Low Back Pain Clinical Care Standard

Early assessment should include a targeted history of symptoms, including attention to the pain, past history, functional capacity and alerting features for specific and/or serious pathology. Consider differential diagnoses – for example, nephritis, colitis, hip osteoarthritis and aortic dissection.

Physical examination should include a postural assessment, bony and soft tissue palpation for tenderness and tone, and movement assessment for range and associated pain. A physical examination supports diagnosis and can help to build the patient’s confidence in the therapeutic relationship.

Consider using an evidence-based low back pain pathway that guides the appropriate assessment of patients who present with low back pain symptoms. The pathway should incorporate screening for specific and/or serious pathology. It should allow the use of validated tools, such as the Brief Pain Inventory (short form) or the Clinically Organized Relevant Exam (CORE) Back Tool, to aid assessment and monitoring of the patient’s progress. It should also allow referral to specialist clinicians, when needed, for management.

For acute leg pain without severe or progressive motor weakness, initial management should be the same as for acute low back pain.

For patients with low back pain symptoms and/or leg symptoms where there is clinical suspicion of neurological impairment, include a focused neurological examination with straight leg raise, deep tendon reflexes, and strength and sensation testing.

Arrange appropriate investigation or intervention if alerting features of specific and/or serious underlying pathology are identified. The presence of multiple alerting features is associated with a greater likelihood of serious pathology compared with the presence of a single alerting feature. Emergency assessment or referral is indicated for clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs or symptoms, suspected spinal infection or cauda equina syndrome, spinal tumour, trauma or fracture.

Determine the most likely diagnosis, document the assessment findings and communicate them to the patient. Arrange follow-up for monitoring or further assessment. Reassess at subsequent visits to check for symptom progression or any new concerning features that need urgent investigation or specialist assessment (refer to Quality statement 8 – Review and referral).

Ensure the use of an evidence-based low back pain pathway that guides appropriate assessment, investigation, referral, management and counselling of patients who present with low back pain symptoms, based on their history and physical examination. The pathway should incorporate screening for specific and/or serious pathology, allow the use of validated tools to aid assessment early in an episode of low back pain and monitoring at subsequent visits40, and allow referral to specialists if needed – for example:

• Brief Pain Inventory (short form)
• Clinically Organized Relevant Exam (CORE) Back Tool

Ensure that clinicians have current training in the clinical assessment of back pain and, when relevant, in the use of validated tools.

If you see a clinician about your low back pain, they will ask:

• about your pain
• how it is affecting your daily activities
• how it is making you feel
• about your previous health issues and background.

This will help them to understand your needs and goals for your care. Your clinician will examine you and check for signs of serious health issues, and may refer you for further tests or investigations if necessary. However, even though back pain can feel bad and interfere with your life, serious causes are very rare (less than 5% of cases).

If a serious underlying problem is unlikely, low back pain can be treated with simple measures because the pain will get better on its own over time. It is often not possible or necessary to identify an exact cause for low back pain, and it can still be treated even if the cause is not known. If you have leg pain, this can be nerve‑related pain – commonly called ‘radicular pain’, ‘sciatica’ or ‘referred’ pain – which starts somewhere in your back but is felt in your legs. For most people, this is managed the same way as low back pain.

You and your clinician should discuss what follow-up you may need. You may need further visits to check on your symptoms and wellbeing, and to adjust your treatment if necessary. See your clinician urgently if new symptoms appear, such as problems with controlling urine or bowel movements, or numbness or weakness in your legs, back or genitals.

Healthcare services

Evidence-based pathways to guide assessment:

• New South Wales Agency for Clinical Innovation Management of People with Low Back Pain: Model of care – provides guidance on the care to be provided to patients who present to their general practitioner or the emergency department with low back pain
• Emergency Care Institute New South Wales Acute Low Back Pain – provides guidance on the care to be provided to patients who present to the emergency department with acute low back pain
• Queensland Health clinical prioritisation criteria Spine (Orthopaedics) – provides guidance to assist with the clinical assessment and referral of people with low back pain to specialist services according to clinical urgency.

