Why tackle acute non-specific low back pain now?

Low back pain is a leading cause of disability in Australia and many patients are not being treated appropriately. Find out more about this NPS MedicineWise program.

  • Low back pain is a leading cause of disability worldwide. 
Why tackle acute non-specific low back pain now?

Low back pain is now the leading cause of disability worldwide,1 and one in seven Australians (13.6%) will suffer from back pain on any day.2

A recent Australian survey found that 67% of participants who presented to their GPs with low back pain reported that they were referred for diagnostic imaging.3

However, early diagnostic imaging of the back is not recommended unless there is clinical suspicion of a serious spinal pathology,4 which accounts for < 1% of all low back pain.2

The vast majority of acute cases are non-specific and self-limiting, resolving within a few weeks. Imaging does not change management for patients with acute non-specific low back pain and may lead to harm, such as fear-avoidance resulting from incidental findings, inappropriate treatment (such as surgery) and unnecessary radiation exposure.5

Imaging is frequently requested, however, to aid in diagnosis, rule out sinister pathology, guide treatment strategies for the clinician, and reassure the patient.6 Another significant driver is that patients commonly believe imaging is essential for assessing low back pain, and that X-rays are routine in the assessment of low back pain. Patients then expect GPs to refer them for X-rays. They have little awareness of the limited value of X-rays for diagnosing acute low back pain and often believe that there is no downside to their use.7,8

Apart from the issue of imaging, other elements of care for patients with acute non-specific low back pain could be improved by sticking more closely to guideline recommendations. These include:

  • educate the patient
  • provide assurance of a favourable prognosis, and
  • encourage the patient to remain active and avoid bed rest.9 


A diagnosis of exclusion

Non-specific low back pain is a diagnosis of exclusion.2,4,5,10

Infographic showing 100 people, of whom around 10% have radicular syndrome, < 1% have serious spinal pathology and the remainder, around 90%, have non-specific low back pain.
Figure 1: Diagnostic prevalence in low back pain

Diagnose radicular syndrome through history and, if necessary, physical examination

Ask about symptoms of radicular pain, radiculopathy and spinal stenosis, including:2

  • leg pain that is worse than back pain
  • progressive muscle weakness
  • neurogenic claudication, tingling and numbness.

Perform (if symptoms present) straight leg-raise testing, and assess nerve root dysfunction, using:11

  • knee strength and reflexes (L4)
  • great toe and foot dorsiflexion (L5)
  • foot plantarflexion and ankle reflexes (S1)
  • distribution of sensory signs.

When should imaging be considered? 

Although serious spinal pathology accounts for less than 1% of all low back pain presentations, strong clinical suspicion of such a pathology may require further investigation (Table 1).2,5,12


Choosing Wisely Australia supports a limited role for imaging

Choosing Wisely Australia logo

Through the Choosing Wisely initiative, five organisations recommend that doctors should not request imaging if there are no indicators of a serious cause for low back pain. 


A biopsychosocial approach to management

Acute non-specific low back pain is self-limiting and resolves after 4–6 weeks for most patients.15 However, for the small number of patients who develop chronic disabling pain,5 the disease burden and cost of treatment can be substantial.16

In recent years, our understanding of the complexity of low back pain and the importance of a biopsychosocial approach, in preference to a purely biomedical approach, has increased significantly.

Guidelines recommend early treatment for patients with acute non-specific low back pain to address risk factors for poor prognosis (yellow flags). The aim is to prevent the development of chronic disabling pain.4,5,10

This can involve a risk stratification approach, where each patient’s risk level is assessed to help determine a specific management strategy.4

Example of tools to assess risk include the Subgroups for Targeted Treatment (STarT) Back, Örebro Musculoskeletal Pain Questionnaire4,5,10 or Predicting the Inception of Chronic Pain (PICKUP).17

Practice points

Identify psychosocial risk factors that can contribute to poor prognosis for the patient at the first or second visit.4,10 These may include:5

Misconceptions about the nature of the pain

  • belief that back pain is harmful to the spine
  • belief that there is structural damage to the spine associated with spinal weakness or instability.

Unhelpful coping strategies

  • fear of pain that leads to avoidance of activities
  • lowered mood and withdrawal from social interaction
  • belief that passive treatments alone will help, rather than active participation. 


First-line treatments

Patient education, reassurance and activity are first-line treatments for all patients with non-specific low back pain.5 NPS MedicineWise has developed a patient factsheet that explains the limited role of imaging and outlines other strategies for managing low back pain.

Encourage patients to stay as active as possible. This includes:5

  • adopting normal movement and physical function
  • continuing or returning to work.

Staying active, through pacing of activities, and resuming usual activities and work in a graded manner,5 helps to avoid:

  • overdoing activity, which can cause pain exacerbations18
  • underdoing activity;18 particularly prolonged bed rest, which can lead to muscle weakness, flexibility loss,19 possible increased low back pain recurrence risk.20

Encourage and collaborate with patients to identify things that make their pain worse, set goals for activity they wish to achieve and devise strategies to achieve them.21,22

NPS MedicineWise has developed a patient action plan, an individualised plan patients and doctors can develop together to set goals.

Practice points

Only consider medicines as an adjunct to activity, after implementing patient education and reassurance.5

If required, medicines aim to reduce pain, rather than abolish it, to maintain function and to facilitate activity.5


More information

Access our free accredited CPD activities on low back pain to find what is most suitable for you.



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