Low Back Pain Key Points

• A careful history and physical examination are essential in diagnosing any case of low back pain.

• Unremitting back pain and loss of bowel control require emergency assessment.

• Radiographs and laboratory tests are generally unnecessary with low back pain.

• With acute low back pain The therapeutic goal is to make the patient ambulatory and return to premorbid status.

• Recurrence of back pain and functional limitation can be prevented with appropriate conservative management, early mobilization, exercise, return to normal activity, and patient education.

• Exercise and physical therapy are the most effective treatment for chronic back pain.

Figure 31-15 Plain radiographs of the lumbar spine. A, Anteroposterior view. B, Lateral view. C and D, Right posterior oblique (RPO) and left posterior oblique (LPO) views. b, Body of vertebra; f, intervertebral (neural) foramen; if, inferior facet; l, lamina; p, pedicle; pi, pars interarticularis; s, spinous process; sf, superior facet; t, transverse process (denotes interpedicular distance). (From Brinker MR, Miller MD. Fundamentals of Orthopedics. Philadelphia, Saunders, 1999, p 249.)

Figure 31-15 Plain radiographs of the lumbar spine. A, Anteroposterior view. B, Lateral view. C and D, Right posterior oblique (RPO) and left posterior oblique (LPO) views. b, Body of vertebra; f, intervertebral (neural) foramen; if, inferior facet; l, lamina; p, pedicle; pi, pars interarticularis; s, spinous process; sf, superior facet; t, transverse process (denotes interpedicular distance). (From Brinker MR, Miller MD. Fundamentals of Orthopedics. Philadelphia, Saunders, 1999, p 249.)

• With chronic low back pain, the therapeutic goal is to provide a long-term increase in function or a decrease in pain and disability.

• Psychological support and therapy may provide relief in chronic low back pain.

Low back pain is the most common cause of both acute and chronic pain. In the United States, approximately 90% of adults experience back pain at some time in their life, and 50% of working persons have back pain annually. As many as 90% of patients with acute back pain return to work within 3 months, but 10% experience symptom recurrence and functional limitations and eventually develop chronic pain. Low back pain is one of the leading causes of both disability and absenteeism from work. Less than half of patients out of work for more than 6 months secondary to low back pain will ever work again, creating an enormous financial strain on the patient, family, and community.

In primary care practice the specific anatomic cause of low back pain is usually not known; only a small percentage of patients have an identifiable underlying etiology. Less than 2% of patients have disk herniation, and only rarely do patients have a life-threatening condition. The most common cause of back pain is the lumbosacral strain following a single action or multiple lifting or twisting maneuvers. Factors that predispose to low back strain include repetitive use of poorly toned muscles, obesity, smoking, poor work habits, high-heeled shoes, and lack of physical activity. Most patients with acute low back pain improve in 2 to 4 weeks. Patients who progress to chronic back pain spend much time and money to become "pain free."

Assessment and Clinical Features

Most causes of low back pain are benign, but a thorough history and physical examination can identify a small percentage of patients with serious infection, malignancy, rheu-matologic disease, or neurologic disorder. These serious conditions need immediate further evaluation. The review of systems includes constitutional symptoms, night pain, bone pain, morning stiffness, visceral pain, and claudication. The history includes exact location of the pain and the day, time, and activity involved in the initial back pain.

The patient's occupational risk assessment includes heavy lifting, prolonged sitting or standing, bending or twisting, and work with heavy, vibrating equipment. Patients often point to a well-localized area of the lower part of the back. Patients may have paraspinal muscle spasm and tenderness. Any movement may be painful, and the patient may walk in a slightly flexed position. Muscle spasm may be severe enough to cause loss of normal lumbar lordotic curve. If the strain is unilateral, the back may tilt to the affected side secondary to muscle spasm. The patient has reduced ROM, especially flexion and lateral bending secondary to pain. Neurologic examination should reveal no signs of radiculopathy in a normal back exam.

At subsequent visits, further assessment and evaluation are based on the history of persistence, recurrence of pain, and functional limitations. Functional overlay and signs of excessive pain behavior should be sought. Complaints without objective findings suggest a psychological role in symptom formation; psychological testing and behavior intervention may be needed. During further encounters, psychosocial obstacles to recovery should be explored. Patients whose work provides lower job satisfaction are more likely to report back pain and have a delayed recovery. Patients with affective mood disorders (e.g., depression) or substance abuse problems are more likely to have chronic pain and difficulty with pain resolution.

