Your Recent Highlights paper shows just how rare serious spinal pathology is. How should clinicians interpret and use red flags when assessing people with low back pain? 

We encourage clinicians to use a decision support tool based on a combination of alerting features. 

These include not only the presence of red flags but also the individual patient’s profile (ie, age, comorbidities and symptom progression). 

This combined information helps determine the overall level of concern and informs the appropriate clinical action. 

In cases where some alerting features are present, further investigation or referral may be appropriate. 

Imaging is still overused for back pain. What does the latest evidence suggest about when imaging is—and is not—helpful?

Imaging is rarely helpful for most people with low back pain, especially in the early stages. 

The latest evidence reinforces the fact that routine imaging does not improve outcomes and often leads to unnecessary interventions, increased worry and higher healthcare costs. 

Imaging should only be considered when there are specific clinical features present that suggest a serious underlying condition (eg, cancer, infection or fracture) or when imaging results would clearly change management. 

For most patients, clinicians should focus on active care strategies and reassure patients about the limited role of imaging. 

Diagnostic uncertainty remains a major challenge in clinical practice. Why is it so difficult to pinpoint a precise cause of low back pain in most cases? 

Our current clinical tests aren’t accurate enough to confirm suspected sources of pain such as discs, facet joints or muscles. 

Importantly, low back pain isn’t just generated by spinal tissues; it’s influenced by a wide range of factors including psychological distress, social circumstances and work-related demands. 

Diagnostic uncertainty is an expected part of managing low back pain and we need to acknowledge and explain this when we’re communicating with patients. 

Your review suggests that labels like ‘acute’ and ‘chronic’ don’t capture the reality of people’s experiences. What do we now know about pain trajectories over time? 

We’ve traditionally used terms like ‘acute’ and ‘chronic’ to describe how long someone has had low back pain. 

However, these labels don’t truly capture how people experience pain in reality. 

Pain doesn’t follow a simple, linear path. 

Longitudinal studies have shown that low back pain often takes a variable and fluctuating course. 

Some people recover completely after a first episode but for many, the pain fluctuates. 

Even for those with longstanding pain, improvement is still very possible. 

Rather than thinking of low back pain as something that either resolves or becomes chronic, it’s more helpful to think of it as a condition with different patterns or trajectories over time. 

This shift in perspective allows us to set more realistic expectations with patients and better support their long-term management. 

Further research is needed to determine whether classifying patients by these trajectories can actually improve our ability to predict outcomes or guide treatment. 

Which factors consistently predict a poorer prognosis or delayed recovery for people with low back pain? 

Certain factors tend to show up again and again when we are investigating those who have a poorer prognosis or delayed recovery from low back pain. 

Factors such as higher levels of pain and disability at baseline, psychological distress (ie, anxiety or depression), beliefs about pain not aligned with current evidence, physically demanding jobs, poor sleep and low expectations of recovery are common. 

However, these associations do not mean that the factors directly cause delayed recovery. 

We can’t assume that targeting them will automatically improve outcomes. 

More validation studies are needed before we can use these insights confidently in clinical decision-making. 

What are the key priorities for future research to improve diagnosis, prognosis and clinical decision-making in low back pain? 

One clear priority is improving how we communicate diagnostic uncertainty. 

Clinicians often feel uncomfortable when they can’t provide a precise cause for back pain, leading to overdiagnosis or unnecessary treatments. 

Future studies should explore ways to support clinicians in these conversations, including how to communicate uncertainty in a way that maintains trust and empowers patients. 

Another key area is prognosis. While we’ve identified individual risk factors for delayed recovery—such as pain intensity, distress and unhelpful beliefs—we still can’t reliably predict outcomes in clinical practice. 

More research is needed to validate prognostic models and determine whether using them in real-world settings can actually improve care. 

The use of red flags and decision-making tools for serious pathology needs attention. 

We need studies that test structured tools based on combinations of alerting features and we must understand how those tools affect clinician behaviour and patient outcomes. 

Our paper calls for research that’s not just about what we should do, but about how to implement it in a way that supports clinicians and benefits patients. 

>>Dr Rafael Zambelli Pinto is an associate professor at the University of Technology Sydney, a physiotherapist and a researcher specialising in musculoskeletal conditions. He has published over 150 papers, with a research focus on innovative approaches to managing chronic musculoskeletal conditions in adults and older populations. Committed to advancing evidence-based practice, he integrates research into clinical decision-making through educational initiatives.