Workers Compensation
NSW's ACI and SIRA jointly publish a low back pain model of care that sorts every claim into one of three pathways, and it sets the review points and medication rules insurers should expect a treating GP to follow.
What the low back pain model of care actually is
The Agency for Clinical Innovation (ACI) and the State Insurance Regulatory Authority (SIRA) convened a Back Injury Clinical Advisory Group to review and update the summary model of care for the management of low back pain, most recently in February 2024. The revision draws on the ACI's broader Management of People with Acute Low Back Pain: Model of Care and was formally reviewed by an expert clinical reference group between 2019 and 2022, with representatives from bodies including the Australian Medical Association, the Royal Australian College of General Practitioners, the Faculty of Pain Medicine, and WorkSafe Victoria's Surgery Advisory Panel. It is consistent with the Australian Commission on Safety and Quality in Health Care's Low Back Pain Clinical Care Standard.
The model is written for the primary care team: the patient, the treating GP and practice nurse, and treating allied health practitioners. It is not written for insurers, but every decision point in it, from the first history and exam through to a 12-week review, is a decision point that shows up on a claim. A treatment plan that follows the model looks different on paper from one that does not, and that difference is something injury managers can learn to read.
How the pathway decision gets made: red flags, yellow flags and risk screening
Every presentation starts with a systematic history and physical examination that specifically considers red flags. If red flags are present and of concern, the model directs urgent escalation for suspected cauda equina syndrome, and urgent specialist referral for suspected infection or fracture, with less urgent specialist referral for suspected spondylarthritis or malignancy.
Where red flags are excluded, the practitioner administers either the Örebro Musculoskeletal Pain Screening Questionnaire Short Form (ÖMPSQ-SF) or the Keele STarT Back tool to screen for yellow flags and stratify the person into a low, medium or high risk of delayed recovery. On the ÖMPSQ-SF, a score of 49 or below is low risk and 50 or above is high risk. On STarT Back, a score of 3 or less is low risk; a score of 4 or more is medium or high risk depending on a psychosocial distress sub-score calculated from the last five items.
| Red flags (urgent escalation) | Yellow flags (recovery risk) |
|---|---|
| Signs and symptoms of infection | Belief that pain and activity are harmful |
| Signs and symptoms of inflammatory spondylarthritis | Sickness behaviours, such as extended rest |
| Features of cauda equina syndrome or severe neurological deficit | Low or negative mood, social withdrawal |
| History of malignancy | Treatment that does not fit with best practice |
| Significant trauma | Problems with the compensation system |
| Unexpected weight loss | Previous history of back pain, time off work or other claims |
| Minimal trauma fracture risk in the elderly or on corticosteroids | Problems at work, poor job satisfaction, or overprotective family and lack of social support |
For a claims file, the yellow flag list is worth reading twice. Problems with the compensation system and a previous history of claims are named recovery risk factors in the model itself, not incidental detail. A claim carrying several of these from the first assessment is a candidate for closer case management from week one, independent of what the imaging or diagnosis eventually shows.
Pathway A, B and C: what each looks like on a claim
The result of the initial assessment determines which of three pathways applies.
| Pathway | Trigger | What happens |
|---|---|---|
| Pathway A | Non-specific acute low back pain, no red flags | Education, reassurance and encouragement to stay active and stay at work, with reviews at 2, 6 and 12 weeks and escalating physical therapy or a cognitive behavioural approach for medium and high risk presentations |
| Pathway B | Acute low back pain with radiculopathy and leg dominant pain with progressive neurological loss | Urgent, immediate referral to a tertiary referral hospital or other specialist care |
| Pathway C | Acute low back pain with leg pain, no progressive neurological loss | Same staged review structure as Pathway A, with lowest effective dose, shortest duration pain medicine where radicular pain warrants it, MRI where available if the person deteriorates, and a track back to Pathway A on improvement |
People with chronic non-specific pain and significant yellow flags are directed straight to consideration of a multidisciplinary pain management program rather than into Pathway A. Progressive loss of lower limb neurological function is defined in the model as motor weakness with radicular pain into one or both legs, often with numbness, tingling or diminished deep tendon reflexes corresponding to the nerve root involved. That distinction is what separates an urgent Pathway B referral from the staged, primary-care-led management under Pathway C.
Why imaging is restricted, not routine
Principle 3 of the model states that imaging is only indicated when a thorough history and examination point to a possible serious cause for the pain. Outside suspected serious pathology, imaging is not part of the standard pathway at 2, 6 or 12 weeks. In Pathway C, imaging appears only where a person is deteriorating with progressive or severe leg pain, or progressive neurological deficits unresponsive to other therapy, at which point MRI is used where available.