Certain psychosocial factors and emotional responses to pain are associated with delayed recovery, and their presence indicates the need for further assessment and appropriate intervention (see Box 1). Use a biopsychosocial approach that considers the relationship between the patient’s beliefs and pain behaviours to manage the patient.

Consider using risk assessment tools early in each new episode (first or second visit) of low back pain (see the clinician practice points). These tools can help to identify a patient‘s risk of poor functional outcome or long-term pain and disability, and reduce the time involved in assessment and investigation.  Examples include:

• STarT Back Screening Tool
• Örebro Musculoskeletal Pain Screening Questionnaire (10-item version).

Repeat risk assessment at subsequent visits to measure progress.

Listen to the patient, and validate that their thoughts and feelings are understandable, and the pain they are experiencing is real. Explore the patient’s reasons for presenting and perception of their pain, and identify harmful misconceptions, including fear-avoidance behaviour. Motivational interviewing techniques can help to explore and dispel misconceptions in a non-threatening way.

For healthcare services

Provide clinicians with training and skills to support them in managing patients with low back pain, including biopsychosocial pain management.

Provide access to assessment tools that include screening for psychosocial barriers to recovery in patients with low back pain, such as the STarT Back Screening Tool, or the short form Örebro Musculoskeletal Pain Screening Questionnaire. Ensure that systems and processes are in place to distribute and score risk assessment tools, and that clinicians are trained in their use.

It can be harder to recover from back pain if there are other issues that are influencing your experience of pain. These might include:

• your general mood
• your understanding about what is causing your pain and what you can do about it
• other factors in your life such as financial, family or work issues that may be causing you distress
• the impact the pain is having on your life (such as sleep).

Your clinician may ask you about such issues to understand how they relate to your pain. They may use questionnaires to help understand how your pain is affecting your life, and to help identify the best treatment and support for you. For example, you might not be able to change factors causing distress, but you can learn ways to reduce their impact on you, which can also help with your pain. This is why it is important to identify and understand what is influencing your pain and what can be done to help with your recovery.

Healthcare services

Risk assessment tools to identify patients at risk of poor functional outcomes:

• See the STarT Back website for further guidance on using the risk assessment tool, including an Online STarT Back Calculator and downloadable screening tool
• The Örebro Musculoskeletal Pain Screening Questionnaire (10-item version) is available on the Western Australian Department of Health PainHealth website or on the OrthoToolKit website, and a downloadable version with scoring instructions is available on the Central and Eastern Sydney Primary Health Network website.

A patient without alerting features for serious underlying pathology may not receive any clinical benefit from diagnostic imaging. Explain that investigations are rarely helpful or indicated for low back pain. Explain that imaging outside recommendations can create unnecessary concerns and that incidental findings with no clinical significance can lead to unnecessary tests.

Early imaging is appropriate for a patient with alerting features for specific and/or serious underlying pathology; consider specialist involvement to obtain guidance and appropriate imaging studies. MRI is generally preferred because it offers better sensitivity and a superior safety profile. However, it is not covered by the Medicare Benefits Schedule if requested by a general practitioner, a physiotherapist or a chiropractor. CT has a limited role but in the presence of alerting features may be considered in some cases, such as when MRI is unavailable or contraindicated, or early consultation with a specialist is not available.

Ensure that sufficient detail is included on the radiological referral, such as the provisional diagnosis and the clinical question being asked, to ensure appropriate imaging and reporting (see Box 2), and discuss any risks of radiation exposure with the patient.

Ensure that the patient understands the radiological findings. When no serious pathology is found, discuss the report in the context of history, examination and other investigations. Patient interpretations of imaging findings can lead to unnecessary distress and fear-avoidance behaviour. Advise the patient that findings such as disc degeneration; facet joint arthritis; and disc bulges, fissures and protrusions are very common in people without pain and are usually a normal feature of ageing. Epidemiological reporting of imaging findings may help patients understand the probability and significance of incidental findings.

The need for imaging should be reassessed for patients with changing or worsening symptoms. Patients with unchanged symptoms should not undergo repeated imaging unless a diagnosis that was not considered on previous imaging is being contemplated.

