Back Pain Management


CME: The Latest in Back Pain Management

Hamilton Hall, MD, FRCSC Professor, Department of Surgery, University of Toronto; Medical Director, CBI Health Group; Executive Director, Canadian Spine Society.

This evidence-based learning program has been developed by physicians, in association with the Canadian Spine Society, for primary care physicians, educators, and other health professionals. Learners will utilize this program to assist with the diagnosis, sound management, and appropriate treatment of Back Pain in patients.

  • This program runs in a sequence, and is accompanied by informative illustrations, and animations. To advance you must complete the quizzes.
  • Best viewed with accompanying voice-over narration.
  • You may pause, rewind, or fast-forward at any point.
  • Slides with links to figures or tables will pause automatically to allow the user time to view the additional material.

After participating in this online CME program, physicians should be able to:
  • Cite common presentations of mechanical low back pain and its natural history
  • Outline the appropriate components of a focused back history and complementary physical examination
  • Identify the four syndromes (patterns) of low back pain
  • Describe the proper indications for imaging and laboratory tests
  • List the findings that are of concern and necessitate further investigation
  • Develop a basic treatment program based on the patterns of pain
  • Counsel patients on the realistic expectations for managing low back pain including simple initial pain control manoeuvres

This interactive online program meets the accreditation criteria of The College of Family Physicians of Canada and has been accredited for up to TWO (2) MAINPRO-M1 credits. The accreditation expires on May 8th, 2015.

Views and opinions in this program are of the faculty and not necessarily endorsed by, or reflective of, those of the publisher or editors of Health Plexus.

The development of this CME program was supported by an unrestricted educational grant from Medtronic of Canada.


A LOT of good info. I'd like to add my name to the list of those who would like to see this program downloadable so it can be reviewed anytime, anywhere and for teaching others in overseas postings where there is no internet. Otherwise it has limited value.
Hamilton Hall's picture

We currently do not offer the option to download the slides for offline teaching. However, CSS will discuss the suggestion you posted as it may fit into our future plans for dissemination of the Back Health CMEs in the primary care field.

How do you diagnose Sacro Iliac joint problem causing pain or sasy ankylosing spondylosis how can distinguish clinically both Dr changela\ My email;; ""
Hamilton Hall's picture

Sacroiliac pain has a pattern all its own. It is buttock dominant, centered in the mid to lower section. It is constant, although the amount of pain varies much more than the typical back pattern and can go from almost absent to severe in the course of the day. The pain is least in the morning and increases during the day. It is aggravated by twisting (rolling over in bed is a common cause of pain), by walking or prolonged standing. When severe, the pain can radiate down the back of the thigh to the knee. SI pain is more common in women and is frequent during pregnancy. It can be relieved by the use of a pelvic belt. A positive response is a good diagnostic test. The physical examination includes tests that stress the SI joint. I suggest that the examiner select four (anterior gapping of the iliac crests, lateral compression, posterior pressure on the sacrum and the FABER manoeuver are fairly standard) and three of the should reproduce the patient’s typical buttock dominant pain. The diagnosis of ankylosing spondylitis is the diagnosis of Pattern 1 PEN or more commonly Pattern 2 in a young person in their 20s or 30s (the sex difference with males more likely to have the disease is no longer widely accepted) with a history of prolonged morning back stiffness. The diagnosis is made on the lack of sustained improvement with mechanical therapy and a significant temporary improvement with NSAIDs. Early in the course of the disease the diagnosis can be difficult and relates more to the recurrent clinical course and lack of anticipated response than to any single presenting symptom. I have added the question, “If you are under 45 do you have morning back stiffness lasting more than 30 minutes?” to my standard eight questions. Now there are nine.

Please tell Dr Hall that I have practiced family medicine for 22 years and have gone to many a cme on mechanical low back pain. This was the most concise and pertinent assessment with relevance to every day practice. It was much appreciated! Thank you for his refreshing words of wisdom. Yours truly, Dr P Borger

Outstanding and practical programme, very relevant to FP.

