Musculoskeletal lower back pain

An appropriate follow-up is to ask the patient to return in 4 to 6 weeks if pain is unimproved. If pain is progressive or its nature changes to include red-flag symptoms, then more urgent follow-up is necessary. Patients who are at medium and high risk of chronic pain may benefit from earlier physiotherapy.[184]Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011 Oct 29;378(9802):1560-71. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208163 http://www.ncbi.nlm.nih.gov/pubmed/21963002?tool=bestpractice.com

If at 4 to 6 weeks symptoms have not improved, imaging and referral to a physiotherapist and/or a spine consultant should be considered. Consultants typically employ a multidisciplinary approach and are well equipped for monitoring pain medicines and physiotherapies. They can provide comprehensive diagnostic work-up and refer patients to additional services (e.g., for pain psychology, surgical interventions).

When a patient does not respond to initial standard care, other measures that have some supportive evidence can be tried (e.g., multidisciplinary rehabilitation).