Low Back Pain Clinical Care Standard

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

This standard aims to:

• To improve the early assessment, management, review and appropriate referral of patients with low back pain 
• To reduce the use of investigations and treatments that may be ineffective or unnecessary in managing low back pain.

This clinical care 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. 

Application to healthcare settings

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

• Primary healthcare services
• Emergency departments.

The clinical care 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.

What is not covered

This clinical care standard does not cover:

• Delivery of surgical interventions or their indications for use (for example, fusion and disc replacement, discectomy, laminectomy)
• Ongoing management of low back pain persisting longer than 12 weeks, beyond the initial management of an acute exacerbation (although many of the principles of care described may still be relevant)
• Diagnosis or treatment of specific causes of low back pain, such as
  • inflammatory conditions (for example, axial spondyloarthritis)
  • infections (for example, discitis, osteomyelitis, epidural abscess)
  • fracture
  • neoplasm
  • metabolic bone disease (for example, osteoporotic fracture, Paget’s disease)
  • non-spinal causes of back pain
  • degenerative spinal disorders.

The standard was developed in consultation with a topic working group of clinicians, researchers and consumers. Public consultation on the clinical care standard was carried out between March and April 2021. 

The 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).

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

Further information is available on the evidence base which underpins the Low Back Pain Clinical Care Standard, and the rapid literature and evidence review commissioned to inform the standard’s development.

1. Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64(6):2028–37.
2. Apos E, Cunningham J, Ahern S, Truong T, Hansen J, Johnson MA. The Australian Spine Registry annual report, 2019. Melbourne: Spine Society of Australia and Public Health and Preventive Medicine, Monash University; 2020.
3. Australian Institute of Health and Welfare. Back problems. Canberra: AIHW; 2020.
4. Froud R, Patterson S, Eldridge S, Seale C, Pincus T, Rajendran D, et al. A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskelet Disord 2014;15(1):50.
5. Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390(10100):1211–59.
6. da C Menezes Costa L, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ 2012 Aug 7;184(11):E613–24.
7. NSW Agency for Clinical Innovation. Management of people with acute low back pain: model of care. Chatswood: NSW Health; 2016.
8. Schofield DJ, Shrestha RN, Passey ME, Earnest A, Fletcher SL. Chronic disease and labour force participation among older Australians. Med J Aust 2008 Oct 20;189(8):447–50.
9. Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ 2017 Nov 13;189(45): E1386–95.
10. Schofield DJ, Shrestha RN, Cunich M, Tanton R, Kelly S, Passey ME, et al. Lost productive life years caused by chronic conditions in Australians aged 45–64 years, 2010–2030. Med J Aust 2015 Sep 21;203(6):260.e261–6.
11. Australian Institute of Health and Welfare. Disease expenditure in Australia 2018–19. Canberra: AIHW; 2021.
12. Australian Commission on Safety and Quality in Health Care, National Health Performance Authority. Australian atlas of healthcare variation. Sydney: ACSQHC; 2015.
13. Australian Commission on Safety and Quality in Health Care. The Third Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2018.
14. Australian Commission on Safety and Quality in Health Care. The Second Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2017.
15. Bogduk N. Management of chronic low back pain. Med J Aust 2004 Jan 19;180(2):79–83.
16. McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine (Phila Pa 1976) 2001 Dec 1;26(23):2615–22.
17. Ferreira GE, Machado GC, Abdel Shaheed C, Lin CC, Needs C, Edwards J, et al. Management of low back pain in Australian emergency departments. BMJ Qual Saf 2019 Oct;28(10): 826–34.
18. Layne EI, Roffey DM, Coyle MJ, Phan P, Kingwell SP, Wai EK. Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines? Spine J 2018 Apr;18(4):614–9.
19. van Wambeke P, Desomer A, Ailliet L, Berquin A, Demoulin C, Depreitere B, et al. Low back pain and radicular pain: assessment and management. Brussels: Belgian Health Care Knowledge Centre; 2017. KCE Report 287.