Management of Low Back Pain
Therapy Guidelines
Mechanical Low Back Pain
A wide range of therapies, including rest, medications, physical modalities,
and surgery, to name only a few, are available to treat mechanical low back
pain.
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The variety of possible therapies has resulted in confusion for the
concerning appropriate treatment for specific forms of mechanical low back pain.
The absence of consensus was documented in a study of 2,897 physicians who
responded to a questionnaire concerning the prescribing of therapy for patients
with acute muscle strain, sciatica, and chronic low back pain.
Treatment recommendations chosen by the respondents followed the specialty of
the physician (i.e., surgery for orthopedic surgeons, rehabilitation for physio
theraptrists).
The practicing physician must make a cost-effective choice of therapy for the
low back pain patient. In 1994, the Agency for Health Care Policy and Research (AHCPR)
published guidelines for the diagnosis and treatment of acute low back pain.
The physician members of the advisory group agreed that the recommendations
were options, and not the sole method, for treating acute low back pain.
It is also important to remember that these recommendations are for acute low
back pain. The guidelines do not apply to disorders associated with chronic
low back pain.
Despite these limitations, some of the general themes of the guidelines for
acute low back pain are important clinical recommendations for the primary care
physician.
Patients should be encouraged to limit bed rest. A major thrust of the
guidelines is to encourage movement and a return to full function.
The recommendations on bed rest, spinal manipulation, and exercise may all be
seen as methods to motivate patients to regain normal motion of the lumbo-sacral
spine.
Recommendations for medications maximize the use of agents with mild
toxicities and little abuse potential.
In general, invasive therapies are limited to those low back pain patients
who fail to improve over a 4 to 12-week period. Only a small minority of
patients require surgical intervention.
Recommendations generally incorporates some of the ACHPR guidelines along
with practical recommendations that improve patient adherence
Soft tissue strain
Therapy of muscle and ligament strain of the spine includes controlled
physical activity, NSAIDs, muscle relaxants, and physical therapy.
Muscle strain is improved with controlled activity. A period of bed rest as
short as 2 days has been shown to be effective at relieving back pain.
As soon as the very acute pain is diminished, patients should be encouraged
to increase physical activity. The efficacy of bed rest for 2 days,
back-mobilizing exercises, and ordinary activity as tolerated for low back pain
therapy in 186 city employees in Helsinki, Finland. Better recovery, improved
function, and fewer missed work days were associated with ordinary activity.
Physical modalities, in the form of ice
massage, initially, or warm baths or
heating pads,
subsequently, may also decrease pain and diminish spasm.
Non-narcotic analgesics in the form of NSAIDs relieve pain, allowing patients
to be more mobile. Nonsteroidal drugs with a rapid onset of action and analgesic
properties are most helpful in patients with acute pain. Muscle relaxants may be
helpful in the patient who has palpable muscular spasm on physical examination
or has difficulty sleeping at night because of muscle pain. The combination of
an NSAID with a muscle relaxant is better than an NSAID alone in improving pain
relief in acute low back pain patients with muscle spasm on physical
examination.
With resolution of back pain, the usual occupational and recreational
activities may be resumed.
Some patients require no additional encouragement to return to their usual
lifestyle. Others benefit from a few sessions with a physical therapist
reviewing proper body mechanics and range of motion exercises. Some, especially
those with recurrent acute attacks, may benefit from preventive measures that
include, in addition to the above, weight reduction, when needed, and flexion
and extension exercises.
Therapy For Chronic Low Back Pain
Chronic low back pain therapy requires additional interventions. The goal of
therapy for patients with chronic pain is maximum physical function despite
continued pain, rather than complete pain relief. If the patient does not accept
this goal, the outcome is likely to be disappointing.
Patients with chronic back pain are treated with NSAIDs, muscle relaxants, or
injection therapy. Alternative medications should be offered if the initial
choices are ineffective. Patients should be assessed for psychological factors
including depression disorders. Fibromyalgia is a common cause of chronic back
pain. Tricyclic antidepressants may offer additional analgesia in patients with
persistent pain even in the absence of clinical depression. Referral to a
physical therapist is warranted for exercises to improve general conditioning as
well as to correct any imbalance in the spine with stretching and strengthening
exercises of the flexion, extension, or isometric variety.
Patients should be encouraged to return to work. Modifications in work
responsibilities or hours may be necessary to assure continued success in the
workplace. Vocational rehabilitation counselors are helpful in determining the
capability of individuals to perform the tasks associated with a job.
Referral to a back school or a pain clinic should be considered for an
individual who experiences increasing pain despite these interventions. Pain
clinics offer a multidisciplinary approach to pain, employing neurosurgeons,
anesthetists, psychiatrists, physical therapists, vocational rehabilitation
counselors, and other health professionals interested in the special problems of
the chronic pain patient.
Summary
The therapy of low back pain patients can be frustrating for the busy primary
care physician. A number of therapeutic options are possible for these patients,
but none are clearly curative. Published guidelines are useful for treating most
patients with acute low back pain. They are not applicable to the most difficult
patients with lumbosacral disease including those with systemic causes of low
back pain.
There are a number of myths about back pain that have now been debunked and
are worthwhile reviewing The natural history of mechanical spinal
disorders do improve with time. Patients with herniated discs and spinal
stenosis can be effectively treated with medical therapy. The primary care
physician plays an important role in the resolution of symptoms by educating
patients about the time course of improvement and encouraging movement and
return to normal function.
Common myths associated with back pain
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- • If you have a herniated disc, you must have surgery.
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- • X-ray, CT, and MRI can accurately identify the cause of pain in most
cases.
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- • If your back hurts, you should rest until the pain goes away.
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- • Most back pain is caused by injuries or heavy lifting.
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- • Back pain usually leads to chronic disability.
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- • Everyone with back pain should have a spine x-ray.
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- • Bed rest is the mainstay of therapy.
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