Low back pain in an adult (16 years and over)
Pain in the lumbosacral region, with or without leg pain. Screen every patient for red flags first.
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Family MedicineDiagnostic
Acute Low Back Pain Evaluation & Management (ACP 2017)
Acute Low Back Pain Evaluation & Management (ACP 2017): Low back pain in an adult (16 years and over) → Screen for red flags (serious causes) → Any red ...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Warning Screen for red flags (serious causes)
Ask and examine at every visit. Emergency if cauda equina or cord compression is possible. Also ask about inflammatory back pain.
- Cauda equina or cord: new urinary retention or incontinence, faecal incontinence, saddle numbness, bilateral leg symptoms, severe or progressive leg weakness (e.g. foot drop)
- Cancer or infection: past cancer, unexplained weight loss, age <16 or >50 with new pain, fever, IV drug use, recent spinal procedure or surgery, recent serious infection, immunosuppression
- Fracture, aorta or bleed: significant trauma, osteoporosis, long-term corticosteroids; AAA or dissection (age >60, vascular disease, pulsatile abdominal mass, tearing pain); sudden severe pain on an anticoagulant
03Decision Any red flag present?
Yes: urgent assessment for the suspected cause. No: manage as nonspecific low back pain or sciatica.
- If Yes
04Action Red flag present: urgent assessment for the suspected cause
Several red flags together raise the risk. If serious causes are excluded, manage as for no red flags.
- Suspected cauda equina or cord compression, or severe or progressive weakness: emergency MRI and same-day spinal surgical review
- Suspected leaking AAA or aortic dissection: emergency (call 000 in the community); CT angiography and vascular surgery
- Sudden severe pain on an anticoagulant: emergency assessment for spinal or retroperitoneal bleed
- Suspected spinal infection (fever, IV drug use, recent spinal procedure): same-day assessment; FBC, CRP, ESR, blood cultures; emergency MRI if neurological signs or unwell
- Suspected spinal cancer: with neurological signs, oncology emergency and MRI within 24 hours; pain only, MRI within 1 week
- Suspected fracture: X-ray or CT (MRI if neurological signs); assess bone health if fragility fracture
- Inflammatory back pain (onset before 45 years, more than 3 months, morning stiffness, better with movement): CRP and rheumatology referral
If No05Action No red flags: reassure, keep active, no imaging
Most back pain is nonspecific: no specific cause is found. This also applies to people with sciatica (next step).
- Reassure: most people improve over the first few weeks, whatever the treatment
- Stay active and continue usual activities and work; avoid bed rest
- Safety-net: new bladder or bowel change, saddle numbness or leg weakness needs emergency review
- No imaging without red flags
- Screen for psychosocial risk of slow recovery (e.g. STarT Back tool)
06Action If sciatica (radicular leg pain) without severe or progressive weakness
Same care as low back pain, plus the points below. Most improve without surgery.
- Sciatica: leg pain worse than back pain, below the knee, dermatomal; check straight leg raise, reflexes, power and sensation
- Do not use oral corticosteroids, gabapentinoids or benzodiazepines for sciatica: no benefit and evidence of harm
- Safety-net: new bladder or bowel change, saddle numbness or worsening leg weakness needs emergency review
- Severe or persistent disabling sciatica despite conservative care: spinal specialist referral; MRI only if epidural injection or surgery is considered
07Action First-line: non-drug treatment
Acute and subacute pain: non-drug options first (ACP 2017)
- Superficial heat (moderate-quality evidence)
- Massage, acupuncture or spinal manipulation (low-quality evidence); NICE advises against acupuncture
- Physical activity and graded return to usual activities; manual therapy only with exercise
- Pain medicine only if needed to stay active (next steps)
- If a medicine is needed
08Warning If a medicine is needed: check NSAID risks first
Lowest effective dose for the shortest time. Add a PPI if GI risk.
- Avoid: NSAID or aspirin allergy or NSAID-induced asthma; active or past peptic ulcer or GI bleed; anticoagulant or bleeding disorder; severe heart or liver failure; eGFR <30 mL/min; pregnancy
- High risk, use only with care: age 65+, antiplatelet, corticosteroid or SSRI, CKD, ACE inhibitor or ARB plus diuretic, heart disease, hypertension, IBD
- If GI risk and an NSAID is still needed: add a PPI. Check creatinine if kidney risk
09Action Medicines (only if needed to stay active)
Goal: enable activity, not remove all pain. Set a stop date. Review early.