Ensure that policies, processes and pathways are in place for appropriate assessment of low back pain, with or without leg pain, that describe indications for imaging patients with alerting features for serious underlying pathology and when imaging is not needed.

Support clinicians to provide advice about the limited role of imaging and make information resources – such as those produced by the Commission and NPS MedicineWise – available to provide to patients.

Ensure that systems are in place to monitor the appropriateness of imaging requests for low back pain as part of quality improvement processes. Consider use of a template for reporting of imaging results that includes epidemiological reporting of common imaging findings to help clinicians and patients understand the probability and significance of incidental findings.

In most cases of low back pain, an imaging test such as an X-ray, a CT (computed tomography) scan or MRI (magnetic resonance imaging) is not necessary. These tests are usually only needed when your clinician needs to rule out a serious cause for your back pain. It is important to remember that more than 95% of low back pain cases do not have serious underlying causes.

Your clinician will talk to you about the role of imaging in your situation. Unless there is a good reason, it is best to avoid scans because they are unlikely to find the reason for your pain or change how it is treated. Scans can often show changes that are normal for your age and may not be causing your pain, such as:

• disc degeneration
• facet joint changes
• disc bulges
• disc protrusions.

Changes such as these are also found on the scans of people who do not have low back pain. Knowing about these changes may worry you and can lead to further tests, consultations or treatments that do not help your back pain. Scans can also be expensive and inconvenient, and some can expose you to radiation.

Recognise and validate the patient’s experience of pain. Reassure patients about the benign nature of low back pain, the low risk of serious underlying disease and the likelihood of recurrence. Provide educational materials that are consistent with your verbal advice to reinforce key messages, taking into consideration the patient’s culture and health literacy. Address any unhelpful beliefs and thoughts identified in the psychosocial assessment that may affect how the patient manages their symptoms, including anxiety or fear about their condition. Use motivational interviewing techniques to help explore and dispel misconceptions in a non-threatening way. Check for understanding and whether the patient feels reassured. Repeat education at subsequent visits.

Discuss the patient’s expectations about management of their condition, and address any misconceptions about tests and interventions. Explain the evidence for treatment options, so the patient can understand why some strategies are, or are not, being recommended. Inform patients about the potential benefits, risks and costs of any treatment being considered.

Ensure that clinicians have the knowledge, information and relevant training to provide information about the nature of low back pain and to support shared decision making. Ensure that patient educational materials are available – including on the potential benefits, risks and costs of treatment options – to support the patient to be engaged in their care and to participate in decision-making.

One of the best ways to manage low back pain is to learn about the condition, what to expect and how to manage it.  Ask questions to make sure you receive the care that is right for you (see Box 3 for examples of the types of questions you could ask). Your clinician will offer you information and help you understand more about back pain. They may provide you with fact sheets and direct you to useful resources. Information will be provided in a format and language you can understand.

There are many different treatments for low back pain. In most cases, simple, cost-effective measures will give you the most benefit. Your clinician will help you to consider the best treatment for your back pain, considering the evidence, and the potential benefits, risks and costs, so that you can share in decisions about your care.

Box 3: Five questions to ask your doctor or other healthcare provider before you get any test, treatment or procedure

physical activity and a graded return to work and/or other meaningful activity (see Box 4).  Listen to the patient, and validate that their thoughts and feelings are understandable, and the pain they are experiencing is real (see Quality statement 2 – Psychosocial assessment). Discuss strategies to support the patient to continue to engage or quickly re-engage socially. Prolonged bed rest is harmful and should be discouraged.

Consider the impact of lifestyle factors that are associated with occurrence of low back pain episodes, such as smoking and obesity.

Encourage patients to take control of their condition by following advice about ways to self-manage their back pain symptoms.  Assess the patient’s confidence and ability to engage in self-management, particularly for patients with a history of recurrent back pain and identified psychosocial risk factors. Where potential barriers appear to exist for the patient to undertake self-management and active strategies, discuss strategies to overcome them.

