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msk.low-back-pain.core.v1PRODUCTION
msk.low-back-pain.core.v1

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

rheumatologyacutesubacutechronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Low back pain is a symptom, not a diagnosis: triage-first. ≥90% is non-specific mechanical LBP; the engine exists to NOT miss the cannot-miss serious-secondary minority and to match care intensity to prognostic risk (Lancet 2018 Foster PMID 29573872; ACP 2017 Qaseem PMID 28192789)

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Advance rule
Set
Advance when

Scope framed: acuity band + axial-vs-radicular established against the serious-secondary screen

Patient inputs (16)

Acute (<6 wk) vs subacute (6–12 wk) vs chronic (>12 wk) drives acuity branch, imaging-restraint window and treatment ladder (ACP 2017 Qaseem; NICE NG59)

Radicular/sciatica phenotype vs non-specific axial LBP; gates SLR/crossed-SLR interpretation (van der Windt Cochrane 2010 PMID 20166095)

Age <40 supports inflammatory back pain (Sieper ASAS 2009 OR 9.9); age >50 with cancer hx raises malignancy prior (Galliker 2019)

Saddle anaesthesia, bilateral sciatica, urinary retention/incontinence, faecal incontinence = surgical emergency (NICE NG59; Galliker Am J Med 2019)

History of malignancy is the single highest-value malignancy red flag (Verhagen Pain 2017 PMID 28708761 — LR+ ≈ 7)

IVDU / immunosuppression / indwelling vascular catheter / recent infection raise spinal infection prior (Galliker Am J Med 2019 PMID 31278933)

Fever + back pain → discitis / vertebral osteomyelitis / epidural abscess; constitutional symptoms → malignancy (Galliker Am J Med 2019)

Trauma, age >70, osteoporosis, prolonged corticosteroid → vertebral fracture; routes fracture-triage (ACR Appropriateness 2021)

Progressive or severe motor weakness / multi-level deficit = urgent imaging + surgical referral (NICE NG59; Lancet 2018 Foster)

Distress, fear-avoidance, low recovery expectation, work issues drive STarT Back risk + chronicity (Hill Lancet 2011 PMID 21963002)

STarT Back tool low/medium/high prognostic risk → matched-care intensity (Hill Lancet 2011 PMID 21963002)

eGFR / Child-Pugh / CVD / PUD gate NSAID; informs the drug × comorbidity matrix (ACP 2017 Qaseem; Cashin Cochrane 2023)

Existing opioid / gabapentinoid / NSAID exposure drives deprescribing + safety (Lancet 2018 Foster; McKenzie Spine J 2025)

Pregnancy/lactation contraindicates NSAID (esp. 3rd trimester) + duloxetine caution → special-population branch (ACP 2017 Qaseem)

Insidious onset, night pain, morning stiffness >30 min, exercise-improved, rest-unrelieved → ASAS IBP → axSpA route (Sieper ASAS 2009 PMID 19147614)

