitting breaks
Follow-up
  • 6–12 weeks for symptom management and determination of functional impact
Self management37-40
  • Self management can be initiated in 1st or 2nd session with most patients

 

Non-spine related pain
  • Consider other etiologies prior to pain medications
  • Consider internal organ pain referral such as kidney, uterus, bowel, ovaries
Spine pain does not fit mechanical pattern
  • Consider centralized pain medications (i.e. anti-depressants, anti-seizure, opioids)
  • Consider pain disorder

Referral (if required)

Diagnostic imaging: Tests like X- rays, CT scans and MRIs are not helpful for recovery or management of acute or recurring low back pain unless there are signs of serious pathology. Refer to red flags for details.

Rehabilitation referral criteria (4–12 treatments)

  • Absence of red flags
  • Pain is managed well so that patient can tolerate treatment
  • Pain has mechanical directional preference – varies with movement, position or activity
  • Patient is ready to be an active partner in goal setting and self management

Surgical referral criteria23

  • Failure to respond to evidence based compliant conservative care of at least 12 weeks
  • Unbearable constant leg dominant pain
  • Worsening nerve irritation tests (SLR or femoral nerve stretch)
  • Expanding motor, sensory or reflex deficits
  • Recurrent disabling sciatica
  • Disabling neurogenic claudication

Specialist referral

  • Physiatry
  • Cognitive Behavioural Therapy
  • Pain specialist
  • Multidisciplinary Pain Clinic
  • Rheumatologist

Supporting material

References

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