Self-management will differ for each patient depending on their history, pain severity and confidence to undertake self-management. A self-management plan may vary from brief advice to a more detailed management plan, according to the needs of the patient, and may include:

• prioritising active management strategies (such as physical activity, social connection, healthy sleep habits and use of heat) over passive strategies (such as pain medicines, activity avoidance and massage)
• gradually increasing activity levels by using pacing to prevent overexertion followed by inactivity
• supporting the patient to set SMART (specific, measurable, achievable, realistic and time‑bound) goals that are important to them.

If physical activity causes the patient’s symptoms to spread (pain or other symptoms radiating to the leg), activity limitation but not cessation may be required.

Box 4: Advice to stay active for people with acute low back pain

Ensure that clinicians have the knowledge, information and relevant training to support people with low back pain to self-manage their condition in line with current guidelines.

Ensure that pathways are in place so that patients with low back pain receive advice and encouragement to remain as active as possible.

Ensure that appropriate services and referral pathways are available to support physical activity programs and interventions.

Do not wait for all the pain to be gone before you start moving. Staying active and continuing daily activities as normally as possible (including work) leads to the most rapid and complete recovery. Your clinician will encourage you to stay active and continue or quickly get back to normal activities, including exercise and work, wherever possible. If your pain is worse after activity and persists, you may be advised to take things a little easier at first and gradually build up over a few days or weeks. Avoid long periods of bed rest, which can slow down recovery. Try to remain at work, or get back to work as soon as possible.

Your clinician will suggest ways for you to manage your pain and can develop a self‑management plan with you, so you know what to do. Things that you do yourself to control your pain (like pacing yourself when carrying out physical activity) are more likely to help than treatments that are done to you (like medicines, massage or surgery). Refer to the patient information sheet How to manage your back pain for things that you can do.

You will be encouraged to set treatment goals. Your clinician can also discuss monitoring your symptoms; pacing (or spreading out) activity into small, regular periods; relaxation techniques; and exercise routines and activities. If activities or treatments in your self‑management plan make your pain worse, talk to your clinician about other strategies you can try.

Continue with physical activity even after your back pain has improved, because this is important for preventing future episodes

• How to manage your low back pain – Information for patients

Use the findings from the psychosocial assessment (see Quality statement 2 – Psychosocial assessment) to determine the complexity and intensity of support the patient may need.

For patients with few psychosocial risk factors, who are likely to improve quickly, consider simpler and less intensive support such as reassurance, guidance on self-management and advice to keep active (see Box 4 in Quality statement 5). Offer a review at one to two weeks to assess recovery and the need for further physical or psychological interventions.

For patients at higher risk of a poor outcome, consider early referral for physical and/ or psychological therapies. A patient with moderate to high levels of distress who has difficulty overcoming fear of movement or changing their beliefs or behaviours may require more specific psychological interventions, such as cognitive behavioural therapy, progressive relaxation or mindfulness-based stress reduction. A cognitive behavioural approach can help the patient to develop adaptive coping strategies to self‑manage their pain.9 Where possible, refer patients to a clinician who has experience in pain management and understands the biopsychosocial factors that influence it.  Assess and resolve any concerns the patient may have about such a referral.

For patients with an acute exacerbation of persistent or chronic low back pain, advise that physical activity and exercise therapy can help to relieve pain and improve function (see Box 5), and check adherence to, and effectiveness of, any previous physical and psychological treatments.

Since the evidence does not show that one form of exercise is superior, exercise should be individualised to the patient’s activity preferences, beliefs and functional impairment. The effects of treatment should be documented, with attention to objective and functional improvements. Advise the patient they may be eligible for Medicare rebates as part of a GP Management Plan and Team Care Arrangements.

Physical therapies (such as heat wraps and massage)26 may also help to improve function and mobility, but only as part of a treatment package including physical activity, with or without psychological therapy, and only for a short period of time.

Ensure that systems, processes and appropriate resources are in place so that adults with low back pain can access the physical and psychosocial clinical services they need. Identify where access issues are likely barriers to appropriate treatment and develop strategies to address them (such as telehealth).

Your clinician will offer information and support based on your individual needs, values and preferences, and discuss your goals for improved function and mobility.  For many people with new back pain, additional therapies are not necessary because the pain will improve naturally as you follow the advice of your clinician about physical activity and self‑management. To avoid ongoing issues, treatments that target both the mind and the body will be considered because they are more likely to help with reducing your pain and improving your function long term.

