How should I assess and manage a patient presenting with acute low back pain in primary care?

Assessment: When a patient presents with acute low back pain (less than 3 months duration) in primary care, first perform a risk stratification assessment (e.g., STarT Back tool) to identify risk factors for prolonged or complicated recovery and to guide management decisions. Exclude red flag symptoms or signs that suggest serious underlying causes such as cancer, infection, trauma, or inflammatory disease. If red flags or suspicion of another underlying cause are present, arrange urgent hospital admission or specialist referral based on clinical judgement. Do not routinely offer imaging unless it is likely to change management or if referred to specialist care. Consider alternative diagnoses if symptoms change or new symptoms develop ¹,²,³.

Management: Offer reassurance that acute non-specific low back pain is unlikely to have a serious structural cause and most people recover within weeks. Advise the patient to keep active, resume normal activities, and return to work or study as soon as possible, discouraging prolonged bed rest. Explain that normal back movements may cause some pain but are not harmful if activities are resumed gradually, and there is no need to be pain-free before resuming normal activities. Consider short-term use of local heat (e.g., heat pack) for symptom relief. Provide tailored advice and information to support self-management ¹,²,³.

For pharmacological treatment, do not recommend paracetamol alone. First-line drug treatment is an over-the-counter NSAID such as ibuprofen at the lowest effective dose for the shortest possible time, considering gastroprotection if clinically indicated. If NSAIDs are contraindicated, not tolerated, or ineffective, consider short-term use of weak opioids (e.g., codeine with or without paracetamol), taking into account risks of dependence and adverse effects. Do not recommend benzodiazepines, gabapentinoids, antiepileptics, antidepressants, or opioids for chronic low back pain ¹,²,³.

Provide information on reliable sources such as Backcare, Versus Arthritis, and the Chartered Society of Physiotherapy for patient education and support. Reassess the patient if symptoms change or do not improve, and consider referral to physiotherapy or combined physical and psychological treatments if risk factors for poor outcome are present or if symptoms become chronic ¹,²,³.