Diagnostic Testing

Radiographic imaging in uncomplicated cases of lumbosa-cral strain is rarely necessary and usually does not correlate with the patient's pain. Most people older than 40 years have anatomic defects on plain films of the spine. If the low back pain is probably more than a lumbosacral strain or has persisted for more than 6 weeks, radiographs may be helpful. CT or MRI should be reserved for low back pain accompanied by moderate to severe radicular symptoms, in the presence of motor weakness and neurologic deficits.

Treatment

Once it is determined that the patient has an uncomplicated lumbosacral strain, the goal of therapy for acute low back pain is to make the patient ambulatory and return to pre-morbid status. This goal should be explained to the patient, whose active participation is critical. Successful treatment depends on the patient's understanding of the disorder and the prevention of repeat injury. Patients should remain active to assist recovery, compared with short-term bed rest.

Family physicians should begin with conservative therapy. Most patients with acute low back pain improve with conservative management within 2 to 4 weeks. Early mobilization and return to normal activities should be encouraged. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are mainstays of pharmacologic therapy for acute low back pain. Muscle relaxants are effective for short-term relief. Short-term use of a narcotic could be considered for relief of severe, acute pain. As the pain permits, gentle stretching exercises should be initiated (Fig. 31-16). Patients should taper use of the analgesics while gradually increasing their normal activities. Extremes of twisting, bending and tilting should be avoided. If these are work-related activities, the patient may require a change to "light duty." Teach techniques to lift heavy objects and educate patients about maintaining proper posture (Fig. 31-17).

Most patients recover and require no additional evaluation. Prevention of repeated back injuries is then the focus. The patient should be instructed on overall body conditioning. Exercises that do not stress lower back muscles include swimming, water aerobics, and low-impact walking. Rehabilitation exercises and aerobic conditioning for trunk extensors, abdominal muscles, and back strengthening (modified sit-ups, weighted side bends, gentle extensions) should become part of the patient's daily routine (Fig. 31-18).

The patient with chronic low back pain remains a challenge. The ultimate goal in chronic pain management is long-term increase in function or decrease in pain and disability. Typically these patients already had multiple therapies for acute back pain. Assessment of social and psychological factors may help identify a pain etiology that affects treatment.

Exercise is more effective for chronic low back pain than treatment with medication plus return to usual activity. Exercise is as effective as conventional physiotherapy. Exercise and physical modalities are the mainstays of therapy. Heat, cold, massage, ultrasound, and muscle stimulation

Back-stretching exercises play a vital role in the treatment of lumbosacral muscle spasms. The lower back is heated for 15 to 20 minutes. Sets of 10 to 20 stretches, each held for 5 seconds, are performed on each side. The muscles are kept relaxed. Rest for 1 to 2 minutes between exercises. Mild muscle soreness is to be expected. Severe pain, electric-like sharp pain, or severe muscle spasms suggest overstretching.

Knee-chest pulls

Bring your knee slowly up to your chest, holding it in place with your hands. Relax the buttock and back muscles. Do the left side, then the right side, and then both simultaneously (curling up in the fetal position).

Pelvic rocks

With knees bent, rotate your pelvis forward and then backwards. The abdominal muscles do the work, as the back muscles are relaxed.

Caution: Do not overextend when arching the back!

Side bending

While lying down, crawl your fingers down the side of your thigh. Hold in this tilted position for 5 seconds. Return to a neutral position. Repeat on the other side.

Initially, these exercises should be performed while lying down or floating in the bath or hot tub. With improvement, these exercises can be performed standing or sitting. Follow these movements with exercises to strengthen the back.

Figure 31-16 Back-stretching exercises. (Redrawn from Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed. Philadelphia, Saunders, 1999, p 266.)

are effective modalities. NSAIDs or acetaminophen can be reinitiated. The need for prolonged narcotic therapy should prompt reevaluation of a patient's back pain. Reassurance and psychological support are also important. Often, depression accompanies the pain; addressing psychological issues may provide some relief. Patients often require referral to a specialized pain clinic or multidisciplinary back program. These clinics offer education, physical therapy, pharmaco-logic treatment, epidural steroid injections, chiropractic therapy, and psychological services.

Family physicians should emphasize the prevention of reinjury, review healthy lifestyle changes, and address weight loss, if indicated, as well as continue primary care for the patient.

KEY TREATMENT

Acetaminophen and NSAIDs are effective for pain relief in patients with acute low back pain; muscle relaxants are effective for short-term relief (Harwood and Chang, 2002) (SOR: A). Remaining active speeds recovery from low back pain compared with short-term bed rest (Harwood and Chang, 2002) (SOR: A). For chronic low back pain, exercise is more effective than treatment with medication plus return to usual activity. Exercise is as effective as conventional physiotherapy (Carter and Lord, 2002) (SOR: A).

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