You may be referred to other clinicians for physical therapy, psychological pain management support or a combined treatment approach. Although hands-on therapies may be offered, the overall goal should be to support you to manage your symptoms independently in the longer term. There are many types of clinicians who can help you to set achievable movement and exercise goals, and show you how to pace your activities. For some people with repeated episodes, a psychologist or counsellor can also help you to understand your pain and how it affects your body, thoughts and behaviours, and help you to develop effective coping strategies. Your general practitioner may be able to advise about options for receiving Medicare rebates for these services, if you meet the criteria. You should always receive strategies that support you to manage your symptoms independently in the longer term.

Explain that the goal of pain medicines is to reduce pain to support continuation of usual activities, including physical activity and work, rather than to eliminate pain. Offer information on how pain medicines may be combined with physical activity and self‑management strategies to help the patient improve their function and mobility.

If a pain medicine is being considered:

• discuss the patient’s individual expectations, preferences, comorbidities, needs and treatment goals
• review the patient’s current medicines, including use of over-the-counter medicines, and previously prescribed medicines used to manage pain
• provide information about the risks and benefits associated with specific pain medicines, including the potential for dependency and how to manage side effects
• prescribe the lowest effective dose for the shortest possible time in line with current Therapeutic Guidelines
• establish and document clear stopping goals
• encourage the patient to continue other self-management strategies after they start the medicine
• review early and frequently to assess and monitor the effectiveness of the treatment, adverse effects, misuse and functional gains.

Evidence has shown that anticonvulsants (pregabalin and gabapentin), tricyclic antidepressants, selective serotonin reuptake inhibitors and benzodiazepines have no or limited effectiveness in reducing low back pain or disability, and have significant risks.

Opioid analgesics have limited evidence of short-term effectiveness. In addition to side effects such as constipation and somnolence, they carry the risk of overdose and dependency, and can prolong the time to recovery. If opioid analgesics are used for severe acute pain – for example, in patients who present to the emergency department – prescribe immediate-release formulations on a limited trial basis for a defined duration, as part of an overall pain management strategy that takes into account the patient’s opioid status. Before prescribing an opioid analgesic, it is essential that the patient and anyone involved in their care understand how to use these medicines safely, including their correct storage and disposal.

• See Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

Ensure that systems, processes and resources are in place to support clinicians to provide information to patients about their treatment. Ensure that patients have access to medicines advice, including information on the risks and benefits of pain medicines. Provide clinicians with access to current Therapeutic Guidelines and monitor appropriate adherence.

Policies should limit prescribing of opioid analgesics for low back pain to immediate-release formulations for a limited duration. Ensure that information is provided to manage patient expectations about ongoing opioid analgesic treatment. In the emergency department setting, durations of therapy should be explained to the patient. This information should also be included in the discharge summary, along with a description of the advice and the limited dose and quantity given to the patient, with the goal of avoiding prolonged use, in accordance with the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, (see Quality statement 9 – Transfer of care).

The aim of taking medicines is to reduce pain enough to help you stay active, rather than to completely stop the pain. Medicines are only one part of pain management. They are most effective in the short term to help get you moving and support you while you learn active self-management strategies. It is important to remain physically active and continue with physical activity and self-management strategies after you start any medicine.

When suggesting a medicine, your clinician will consider your symptoms, any other conditions you may have, other medicines you take and your treatment preferences. They will explain:

• what the medicine is for
• how much to take
• how long to take it for
• the expected benefits and risks, including possible side effects.

Ask questions to decide if the medicines being suggested are right for you, and to make sure you understand how to use them.

Medicines that are generally not recommended for low back pain include benzodiazepines (sometimes prescribed as muscle relaxants), anticonvulsants (also used to treat epilepsy) and antidepressants. This is because these medicines are not very effective for low back pain and can have significant side effects.

Opioid analgesics should only be used short term at the lowest dose that helps your symptoms and as recommended by your clinician. Do not use these for long periods because they can cause significant side effects and can be addictive.

