• Dr. Samantha Balass MD CCFP

How do you lower back pain?

BONUS: See the helpful Low Back Pain tool - link at the end of the blog post

Low back pain is the second most common reason patients present to their family doctor, (1) walk-in clinic or emergency room, and therefore a likely possibility for a SAMP or SOO. So what are key learning points about that, sometimes DEADLY, lower back pain?

Firstly, most acute back pain is mechanical, and therefore does NOT require imaging. Don’t let a patient with acute back pain for less than 4-6 weeks and no red flags push you into ordering an X-ray or MRI. Studies show that this can actually cause more harm than good to the patient (2) and Choosing Wisely Canada delves into this topic as well.

Remember to rule out ALARM or RED FLAG symptoms, which can be summarized in this great mnemonic: BACKPAIN12

B – Bowel/bladder dysfunction

A – Anesthesia (Saddle)

C – Constitutional symptoms (i.e. fever, weight loss, night sweats)

K – Khronic disease: cancer, osteoporosis

P – Paresthesia

A – Age > 50 or 65 (depending on the guideline)

I – IV drug use, Immunosuppression (i.e. Steroids, HIV)

N – Neurological deficit, Night pain, or pain worse with lying down

12 – Longer than 12 weeks

So how do you treat back pain that you’ve diagnosed as mechanical, after ruling out the above with a good history and neuro exam? If your first thoughts were NSAIDs with some rest, this would be the WRONG answer. In fact, a recent article in the CMAJ (3) suggests that we should be offering NON-pharmacological management as first line.

Here are some examples:

  1. Education and reassurance

  2. Heat

  3. Massage

  4. Spinal manipulation

  5. Exercise programs

  6. Cognitive Behavioural Therapy

  7. Mindfulness

  8. Operant therapy

  9. Acupuncture

  10. Multidisciplinary rehab programs

Only after your patient has tried these and continues to have low back pain, should you consider offering medications, but even then, evidence is limited. (3) In general, you can offer NSAIDs or muscle relaxants; opioids, acetaminophen and oral steroids are to be avoided in most cases. (3)

BONUS: Download the helpful bedside CORE Low Back Pain tool (.pdf)

It contains

  • a quick algorithm to classify low back pain

  • tool to come up with an evidence-based plan

  • checklist to rule out red flags.


  1. Deyo RA, Weinstein JN. Low back pain. 2001;344:363-70.

  2. Srinivas, S.V., Deyo, R.A., Berger, Z.D., "Application of "less is more" to low back pain." (2012) Vol. 172 No. 13, p.1016

  3. Traeger, Adrian et al. Diagnosis and management of low-back pain in primary care. CMAJ 2017 November 13;189:E1386-95. doi: 10.1503/cmaj.170527


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The only Canada-Wide CCFP exam course - created by two Family Doctors who wished this existed when we were residents, and are on a mission to help CCFP exam candidates. Disclosures: The Review Course founders have no conflicting commercial interests. As is the case with any private events hosted on a university campus or hospital, this event is not affiliated with nor endorsed by the host venues. Our materials are peer-reviewed and prepared by Canadian physicians; we do not guarantee that our preparation materials are representative of any Canadian examination and we do not provide questions from any other examination nor are they intended as medical advice. The College of Family Physicians of Canada does not affiliate with nor endorse any exam preparation course.