Evaluating and managing acute low back pain in the primary care setting

Acute low back pain is a common reason for patient calls or visits to a pri mary care clinician. Despite a large differential diagnosis, the precise et iology is rarely identified, although musculoligamentous processes are usua lly suspected, For most patients, back symptoms are nonspecific, meaning th at there is no evidence for radicular symptoms or underlying systemic disea se. Because episodes of acute, nonspecific low back pain are usually self-l imited, many patients treat themselves without contacting their primary car e clinician, When patients do call or schedule a visit, evaluation and mana gement by primary care clinicians is appropriate. The history and physical. examination usually provide clues to the rare but potentially serious caus es of low back pain, as well as identify patients at risk for prolonged rec overy, Diagnostic testing, including plain x-rays, is often unnecessary dur ing the initial evaluation, For patients with acute, nonspecific low back p ain, the primary emphasis of treatment should be conservative care, time, r eassurance, and education. Current recommendations focus on activity as tol erated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patient s whose symptoms are not improving over 2 to 4 weeks. Specialty referral sh ould be considered for patients with a progressive neurologic deficit, fail ure of conservative therapy, or an uncertain or serious diagnosis. The prog nosis for most patients is good, although recurrence is common. Thus, educa ting patients about the natural history of acute low back pain and how to p revent future episodes can help ensure reasonable expectations.