Great stuff.

Well Done Keep it up.Thank you.

Dr. Hall has been and is an outstanding teacher.

Thank you

Would be helpful to know probable time requirement of the program and whether program can be stopped and returned to at a later time if necessary.

Very useful.

I have had good success in using Low Level Laser Therapy for low back pain (pattern 1, 2 and 3). Are you aware of any data to support its use in this situation? It feels odd to use a modality because I have had success with it, yet there is no "evidence" supporting it...
Hamilton Hall's picture

Dear Dr. Lockner,
The reason there is no literature support is because there has never been a study to demonstrate that Low Level Laser Therapy has an effect. There is, however, good evidence both from laser physics and human physiology that the laser beam (which incidentally is about the intensity of the standard laser pointer) does not penetrate the skin surface more than a few millimeters before it loses the coherence, columnation and energy that make it a laser. All that is left is the colour of the light. It is actually for this reason that many low intensity laser proponents suggest that different conditions require different colour lasers.

Laser is far from the only “unproven” technique that helps back pain. Any online search will uncover dozens of approaches that purport to eliminate back pain and all come with sincere testimonials as to their effectiveness. Back pain is a transient, recurring condition and can be influenced by a number of factors. The most powerful of these is a beneficial placebo effect. Functional MRI studies have demonstrated amazing levels of observable change in brain activity and pain reduction with nothing more than powerful suggestion.

It is highly unlikely that you will find support for your use of the laser in any controlled study. But that doesn’t mean that it won’t work. If you are having success with Low Level Laser and your patients are returning to normal function in a consistent and sustained fashion, I see no harm. There are many facets to the Art of Medicine and evidence base is only one.

Hamilton Hall

How soon do you reevaluate respond to treatment? What exactly do you write to physiotherapy for treatment instructions?
Hamilton Hall's picture

Instructing the physiotherapist requires a sense of balance. Too much instruction may be poorly received and limits the therapist’s initiative. Too little instruction allows the all-too-common passive approach of modalities and manipulation. The communications should state the mechanical pattern or syndrome and ask for patient education, specific pain control strategies based upon the presenting mechanical pattern and an estimate of treatment frequency and duration.
Hamilton Hall's picture

Mechanical back pain changes quickly. A response can be seen almost immediately and typically, within 24 hours. The change may not be sustained but it will be apparent and serves to direct further interventions. Because of this, the re-evaluation should take place within 24 to 48 hours if at all possible. Clearly sooner is better than later.

I dont use facebook and couldn`t visualize te pretest questionnaire

Dear Dr. Defay, Thank you for your question. We are not sure how Facebook came up in your experience. The Pre-test and Facebook have no known connection to us. Please feel free to reach out to us directly via email and we will try to help you.

You are forgetting a major source of low back pain: sacroiliac joint subluxation. An easy way to examine the sacroiliac joint is to feel for the posterior superior iliac spines. If they are not level, the chances are that there is a subluxation of the ilium on the sacrum. If the back pain is unilateral to the right, if the posterior superior iliac spine is higher on the right, you have an anterior subluxation of the right ilium on the sacrum, and if the PSIS is lower on the right than on the left, you have a posterior subluxation of the right ilium on the sacrum. Often these subluxations can be treated with manipulation, or with exercises. In my experience, about 70% of all cases of low back pain suffer from these subluxations and have often been misdiagnosed I other physicians as coming from the spine.

I could not find a link to submit my name and Membership number for direct submission of credits.

Dear Dr. Dickson thank you for your question. The link to enter your CCFP ID is located on the last, (Appendix) slide of the CME. Please don't forget to press the Save button at the bottom of the screen.

I participated in the CME on back pain management but was unable to submit my credits directly to CFPC. Please advise how I may do so. I clicked on the link in the last slide, but there was no link for me to enter my CCFP ID in the tab that opened. Also there was no save button anywhere.

there are still pointers to learn and apply to my practice about low back pain