1 INTRODUCTION.12 -- 1.1 BACKGROUND: A FREQUENT PROBLEM WITH HIGH SOCIETAL IMPACT 12 -- 1.2 STUDY OBJECTIVES AND RESEARCH QUESTIONS.13 -- 1.3 DEFINITION OF CONCEPTS 13 -- 1.3.1 Definition of low back and radicular pain .13 -- 1.3.2 Definition of clinical pathway 14 -- 1.4 STUDY PROCESS.14 -- 2 A SYSTEMATIC REVIEW OF LITERATURE .15 -- 2.1 RESEARCH OBJECTIVE 15 -- 2.2 METHODS 15 -- 2.3 RESULTS 16 -- 2.4 LIMITATIONS 22 -- 3 INTERNATIONAL COMPARISON OF PATHWAYS 22 -- 3.1 RESEARCH OBJECTIVE 22 -- 3.2 METHODS 22 -- 3.2.1 Identification of eligible pathways and countries 22 -- 3.2.2 Identification of variables relevant to the quality, efficacy, feasibility and applicability of low back pain care pathways .23 -- 3.2.3 Data collection 23 -- 3.2.4 Processing and analysis of the data 24 -- 3.3 RESULTS 24 -- 3.3.1 Number of identified pathways 24 -- 3.3.2 Characteristics of retrieved pathways26 -- 3.3.3 Pathway components related to quality and efficiency.38 -- 3.3.4 Key interventions and building elements for LBP pathways 38 -- 3.3.5 Organizational challenges in the development of LBP pathways 39 -- 3.4 LIMITATIONS 40 -- 4 THE BELGIAN CONTEXT.41 -- 4.1 RESEARCH OBJECTIVE 41 -- 4.2 METHODS 41 -- 4.3 RESULTS41 -- 4.3.1 Structural initiatives for managing pain.41 -- 4.3.2 A variety in initiatives for the patients.45 -- 4.3.3 Initiatives regarding work ability and work conditions. 45 -- 4.4 LIMITATIONS46 -- 5 DESCRIPTION OF SOME BELGIAN INITIATIVES OF PATHWAYS 46 -- 5.1 RESEARCH OBJECTIVE 46 -- 5.2 METHODS 46 -- 5.3 RESULTS 47 -- 5.3.1 Characteristics of the Belgian pathway initiatives 47 -- 5.3.2 Key interventions and building elements .56 -- 5.4 LIMITATIONS59 -- 6 HEALTHCARE PROVIDERS PERCEPTION - NOMINAL GROUPS.60 -- 6.1 RESEARCH OBJECTIVE 60 -- 6.2 METHODS 60 -- 6.3 RESULTS60 -- 6.3.1 First contact and Triage 63 -- 6.3.2 Diagnostic 64 -- 6.3.3 Treatment.64 -- 6.3.4 Return to work 66 -- 6.4 LIMITATIONS66 -- 7 PATIENTS PERCEPTION – FOCUS GROUPS.67 -- 7.1 RESEARCH OBJECTIVE 67 -- 7.2 METHODS 67 -- 7.3 RESULTS 68 -- 7.3.1 Decision to consult 69 -- 7.3.2 First contact: “I felt not taken seriously” 70 -- 7.3.3 Triage: a long process of trial and error 70 -- 7.3.4 (Lack of) Diagnosis and “learn to accept your condition”.72 -- 7.3.5 Treatment.73 -- 7.3.6 Impact on patients’ life 77 -- 7.3.7 Professional life and Return to work 78 -- 7.4 LIMITATION 80 -- 8 TRANSVERSAL ANALYSIS 80 -- 8.1 FINDING 1: CURRENT TRAJECTORIES ARE HETEROGENEOUS.80 -- 8.1.1 The first contact with the healthcare system is not so early 81 -- 8.1.2 A large heterogeneity of professionals can be involved in the first contact 81 -- 8.1.3 The search for a solution is a trial and error process.81 -- 8.1.4 Professionals and patients have not the same perception of ‘the trajectories’ heterogeneity .82 -- 8.2 FINDING 2: DIAGNOSTIC AND CAUSE ARE UNCERTAIN 82 -- 8.2.1 Rarely there are underlying severe pathologies 82 -- 8.2.2 Radicular pain should be distinguished from low back pain 84 -- 8.2.3 Imaging does not improve diagnosis .85 -- 8.2.4 Follow-up is important to reassure the patient… and the care provider 86 -- 8.3 FINDING 3: THE BIO-PSYCHO-SOCIAL PERSPECTIVE: A NEW APPROACH FOR SOME .86 -- 8.3.1 The obsolete biomechanical model still used 86 -- 8.3.2 A risk assessment of the bio-psycho-social factors is possible 89 -- 8.3.3 Stratifying care according to the risk assessment can be useful for LBP93 -- 8.3.4 Multidisciplinary rehabilitation since the subacute phase if needed 93 -- 8.4 FINDING 4: PATIENT-CENTERED CARE IS NOT SO EASY 95 -- 8.4.1 Not all patients’ needs and expectations can be satisfied 95 -- 8.4.2 Patients’ empowerment is a challenge .97 -- 8.5 FINDING 5: WORK AND SOCIAL ACTIVITIES ARE PART OF THE MANAGEMENT .99 -- 8.5.1 The risk for long term absence can be assessed 99 -- 8.5.2 Healthcare providers have a role for maintaining the patient in the work environment.100 -- 8.5.3 The continuation of social activities, outside the work, should also be promoted 102 -- 8.6 FINDING 6: A STEPWISE PROCESS PROVIDES A ROLE TO EACH TYPE OF HEALTHCARE PROVIDER 103 -- 8.6.1 The primary care should be reinforced 103 -- 8.6.2 The referral to the secondary care could be improved 107 -- 8.6.3 Coordination of care is not optimal 108 -- 8.7 FINDING 7: GATHERING DATA AND MONITORING SHOULD BE FORESEEN BEFORE THE PATHWAY IMPLEMENTATION 110 -- 8.7.1 The COMI questionnaire 111 -- 8.7.2 The ICHOM set of measures 112 -- 9 BELGIAN PATHWAYS.115 -- 10 CONCLUSION 118 -- 10.1 ORGANISATIONAL ASPECTS TO BE TAKEN INTO ACCOUNT.118 -- 10.1.1 Importance of healthcare professionals training 118 -- 10.1.2 Improvement of communication between professionals 118 -- 10.1.3 Change within population and patients 119 -- 10.1.4 Incentives for healthcare providers 120 -- 10.1.5 Respect of local initiatives.120 -- 10.1.6 Monitoring/evaluation 120 -- 10.1.7 Research questions .121 -- 10.1.8 Prevention of low back pain is important although out of the scope of this project .121 -- 10.1.9 Electronic tools to support the pathway .121 -- 10.2 DIFFUSION OF THE BELGIAN PATHWAYS 122 -- 10.2.1 Target users .122 -- 10.2.2 Ways for disseminating 122 -- REFERENCES 123