Low Back Pain Diagnosis
Specific treatment plans can differ significantly depending on whether the back pain is acute or chronic, radiating or non-radiating. It is therefore important to make an early and accurate diagnosis.
The initial visit of an low back pain (LBP) patient to a general practitioner should include a thorough history and assessment of “red flags” for serious disease.
Common red flags for serious disease of low back pain include:
- loss of balance or strength
- nocturnal or resting pain
- night sweats
- substance abuse
Following the initial examination, acceptable treatment options at this early stage include ice, NSAIDs, muscle relaxants and return to usual activities. Strict bed rest is not recommended. Cox-2 inhibitors are no more effective than traditional NSAID agents and should be reserved for carefully selected patients. Close clinical follow up should be maintained until the patient is able to return to work and/or key life activities.
If the patient’s pain and disability do not improve or in fact worsen after a period of four weeks, consultation with a spine specialist should be considered. As most acute low back pain is responsive to non-operative treatment, consultation with a physiatrist, a specialist in physical medicine and rehabilitation, is the best first step for many patients. Such consultation will help clarify the often complex diagnosis of the pain generator in low back pain and allow early aggressive conservative care.
In cases of acute low back pain with weakness, bowel or bladder incontinence, severe trauma, or known tumors, immediate consultation with a surgeon is appropriate.
The duration of low back pain can be categorized as follows:
- Acute Low Back Pain – less than six weeks
- Subacute Low Back Pain – if symptoms persist six weeks
- Chronic Low Back Pain – if symptoms persist at least 12 weeks
Treatment and Recovery of Low Back Pain
Excessive bed rest is no longer advocated for the treatment of low back pain. Indeed, recent studies have shown it actually to be counterproductive. Experts now understand that muscle weakness occurs rapidly with bed rest, so it is generally not recommended. Most practitioners prefer to get the patient moving as soon as possible. Oral or injectable medication may be used to manage back pain. In cases of chronic pain in compliant patients practitioners can prescribe pain medication, even opioids. Adequate medication for pain allows chronic back pain patients to properly execute their home exercises, leading to a sense of control over their condition and possibly leading to lower doses of medication at a later time. In cases of acute pain,aggressive pain medication regimens are followed by rapid tapering to avoid dependence. In all cases, adequate medication is used to facilitate the exercise program.
Under the direction of a physician, physical therapists educate the patient regarding proper body mechanics and establish an individualized exercise program that enables self-management of the condition at home. The therapy also modifies harmful behaviors fostered by prolonged pain and disability.
Compliance with home exercise programs can be encouraged by therapists and physicians by educating patients that home exercises are the most effective “medication” for their back pain, and, just like other medications, need to be administered regularly to be beneficial.
Many back pain patients are afraid that any activity, including exercise, will harm their backs further and cause significant discomfort. Additionally, therapist and patient views of ability to perform a particular exercise may differ, leading to patient non-compliance. Physicians need to help patients understand that there is no quick fix for back pain, not even surgery.
The aforementioned barriers to recovery can be averted through patient education and by determining which aspects of the pain are treatable and which are not, setting realistic expectations for the patient and getting him or her to accept the level of relief that can be achieved. Recent models suggest that back pain episodes may represent minor acute injuries of spinal structures that are weakened by age-related degeneration. Under this model, back pain episodes can occur coincidentally during any human activity, including exercise, but with exercise causing no additional risk compared to other activities. There is no evidence that exercise places people at increased risk for harming their backs, that it fosters more rapid degeneration, or that it induces excessive pain. It is imperative that patients be convinced that active participation in the prescribed physical therapy is necessary to facilitate their recovery.
Prescribing Physical Therapy for Treatment of Low Back Pain
The NorthShore spine specialists firmly believe with the need for patients to be more receptive to exercise regimens and their potential benefits. Consistent exercise is really key for patients who suffer from back pain. Maintaining a home exercise program helps to maintain core muscles, which in turn keep pressure off of the spine. By stretching tight muscles affecting the injured area and strengthening weak muscles supporting the injured area, the patient is allowed to heal naturally. The goal of physical therapy is to keep the spine in as neutral a position as possible.
A good rule of thumb when prescribing physical therapy is to ask the therapist to improve flexibility, teach proper body mechanics, increase aerobic endurance and work on core stabilization—the mainstay of treatment for back pain.
Additionally, the prescribed exercise treatment should observe the following five general principles for optimization:
- Avoid mechanical strain on injured area, restrain range of motion initially
- Stretch before strengthening
- Think gradual progression (rapid progression equals re-injury)
- Add range of motion gradually as injury heals
- Train patient for appropriate functional tasks
There is some evidence indicating that specific exercises improve abdominal and trunk extensor strength and endurance. Specific exercises should be prescribed categorically, either in response to flexion-based back pain or extension-based back pain, and can be categorized further to address the specific needs of acute or subacute conditions. As for treating chronic low back pain, the general consensus from extensive reviews is that specific exercise therapies are not effective, but rather general exercises in a variety of forms can be used to reduce pain.
For acute flexion-based low back pain, McKenzie exercises and those that emphasize stretching of the hamstrings are often best. For acute extension-based low back pain, Williams exercises are effective as well as exercises that stretch hip flexors (iliopsoas and rectus femoris) or strengthen hip extensors (gluteus maximus and abdominals). Exercises addressing subacute pain, both flexion- and extension-based, should be aimed at discouraging reflex (abnormal) firing of paraspinals and strengthening paraspinals in the pain-free range.
The progression of an exercise program can be supported through treatments such as heat, ice, electrical stimulation, massage, medications, injections and manipulations. Throughout these treatments, it is recommended that the lines of communication between specialists and the patient’s general practitioner be kept open. In our experience, the general practitioners who achieve the best results for their patients are those who develop a solid relationship with the physical therapist. A good PT will provide progress notes and keep the referring physician informed about potential problems or plateaus in treatment.
Low back pain can be challenging to diagnose and treat effectively, but the continually emerging evidence in support of exercise and physical therapy treatments bodes well for present and future low back pain sufferers. Exercise empowers patients to take an active role in their treatment. It places the patients in control and decreases their reliance on passive treatments and the medical system. It also encourages the long-term prevention of repeat injury.