We often get patients who are unsure of the best evidence related to low back pain. Here is a concise post showing best practices. Perhaps the two key points are:

1. Avoid Bed Rest (keep moving)

2. X-rays are usually unnecessary.

Patients with Low Risk of Serious Pathology (No Red Flags)

  • 90% of episodes resolve within 6 weeks regardless of treatment [C]. Advise that minor flare-ups may occur in the subsequent year.


  • Stay active and continue ordinary activity within the limits permitted by pain. Avoid bed rest [A]. Early return to work is associated with less disability.
  • Injury prevention (e.g., use of proper body mechanics, safe back exercises).
  • Recommend ice for painful areas and stretching exercises [D].
  • McKenzie exercises [A] are helpful for pain radiating below the knee.


  • Before considering surgery refer patient for physiatry consult [B], or manual therapy [D].
  • If persistent disability at 2 weeks, consider referral for non-invasive therapy for improving flexibility and strength, not modalities such as heat, traction, ultrasound, transcutaneous electrical nerve stimulation (TENS).
  • If persistent disability at 6 weeks, consider referral to a program that provides a multidisciplinary approach for back pain, especially if psychosocial risks to return to work exist.
  • Surgical referral usually not required.

Medication Strategies

  • Prescribe medications on a time-contingent basis, not pain-contingent basis.
  • No drug categories have been proven to be more effective in pain control, consider side-effect profiles.
  • Opiates are generally not indicated as first-line treatment. Although opiates relieve pain, early opiate use may be associated with longer disability, even after controlling for case severity [D].
  • If prescribed, opiate use should be limited to short-term (i.e., two weeks).


  • Diagnostic tests or imaging usually not required. Consider imaging if red flags are present, or if no improvement after 6 weeks.

Patients with High Risk of Serious Pathology (Red Flags and High Index of Suspicion)

  • Cauda equina syndrome or severe or progressive neurologic deficit—refer for emergency studies and definitive care [C].
  • Spinal fracture or compressions—plain lumbosacral (LS) spine X-ray [B]. After 10 days, if fracture still suspected or multiple sites of pain, consider either bone scan [C] or referral [D] before considering computed tomography (CT) or magnetic resonance imaging (MRI).
  • Cancer or infection—complete blood count (CBC), urinalysis, erythrocyte sedimentation rate (ESR) [C]. If still suspicious, consider referral or seek further evidence (e.g., bone scan [C], other labs—negative plain film X-ray does not rule out disease).

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel

Bibliographic Source      Michigan Quality Improvement Consortium. Management of acute low back pain. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Sep. 1 p.