Management of Acute Lower Back Pain in Australia
For acute lower back pain in Australia, non-pharmacological approaches including maintaining physical activity, applying heat, and education on self-care should be first-line management, with NSAIDs recommended over paracetamol when medication is needed. 1
Initial Assessment and Red Flags
- Screen for red flags that require urgent intervention:
- Fever, night pain, constant pain unrelieved by position change
- Bowel/bladder dysfunction, saddle anesthesia
- Progressive neurological deficits
- Recent trauma (especially in elderly or osteoporotic patients)
- Immunosuppression (including HIV, chronic steroids)
First-Line Management
Non-Pharmacological Interventions
- Maintain tolerable physical activity and avoid prolonged bed rest
- Apply local heat for moderate pain relief
- Provide education on self-care and body mechanics
- Encourage normal activities as tolerated
Pharmacological Interventions
- NSAIDs (e.g., ibuprofen, naproxen) should be considered as first-line medication
- This represents a shift from previous recommendations that favored paracetamol
- High-quality evidence from a 2014 randomized controlled trial showed paracetamol was no more effective than placebo for acute low back pain 2
- Approximately 75% of Australian pharmacists already recommend ibuprofen over paracetamol for low back pain 3
- Use NSAIDs with caution in elderly patients and those with comorbidities
- If using NSAIDs, monitor for adverse effects, especially gastrointestinal and cardiovascular
Second-Line Management
- Muscle relaxants (e.g., cyclobenzaprine) may be considered for short periods (2-3 weeks) if spasm is present
- Massage therapy has demonstrated short-term efficacy
- Spinal manipulation may be considered, especially in patients with a history of good response
- For pain with neuropathic components, consider gabapentin or pregabalin
Avoid in Acute Lower Back Pain
- Routine imaging in the first 4-6 weeks unless red flags are present 4
- Opioids as first-line treatment due to risks generally outweighing benefits
- Prolonged bed rest, which can delay recovery
Follow-Up and Progression
- Regular reassessment of pain and function
- Adjust treatment plan based on response
- Consider imaging if symptoms worsen or new neurological symptoms develop
- If pain persists beyond 4 weeks (becoming subacute), consider:
- More structured physical therapy
- Mind-body approaches (mindfulness, tai chi, yoga)
- Cognitive-behavioral therapy to address fear of movement
Important Clinical Considerations
- Most acute low back pain is self-limited with no serious underlying pathology 4
- Emphasize the generally favorable prognosis to patients
- There appears to be a knowledge gap among some Australian healthcare providers regarding current guidelines for LBP management 3
- Surgical consultation should only be considered for persistent disabling symptoms despite conservative treatment, progressive neurological deficits, or cauda equina syndrome
This approach aligns with current evidence showing that active management strategies are more effective than passive ones, and that paracetamol, despite historical recommendations, lacks evidence for efficacy in acute low back pain.