Patient handout

Low back pain (acute → subacute → chronic, primary-care)

PRODUCTION

1. Your condition

This handout is for low back pain (acute → subacute → chronic, primary-care). Your care team identified this based on: acute low back pain <6 weeks ± leg pain (acp 2017 qaseem; lancet 2018 foster).

Other reasons your team may use this plan: subacute low back pain 6–12 weeks (nice ng59; acp 2017 qaseem); chronic low back pain >12 weeks / flare of chronic lbp (acp 2017 qaseem; lancet 2018 foster); leg pain below the knee in a dermatomal pattern (sciatica) (van der windt cochrane 2010).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
stay active + reassurance + education	—	—	—	Favourable natural history (median recovery ~17 d, PACE Williams Lancet 2014 PMID 25064594); advise against bed rest; ACP 2017 Qaseem strong rec
superficial heat	—	—	—	Moderate-quality evidence for short-term pain/function improvement (ACP 2017 Qaseem)
exercise / structured activity ± manual therapy or acupuncture	—	—	—	Massage / acupuncture / spinal manipulation low-quality but recommended options; structured physio for STarT medium/high (ACP 2017 Qaseem; Hill Lancet 2011 PMID 21963002)

Plan: Acute / subacute LBP — non-pharm-first symptom-control ladder (ACP 2017 Qaseem; Cashin Cochrane 2023)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Improving / manageable back pain

If you have:

Pain improving or stable, no leg weakness or numbness spreading
Able to stay active and do usual activities with modification
No new red-flag symptoms

Do this:

Stay active — keep moving and return to normal activities; avoid bed rest (ACP 2017 Qaseem; Lancet 2018 Foster)
Use heat and your exercise programme; most acute back pain improves within ~6 weeks (Williams PACE Lancet 2014)
Take an NSAID as advised (with food) only if needed and safe for you (Cashin Cochrane 2023)
Do NOT expect a scan — imaging does not help and is not needed without warning signs (Chou Lancet 2009)
Keep working or return to work early with modified duties if needed (Lancet 2018 Foster)

YELLOW — Not improving / spreading leg pain

If you have:

No improvement after a few weeks of staying active + treatment
Leg pain below the knee or pins-and-needles getting worse
Pain limiting work / daily life or causing distress

Do this:

Contact your provider for review and possible referral to structured/physio or psychologically-informed care (Hill STarT Back Lancet 2011 PMID 21963002)
Continue activity within tolerance; do not rest in bed (ACP 2017 Qaseem)
Review your medication plan — do NOT add gabapentin/pregabalin for sciatica (no benefit; Mathieson NEJM 2017 PMID 28328324)
Discuss a graded return-to-work / function plan (Lancet 2018 Foster)

Call your provider if:

Back pain not improving by ~6 weeks
Leg symptoms worsening or new weakness
Pain severe enough to stop usual function

RED — Emergency warning signs — go to ED now

If you have:

Loss of bladder or bowel control, difficulty urinating, or numbness around the genitals/buttocks (cauda equina) (NICE NG59)
New or rapidly worsening leg weakness in one or both legs
Fever with severe back pain, especially with IV drug use or weak immune system (spinal infection) (Galliker Am J Med 2019)
Severe back pain after major trauma, or known cancer with new severe night/rest pain
Sudden tearing back/abdominal pain with feeling faint (possible aneurysm)

Do this:

Go to the emergency department immediately — these need urgent imaging and may need emergency surgery
Do not wait for a routine appointment
Bring your medication list and tell ED about cancer history, IV drug use, or immune problems

Call your provider if:

Always seek emergency care for any red zone trigger — cauda equina is a surgical emergency (NICE NG59)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Saddle anaesthesia, bilateral sciatica, new urinary retention/incontinence, faecal incontinence, or reduced anal tone (ED pre-test prior cord/cauda compression 0.1–1.9% — Galliker Am J Med 2019; NICE NG59)(life-threatening)
Progressive or severe motor weakness, multi-level/bilateral radiculopathy, or rapidly worsening neurological signs (NICE NG59; Lancet 2018 Foster)(life-threatening)
History of cancer (LR+ ≈ 7), or unexplained weight loss + age >50 + night/rest pain unrelieved by position (primary-care malignancy prior 0–0.7%; ED 0–2.1% — Verhagen Pain 2017; Galliker Am J Med 2019)
Fever + back pain with IVDU / immunosuppression / indwelling vascular catheter / recent bacteraemia or other infection site (ED prior spinal infection 0–1.9% — Galliker Am J Med 2019)

5. Follow-up

Self-management, activity maintenance, exercise programme adherence, fear-avoidance counselling and early/sustained work participation (Lancet 2018 Foster PMID 29573872). Persistent or worsening LBP → re-evaluate phenotype, re-stratify, consider specialist/multidisciplinary referral; reinforce against opioid escalation and unnecessary imaging/surgery

6. Sources

Guideline: ACP 2017 Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain (Qaseem, Ann Intern Med) + NICE NG59 (2016, 2020 update) + Lancet 2018 Low Back Pain Series (Buchbinder; Foster) + ACR Appropriateness Criteria Low Back Pain 2021 + NASS