CCFP priority topic 63 of 105
Low-back Pain on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Low-back Pain. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
Red flags first
In new low back pain, exclude dangerous causes, then confirm a muscle or joint cause.
CFPC skill Selectivity, clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
A man of 58 hurt his back lifting; the pain spreads into both thighs. Expect a short menu (pick several from a list) of causes to exclude.
Pick the causes you must exclude today.
Common mistakes
Picking hip arthritis, spinal stenosis or shingles. None fits sudden pain after a lift, and none is an emergency. The real dangers here include a leaking aortic aneurysm, cauda equina syndrome and cancer in the spine.
Approach
- Ask and examine for every red flag in the table below, in every patient.
- Ask about bladder and bowel control and numbness in the genital area. Check leg strength, reflexes and feeling.
- In an older patient, feel the abdomen for a pulsing mass. A possible leaking aortic aneurysm is assessed before he leaves, not booked for another day.
- Fever with flank pain or burning urine points to a kidney infection, not a back strain.
- Make the diagnosis on positive features: pain that began with a lift or twist, sits low in the back, and changes with movement.
- Pain into the buttock or thigh can still come from the back muscles and joints. With a normal nerve exam, it is not a red flag on its own.
| Red flag | Think of | Next step |
|---|---|---|
| New trouble controlling bladder or bowel, numbness in the genital area | Cauda equina syndrome (pressure on the nerve roots at the base of the spine) | Assess and image right away |
| History of cancer, weight loss you cannot explain | Cancer in the spine | Image |
| Fever, recent infection | Infection in the spine, or a pus collection around the spinal nerves (epidural abscess) | Image, urgently if a pus collection is possible |
| Severe or worsening leg weakness or numbness, abnormal reflexes | Nerve compression | Image |
Key feature 2 of 5
Hold the scan
Once the pain is clearly mechanical, skip early tests, explain the good outlook, and arrange review.
CFPC skill Clinical reasoning, selectivityPhase Investigation, treatmentSources Choosing Wisely Canada
On the exam
Day 2 of back pain after a lift, and a normal exam. Expect a short menu (pick several from a list) of tests to order or avoid.
Pick the tests that would help today.
Common mistakes
A lumbar X-ray because of the patient's weight or request, or magnetic resonance imaging (MRI) for thigh pain with a normal exam. Without red flags, imaging before 6 weeks does not help.
Approach
- No red flags: no X-ray, computed tomography (CT) scan or MRI. Imaging the low back before 6 weeks does not improve outcomes.
- Scans often show changes that have nothing to do with the pain. They lead to worry, more tests and more surgery, not faster recovery.
- Suspected disc or narrowed spinal canal, no red flags: image only after 6 or more weeks of care, if surgery is considered.
- Tell the patient most people get better on their own. Many recover within a week or two, and most within about a month, with or without a scan.
- Warn that symptoms often come and go. A flare does not mean something serious is wrong.
- Book a review. If the pain is not settling, see the patient again and recheck for red flags.
Key feature 3 of 5
Pain relief that works
Relieve back pain from muscles and joints, new or long-standing, and adjust the medicine to the pain.
CFPC skill Clinical reasoningPhase TreatmentSources Choosing Wisely Canada
On the exam
A truck driver, 2 days into back pain after a lift, asks for an opioid by name. Expect one best answer for the medicine.
Pick the best medicine for now.
Common mistakes
Giving the opioid because the patient asks. It is not first line for new back pain. Staying on acetaminophen that has not helped leaves the pain undertreated.
Approach
- Start with heat and staying active. Add an anti-inflammatory (NSAID) such as ibuprofen or naproxen, if nothing rules one out.
- If a medicine has not helped at a full dose, change the plan. Do not just continue it.
- No opioid as first line for new, uncomplicated back pain from muscles and joints.
- If an opioid is needed for severe new pain, use the lowest dose and the fewest doses. Stop when the episode ends, usually within 3 days and rarely past 7.
- Long-standing back pain: physical activity is the base. Do not start long-term opioids. Past 4 weeks, they did no better than placebo.
- No pain medicine should run for a long time unchecked. Review it at each visit.
| New pain | Long-standing pain | |
|---|---|---|
| Base of care | Heat, keep moving, an NSAID | Exercise and physical activity |
| Opioids | Not first line. If used for severe pain, stop when the episode ends. | Not for ongoing use. No clear gain in pain, function or quality of life. |
| Review | Pain and function at follow-up | Benefit against side effects at every visit |
Key feature 4 of 5
When to come back
Tell a patient with a back strain which new nerve symptoms mean coming back at once.