The model also sets out the language a treating team is asked to use with a patient, and by extension the language that should appear in clinical notes on a claim. It asks practitioners to avoid describing structural findings in terms that promote a belief in damage, such as "disc bulge", "slipped disc" or "wear and tear", and to avoid phrases such as "let pain guide you" or "stop if you feel any pain". Recommended alternatives include "your back gets stronger with movement" and "most back pain is linked to minor strains that can be very painful". A claim where imaging was requested early, or where clinical language leans on structural damage framing, is a signal the treatment plan may be drifting from the model rather than following it.
The medication rules built into the model
Two of the ten key principles deal directly with medicines. Principle 7 states that where pain medicines are required, treatment should begin with simple analgesics using time-contingent dosing, with over the counter or prescription medicines used short term to help the person keep moving while they recover. Principle 8 sets the goal of complex pain medicines as enabling physical activity, not eliminating pain. In the presence of severe acute pain, complex medicines may be used in immediate-release formulations on a limited trial basis, for a defined duration, in line with current Therapeutic Guidelines. Anticonvulsants, benzodiazepines and antidepressants should be avoided for low back pain.
The staged reviews build weaning into the pathway itself. At the 6-week review in Pathway C, the model directs the treating team to continue evidence-based physical therapies and to consider weaning pharmacological therapies as appropriate, both where the person is improving and where neurological loss is persisting. That instruction repeats at the 12-week review. A file where opioids, benzodiazepines or anticonvulsants are still on the script unreviewed well past the 6-week mark, with no documented weaning discussion, is not matching what the model asks the treating team to do.
What the 2, 6 and 12-week reviews should trigger
Principle 9 fixes review points at 2, 6 and 12 weeks, with the treatment plan changed if progress is insufficient. Principle 10 attaches specific escalation triggers to those points. At 6 weeks, no improvement or worsening supports considering referral to a musculoskeletal specialist, defined in the model as a specialist physiotherapist, rheumatologist, sport and exercise physician, spine surgeon or pain or rehabilitation physician, with a cognitive behaviour therapy trained physiotherapist or clinical psychologist also considered for medium or high risk presentations. At 12 weeks, no improvement or worsening supports considering referral to a multidisciplinary pain management program.
- 2-week review: repeat history and physical exam, re-administer the risk screening tool in Pathway C, and confirm the person is receiving the risk-appropriate level of education, analgesia and physical therapy.
- 6-week review: repeat history, exam and risk screening; consider specialist referral if there is no improvement; consider weaning pharmacological therapies where the person is improving.
- 12-week review: repeat history and exam; consider referral to a multidisciplinary pain management program, or spinal surgical review in Pathway C where neurological loss persists, if there is no improvement or the condition is worsening.
For an injury manager, these three dates are natural checkpoints to ask the treating GP a direct question: which pathway is this claim on, what did the risk screening tool score at the last administration, and what changed in the medication or therapy plan as a result. A file that cannot answer those questions at 6 and 12 weeks is a candidate for an independent review.
Key Takeaways
- The February 2024 update sorts every low back pain presentation into Pathway A, B or C based on red flags, leg pain and progressive neurological loss.
- Yellow flags recorded at intake, including problems with the compensation system and a prior claims history, are named recovery risk factors, not incidental notes.
- Imaging is reserved for suspected serious pathology and is not part of the standard pathway at any of the fixed review points.
- Review points are fixed at 2, 6 and 12 weeks, with musculoskeletal specialist referral considered at 6 weeks and multidisciplinary pain program referral considered at 12 weeks.
- The model directs practitioners to start with simple analgesics, avoid anticonvulsants, benzodiazepines and antidepressants, and actively consider weaning medication at each review.
- A treatment plan that skips risk screening, images early or leaves complex medicines unreviewed past 6 weeks is drifting from the model, not following it.
Frequently Asked Questions
What is the ACI/SIRA model of care for low back pain?
It is a primary care based, evidence informed care pathway published by NSW's Agency for Clinical Innovation and the State Insurance Regulatory Authority, updated in February 2024, that sorts people with low back pain into one of three care pathways based on red flags, leg pain and neurological findings, with review points set at 2, 6 and 12 weeks.
When should a low back pain claim escalate to a specialist?
The model recommends considering referral to a musculoskeletal specialist at the 6-week review if there has been no improvement, and considering referral to a multidisciplinary pain management program at the 12-week review if there is still no improvement or the condition is worsening.
Does the model support routine imaging for low back pain?
No. Imaging is only indicated when a thorough history and physical examination point to a possible serious underlying cause. The model treats imaging as an exception for suspected serious pathology, not a routine early step.
What medications does the model recommend avoiding for low back pain?
It recommends starting with simple, time-contingent analgesics and avoiding anticonvulsants, benzodiazepines and antidepressants. Where complex pain medicines are used for severe acute pain, they should be immediate-release, time-limited and actively considered for weaning at each review.
Primary source: NSW Agency for Clinical Innovation and State Insurance Regulatory Authority, Model of Care for the Management of Low Back Pain: Summary, February 2024.
