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Lower back pain is a common presentation in general practice, and with many treatments available, knowing which ones are effective — and which are not — can guide better care.
Margaret, a 54-year-old woman, presents to your practice with lower back pain that began a few weeks ago. Once active and independent, she now avoids routine tasks like gardening and walking the dog, worried that she’ll worsen the pain.
Margaret’s presentation is common, with one in six Australians reporting back pain at any one time. Back pain is the leading cause of years lived with disability and the most common symptom-related cause for seeking care in Australian general practices. It is a complex condition associated with reduced physical and mental capacities and a higher risk of comorbid chronic disease, which can influence treatment decisions.
Margaret, like many individuals experiencing back pain, was concerned about the possibility of a serious underlying condition and explored treatment options on Google and social media platforms before consulting her GP. Patients often arrive at consultations with preconceptions, expectations and preferences regarding the treatment they believe they should receive.
Clinical practice guidelines for back pain management routinely recommend initial screening for any serious conditions. This includes identifying “red flags” such as recent trauma, unexplained weight loss, history of cancer, neurological deficits, or signs of infection. While serious specific pathology is rare — accounting for less than 5% of cases — it is far more common for GPs to encounter non-specific lower back pain where no specific cause can be reliably identified clinically. In these cases, treatment decisions shift towards reassuring the individual about the favourable prognosis of back pain and low risk of serious underlying disorder, providing personalised information and advice, and prescribing non-pharmacological (first-line) and pharmacological (second-line) interventions.
Which treatments work and which don’t
In recent weeks, we published two comprehensive reviews summarising the evidence for back pain treatments in comparison to placebo or no treatment/usual care.
A recent overview published by the Cochrane Collaboration synthesised findings from 31 Cochrane systematic reviews involving nearly 97 000 individuals. It examined the effectiveness of non-drug, non-surgical treatments for lower back pain, providing a robust evidence base to support most first-line care decisions.
In another review published in BMJ Evidence-Based Medicine, we synthesised the evidence from 301 randomised controlled trials that compared non-surgical and non-interventional treatments with placebo.
We summarised the treatments supported by at least a moderate certainty of evidence — that is, findings likely to be close to the actual effect, based on assessments of risk of bias, consistency of findings, precision of estimates, and risk of publication bias.
The most certain treatments for (sub)acute back pain
Advise to stay active despite back pain
There is a natural response to encourage patients to rest when they experience recent onset (acute) back pain. However, we now know that excessive protective behaviours like prolonged rest can make it harder to return to meaningful activities later. Advising patients to stay as active as tolerable can reduce pain and improve function compared to rest in bed. However, prescribing a structured exercise program is not necessary.
This recommendation might be counterintuitive for patients, requiring GPs to provide personalised information and advice to reassure the patient that gradually increasing movement is safe and important for recovery.
Spinal manipulative therapy
Although effects may vary, spinal manipulative therapy is likely to provide small reductions in pain for some individuals compared with placebo, but it is probably less effective in improving function.
Multidisciplinary care
For pain lasting six to 12 weeks, multidisciplinary treatment is likely to reduce pain compared to standard care.
This approach involves coordinated care from GPs, physiotherapists, and psychologists to address movement patterns, thoughts, emotions, environmental factors, and sensitisation of the pain system to manage back pain and minimise the risk of it becoming persistent.
Multidisciplinary care might not be accessible for all patients. GPs may consider timely referrals to other health professionals and follow up with patients to monitor their recovery progress.
Medications
Non-steroidal anti-inflammatory drugs (NSAIDs) are likely to reduce pain compared to the placebo and may be considered for short term adjunctive treatments, considering their potential adverse effects and relevant contraindications.
The most certain treatments for persistent (chronic) back pain
Exercise therapy
Exercise — especially programs designed to match the patient’s needs and preferences — likely reduces pain and disability compared with placebo, no treatment, or standard care. This could encompass aerobic activity (eg, walking), strength training (eg, weights or resistance exercise), yoga, or Pilates-based movements.
Multidisciplinary care
As with subacute back pain, coordinated care addressing physical, psychological and environmental factors offered by two or more professionals likely works better than usual care alone.
Psychological therapies
The use of psychological therapies aimed at helping people change their thinking, feelings, behaviours, and reactions likely reduces pain; however, it may not be as effective in improving physical function.
Acupuncture
While some debate remains about how acupuncture works, the evidence suggests it probably reduces pain and improves your function compared to placebo or no treatment.
Medications
NSAIDs and transient receptor potential vanilloid 1 agonists (topical cayenne pepper) may provide small reductions in pain compared to placebo. Given their potential adverse effects and relevant contraindications, they may be considered for short term adjunctive treatments. There is mixed evidence for other medicines, including antidepressants, muscle relaxants and opioids, which may be associated with increased risk of harm.