Baseline + serial functional disability quantification for chronic LBP tracking (ACP 2017 Qaseem; NICE NG59)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningcauda_equina_syndrome
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningprogressive_severe_neuro_deficit
    Progressive or severe motor weakness, multi-level/bilateral radiculopathy, or rapidly worsening neurological signs (NICE NG59; Lancet 2018 Foster)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremalignancy_red_flag
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespinal_infection_red_flag
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevertebral_fracture_red_flag
    Significant trauma, OR age >70 / known osteoporosis / prolonged corticosteroid with acute focal pain (ED prior vertebral fracture 0–7.2% — Galliker Am J Med 2019; ACR Appropriateness 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateinflammatory_back_pain_axspa_route
    ASAS inflammatory-back-pain pattern: ≥4 of 5 — exercise-improved (OR 23.1), night pain (OR 20.4), insidious onset (OR 12.7), onset <40 y (OR 9.9), no rest improvement (OR 7.7) (Sieper ASAS 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildopioid_or_gabapentinoid_misalignment
    Patient on opioid for non-specific LBP, or on gabapentinoid for sciatica, or repeat imaging without red flags (low-value care — Lancet 2018 Foster; McKenzie Spine J 2025)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Acute / subacute LBP — non-pharm-first symptom-control ladder (ACP 2017 Qaseem; Cashin Cochrane 2023)
axis: lbp_acute_subacute_symptom_controlstep 1 - Step 1 — Non-pharmacologic core (FIRST-LINE for everyone)
Selected step "Step 1 — Non-pharmacologic core (FIRST-LINE for everyone)" — Any red-flag-negative acute/subacute LBP
  • stay active + reassurance + education
    first line
    self_management
    triggers: red_flag_negative_acute_lbp
    Favourable natural history (median recovery ~17 d, PACE Williams Lancet 2014 PMID 25064594); advise against bed rest; ACP 2017 Qaseem strong rec
  • superficial heat
    first line
    physical_modality
    triggers: acute_subacute_lbp
    Moderate-quality evidence for short-term pain/function improvement (ACP 2017 Qaseem)
  • exercise / structured activity ± manual therapy or acupuncture
    first line
    physical_therapy
    triggers: subacute_lbp, start_back_medium_or_high
    Massage / acupuncture / spinal manipulation low-quality but recommended options; structured physio for STarT medium/high (ACP 2017 Qaseem; Hill Lancet 2011 PMID 21963002)

outpatient playbook — drug actions (5)

  1. 1. non-pharm core (stay active, education, heat, exercise)
    n/a • n/a • ongoing
    trigger: Any red-flag-negative LBP
    First-line for all; favourable natural history (ACP 2017 Qaseem; Williams PACE Lancet 2014 PMID 25064594)
  2. 2. naproxen (NSAID first-line)
    250–500 mg BID with food • PO • BID
    trigger: Pharm desired, no NSAID contraindication
    Acute pain MD −7.29; chronic MD −6.97 (Cashin Cochrane 2023 PMID 37014979)
  3. 3. cyclobenzaprine or methocarbamol (SMR short course)
    Cyclobenzaprine 5 mg qHS / methocarbamol 1500 mg QID • PO • qHS–QID ≤2–3 wk
    trigger: Painful paraspinal spasm, NSAID insufficient
    Small benefit + AE RR 1.6; methocarbamol preferred in elderly (Cashin BMJ 2021 PMID 34233900)
  4. 4. duloxetine (chronic 2nd-line)
    30 mg → 60 mg daily • PO • once daily
    trigger: Chronic LBP, NSAID inadequate/contraindicated
    ACP 2017 Qaseem 2nd-line; Skljarevski Spine 2010 PMID 20461028
  5. 5. tramadol (last-line short course)
    50 mg q6h PRN • PO • q6h PRN
    trigger: Severe refractory pain after failed alternatives
    Weak rec, shortest course; serotonergic-DDI caution (ACP 2017 Qaseem)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute low back pain <6 weeks ± leg pain (ACP 2017 Qaseem; Lancet 2018 Foster); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Low back pain (acute → subacute → chronic, primary-care)** (msk.low-back-pain.core.v1).
Phenotype framing: Terminal phenotype: (1) non-specific mechanical LBP (≥90%); (2) radicular pain / lumbosacral radiculopathy (SLR LR− ≈ 0.29 rules OUT, crossed-SLR LR+ ≈ 2.8 rules IN — van der Windt Cochrane 2010 PMID 20166095); (3) symptomatic spinal stenosis (neurogenic claudication, older, flexion-relieved); (4) inflammatory back pain / axial spondyloarthritis (ASAS ≥4/5 → route rheum.axial-spondyloarthritis.core.v1); (5) serious-secondary (escalate). Look-alike: lumbar facet/spondylotic osteoarthritis shares the chronic axial phenotype (msk.osteoarthritis.core.v1)
Scope: Low back pain is a symptom, not a diagnosis: triage-first. ≥90% is non-specific mechanical LBP; the engine exists to NOT miss the cannot-miss serious-secondary minority and to match care intensity to prognostic risk (Lancet 2018 Foster PMID 29573872; ACP 2017 Qaseem PMID 28192789)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute / subacute LBP — non-pharm-first symptom-control ladder (ACP 2017 Qaseem; Cashin Cochrane 2023)** — step "Step 1 — Non-pharmacologic core (FIRST-LINE for everyone)".
1. stay active + reassurance + education (self_management, first line) — Favourable natural history (median recovery ~17 d, PACE Williams Lancet 2014 PMID 25064594); advise against bed rest; ACP 2017 Qaseem strong rec
2. superficial heat (physical_modality, first line) — Moderate-quality evidence for short-term pain/function improvement (ACP 2017 Qaseem)
3. exercise / structured activity ± manual therapy or acupuncture (physical_therapy, first line) — Massage / acupuncture / spinal manipulation low-quality but recommended options; structured physio for STarT medium/high (ACP 2017 Qaseem; Hill Lancet 2011 PMID 21963002)

