Sign in

Low Back Pain

Written 15th February 2020 - Last Update 25th August 2026

Low back pain Assessment

The regional hub for low back pain.

One in six Australians report back pain; it is the most frequent musculoskeletal condition in Australian general practice (~3 in 100 GP encounters), the leading cause of disability burden and lost work productivity, and most common in the 30s–50s (peak ~45).

Prognosis: usually good — ~50% recover in 2 weeks and ~90% by 6 weeks; improvement then slows, and over 40% of those still symptomatic may develop chronic low back pain (LBP). Recurrences are common. Duration bands: acute <6 weeks, subacute 6–12 weeks, chronic >12 weeks.

Red flags by condition

Patients need to be assessed early in each new presentation of LBP, with a targeted history and examination to exclude serious pathology and differential diagnoses.

ConditionRed flags
CancerHistory of cancer with new-onset LBP; unexplained weight loss; failure to improve after 1 month; age >50; night pain
Vertebral infectionFever; IV drug use; recent infection; immunocompromise; rest pain
Cauda equina syndromeUrinary retention; faecal incontinence; saddle anaesthesia; lower-limb weakness or numbness
Vertebral fractureOsteoporosis; corticosteroid use; older age; fall or other trauma
Ankylosing spondylitisMorning stiffness; improvement with exercise; alternating buttock pain; waking with pain in the second half of the night; younger age

Yellow flags (risk of chronicity)

Abnormal illness behaviour · fear avoidance (high concern that activity will precipitate pain) · compensation issues · failure to return to work · unsatisfactory response to or refusal of treatment · atypical physical signs. Useful screening questions: beliefs that pain means damage, expectations of passive rather than active treatment, low mood/withdrawal, and worry that something serious has been missed. Asking a patient directly what they think will help them recover is itself informative: what to listen for is expectations of passive treatment, rather than expectations that active participation will help.

Imaging

Not routinely indicated for non-specific LBP <6 weeks — reserve for suspected serious pathology, significant/progressive neurology, or radiculopathy being considered for surgery. Degenerative findings are near universal in asymptomatic people (at age 40: disc degeneration ~68%, disc bulge ~50%, disc protrusion ~33%) and do not predict pain — inappropriate imaging generates worry and cascades of low-value care, and is associated with worse outcomes.

Non-specific low back pain (vertebral dysfunction with non-radicular pain)

The commonest cause — often facet-joint dysfunction, though the precise pain source is usually impossible to pinpoint. Typical picture: onset with lifting/twisting; unilateral lumbar pain referring to sacrum/buttock (not down the legs); worse with activity and sitting; associated stiffness; normal reflexes and sensation; restricted flexion/lateral flexion.

First-line care (for every patient)

  • Assessment, reassurance and education: no indication of serious disease; most acute episodes settle within a couple of weeks. Avoid the terms “injury”, “degeneration” or “wear and tear”, and language promoting fear (“let pain be your guide”, “be careful”).
  • Stay active: avoid bed rest, continue daily activities, stay at or return to work as soon as possible.
  • Self-management with positive coping strategies.
  • Screen psychosocial risk and stratify care — STarT Back, Örebro Musculoskeletal Pain Screening Questionnaire, or PICKUP; low-risk patients get simpler support, medium/high-risk get structured exercise ± psychological therapies.

Second-line care

  • Non-pharmacological first: superficial heat, massage; structured/group exercise, CBT/mindfulness, and multidisciplinary rehabilitation (chronic or medium–high risk not responding to single-discipline care).
  • Pharmacological only if the above fail, shortest period at lowest effective dose after discussing realistic benefits and harms:
    • NSAIDs — first choice in acute and chronic LBP.
    • Paracetamol is no longer recommended alone (no better than placebo used alone in acute non-specific LBP).
    • Muscle relaxants — acute pain only.
    • Opioids — only if other options are contraindicated/not tolerated/ineffective, with careful risk–benefit assessment; discouraged for chronic LBP. Pain-service referral if ongoing controlled analgesia is needed. See Chronic Non-Cancer Pain & Opioid Stewardship for dosing ceilings, monitoring and tapering if an opioid trial is started.
    • Antidepressants (chronic LBP) — modest benefit, best when depression coexists.
  • Invasive/surgical treatment is usually not recommended for non-specific LBP: denervation procedures, corticosteroid/anaesthetic/sclerosant/PRP/stem cell injections, spinal fusion and disc replacement all have narrow or no indications here (facet-nerve blocks ± radiofrequency ablation have a limited role in refractory facet-mediated pain).