CFPC skill Clinical reasoningPhase Follow-up, treatmentSources Choosing Wisely Canada
On the exam
A man with a back strain goes home today. Expect a short menu (pick several from a list) of signs that should bring him back.
Pick the signs that need care right away.
Common mistakes
Saying only “come back if it gets worse”, or booking a routine review and nothing else. He needs the exact signs, and he needs to know to return at once.
Approach
- Give specific signs. “Come back if worse” is not enough.
- Return right away: numbness in the genital area, or new trouble controlling bladder or bowel. Think of cauda equina syndrome.
- Return right away: new or worsening weakness or numbness in a leg or foot.
- Return right away: leg pain, numbness or weakness that is more disabling than the back pain.
- Return right away: severe constant back pain with fever, or severe constant back pain for more than 48 hours.
- Any of these means seeing the patient again promptly. Image only if the exam finds a red flag, such as cauda equina syndrome, infection or a worsening nerve deficit.
Key feature 5 of 5
Prevent the next one
With every patient who has a back strain, talk through exercise and positions that lower the chance of another episode.
CFPC skill Clinical reasoning, patient-centred approachPhase TreatmentSources Choosing Wisely Canada
On the exam
A truck driver who loads freight is recovering from a back strain. Expect one best answer for the plan to stop it coming back.
Pick the best prevention plan.
Common mistakes
Telling the patient to avoid lifting and rest the back. Bed rest weakens muscles fast and slows recovery. Pain with activity does not always mean harm.
Approach
- Advise against bed rest. It costs about 1% of muscle strength a day, and 20 to 30% in a week.
- Start moving early, even a little. The sooner the patient moves, the faster recovery tends to be.
- Build a lasting habit: walking, yoga, water exercise or light weights.
- Early on, skip straight-leg sit-ups, lying leg lifts, shoulder presses and standing curls. Add core work as the back improves.
- Offer a physiotherapist, or an exercise program for long-standing back pain.
- For sleep, it may help to lie on the side with a pillow between the knees, or on the back with pillows under the knees.
Flashcards
Answer it first, then check.
KF 1Which history points to cauda equina syndrome in a patient with back pain?
New trouble controlling bladder or bowel, or numbness in the genital area. It needs care right away. Source: Choosing Wisely Canada
KF 1Name four red flags that make back imaging worthwhile.
Any four of: history of cancer, unexplained weight loss, fever, recent infection, bladder or bowel loss, leg weakness. Source: Choosing Wisely Canada
KF 2No red flags and 10 days of back pain. Does a lumbar X-ray help?
No. Without red flags, imaging the low back before 6 weeks does not improve outcomes. Source: Choosing Wisely Canada
KF 2What do you tell the patient about how long back pain lasts?
Most people feel better in about a month, with or without a scan. Flares can come and go. Source: Choosing Wisely Canada
KF 3New, uncomplicated back pain from a lift. Is an opioid the first choice?
No. Start with heat, staying active and an NSAID such as ibuprofen or naproxen. Source: Choosing Wisely Canada
KF 3Back pain for a year. What is the base of care?
Physical activity and exercise. Do not start long-term opioids for it. Source: Choosing Wisely Canada
KF 4Which new symptoms should bring a patient with back strain straight back?
Genital numbness, bladder or bowel change, new leg weakness or numbness, or severe constant pain with fever or past 48 hours. Source: Choosing Wisely Canada
KF 5How much muscle strength does a patient lose on bed rest?
About 1% of muscle strength a day, and as much as 20 to 30% in one week. Source: Choosing Wisely Canada
FAQ
Which guideline does the exam follow for back pain?
No single national Canadian guideline covers back pain. Choosing Wisely Canada lists from family doctors, radiologists and spine surgeons agree: image only for red flags. The spine list adds: no opioid as first line.
Do scans help back pain settle sooner?
No. Most people feel better in about a month, with or without a scan. Scans often show changes that are not causing the pain, which leads to worry and more tests.
Is pain into the thigh a red flag?
Not on its own. Back strain often spreads to the buttock or thigh. Weakness, numbness, or leg pain worse than the back pain needs a closer look.
When is imaging the right call?
When a red flag is present, such as cauda equina syndrome, cancer, infection or a worsening nerve deficit. For a disc or stenosis, only after 6 weeks of care, if surgery is considered.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada