Acute low back pain patient information
The pain may be in the center of the back or to one side, or even move down the leg. Symptoms may also include pain in the back and the buttocks or legs, stiffness, limited motion and spasm.
Acute low back pain is the fifth most common reason for all physician visits. Even though this ailment usually has a benign course, it is responsible for direct health care expenditures of more than $20 billion annually and as much as $50 billion per year when indirect costs are included.
In the United States, approximately 90 percent of adults experience back pain at some time in life, and 50 percent of persons in the working population have back pain every year. As many as 90 percent of patients with acute back pain return to work within three months, but many experience symptom recurrence and functional limitations. Only a small percentage of patients have an identifiable underlying cause. Fewer than 2 percent of patients have disc herniation. Even fewer have a life-threatening disease. Most patients with acute low back pain improve with conservative management and do not require immediate diagnostic studies. A comprehensive history and physical examination can identify the small percentage of patients with serious conditions that require immediate further evaluation. These conditions include infection, malignancy, rheumatologic diseases and neurologic disorders. The possibility of referred pain from other organ systems should also be considered.
The history and review of systems include patient age, constitutional symptoms and the presence of night pain, bone pain or morning stiffness. The patient should be asked about the occurrence of visceral pain, symptoms of claudication and neurologic symptoms such as numbness, weakness, radiating pain, and bowel and bladder dysfunction.
It is also important to inquire about the specific characteristics and severity of the pain, a history of trauma, previous therapy and its efficacy, and the functional impact of the pain on the patient's work and activities of daily living. An assessment of social and psychologic factors (e.g., depression) may yield information that affects the treatment plan.
As part of the initial evaluation, the physician should perform a thorough neurologic examination to assess deep tendon reflexes, sensation and muscle strength. Peripheral pulses should also be assessed, and the abdomen should be palpated to search for organomegaly. The physician should assess joint and muscle flexibility in the lower extremities, examine the entire spine and assess stance, posture, gait and straight leg raising. At subsequent visits, further assessment and a comprehensive evaluation can be carried out based on the history and persistence of symptoms. Functional overlay, or signs of excessive pain behavior, should be assessed. Physiologic plausibility and consistency of physical findings should be addressed. "Nonorganic" signs of physical impairment have been described. The presence of three or more of these signs is thought to suggest a nonphysiologic element of the patient's presentation. In this situation, further psychologic testing and/or behavioral intervention may be warranted.
Things like obesity, lack of exercise, heavy physical work, accidents, vibration (i.e., driving a truck), smoking, and family history may add to the chance of having low back pain.
Being overweight may increase risk for low back pain because of the added stress on the back.
We don't know a lot about just what does cause low back pain. Pulled muscles, strained ligaments, tight joints or small tears in the disks (shock absorbers which are stacked between the spine bones) are all likely causes. The problem is that these tears and pulls don't show up well on x-rays.
Your doctor may order x-rays or other studies if your specific symptoms indicate a need for these tests or if your back pain does not go away in 4-6 weeks.
The comprehensive evaluation may include a complete blood count, determination of erythrocyte sedimentation rate and other specific tests as indicated by the clinical evaluation. In particular, these tests are useful when infection or malignancy is considered a possible cause of a patient's back pain.
Plain-film radiography is rarely useful in the initial evaluation of patients with acute-onset low back pain. At least two large retrospective studies have demonstrated the low yield of lumbar spine radiographs. In one of these studies, plain-film radiographs were normal or demonstrated changes of equivocal clinical significance in more than 75 percent of patients with low back pain. The other study found that oblique views of the spine uncovered useful information in fewer than 3 percent of patients.
Magnetic resonance imaging (MRI) and computed tomographic (CT) scanning have been found to demonstrate abnormalities in "normal" asymptomatic people. Thus, positive findings in patients with back pain are frequently of questionable clinical significance. In one study, MRI scans revealed herniated discs in approximately 25 percent of asymptomatic persons less than 60 years of age and in 33 percent of those more than 60 years of age. Clearly, the presence of abnormalities does not correlate well with clinical symptoms. Nonetheless, MRI may provide important clues when used judiciously.
MRI uses no ionizing radiation and is better at imaging soft tissue (e.g., herniated discs, tumors). CT scanning provides better imaging of cortical bone (e.g., osteoarthritis). Compared with MRI, CT scanning is less sensitive to patient movement and is also less expensive.
MRI or CT studies should be considered in patients with worsening neurologic deficits or a suspected systemic cause of back pain such as infection or neoplasm. These imaging studies may also be appropriate when referral for surgery is a possibility.
Electrodiagnostic assessments such as needle electromyography and nerve conduction studies are useful in differentiating peripheral neuropathy from radiculopathy or myopathy. If timed appropriately, these studies are helpful in confirming the working diagnosis and identifying the presence or absence of previous injury. They are also useful in localizing a lesion, determining the extent of injury, predicting the course of recovery and determining whether structural abnormalities (as seen on radiographic studies) are of functional significance.
The physician needs to be aware of the limitations of electrodiagnostic studies. Because the tests depend on patient cooperation, only a limited number of muscles and nerves can be studied. In addition, the timing of the studies is important, because electromyographic findings may not be present until two to four weeks after the onset of symptoms.
Laboratory and imaging studies, performed as indicated, provide information that can be useful in establishing a diagnosis and developing a treatment plan in the patient with acute back pain.
If no significant improvement in symptoms is noted after four to six weeks of treatment, the physician should reassess the treatment plan. To avoid misdiagnosis and unnecessary or inappropriate treatments, the physician may then want to refer the patient to a spine specialist.
The good news is that 90% of people with acute low back pain recover within 4 - 6 weeks.
The mainstay of pharmacologic therapy for acute low back pain is acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If no medical contraindications are present, a two- to four-week course of medication at anti-inflammatory levels is suggested.
Adequate gastrointestinal prophylaxis, using a histamine H2 antagonist or misoprostol (Cytotec), should be prescribed for patients who are at risk for peptic ulcer disease.
Previously, bed rest was frequently prescribed for patients with back pain. However, several studies have shown that this measure has an adverse effect on the course and outcome of treatment. One randomized clinical trial found that patients with two days of bed rest had clinical outcomes similar to those in patients with seven days of bed rest. The group with a shorter rest period missed 45 percent fewer days of work and presumably avoided the effects of deconditioning and the fostering of a dependent sick role.
The current recommendation is two to three days of bed rest in a supine position for patients with acute radiculopathy. Sitting, even in a reclined position, actually raises intradiscal pressures and can theoretically worsen disc herniation and pain.
Activity modification is now the preferred recommendation for patients with nonneurogenic pain. With activity restriction, the patient avoids painful arcs of motion and tasks that exacerbate the back pain.
Superficial heat (hydrocolloid packs), ultrasound (deep heat), cold packs and massage are useful for relieving symptoms in the acute phase after the onset of low back pain. These modalities provide analgesia and muscle relaxation . However, their use should be limited to the first two to four weeks after the injury. The use of deep heat may be subject to a number of restrictions.
Aerobic exercise has been reported to improve or prevent back pain. The mechanism of action is unclear. In general, exercise programs that facilitate weight loss, trunk strengthening and the stretching of musculotendinous structures appear to be most helpful in alleviating low back pain. Exercises that promote the strengthening of muscles that support the spine (i.e., the oblique abdominal and spinal extensor muscles) should be included in the physical therapy regimen. Aggressive exercise programs have been shown to reduce the need for surgical intervention.
Basic points of a program for treating low back pain include:
Stay active. Lying in bed or cutting back on activity is not helpful. People get better faster if they stay active at home and work. Common exercise such as walking, swimming or riding a stationary bike can be helpful in many cases. Your doctor may limit your activity if your job or the sports you play are very physical. Call your doctor right away if you have: trouble controlling your bladder or bowels You can reduce the strain on your back by doing the following: To rest your back, hold each of these positions for 5 minutes or longer:
Lie on your back, bend your knees, and put pillows under your knees. The goal of rehabilitation is to return you as soon as is safely possible to your normal activity. This includes strenuous activity and sports. If you return too soon you may worsen your injury, which could lead to permanent damage. People recover from injury different rates. When you can return to your activity will depend on how soon your back gets better. It does not depend on how many days or weeks it has been since you were injured. Most of the time, the longer you have symptoms before you start treatment, the longer it will take to get better.
It is important that you have fully recovered from your low back pain before you return to any strenuous activity, which includes sports. You must be able to have the same range of motion that you had before your injury. For sports you must be able to run, jump and twist without pain.
Exercises that stretch and strengthen the muscles of your abdomen and spine can help prevent back problems. If your back and abdominal muscles are strong, it will help you to maintain good posture and keep your spine in its correct position.
Warm up your muscles with light aerobic activity like brisk walking before doing any strengthening or stretching. Wear loose clothing to make it easier to do the exercises. Stop doing any exercise that causes pain until you have talked with your doctor. These exercises are meant only as suggestions. Ask your doctor or physical therapist to
help you design a program to fit your unique needs.
Caution: If you have a herniated disk or other disk problem, check with your doctor before doing these exercises.
Lying supine hamstring stretch: Lie on your back with a small rolled towel under
your waist (lower back). Place your left leg down with knee straight. Bend your right
hip so your knee is pointing to the ceiling. Hold your right thigh by locking your
fingers. Keep your elbows straight while holding and straighten your right knee and
move the foot toward the ceiling. You should feel a stretch on the backside of your
thigh. Hold for 30 seconds and repeat 2 times. Repeat the same stretch on your
other leg.
Cat Stretch: In a hands and knee position, place your hands under the shoulders and the knees under your hips. Let your head drop down while at the same time tuck your hips under and raise the middle of your back as high as you can. You should try to create a gradual curve of your back towards the ceiling. Hold the position for 5 seconds and repeat 10 times.
Camel Stretch: In a hands and knee position, place your hands under the shoulders and the knees under your hips. Raise your head up while at the same time raise your hips up and allow your stomach to fall to the floor. Hold the position for 5 seconds and repeat
10 times.
Pelvic tilt: Lie on your back with your knees bent and your feet flat on the floor. Tighten your abdominal muscles and push your lower back into the floor. Hold this position for 5 seconds, and then relax. Do 2 sets of 10.
Partial curl: Lie on your back with your knees bent and your feet flat on the floor. Tighten your stomach muscles and flatten your back against the floor. Tuck your chin to your chest. With your hands stretched out in front of you, curl your upper body forward until your shoulders clear the floor. Breathe out as you come up. Hold this position for 3 seconds. Relax. Repeat 10 times. Build to 3 sets of 10. To challenge yourself, clasp your hands behind your head and keep your elbows out to the side.
Prone hip extension: Lie on your stomach with your legs straight out behind you. Tighten up your buttocks muscles first and then lift one leg off the floor about 4-8 inches. Keep your knee straight. Hold for 5 seconds. Then lower your leg and relax. Repeat with the other leg. Do 3 sets of 10.
Exercises to avoid
Dont do these exercises because they strain the lower back:
Lying on your stomach with legs extended and lifting together
Sports and other activities
Besides conditioning your back, you need to condition your whole body. Physical activities such as walking or swimming can help strengthen your back. It is always best to check with your doctor before you start any rigorous exercise program. Always begin your program slowly. Good activities for people with back problems include:
walking
Sports that may not be safe for your back because of rough contact, twisting, sudden impact, or direct stress on your back include:
football It is critical to solicit the active participation of patients in spine care. Successful treatment depends on the patient's understanding of the disorder and his or her role in avoiding re-injury. Many hospitals and large businesses offer programs on back protection. These programs emphasize measures for avoiding spinal injury and review appropriate postures for sitting, driving and lifting. Weight loss and healthy life-style classes are also widely available.
Psychosocial obstacles to recovery may exist and must be explored. Studies have shown that workers with lower job satisfaction are more likely to report back pain and to have a protracted recovery. Patients with an affective disorder (e.g., depression) or a history of substance abuse are more likely to have difficulties with pain resolution. It is important for the physician to find out whether litigation is pending, because this can often adversely affect the outcome of therapy. The United States has the highest rate of spinal surgery (e.g., five times that of Great Britain). Studies examining the outcomes of conservative and surgical treatment of back pain have revealed no clear advantage for surgery. In one prospective study of 280 patients with herniated nucleus pulposus diagnosed by myelography, the surgical group demonstrated more rapid initial recovery than the medical treatment group. However, after approximately four years, outcomes appeared to be roughly equivalent in both groups; by 10 years, no appreciable differences in outcome were found.
Select groups of patients with acute low back pain should undergo immediate surgical evaluation. Patients with suspected cauda equina lesions (characterized by saddle anesthesia, sensorimotor changes in the legs and urinary retention) require immediate surgical investigation. Surgical evaluation is also indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment.
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