Setting playbook (outpatient) — Triage out serious-secondary causes, classify phenotype, STarT-stratify to matched-care intensity, deliver non-pharm-first care, escalate pharm only on the evidence ladder, avoid unnecessary imaging/opioids (ACP 2017 Qaseem; Lancet 2018 Foster; Hill Lancet 2011)
4. non-pharm core (stay active, education, heat, exercise) n/a n/a ongoing — Any red-flag-negative LBP (First-line for all; favourable natural history (ACP 2017 Qaseem; Williams PACE Lancet 2014 PMID 25064594))
5. naproxen (NSAID first-line) 250–500 mg BID with food PO BID — Pharm desired, no NSAID contraindication (Acute pain MD −7.29; chronic MD −6.97 (Cashin Cochrane 2023 PMID 37014979))
6. cyclobenzaprine or methocarbamol (SMR short course) Cyclobenzaprine 5 mg qHS / methocarbamol 1500 mg QID PO qHS–QID ≤2–3 wk — Painful paraspinal spasm, NSAID insufficient (Small benefit + AE RR 1.6; methocarbamol preferred in elderly (Cashin BMJ 2021 PMID 34233900))
7. duloxetine (chronic 2nd-line) 30 mg → 60 mg daily PO once daily — Chronic LBP, NSAID inadequate/contraindicated (ACP 2017 Qaseem 2nd-line; Skljarevski Spine 2010 PMID 20461028)
8. tramadol (last-line short course) 50 mg q6h PRN PO q6h PRN — Severe refractory pain after failed alternatives (Weak rec, shortest course; serotonergic-DDI caution (ACP 2017 Qaseem))

Non-pharmacologic actions:
- STarT-matched care: low → reassurance/self-management; medium → structured physio; high → psychologically-informed physio/CBT (Hill Lancet 2011 PMID 21963002)
- CBT / MBSR / multidisciplinary rehab for chronic disabling LBP (ACP 2017 Qaseem)
- Explicitly do NOT order routine spine imaging without a red flag / within ~6 wk (Chou Lancet 2009 PMID 19200918; ACR Appropriateness 2021)
- Do NOT use acetaminophen monotherapy for acute LBP or gabapentinoids for sciatica (PMID 25064594; PMID 28328324)
- Route ASAS inflammatory pattern → rheum.axial-spondyloarthritis.core.v1 (HLA-B27 + sacroiliac MRI)

AVOID / contraindication checks:
- NSAID block if eGFR<30 or active PUD or severe HF or 3rd trimester pregnancy (ACP 2017 Qaseem; Cashin Cochrane 2023)
- Cyclobenzaprine avoid in elderly anticholinergic burden prefer methocarbamol (STOPP/START; Cashin BMJ 2021)
- Tramadol avoid with SSRI SNRI or seizure history serotonin syndrome (ACP 2017 Qaseem)
- Acetaminophen monotherapy not effective for acute LBP counsel limited benefit (Williams PACE Lancet 2014 PMID 25064594)
- Opioid shortest lowest not beyond acute episode monitor prescription indicator (Lancet 2018 Foster; McKenzie Spine J 2025)

