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Clinical Decisionmaking

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Sophisticated imaging tests and specialty care usually are not necessary to evaluate and manage acute low back pain

Two out of three people will develop low back pain at some point in their lives. While low back pain rarely indicates a serious disorder, it is a major cause of pain, disability, and lost social life, and it accounts for one-third of workers' compensation costs. The good news is that 75 to 90 percent of patients who see primary care doctors for acute low back pain report improvement within a month.

Steven J. Atlas, M.D., M.P.H., of Harvard Medical School, and Richard A. Deyo, M.D., M.P.H., of the University of Washington, recently reviewed studies outlining approaches to the evaluation and management of acute low back pain in the primary care setting. Their study was supported in part by the Agency for Healthcare Research and Quality (HS06344, HS08194, and HS09804).

Drs. Atlas and Deyo point out that most back symptoms are nonspecific, and the precise cause of low back pain is rarely identified. Furthermore, most episodes of acute, nonspecific low back pain are self-limited. In fact, many patients treat themselves without seeing a doctor. When they do see a doctor, a medical history and examination usually provide clues to the rare but potentially serious causes of low back pain and identify patients who are at risk for prolonged recovery.

Imaging and laboratory tests should not be routinely ordered for these patients. Rather, selective use of tests should be based on the history and physical examination and the patient's initial response to treatment. In fact, the primary emphasis of treatment should be conservative care, time, reassurance, and education.

Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain but potentially serious diagnosis. The prognosis for most patients is good, although recurrence is common. Educating patients about the natural history of low back pain and how to prevent future episodes can help ensure reasonable expectations.

See "Evaluating and managing acute low back pain in the primary care setting," by Drs. Atlas and Deyo, in the February 2001 Journal of General Internal Medicine 16(2), pp. 120-131.

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