Low back pain (LBP) is the most common form of musculoskeletal back problem and most people experience it at some point in their lives. 

In Australia, back problems are the second most common reason to visit the GP and a leading cause of presentation to emergency departments.

In addition to the pain itself, LBP often leads to psychological distress and a poorer quality of life and is the leading cause of disability worldwide. 

Despite the enormous healthcare costs spent on care for people with LBP, the disability burden is growing. 

Around 25 to 30 per cent of people with acute LBP go on to develop persistent and disabling pain.

 While there are guidelines and recommendations for management of LBP, many people still don’t receive best-practice care, says Professor Peter O’Sullivan, a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2017) and a John Curtin Distinguished Professor at Curtin University. 

Peter is a member of the Low Back Pain Clinical Care Standard Topic Working Group, which developed the Low Back Pain Clinical Care Standard for the Australian Commission on Safety and Quality in Health Care.

‘As a society, the way we often manage back pain is not helpful and the disability burden is getting worse,’ he says. 

‘There are a lot of concerns about the way back pain has been managed and misconceptions about the causes of LBP. 

'Patients are over-scanned, leading to inaccurate diagnostic labels, too many patients become dependent on opioids and there is too much unnecessary surgery.’

The new clinical care standard aims to improve the early assessment, management, review and appropriate referral of patients with LBP.

It focuses on patients presenting with an acute episode of LBP, specifically in primary care or emergency care settings, including GP and allied health clinics and emergency departments. 

This may be a new presentation or a recurrence or exacerbation of chronic LBP.

The standard does not cover the ongoing management of chronic LBP, including surgery or treatments for specific causes.

The clinical care standard consists of eight quality statements that describe the expected standard for key components of patient care (see below). 

Each quality standard is accompanied by one or two indicators—assessment measures that can be used by a healthcare service or provider to monitor implementation of the recommended care.

The first quality standard covers the initial clinical assessment.

‘You need to make sure you’ve thoroughly examined your patient so you can identify the one per cent of people who may have specific pathology—for example, an infection, a fracture, a malignancy, nerve compression, cauda equina syndrome or an inflammatory disease,’ Peter says.

This is followed by a psychosocial assessment, which screens for factors that might adversely influence a patient’s recovery, such as beliefs about back pain, sleep, fear of movement, anxiety, stress or depression.

‘These are all factors that we know are predictive of poor outcomes for patients. 

'Screening for them early allows us to flag people who might be more distressed or have other psychosocial factors so we can make sure that we give them extra support and connect them with additional interdisciplinary care if needed,’ says Peter.

The third standard focuses on the use of imaging when assessing a patient with LBP. 

Only a very small percentage of people who present have serious pathology, says Peter. 

As people age, disc degeneration, disc bulges and protrusions are prevalent in pain-free populations and not predictive of a person’s pain experience. 

Unfortunately, patients are commonly referred to imaging and are often given diagnoses based on scans that lead to unhelpful adviceand care. 

He advocates setting realistic expectations with the patient.

‘Many people end up getting imaged for their backs and are given diagnoses like degenerative discs, disc bulges, fissures or arthritis and it leads them down this path of worrying and over-protecting the back, guarding their posture, trying to be careful about how they move and avoiding activity, which actually makes the problem worse,’ Peter says. 

‘Patients should be reassured that their scan is normal in that situation and not go down the rabbit hole of thinking that they have to protect their back.’

The next two quality standards concern education and self-management.

‘Patients want to know what’s going on and they want to have a clear pathway to recovery. 

'We need to make sure that we educate people carefully and in an evidence-based way with simple language about the natural history of their problem,’ says Peter.

‘The majority of acute back pain will get better with the right care. 

'The predictors of poor recovery are usually not what you see in the scan. 

'They’re things like becoming over-worried, over-protective and fearful or avoiding movement and exercise. 

'By guiding patients onto a self-management pathway, we can build their confidence in engaging with movement and activity and getting back to work, which is really important.’

The clinical care standards also recommend using physical and psychosocial approaches to manage LBP rather than immediately reaching for pain medicines, especially opioids.

The important point in the final standard, says Peter, is knowing when to seek a second opinion.

‘If those people are not responding to care, don’t hang onto them; get a second opinion. 