- NSAID first (adult, oral, with food): ibuprofen 400 mg three or four times a day (max 1600 mg/day) or naproxen 500 mg first dose, then 250 mg every 6-8 hours (max 1250 mg/day)
- Opioids: not routine; no better than placebo for acute low back pain (OPAL trial 2023). Only for severe pain with NSAID unsuitable or ineffective: immediate-release, lowest dose, short defined duration, stop plan; avoid with benzodiazepines or other sedatives
- Skeletal muscle relaxants (ACP option): sedating; avoid in older adults; warn about driving; cyclobenzaprine is not registered in Australia; avoid benzodiazepines
- Do not use gabapentinoids, antidepressants (acute pain) or systemic corticosteroids
- Paracetamol alone: not effective for acute low back pain
10Decision Review at 1-2 weeks, then by 6 weeks: improving?
Worse or any new red flag: repeat the red-flag screen. Check function and psychosocial barriers at every review.
- If Yes
- Improving
11Outcome Improving: continue self-management
Keep active. Taper and stop medicines. Return if pain worsens or any red flag appears.
If No- Not improving
12Action Not improving at 2-6 weeks: reassess and refer
Review the diagnosis, red flags and barriers to recovery
- Refer for exercise therapy or physiotherapy; add a psychological approach (e.g. CBT) if high risk
- No routine X-ray or repeat imaging; image only for red flags or if surgery or injection is considered
- Stop medicines that do not help; do not add more
- Not recovered by 12 weeks: manage as chronic low back pain
13Action Pain for more than 12 weeks: chronic low back pain
Non-drug care first; refer to a multidisciplinary pain program if disabling
- Exercise, multidisciplinary rehabilitation, CBT, mindfulness, yoga or tai chi
- If a medicine is needed: NSAID first (same cautions as above)
- ACP second-line: duloxetine or tramadol. NICE advises against both; the Australian standard avoids antidepressants
- Tramadol: not with an SSRI, SNRI (including duloxetine) or MAOI (serotonin syndrome); avoid in uncontrolled epilepsy
- Avoid long-term opioids; review and taper existing opioids
- Worse or new red flag
- Path rejoins step 02Shared downstream outcome
- Path rejoins step 10Shared downstream outcome
Guideline Source
ACP Clinical Practice Guideline: Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain (2017)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults 16 years and over only; children and adolescents with back pain need a lower threshold for investigation.
- Guidelines differ: ACP supports acupuncture, muscle relaxants and (chronic pain) duloxetine or tramadol; NICE and the Australian standard advise against some of these.
- Does not detail surgical, injection or specialist spinal management.
- Not for back pain after major trauma or in pregnancy-specific care.
Contraindicated Populations
pediatricmajor trauma
Applicable Regions
USAUUKEU
AU: ACSQHC Low Back Pain Clinical Care Standard (2022): reserve imaging for suspected serious pathology; avoid anticonvulsants, benzodiazepines and antidepressants; opioids only in carefully selected patients. Cyclobenzaprine is not registered in Australia.
UK: NICE NG59 (2016, updated 2020, amended 2026): no acupuncture, no paracetamol alone, no oral corticosteroids or gabapentinoids for sciatica.
US: ACP 2017 noninvasive treatment guideline.
Version 2Next review: 2027-09-30
Next steps
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Related Resources
Frequently Asked Questions
What is the Acute Low Back Pain Evaluation & Management (ACP 2017)?
The Acute Low Back Pain Evaluation & Management (ACP 2017) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on ACP Clinical Practice Guideline: Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain (2017).
What guideline is the Acute Low Back Pain Evaluation & Management (ACP 2017) based on?
This algorithm is based on ACP Clinical Practice Guideline: Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain (2017) (DOI: 10.7326/M16-2367).
What are the limitations of the Acute Low Back Pain Evaluation & Management (ACP 2017)?
Known limitations include: Adults 16 years and over only; children and adolescents with back pain need a lower threshold for investigation.; Guidelines differ: ACP supports acupuncture, muscle relaxants and (chronic pain) duloxetine or tramadol; NICE and the Australian standard advise against some of these.; Does not detail surgical, injection or specialist spinal management.; Not for back pain after major trauma or in pregnancy-specific care.. Individual patient factors may require deviation from these recommendations.
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