Indications for Rehabilitation in Acute Low Back Pain: Making a Correct Referral

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, 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.

Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto’s Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

This article helps clinicians decide on appropriate referral to rehabilitation professionals while answering some of the common questions that clinicians are often asked by low back patients. The evidence for appropriate rehabilitation techniques will be interwoven into this article to promote a critical appraisal approach to evaluating rehabilitation outcomes. At the conclusion of this paper, clinicians should be able to identify best practices for rehabilitation referral.
Key Words: Low back pain, indications, rehabilitation, inter-professional referral.


Good article. I like the format used to communicate between doc/therapist and will adopt

Thank you to all those who took the time to post comments and questions and to Dr. Julia Alleyne who provided highly insightful answers. We would like to add that the Back Health Resource just released an accredited (2 Mainpro-M1 credits), interactive CME program called "The Latest in Back Pain Management." We wanted to share with you one of the excerpts from the longer list of Learning Objectives that states:

  • List the findings that are of concern and necessitate further investigation


Great info..thank you.

Yes, you are correct. They often provide short term symptom relief and they don't generally flare pain symptoms but they also don't promote recovery of function, strength or mobility. If they are uses short term( 4-6 sessions)in conjunction with education, exercise and postural awareness, they have a place ! Agree with your comment!

Excellent article but double check for red flags e.g. weight loss, cancer history,osteoporosis history, fracture history, age and sex, prior accidents or injuries, disability and WSIB claims. At 6 weeks of unchanged spts pt of any red flags a complete physical should be done and imaging seriously considered. L. Sadinsky M.D.

Thanks for your comments. The Red Flags have undergone some scrutiny since the initial guidelines identified them as indicators of possible underlying organic pathology. For example, age, as a red flag has never actually been proven and if we think about it, as we get older most back dominant pain improves. Disability or third party claims is now called a blue flag meaning that there are work related factors, often psychosocial, that if not resolved, could prolong recovery. Even the good old 6 week rule is under fire. We now say, low back pain that is unchanged after 12 weeks of compliant evidence based therapy should be evaluated further with a specialist referral +/- investigations. I like your comment about repeating a complete physical at 6 weeks, that is very useful and it often creates a fresh approach to your management plan when you put fresh eyes on the whole patient.

Did I miss something? Such as the results of X-Rays and an M.R.I. Possible metastases in spine? Prostate Ca?

We have put red flags first for decades. In other words, let's check out the red flags, ask, investigate, consult, then after ruling out, treat. But in actual fact, red flags occur in 10% of low back pain patients so currently, the move is to screen for red flags in your history and physical but get on with treatment and then look for treatment response. If no response, look harder for red flags. Most of the time, that is 90% of the time, treatment should not be delayed as red flags are not present. We actually create disability and fear in our patients when we seek out red flags where there are no indicators present. In this article, we wanted to focus on the rehab side and emphasize the need for active goal-oriented rehab so that a positive outcome in patient care was realized. Thanks for your comments. I think an article on Red Flags might be in order.
Theodore Derek Cooke's picture

Thanks Great article Sadely the passive modalities are widely used for protracted periods, even in very chronic LBP issues Derek