The Low Back Pain Clinical Care Standard includes eight evidence-based quality statements to improve the early assessment, management, and review and referral of patients with low back pain, and to improve shared decision making about which tests and treatments are most effective in managing low back pain.
A set of indicators is provided to support clinicians and healthcare services to monitor how well they are implementing the care recommended in this clinical care standard and to support local quality improvement activities.
The assessment of a patient with a new presentation of low back pain symptoms, with or without leg pain or other neurological symptoms, focuses on screening for specific and/or serious pathology and consideration of psychosocial factors. It includes a targeted history and physical examination, with a focused neurological examination when appropriate. Arrangements are made for follow-up based on an evidence-based low back pain pathway.
What this means for you
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).
Early in each new presentation, a patient with low back pain, with or without leg pain or other neurological symptoms, is screened and assessed for psychosocial factors that may affect their recovery. This includes assessing their understanding of, and concerns about, diagnosis and pain, and the impact of pain on their life. The assessment is repeated at subsequent visits to measure progress.
What this means for you
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:
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.
Box 1: Psychosocial factors associated with delayed recovery
Factors associated with delayed recovery from low back pain include:
Belief that pain and activity are harmful
‘Sickness behaviours’ (such as extended rest)
Low or negative moods, or social withdrawal
Mental health comorbidities or trauma history
Treatment that does not fit with best practice, but remains the focus of the patient’s requests
Problems with the compensation system
Previous history of back pain, time off work or other claims
Expectations of imaging and its limited role in diagnosing low back pain are discussed with a patient. Early and appropriate referral for imaging occurs when there are signs or symptoms of specific and/or serious pathology. The likelihood and significance of incidental findings are reported and discussed with the patient.
What this means for you
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.
Box 2: Essentials to include in a medical imaging referral
Clinical question being addressed – A clear diagnostic question will help focus the radiologist’s interpretation of results.
Provisional diagnosis – A provisional diagnosis on the request can help guide the protocol for imaging investigation. This will help to determine what conditions are being ruled in and ruled out.
Relevant clinical details and family history – Can give clues as to the most likely diagnosis and area to focus on.
Alerting features of serious pathology, symptoms or warning signs –
Note any alerting features that can indicate a specific clinical suspicion.
A patient with low back pain is provided with information about their condition and receives targeted advice to increase their understanding, and address their concerns and expectations. The potential benefits, risks and costs of medicines and other treatment options are discussed, and the patient is supported to ask questions and share in decisions about their care.
What this means for you
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.
A patient with low back pain is encouraged to stay active and continue, or return to, usual activity, including work, as soon as possible or feasible. Self-management strategies are discussed. The patient and clinician develop a plan together that includes practical advice to maximise function, and limit the impact of pain and other symptoms on daily life. The plan addresses individual needs and preferences.
What this means for you
Explain the importance of maintaining or quickly returning to normal activities, including 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
Staying active, instead of resting in bed, is recommended for a low back pain episode. It can improve pain relief and the ability to perform everyday activities (functional state), reduce sick leave and enable people to continue or return to work.
Patients can be advised to reduce, alter or modify certain painful activities (for example, lifting) for a few days, as certain activities may exacerbate back pain. Patients need to be reassured that an exacerbation of pain is not an indication of damage, and fluctuations in pain can be expected during recovery from acute low back pain. Patients should feel confident to continue or get back to their normal everyday activities in days to weeks.
Staying active means continuing with normal daily activities as much as possible, including going to work. It also means trying to reduce long periods of inactivity. No specific exercise(s) is needed at this stage.
People with low back pain who remain active, even when in pain, do better in the long term. In fact, it appears that the longer a person stays in bed because of low back pain, the worse their ability to work or return to work becomes.
Tips and challenges
Patients should be advised that it is important not to wait for all pain to be gone before they start moving. Having a strategy whereby they either reduce or alter certain painful activities (for example, lifting) for a few days, and then gradually build up these activities again can be recommended.
Patients often fear that pain is a sign of deterioration and/or further damage. They are often anxious about returning to physical work or activities that are high impact or involve bending, twisting or lifting. Patients may need to be reassured that the back is strong and, although they may need to reduce, alter or modify how they do these activities, they can still do them. They may also need reassurance that the pain is likely to subside and that ongoing pain is not an indication of further damage.
A patient with low back pain is offered physical and/or psychological interventions based on their clinical and psychosocial assessment findings. Therapy is targeted at overcoming identified barriers to recovery.
What this means for you
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.
Box 5: Practice points for recommending exercise for patients
Exercise programs should be individualised, taking into account the patient’s physical activity preferences, beliefs and specific functional impairments.
Exercise programs should include stretching, strengthening and aerobic exercises that are functionally oriented.
Starting with gentle movements is the first step. These might include waterbased walking, land-based walking, gentle swimming and floor stretches that encourage the spine to move in its normal planes. Activity should be graded by the duration of time spent exercising, rather than the pain experienced.
As the patient’s tolerance to activity over longer periods increases, the mode, frequency and/or intensity of activity can be progressed.
Functional exercises can be introduced to encourage activation of large muscle groups (for example, squats, lunges, step-ups).
Exercise that patients enjoy (for example, yoga, Pilates, walking, cycling) can be gradually introduced (for example, start at 15–20 minutes duration and then increase).
In the later stages of rehabilitation, more dynamic and higher-load exercises can be performed.
A patient is advised that the goal of pain medicines is to enable physical activity, not to eliminate pain. If a medicine is prescribed, it is in accordance with the current Therapeutic Guidelines, with ongoing review of benefit and clear stopping goals. Anticonvulsants, benzodiazepines and antidepressants are avoided, because their risks often outweigh potential benefits, and there is evidence of limited effectiveness. Opioid analgesics are considered only in carefully selected patients, at the lowest dose for the shortest duration possible.
What this means for you
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.
A patient with persisting or worsening symptoms, signs or function is reassessed at an early stage to determine the barriers to improvement. Referral for a multidisciplinary approach is considered. Specialist medical or surgical review is indicated for severe or progressive back or leg pain that is unresponsive to other therapy, progressive neurological deficits, or other signs of specific and/or serious pathology.
What this means for you
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).
Box 6: Essential history to include in a referral for urgent imaging and surgical review
Presence and duration of neurological signs and symptoms
Presence or absence of concerning features
Age (at onset) under 16 years and over 50 years with new-onset pain
Motor deficit (such as foot weakness)
Recent significant trauma
Unexplained weight loss
Previous history of malignancy (however long ago)
History of intravenous drug use
Previous longstanding steroid use
Recent serious illness
Recent significant infection
Mechanism of injury
Management to date (including previous spinal surgery and nonoperative
General medical history
Relevant imaging results (such as X-ray, CT, MRI).
Resources for clinicians
The resources below have been developed specifically for clinicians.
You can also see our full list of implementation resources including guidance for healthcare services and resources for consumers.
This resource provides an evidence-based approach to the early assessment, management, review and referral of patients with low back pain, who present with a new acute episode. The guide includes simple guidance and communication tips for physiotherapists.
This quick guide outlines the care described in the Low Back Pain Clinical Care Standard for patients presenting to their chiropractor for a new acute episode of low back pain, with or without leg pain.