1Screen for Red Flags
- Cancer history, unexplained weight loss, fever, night sweats.
- Trauma, age >50 years, osteoporosis, long-term steroids.
- Neurologic deficits (foot drop, saddle anesthesia, incontinence).
If any → immediate X-ray + urgent referral if serious cause is found or still suspected.
2Categorize
- Acute (<4 wks) · Subacute (4–12 wks) · Chronic (>12 wks).
3Initial conservative care (if no red flags)
- Stay active — avoid bed rest, avoid aggravating movements / heavy lifting.
- NSAID first-line: Ibuprofen 400–600 mg TID or Naproxen 250–500 mg BID.
- Education: reassure, ergonomics, natural recovery is common.
- Review after 4–6 weeks.
Note: Paracetamol is not effective; topical diclofenac may help mild acute cases; muscle relaxants only short-term when other measures fail.
4When to order imaging
- Do NOT order imaging at the first visit for non-specific pain without red flags.
- Order X-ray before deciding referral if:
- Pain persists >6 weeks despite optimal conservative therapy.
- Pain is progressive during the conservative management period.
- Pain chronic (>12 wks).
- Symptoms suggest possible structural cause (radicular pain, worsening stiffness, atypical features).
5Referral rules
- Acute/subacute, improved within 4–6 wks → no referral, education only.
- Persistent >6 wks → do imaging first, then:
- Normal → routine referral to physiotherapy.
- Abnormal (disc disease, stenosis, fracture, etc.) → specialist referral.