Managing Low Back Pain: A Practical Guide for Clinicians

Managing Low Back Pain: A Practical Guide for Clinicians

Let's talk frankly about what every clinician needs when the patient with lower back pain walks through the door—a solid, practical thinking tool that keeps the process quick, accurate and effective. This is your actionable, algorithm-driven approach to managing low back pain.

Start With the Basics: Coping, Red Flags, and Timing

First, every initial assessment divides neatly into two parts: conservative management and interventional management. That split is driven by answering four simple—but critical—questions: Is the patient coping? Are there red flags? Has pain lasted more than three months? And is the pain severe?

"Coping," is not just a checkbox. It's a clinical judgment, sometimes as simple as asking, “How are you?” and listening for the degree of self-efficacy in their answer. Patients who can ask how you are in return, or who declare “I'm great,” are basically signaling their resilience. If they're crumbling—“terrible”—you're looking at early referral, maybe to psych support. It's a nuanced, but efficient, read on capacity.

Red flags? Think big. Are you missing anything that could harm the patient in the long or short term? Cancer history, unexplained weight loss, infection symptoms, major trauma, corticosteroid use, osteoporosis, or true neurological emergencies—that's your airways-breathing-circulation checklist for back pain. Never let foundational safety slide because time is tight.

Timing - Pain less than three months? Stick with conservative strategies. Over that, pivot to deeper investigation and referral. Don’t accept the old “it’ll go away” line—decades of medical education have leaned on studies from the 1960s, but modern meta-analyses show only about 20% fully recover by six weeks, with the majority living with ongoing symptoms.

Conservative Management: More Than NSAIDs

Where conservative management is appropriate, empower the patient early. Education matters: explain how pain works, reinforce self-management and provide reassurance. Agency and confidence go hand-in-hand with movement, pacing, and goal setting. You want patients active, not bedbound—a grave error backed by poor data outcomes. Use your allied health network (physios, exercise physiologists) to structure and support proper rehab. The earlier, the better: prevention of deconditioning pays off.

Analgesic options? Paracetamol is a mostly safe placebo, anti-inflammatories come with caveats (GI, cardiovascular, renal risks), and topical lignocaine can help with minimal downside. When neuropathic pain creeps in, select medications thoughtfully—tricyclics, SNRIs, and gabapentinoids, always tailored to co-existing depression or sleep issues. Avoid pregabalin for sciatica; the evidence simply isn't there. Medication is adjunct, not magic—and reviewing at two, six, and twelve weeks keeps you nimble for any needed escalation.

Diagnosis: Get Specific, Ditch the “Non-Specific”

Let’s kill another myth: you can, and should, diagnose lower back pain. The history, examination, and imaging may be imperfect, but with diagnostic blocks, most back pain traces to five sources: facet joints, sacroiliac joints, hips, discs, and nerves. Use structured questioning (pain worse in leg or back?), anatomical zones (above or below the beltline?), and get hands-on—draw the pain, have patients point. It’s not one-size-fits-all, and overlapping symptoms demand flexibility. But rules of thumb, not rigid recipes, make diagnosis actionable, not academic.

Facet joint pain, for instance, is unilateral above the belt and lateralizes left or right; pain radiates down the leg but isn't sciatica. Disc pain centralizes and alternates between dull ache and sharp, movement-stopping pain—matching with imaging only when necessary. Sacroiliac joint pain is broad and may move side to side, gets worse in prolonged positions and ambulating, and typically gets better with forced pelvic closure. Hip pain starts at the groin, goes anterior, and affects functional movements like sitting or shoe-wearing. These clues, layered with exam and selective diagnostic blocks, move you from vague theory and diagnoses like NSLBP, to real-world decision-making.

When to Refer: Know Your Limits

When you hit progressive neurological symptoms, cauda equina signs, or true nerve root compression, escalate to surgical review. But recognize, too, the limits of imaging match-up—treat presentation over scan results, and revert to direct interventions (epidural injections, ablation) as needed for symptom control. Sometimes wait times (twelve months in public settings!) make acute management skills your best friend.

Our Takeaway for You

In summary, clinicians managing back pain should shift from passive observation to active, structured engagement—drive the process, leverage the algorithm, and not settling for “non-specific.” Your patient’s agency, function, and quality of life depend on it.

For more insight and practical advice, tune in to episode 20 of It’s Not in Your Head Podcast.