If the patient’s pain is persisting or worsening on review, assess if the lack of improvement relates to progression of their condition, or physical, functional or psychosocial factors. Review the initial assessment and current management program, including psychosocial factors that may delay recovery, medicines and adherence to self-management strategies, and adjust the treatment plan accordingly. Any treatments trialled should be assessed for efficacy, and ineffective treatments should be discontinued rather than accumulated.

Discuss ongoing compensation or legal actions that may affect a patient’s response to treatment, because there is an association between compensation-related factors and poorer physical and psychological function.

For a patient with disabling low back or leg pain, or significantly limited function on review at 2–6 weeks, consider referral to a healthcare provider with expertise in using evidence-based approaches to support functional improvement  (see Quality statement 6 – Physical and/or psychological interventions).

A multidisciplinary team approach should be used to address both physical and psychosocial barriers to recovery when required. This should include a mechanism for regular shared communication between healthcare providers and ensuring that consistent information is provided to a patient receiving care from multiple clinicians.

Referral to a multidisciplinary chronic pain management program or clinician with appropriate expertise should be considered for patients with recurrent or persistent low back pain, or any patient who has not recovered from the acute episode by 12 weeks. These services can provide more intensive treatment to support resumption of pre-back pain activities. They have improved function and self-management as the main objectives, and allow ongoing regular review of the patient so that care can be modified according to the patient’s condition.

Earlier referral or review may be warranted for patients with an acute exacerbation of chronic back pain, or when it is clear that pain is persisting or worsening despite appropriate early intervention.

Any new concerning features (for example, serious pathologies, neurological deficits) require urgent investigation or specialist assessment. Patients with severe or progressively deteriorating neurological signs and symptoms should be immediately referred for urgent imaging and surgical review (see Box 6 for essential history to be included in the referral).

Ensure that systems, processes and resources are in place to support clinicians to monitor the symptoms, function and psychosocial wellbeing of patients with low back pain. Protocols should describe appropriate referral pathways and support timely access, including for patients with persisting and worsening pain with signs of serious pathology.

For services providing one component of multidisciplinary care, ensure that systems are in place to facilitate effective shared care across multiple healthcare providers, including mechanisms for regular communication among providers to facilitate the delivery of consistent information to the patient.

At a healthcare service level, assess whether multidisciplinary pain clinics and specialised spinal surgical services are meeting the needs of their populations. Consider quality improvement activities to assess effectiveness and improve access to care.

Let your clinician know if your pain continues to be a problem, if your symptoms get worse or if new symptoms appear. Your clinician can monitor your symptoms and wellbeing, and adjust your treatment if needed. You may be referred to another clinician or team of clinicians who can help you with your goals for achieving physical activity and mobility, and help you to understand your pain and how to reduce its impact on your body, mental state and behaviours.

In some instances, your clinician may refer you to a specialist spine service, a pain service or a physician (such as a rheumatologist, a spine surgeon, or a pain or rehabilitation physician). These specialists can assess your condition, provide advice and discuss other specialised treatment options.

Your clinician will also refer you to a spine surgeon if they suspect a serious condition for which surgery is appropriate, or if you have any nerve compression that is getting worse.

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

In Australia, back problems are the number one cause of lost work productivity, early retirement and income poverty.^6,7,8,9,10 In 2018–19, more money was spent on managing musculoskeletal disorders, including back problems, than any other category of disease, condition or injury in Australia.¹¹

The Australian Atlas of Healthcare Variation series has identified marked variation across Australia relevant to the care of low back pain, including in:

• computed tomography (CT) of the lumbar spine¹²
• opioid medicine use^12,13
• lumbar spinal surgery.^12,13,14

The Second Australian Atlas of Healthcare Variation (second Atlas) identified a need for comprehensive Australian guidance on the early management of low back pain, based on the National Institute for Health and Care Excellence guideline Low Back Pain and Sciatica in Over 16s: Assessment and management, and other relevant high-quality Australian and international evidence.¹⁴

The second Atlas recommended that the Australian guidance support appropriate early management, and ensure that patients are informed about and understand the range of treatment options available for low back pain, their risks and their likelihood of benefit.¹⁴

Improved uptake of guideline recommendations for management of low back pain has been shown to result in better patient outcomes, such as in the extent and rate of recovery and a reduced need for ongoing care.^15,16 It could also lead to more judicious use of imaging; lead to more appropriate use of opioids, other medicines and invasive therapies; and ultimately mean that more patients receive high‑value care.^7,17,18,19

Read more about the scope and goal of this Standard or see further background in the Low Back Pain Clinical Care Standard. 

