Assessment and Treatment of Acute Low Back Pain (ALBP): A Systematic Review

Abstract Objectives To synthesize evidence on the evaluation and management of acute low back pain (ALBP) (<6 weeks duration) to support clinical guideline development. Data sources Electronic databases (Ovid® MEDLINE®, PsycINFO®, Embase®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) to March 2025, and reference lists. A targeted bridge search was completed on May 29, 2026. Review methods We selected systematic reviews (SRs) on diagnostic accuracy of factors for serious spine pathology and predictors of chronicity (Key Question [KQ] 1), and randomized controlled trials (RCTs) for imaging (KQ 2) and of treatment options (KQs 3-8). Full economic studies (cost-effectiveness analyses [CEA] or cost utility analyses [CUA]) on imaging (KQ 2d) and treatment (KQ 9) were sought. Meta-analyses were conducted when sufficient evidence was available, and strength of evidence (SOE) was assessed. Results A total of 105 studies (in 111 publications) formed the evidence base for the clinical guideline: KQ 1a (4 SRs, 1 nonrandomized study of interventions [NRSI]), KQ 1b (1 SR, 14 NRSIs), KQ 2 (3 RCTs, 3 NRSIs, 1 CEA), KQ 3 (5 RCTs), KQ 5 (25 RCTs), KQ 6 (34 RCTs), KQ 7 (1 RCT), KQ 8 (9 RCTs) and KQ 9 (2 CUA, 2 CEAs). No studies met inclusion criteria for KQ 4. Two trials identified through the bridge search evaluated heat and transcutaneous electrical stimulation. Few patient characteristics or clinical exam factors were considered highly informative for identifying or ruling out serious spine pathology (red flags). Stronger predictors included cancer history, saddle anesthesia, urinary retention, procedure-related infection, and age (KQ 1a). Maladaptive pain coping behaviors, low general health status, and presence of psychiatric comorbidities were associated with an increased likelihood of developing persistent disabling low back pain (KQ 1b). RCTs of early imaging versus no imaging found no difference in function or pain in patients without signs of serious spine pathology (KQ 2). Opioids generally showed similar pain and function improvement versus placebo and were associated with increased risk for adverse events (KQ3). Oral nonsteroidal anti-inflammatory drugs [NSAIDs] and muscle relaxants improved function and/or pain versus placebo in the first few weeks, however acetaminophen did not (KQ 5). In patients with radiculopathy, systemic steroids (KQ 5) and epidural steroid injections [ESI] (KQ 7) improved function (and back pain for ESI) versus placebo or usual care. Nonpharmacologic treatments (KQ 6) that improved function and/or pain versus sham or usual care included manipulation and mobilization, acupuncture, and advice to stay active. Results from exercise-specific trials were mixed. Early referral to physical therapy, which included similar forms of exercise, improved pain and function versus usual care (KQ 8). Pain or function improvement occurred generally within the first few weeks, and the magnitude of improvement was small for most interventions. Serious treatment-related harms were uncommon for most interventions. Studies were not designed to assess serious or long-term harms and harms were variably reported across interventions. Estimates were imprecise for many outcomes and study limitations contributed to low confidence in the evidence for some interventions. Limited information on cost-effectiveness of imaging or interventions was identified. Conclusions This review informed development of a multidisciplinary guideline on ALBP. The following primary findings were considered. For assessment, few factors used to evaluate serious spine pathology were considered highly informative for ruling such conditions in or out. Psychosocial factors best predicted the development of persistent low back pain. Early imaging did not improve patient outcomes in patients with ALBP who did not have signs of serious spine pathology. Moderate confidence in the evidence of benefit at one or more times was seen for NSAIDs, manipulation and mobilization, acupuncture, muscle relaxants, advice to stay active and early physical therapy referral, which included an exercise focus. The findings support these options for ALBP management. There was low confidence regarding the benefits of steroids in patients with radiculopathy. Opioids may not be more effective than placebo in improving pain or function in patients with ALBP (low confidence) and were associated with higher risk of harms (moderate confidence). Rigorous trials to delineate the optimal dose, frequency, and duration of all treatments, and to evaluate the long-term effects of opioid prescription for ALBP are needed.