International Delphi Consensus · Menorca Summit · May 2026
10 Recommendations for Acute Low Back Pain
Evidence-based, internationally endorsed guidance for managing acute low back pain in adults. Validated by 30 pain medicine experts across 14 countries and 40+ clinical sub-specialties.
30
Global Experts
14
Countries
3
Delphi Rounds
Patient-Centred Care
Self-Management
Escalation Pathway
Safety & Red Flags
Multimodal Care
1
Patient Engagement & Shared Decision-Making
- Acknowledge and validate the patient's pain
- Patient education is critical
- Shared decisions are essential and foundational for all care pathways
2
Self-Care — Start Immediately
- Stay active, stretch, maintain range of motion
- Apply heat; optimize anti-inflammatory medications
- Maintain daily activity — avoid bed rest
- Optimize nutrition, sleep hygiene, and hydration
★ Unanimous · 5.00/5
3
Consider Additional Modalities If Not Improving
- Spinal manipulation or acupuncture
- Optimised NSAIDs and muscle relaxants
- Prioritise multiple non-drug options
- Measure improvement by patient outcomes
4.38/5 · 83% Positive
4
Initiate Further Evaluation If Not Improving
- Clear escalation pathway required
- Seek care if symptoms worsen or persist
- Rule out underlying pathology
- Adjust management based on findings
5
Acute Radiculopathy — Local Steroid Injections
- LOCAL epidural steroids supported for radiculopathy
- Insufficient evidence for systemic steroids
- Temporary relief only — short durations
- Not indicated for non-radicular ALBP
⚠ Most Debated Area
6
Red Flags — Warrant Immediate Evaluation
- Red flags: bowel/bladder dysfunction; new or progressive numbness or weakness
- Clinical history: risk of cancer, infection, or fracture requires prompt assessment
4.60/5 · Strong
7
Imaging — Only With Red Flag or High-Risk History
- Warranted: red flag present
- Warranted: history of cancer
- Warranted: clinical suspicion of infection or fracture
- Avoid routine imaging — does not improve uncomplicated outcomes
4.60/5 · Strong
8
Opioids — Not First-Line Therapy
- Avoid as first-line treatment
- Try non-opioid treatments first
- Generally ineffective for functional improvement
- Unnecessary early use should be avoided
4.33/5 · 88% Positive
9
Opioid Safety & Patient Counseling
- If used: short-acting, time-limited only
- Strict monitoring and regular reassessment
- Counsel on safe use, side effects, and risk of dependence from long-term use
- Avoid when safer alternatives are effective
10
Multimodal Approach to Management
- Psychosocial factors influence recovery
- Escalate only when clinically appropriate
- Combine physical, psychological, and pharmacological interventions
- Tailor to the individual patient
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