Acute low back pain patient information

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Almost everyone has back pain at one time or another.

The pain may be in the center of the back or to one side, or even move down the leg in a fashion often termed "sciatica.". 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 problem 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, rheumatic 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. "Claudication" means the pain comes on with walking and is relieved by rest.

It is also important to ask 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, as well as muscle strength. Peripheral pulses should also be assessed, and the abdomen should be palpated to search for organ enlargement. A pulsating mass may suggest an aneurysm of the aorta. 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 evaluation can be carried out based on the history and persistence of symptoms. Functional signs, meaning evidence of psychologic problems, or signs of excessive pain behavior, should be addressed. "Nonorganic" signs -meaning, the symptoms and the exam don't add up, have been described. The presence of three or more of these signs is thought to suggest a non-physiologic 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.

The underlying cause of the low back pain can be diverse. 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.

If your back pain does not go away in 4-6 weeks, further imaging tests and other tests should be considered.

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 x-rays are 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 x-rays. In one of these studies, plain-film x-rays 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. So, 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. So the important message is that the presence of abnormalities does not correlate well with clinical symptoms. Nonetheless, MRI may provide important clues when used in conjunction with the clinical picture.

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. These benefits are countered by the fact that CT involves substantial radiation exposure.

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 deemed necessary.

Electrodiagnostic assessments such as needle electromyography and nerve conduction studies are useful in differentiating peripheral neuropathy from radiculopathy or myopathy. 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 seen on imaging studies are significant.

There are limitations to electrodiagnostic studies. Because the tests depend on patient cooperation, only a limited number of muscles and nerves can be studied. These tests can be very uncomfortable. 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 can provide useful information for establishing a diagnosis and developing a treatment plan in the patient with acute back pain.

Again, if no significant improvement in symptoms is noted with four to six weeks of treatment, a change in treatment direction needs to occur. If symptoms are worsening, the physician may 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, misoprostol (Cytotec), or a proton-pump inhibitor should be prescribed for patients who are at risk for peptic ulcer disease.

Cardiavascular consequences of NSAIDS should also be considered prior to use.

Previously, bed rest was frequently prescribed for patients with back pain. However, several studies have shown that this 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 non-neurogenic pain, meaning pain without a significant neurologic cause. With activity restriction, the patient avoids painful movements and tasks that worsen back pain.

Superficial heat (hydrocolloid packs), ultrasound (deep heat), cold packs and massage are useful for relieving symptoms in the acute phase after the start 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 considered but should be used cautiously.

Aerobic exercise has been reported to improve or prevent back pain. The mechanism of action is unclear. In general, exercise programs that help aid weight loss, core strengthening and stretching of muscles, 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), often termed "core 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:

• Lying in bed or cutting back on activity is not always helpful. People tend to get better faster if they stay active. Common exercise such as walking, swimming or riding a stationary bike can be helpful in many cases. Avoid high impact exercise.
• Stretching 2-3 times daily is recommended in most cases. Hold the stretch for 20-30 seconds, take a break and do it again. If a stretch seems to make things worse, or if it causes pain to go down your leg, seek further advice from the doctor or physical therapist.
• Ice packs applied for 20-30 minutes at a time may feel uncomfortable at first, but they actually decrease pain, spasm and inflammation in the back. There's nothing wrong with trying heat if it works, but ice may be better.
• Exercise. Common aerobic and conditioning exercises, such as brisk walking, swimming or riding a stationary bicycle can be very helpful.
• Analgesic medications or muscle relaxants may be prescribed.

A physician should be consulted immediately if the following symptoms occur:

• trouble controlling your bladder or bowels
• numbness or weakness in the feet legs, bladder, or bowel
• the pain gets worse or radiates into your leg and below the knees
• pain limits your normal activities for more than 4-5 weeks
• shooting pain starts down the leg

Reduce back strain by doing the following:

• Don't push with your arms when you move a heavy object. Turn around and push backwards so the strain is taken by your legs.
• Regular exercise will help your back, plus it will keep you healthy, overall. Before starting any exercise program you should see a professional trainer or physical therapist for advice that fits your needs. For aerobic exercise such as walking, bicycling or swimming, start with low intensity exercise about 5 - 10 minutes of exercise a day, three days a week, and slowly work up to 30 minutes of exercise a day for five days a week. If you can't start with 5 - 10 minutes of exercise, do 2-3 minutes, or whatever you can. Strength training is also good for your body and back. You can start with leg strengthening exercises that will help your back when it comes to lifting heavy objects. Use strength training machines if you can. Start with lighter weights, completing 10 to 15 repetitions before increasing the weight at your next workout. Keep in mind that, stronger muscles will allow you to do more work and help reduce the risk of back injury.
• When lifting a heavy object keep the object close to your body and bend your knees. The stronger your legs are, the easier it will be to lift.
• When you sit, sit in a straight-backed chair and hold your spine against the back of the chair.
• Bend your knees and hips and keep your back straight when you lift a heavy object.
• Avoid lifting heavy objects higher than your waist.
• Hold objects you carry close to your body, with your arms bent.
• Avoid sitting in one place or in one position for a long time. Get up and stretch, walk about and change positions.
• Use a footrest for one foot when you stand or sit in one spot for a long time. This keeps your back straight.
• Sit close to the pedals when you drive and use your seat belt and a hard backrest or pillow.
• Lie on your side with your knees bent when you sleep or rest. It may help to put a pillow between your knees.
• Put a pillow under your knees when you sleep on your back.
• If you smoke, ask your doctor for help on how to quit. Smoking limits blood flow to the discs and muscles in your back and slows their healing.

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.
• Lie on your back, put a pillow under your neck, bend your knees to a 90-degree angle, and put your lower legs and feet on a chair.
• Lie on your back, bend your knees, and bring one knee up to your chest and hold it there. Repeat with the other knee, and then bring both knees to your chest. When holding your knee to your chest, grab your thigh rather than your lower leg to avoid over-flexing your knee.

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 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.

Here's a disturbing statistic...

The United States has the world's 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.

Here are the people that require immediate surgical evaluation...

Patients with suspected cauda equina lesions (characterized by saddle anesthesia, neurologic changes such as weakness 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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