Treatment decision making
Evidence-based management of back pain requires active patient involvement when discussing the many treatment options available. This includes consideration for the potential benefits and harms of treatments, patient preferences, relevant comorbidities and contraindications, available health resources, and relevant contextual factors. For Margaret, having received a comprehensive assessment, personalised information and advice about her back pain, and a short course of NSAIDs, she felt reassured about her recovery and empowered to gradually increase her activity and resume her meaningful activities as quickly as possible.
Dr Rodrigo Rizzo is a Postdoctoral Research Fellow at the Centre for Pain IMPACT, Neuroscience Research Australia and a Lecturer at the School of Health Sciences, University of New South Wales.
Dr Aidan Cashin is a Senior Research Fellow and Deputy Director at the Centre for Pain IMPACT, Neuroscience Research Australia and Conjoint Senior Lecturer at the School of Health Sciences, University of New South Wales.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Many patients get imaging done, which in this age group (50 and above) often shows osteoarthritis of the spine. sometimes is suggests nerve root compromise due to foraminal stenosis. more rarely it suggests spinal canal stenosis. and sometimes it shows upper lumbar osteoporotic crush fractures. these conditions are all different requiring different approaches, which dont seem to be addressed by the above. recent studies into the use of NSAIDs, Panadol and Placebo for uncomplicated back pain (no neurological compromise or crush fractures) showed no benefit over placebo. A minority of patients report dramatic improvements with NSAIDS, suggesting an inflammatory component to their osteoarthritis. Chronic back pain sufferes often take long term analgaesics of the narcotic variety. I would be iterested to know what interventions have been proven successful in getting them off these drugs? Some patients wean off them themselves,a nd are no better or worse pain wise but much clearer in the head. Some use “medical marijuana, which despite the lack of evidnce, does seem to help some patients get off their narcotics. This impresses me as over the years I have seen many long term back pain sufferers try all sorts of “alternatives” including accupuncture, and I have never seen one able to stop their narcotics.
Symptomatic, degenerative disc “disease” is more common in smokers than non- smokers.
One of the first considerations to be addressed before advising treatment.
The pool in exercise therapy is very useful as it minimises load yet maximises muscle!
If they don’t swim, a noodle costs $1!
I offer a surgeon’s perspective: Lower Back Pain Management Requires Simplicity, but also Sophisticated Vigilance. As a spinal surgeon who regularly manages patients with both acute and chronic low back pain, I appreciate the call for clarity in treatment recommendations. The guidelines and reviews summarised here provide a strong evidence-based foundation, especially for general practitioners navigating the maze of options available to patients. That said, from the surgical end of the care continuum, we must recognise where the simplicity of algorithmic care intersects with the complexity of human pathology.
Encouraging patients like Margaret to remain active, reassuring them of the benign nature of most back pain, and offering structured advice on conservative therapy is not only effective but also often essential in preventing unnecessary investigations or overmedicalization. This reflects a welcome evolution in managing low back pain. However, the danger lies in assuming that every “non-specific” case will behave predictably. I frequently see patients in the surgical clinic whose initial presentations were downplayed as benign, but who later manifest structural pathology, such as pars defects, occult instability, persistent discogenic pain, or, in rare but devastating cases, undiagnosed inflammatory, neoplastic, or neurogenic etiologies. These “outliers” may not fit the standard 12-week progression model and can easily fall through the cracks of guideline-based management.
One of the challenges surgeons face is being the endpoint of failed conservative care. We often see patients only after multiple providers, months (or years) of therapies, and significant psychosocial degradation. While the guidelines rightly stress staying active and avoiding unnecessary scans, we must also be open to earlier referrals and imaging in atypical cases, particularly when recovery stalls or pain becomes disabling.
The emphasis on multidisciplinary care and psychological therapies is well-placed, particularly in chronic pain syndromes. But from the surgical chair, it’s equally important to flag that not all persistent pain is “psychogenic” or maladaptive behavior. We’ve revised patients who were told for years that their symptoms were anxiety-based, only to find large posterior osteophytes compressing the thecal sac, or pseudarthrosis from a previously undiagnosed non-union. We must not let cognitive bias or guideline fatigue dull our clinical vigilance.
The current framework relies heavily on “red flags,” which are undeniably useful. Yet many severe conditions initially present without clear red flags. Discitis, epidural abscess, or metastatic spine disease may emerge subtly, particularly in immunocompromised patients or those with vague constitutional symptoms. From a surgeon’s viewpoint, rigid thresholds for imaging or referral can delay diagnosis in a system already stretched by access limitations and long waitlists.
Ultimately, the message to GPs should be this: simplify, but do not oversimplify. Evidence-based care works best when coupled with a clinician’s instincts and an open channel to specialty care. Encourage movement, smoking cessation, exercise, weight reduction, and avoidance of unnecessary scans, but remain open to second opinions when something doesn’t feel right.
Our role as surgeons is not just to operate, but to support colleagues in identifying when non-operative care has reached its limits, or when a diagnosis may not be as benign as first assumed. The goal is not to overmedicalize, but to ensure patients like Margaret don’t fall through the safety net we’ve tried so carefully to weave.