This Standard applies to all healthcare settings where such care is provided, especially:

• primary healthcare services
• emergency departments.

The Standard is of particular relevance to:

• general practitioners
• allied health providers, including physiotherapists, pharmacists, psychologists, chiropractors, occupational therapists, osteopaths and paramedics
• emergency physicians
• nurses and nurse practitioners.

It may also be relevant in other specialist services that provide care within the scope of this standard.

Not all quality statements in this Clinical Care Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement.

Implementation should consider the context in which care is provided, local variation and the quality improvement priorities of the individual healthcare service.

This Standard relates to the care that should be received by patients aged 16 years and over who present with low back pain, with or without leg pain. It covers the early clinical assessment, management, and review and referral of people with low back pain symptoms who present with a new acute episode. 

Although this Standard does not cover the ongoing management of chronic low back pain, it does include the early management of patients with an acute episode, recurrence or exacerbation of chronic low back pain; such patients may progress more quickly to referral and further assessment.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting. 

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Low Back Pain Clinical Care Standard has been endorsed by 19 key professional associations and consumer organisations including the Australian College of Emergency Medicine (ACEM), Australian College of Rural and Remote Medicine (ACRRM), Australian Physiotherapy Association (APA), The Royal Australasian College of Physicians (RACP), Royal Australian and New Zealand College of Radiologists (RANZCR), Spine Society of Australia (SSA) and the Australian Pain Society (APS).

• Australian Chiropractors Association (ACA)
• Australian College of Emergency Medicine (ACEM)
• Australian College of Nursing (ACN)
• Australian College of Rural and Remote Medicine (ACRRM)
• Australian and New Zealand College of Anaesthetists (ANZCA)
• Australasian College of Sport and Exercise Physicians (ACSEP)
• Australian Orthopaedic Association (AOA)
• Australian Pain Society (APS)
• Australian Physiotherapy Association (APA)
• Australian Rheumatology Association (ARA)
• Chiropractic Australia
• College of Emergency Nursing Australasia (CENA)
• Musculoskeletal Australia
• Osteopathy Australia
• PainAustralia
• The Royal Australasian College of Physicians (RACP)
• Royal Australian and New Zealand College of Radiologists (RANZCR)
• Spine Society of Australia (SSA)
• Therapeutic Guidelines

The Standard is also supported by the Consumer Health Forum (CHF) and the Royal Australian College of General Practitioners (RACGP).

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Low Back Pain Clinical Care Standard Topic Working Group provided expert advice in the development of the Standard. The Commission also consulted with jurisdictional nominees for their perspectives on the draft standard during its development. In addition, a public consultation process was conducted with key stakeholders.

Low Back Pain Clinical Care Standard – Topic Working Group

Low Back Pain Clinical Care Standard - Nominated jurisdictional contacts

The role of the Topic Working Group is to: 

• advise on the scope and key components of care to be the focus of the Standard
• advise on the key sources of evidence to inform the development of the Standard. This might include clinical practice guidelines, clinical standards, systematic reviews and meta-analyses
• advise on the formulation of quality statements and supporting indicators
• recommend strategies to support the implementation of the Standard
• actively support raising awareness of the Standard, and
• advise on a review plan for the Standard, and support any associated revision as required.

For those who are consumers, a key role is to advise on matters relating to their experience - whether as a patient or carer - and provide this perspective during the development of the Standard.

All topic working group members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are managed in line with the Commission’s Policy on Disclosure of Interests.

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence base which underpins the Standard, and the rapid literature and evidence review commissioned to inform the Standard’s development.

Evidence Sources – Low Back Pain Clinical Care Standard