'That might be from another physiotherapist or a specialist physiotherapist or, if appropriate, a psychologist or back to the GP for additional support with pain management,’ he says. 

‘It sounds simple but it often doesn’t happen.’

Peter notes that by following the Low Back Pain Clinical Care Standard, clinicians are guided to best-practice care, whether they are a GP, a specialist physician or a physiotherapist.

‘We all have a place and a role to play and we communicate clearly with people within our care team. 

'The clinical care standard provides a pathway for better care to help patients manage LBP episodes early and reduce their chances of ongoing problems.’

For physiotherapists, Peter says the standard will either validate their existing approach to treating LBP or provide them with a road map to improve their practice.

‘If the way a physio practises is more about providing ongoing passive therapies and symptom relief for people, then it really indicates that there needs to be an expanded role in their practice. 

'It’s not to say that you can’t do hands-on therapy, but it’s an adjunct to all these other things that are really important in the care of your patient. 

'It’s good for the clinician and it’s great for the patient. 

'It’s also good for your business, if you’re in private practice, because you’re going to have a happy customer who is getting back to the things that they love. 

'It’s a win-win,’ he says.

Quality Standards

The Low Back Pain Clinical Care Standard includes the following eight quality standards, which describe the level of clinical care expected. 

There are also indicators (not listed here) to assist healthcare services to monitor how the recommended care is implemented.

1.    Initial clinical assessment

The assessment of a patient with a new presentation of low back pain symptoms, with or without leg pain or other neurological symptoms, focuses on screening for specific and/or serious pathology and consideration of psychosocial factors. 

It includes a targeted history and physical examination, with a focused neurological examination when appropriate. 

Arrangements are made for follow-up based on an evidence-based low back pain pathway.

2.    Psychosocial assessment

Early in each new presentation, a patient with low back pain, with or without leg pain or other neurological symptoms, is screened and assessed for psychosocial factors that may affect their recovery. 

This includes assessing their understanding of, and concerns about, diagnosis and pain, and the impact of pain on their life. 

The assessment is repeated at subsequent visits to measure progress.

3.    Reserve imaging for suspected serious pathology

Expectations of imaging and its limited role in diagnosing low back pain are discussed with a patient. 

Early and appropriate referral for imaging occurs when there are signs or symptoms of specific and/or serious pathology. 

The likelihood and significance of incidental findings are reported and discussed with the patient.

4.    Patient education and advice

A patient with low back pain is provided with information about their condition and receives targeted advice to increase their understanding, and address their concerns and expectations. 

The potential benefits, risks and costs of medicines and other treatment options are discussed, and the patient is supported to ask questions and share in decisions about their care.

5.    Encourage self-management and physical activity

A patient with low back pain is encouraged to stay active and continue, or return to, usual activity, including work, as soon as possible or feasible. 

Self-management strategies are discussed. 

The patient and clinician develop a plan together that includes practical advice to maximise function, and limit the impact of pain and other symptoms on daily life. 

The plan addresses individual needs and preferences.

6.    Physical and/or psychological interventions

A patient with low back pain is offered physical and/or psychological interventions based on their clinical and psychosocial assessment findings. 

Therapy is targeted at overcoming identified barriers to recovery.

7.    Judicious use of pain medicines

A patient is advised that the goal of pain medicines is to enable physical activity, not to eliminate pain. 

If a medicine is prescribed, it is in accordance with the current Therapeutic Guidelines, with ongoing review of benefit and clear stopping goals. 

Anticonvulsants, benzodiazepines and antidepressants are avoided, because their risks often outweigh potential benefits, and there is evidence of limited effectiveness. 

Opioid analgesics are considered only in carefully selected patients, at the lowest dose for the shortest duration possible.

8.    Review and referral

A patient with persisting or worsening symptoms, signs or function is reassessed at an early stage to determine the barriers to improvement. 

Referral for a multidisciplinary approach is considered. 

Specialist medical or surgical review is indicated for severe or progressive back or leg pain that is unresponsive to other therapy, progressive neurological deficits, or other signs of specific and/or serious pathology.

The Australian Commission on Safety and Quality in Health Care has information and resources available for clinicians, healthcare services and consumers. Visit their website to read the Low Back Pain Clinical Care Standard in full.