Monitoring

Regimen monitoring:
- symptom + function reassessment with expected recovery by ~6 weeks (ACP 2017 Qaseem)
- NSAID renal/GI/CV surveillance if comorbid risk (Cashin Cochrane 2023)
- SMR sedation review; stop within 2–3 weeks (Cashin BMJ 2021)
- re-screen red flags at each visit (Galliker Am J Med 2019)

Setting (outpatient) monitoring:
- Reassess at ~2–6 weeks; expect acute recovery by ~6 weeks (ACP 2017 Qaseem)
- Serial ODI + re-run STarT if trajectory changes (Hill Lancet 2011)
- NSAID/opioid/SMR safety review; deprescribe opioids (McKenzie Spine J 2025 PMID 41077079)
- Re-screen red flags every visit (Galliker Am J Med 2019)

Follow-up plan: 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
- Close-out criterion: Long-term self-management + work-participation plan in place with return precautions taught

Monitoring phase: Re-screen red flags at each visit (new neuro deficit / cauda equina / systemic features). Reassess function with Oswestry Disability Index and re-run STarT Back if course changes. Expect acute recovery by ~6 weeks; non-improvement or worsening → re-triage and reconsider imaging. Monitor NSAID/opioid/SMR safety + opioid prescription count as a quality indicator (McKenzie Spine J 2025 PMID 41077079)

Disposition

Current setting: outpatient — Triage out serious-secondary causes, classify phenotype, STarT-stratify to matched-care intensity, deliver non-pharm-first care, escalate pharm only on the evidence ladder, avoid unnecessary imaging/opioids (ACP 2017 Qaseem; Lancet 2018 Foster; Hill Lancet 2011)

Disposition criteria:
- Continue outpatient matched care for non-specific / radicular / stenosis LBP (ACP 2017 Qaseem)
- Escalate to ED / emergency surgical pathway only for a fired red flag (NICE NG59)

Escalation triggers (move to higher acuity):
- New/progressive cauda equina symptoms or motor deficit → ED + emergent MRI + spine surgery (NICE NG59)
- Fever + back pain + infection risk → ED for spinal-infection workup (Galliker Am J Med 2019 PMID 31278933)
- Suspected pathological/unstable fracture or known cancer with new severe pain → urgent imaging (ACR Appropriateness 2021)
- Refractory radiculopathy/stenosis after adequate conservative care → spine surgery referral (Lancet 2018 Foster)

Patient Action Plan

**Low back pain self-management + recovery plan**
Personalised values: phenotype_nonspecific_vs_radicular, start_back_risk_tier, analgesic_plan, comorbid_nsaid_constraints.

**Improving / manageable back pain** (green):
Triggers:
- 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
Actions:
- 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)

**Not improving / spreading leg pain** (yellow):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- Back pain not improving by ~6 weeks
- Leg symptoms worsening or new weakness
- Pain severe enough to stop usual function

**Emergency warning signs — go to ED now** (red):
Triggers:
- 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)
Actions:
- 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
Contact provider when:
- Always seek emergency care for any red zone trigger — cauda equina is a surgical emergency (NICE NG59)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)
- [SEVERE] 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)

Citations

- 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 [PMID:28192789](https://pubmed.ncbi.nlm.nih.gov/28192789/)
- Cited evidence (PMID 29573871) [PMID:29573871](https://pubmed.ncbi.nlm.nih.gov/29573871/)
- Cited evidence (PMID 29573872) [PMID:29573872](https://pubmed.ncbi.nlm.nih.gov/29573872/)
- Cited evidence (PMID 41077079) [PMID:41077079](https://pubmed.ncbi.nlm.nih.gov/41077079/)
- Cited evidence (PMID 31278933) [PMID:31278933](https://pubmed.ncbi.nlm.nih.gov/31278933/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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 — PMID:28192789
  • Cited evidence (PMID 29573871) — PMID:29573871
  • Cited evidence (PMID 29573872) — PMID:29573872
  • Cited evidence (PMID 41077079) — PMID:41077079
  • Cited evidence (PMID 31278933) — PMID:31278933