Comprehensive Guide to Primary Care for Lower Back Pain (2023)


In the realm of primary care, addressing lower back pain (lumbalgia) is a critical facet of healthcare. Timely and accurate assessment is vital to differentiate between routine cases and those requiring urgent attention. This comprehensive guide aims to equip healthcare professionals with a thorough understanding of the evaluation and management of lower back pain in primary care settings.

Identifying Red Flags

Age and History

  • Onset above 70 or below 20 years
  • History of cancer or immunosuppression
  • Presence of systemic symptoms (unintentional weight loss, fever)
  • Non-mechanical or predominantly nocturnal pain
  • Previous diagnosis of osteoporosis

Initial Assessment - OPQRST Mnemonic

  • Onset: Time of initiation
  • Provocation: Factors triggering pain
  • Quality: Nature or type of pain
  • Radiation: Spread of pain
  • Symptoms: Associated symptoms
  • Time: Duration of pain

Intensity Evaluation

  • Utilize a 0-10 scale for pain intensity assessment
  • 0 implies no pain, while 10 represents the worst imaginable pain

Additional Considerations

  • Investigate neurological symptoms
  • Assess for fever or night sweats
  • Inquire about weight loss
  • Explore patient history, including neoplasia, osteoporosis, immunosuppression, smoking, spinal surgeries, occupational factors, and intravenous drug use

Clinical Examination


  • Evaluate physiological (lordosis and kyphosis) and non-physiological (scoliosis) spinal curvatures
  • Assess movements provoking pain, functional limitations, antalgic posture, leg length discrepancy, and improper postures
  • Perform the Schober test for flexibility, particularly for suspected ankylosing spondylitis


  • Examine paraspinal and dorsal muscles, spinous processes, sacroiliac joints, and pelvic bone positions
  • Neurological assessment includes patellar and Achilles reflexes, ankle and big toe flexion, muscle strength, and sensory examination

Screening Tools

  • Utilize the STarT Back Screening Tool to stratify patients based on physical and psychosocial factors
  • Assist in categorizing patients into low, medium, or high-risk groups, optimizing treatment plans

Management Approach

Immediate Referral Criteria

  • Red Flags: Immediate referral for patients exhibiting signs of severity
  • Musculoskeletal Origin: Mild cases managed by nurses or physicians, with pharmacological treatment if necessary
  • Chronic Pain: Maintain or adjust current medication for chronic cases, emphasizing non-pharmacological interventions

Referral for Further Evaluation

  • Persistent or severe pain associated with fever, significant weight loss, functional impairment, claudication, or other signs of concern warrant referral to specialists

Ongoing Primary Care

  • Continued follow-up in primary care for non-severe cases
  • Emphasize pharmacological and non-pharmacological maintenance strategies
  • Facilitate access to specialized care if required (physiotherapy, occupational therapy)


In navigating the complex landscape of lower back pain in primary care, a systematic and thorough approach is paramount. Early identification of red flags, meticulous clinical examination, and stratified management using tools like the STarT Back Screening Tool contribute to optimal patient outcomes. By integrating these practices into primary care, healthcare providers can deliver comprehensive and effective management for lower back pain, ensuring the well-being of their patients.

Top Articles
Latest Posts
Article information

Author: Rob Wisoky

Last Updated: 26/11/2023

Views: 5958

Rating: 4.8 / 5 (68 voted)

Reviews: 83% of readers found this page helpful

Author information

Name: Rob Wisoky

Birthday: 1994-09-30

Address: 5789 Michel Vista, West Domenic, OR 80464-9452

Phone: +97313824072371

Job: Education Orchestrator

Hobby: Lockpicking, Crocheting, Baton twirling, Video gaming, Jogging, Whittling, Model building

Introduction: My name is Rob Wisoky, I am a smiling, helpful, encouraging, zealous, energetic, faithful, fantastic person who loves writing and wants to share my knowledge and understanding with you.