A clinical practice guideline for the Assessment and Treatment of Acute Low Back Pain is being developed by a multidisciplinary guideline development group (GDG), including the American Academy of Pain Medicine (AAPM). The draft guideline features recommendations based on a systematic review (PROSPERO Registration 537276) of evidence and uses Grading of Recommendation Assessment, Development, and Evaluation (GRADE) working group methodology.
The guideline focuses on low back pain that is less than 6 weeks duration, with or without radiculopathy.
3 Areas of Recommendations
Core recommendations focus on the management of low back pain in three areas: self-management, clinical management, and opioid management.
For self-management, clinicians are advised to counsel patients with acute low back pain without red-flag symptoms as follows:
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Provide information on the usual course of acute low back pain and indications for clinical evaluation.
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Provide information and reassurance that movement is safe and important to recovery.
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Consider use of superficial heat.
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Consider short course of oral NSAIDs at over-the-counter doses and frequency.
Physicians providing clinical management for patients who do not improve with self-management after 1 to 2 weeks – and without radiculopathy – are advised to offer patients one or more of the following treatment approaches:
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NSAID optimization
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skeletal muscle relaxants
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referral to physical therapy
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psychologically informed physical therapy
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manipulation and mobilization
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acupuncture
For those patients with radiculopathy, physicians are advised to offer the treatments above, along with:
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systemic steroids
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referral for consideration of epidural steroid injections
The opioid recommendation is to “not routinely use opioids as initial treatment.” However, a short course of short-acting opioids may be considered in select patients when benefits are likely to outweigh the harms.
In terms of imaging, the draft guideline recommends against routine imaging in atraumatic acute low back pain cases unless serious spine pathology is suspected.
Q&A with Jessica Oswald, MD, MPH
Currently, general guidelines for back pain include the American College of Physicians’ 2017 guideline for noninvasive treatments, the American Physical Therapy Association’s 2021 revised guideline on interventions, and VA/DOD 2022 guidelines on diagnosis and treatment.
MedCentral spoke with AAPM’s Acute Low Back Pain Chair Jessica Oswald, MD, MPH, about the pending guideline for acute low back pain and how it will impact care. Dr. Oswald serves as an associate clinical professor of anesthesiology at UC San Diego Health.
MedCentral: This consensus guideline is being developed in partnership with the Pacific Northwest Evidence-Based Practice Center (PNW-EPC) at Oregon Health & Science University (OHSU), and with funding from the FDA and HHS as part of a FAIN grant. Can you share how these relationships have helped the guideline progress?
Dr. Oswald: The collaboration with the PNW-EPC has provided the rigorous methodological support needed for a high-quality evidence review, which has allowed the panel to focus on clinical interpretation. Funding from the FAIN grant has offered the organizational structure and coordination required to keep the project moving. The FDA has also reviewed the developing framework and met with the PNW-EPC team to ensure the process meets federal standards for rigor. Together, these relationships have strengthened the guideline and supported steady, methodical progress.
MedCentral: People with back pain often see their primary care physician (PCP) first – how will this guideline better guide PCPs, as well as those in urgent care, to address various patient presentations of acute low back pain?
Dr. Oswald: Primary care and urgent care clinicians manage most cases of acute low back pain, but there is often a delay between when symptoms begin and when a patient is actually seen. This guideline was designed with that in mind. It starts with the patient and outlines practical steps they can take early to stay active, manage symptoms, and support recovery. When they do see a clinician, the guideline helps the provider build on what the patient has already tried and tailor further evaluation or treatment as needed. The goal is to offer a clearer, patient-centered approach that reflects real patterns of care and supports consistent, evidence-informed decisions in primary and urgent care settings.
MedCentral: What are the guideline authors’ overall goals for changing practice and improving patient outcomes?
Dr. Oswald: The goal of the guideline is to encourage more consistent, evidence-based care and to move away from practices that do not help patients recover, such as unnecessary imaging or ineffective medications. The authors want clinicians to identify risk earlier, use treatments more appropriately, and place greater emphasis on function, education, and active self-management. Ultimately, the aim is to improve how patients feel and function, shorten the course of symptoms when possible, and reduce the number of patients who go on to develop chronic back pain.
MedCentral: The bulk of the recommendations focus on management across three areas. Self-management, in particular, has perhaps gotten the least amount of attention, or support, in the past. Would you say that’s accurate? Could you share more about the motivation behind providing concrete self-management recommendations as well as patient resources?
Dr. Oswald: Yes, self-management has historically received less attention than medications or imaging decisions. Yet, most patients begin managing their symptoms long before they see a clinician, and what they do in that early period can meaningfully influence recovery.
One of the motivations for this guideline was to give patients clear, practical steps they can take right away, rather than leaving them to search for advice on their own. Providing concrete self-management recommendations and patient-friendly resources helps establish a consistent starting point, encourages safe activity, and reduces confusion about what is helpful or harmful. It also allows clinicians to build on a shared foundation when the patient is eventually evaluated, making care more focused and efficient.
MedCentral: The opioid discussion section notes referral to the CDC prescribing guidelines, including to “maximize use of nonopioid and nonpharmacologic treatments.” Any additional takeaways you’d like to note here?
Dr. Oswald: The main point is that opioids are not routinely needed for most cases of acute low back pain, and nonopioid and nonpharmacologic options should be tried first. When opioids are considered, the CDC guidance offers a framework for careful patient selection, limited duration, and clear follow up. The aim is not to exclude opioids entirely, but to ensure they are used thoughtfully and only when the expected benefit outweighs the risk.
MedCentral: Non-opioid medications are not addressed at length in the draft guideline, including the recently approved suzetrigine. The authors noted that this drug has not yet been studied via RCTs for acute low back pain. Do you anticipate adding suzetrigine to the guideline in the future if supportive data become available?
Dr. Oswald: If future studies assess its effectiveness in this population, the panel will review those data and determine whether an update is warranted.