Lower Back Pain:
An Active Approach To Diagnosis and Treatment
Ninety percent of lower back pain (LBP) cases are benign
and typically subside within six weeks regardless of
treatment method.(1,2,3) The diagnosis and treatment
of the remaining 10 percent are more challenging, however,
and demand strict adherence—both from the physician
and the patient—to the latest clinical guidelines
and recommendations. Based on current literature, a
multidisciplinary approach combining drug treatment
with physical and patient education has proven to be
the most successful treatment of back pain.(4)
Diagnosis and Reference Protocol
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. Recently, The University
of Michigan Health System updated a comprehensive set
of clinical guidelines for lower back pain (see
Figure 1).
| Table 1: LBP “Red Flags”
Indicating Potentially Serious Disease |
| Progressive
neurologic deficit |
 |
|
|
|
| Recent
bowel or bladder dysfunction |
|
|
|
|
| Saddle
anesthesia |
|
|
|
|
| Traumatic
injury/onset, cumulative trauma |
|
|
|
|
| Steroid
use history |
|
|
|
|
| Women
age > 50 |
|
|
|
|
| Men
age > 50 |
|
|
|
|
| Male
with diffuse osteoporosis or compression
fracture |
|
|
|
|
| Cancer
history |
|
|
|
|
| Diabetes
Mellitus |
|
|
|
|
| Insidious
onset |
|
|
|
|
| No
relief at bedtime or worsens when supine |
|
|
|
|
| Constitutional
symptoms (e.g. fever, weight loss) |
|
|
|
|
| Hx
UTI/other infection |
|
|
|
|
| IV
drug use |
|
|
|
|
| HIV |
|
|
|
|
| Immune
suppression |
|
|
|
|
| Previous
surgery |
|
|
|
|
|
|
The initial visit of an LBP patient to a general practitioner
should include a thorough history and assessment of
“red flags” for serious disease (see Table
1), as well as psychological and social risks for chronic
disability.(5) Common red flags for serious disease
include fever, incontinence, loss of balance or strength,
nocturnal or resting pain, night sweats, substance abuse
and trauma.vi Diagnostic tests are typically unnecessary,
but red flags should be aggressively investigated. Following
the initial examination, acceptable treatment options
at this early stage include ice, NSAIDs(6), 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.(7)
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 LBP is amenable to non-operative treatment, consultation
with a physiatrist, a specialist in physical medicine
and rehabilitation, is the best first step for most
patients. Such consultation will help clarify the often
complex differential diagnosis of LBP and allow the
institution of early aggressive conservative care. In
cases of acute LBP in the presence of progressive weakness,
bowel or bladder incontinence, severe trauma, or known
tumors, initial surgical consultation is warranted.
Prior to the six-week mark, the patient’s LBP
is still acute. If symptoms persist at six weeks, the
LBP should be regarded as subacute. By 12 weeks the
condition is chronic.
Treatment and Recovery
Excessive bed rest is no longer advocated for the treatment
of LBP. Indeed, recent studies have shown it actually
to be counterproductive.(8) “Muscle weakness occurs
rapidly with bed rest, so we generally don’t recommend
it,” affirms Dr. Lawrence Frank, Chicago Institute
of Neurosurgery and Neuroresearch (CINN) physical medicine
and rehabilitation specialist and assistant professor
of physical medicine, rehabilitation and neurosurgery
at Rush University Medical Center. “We like to
get the patient moving as soon as possible.”
Oral or injectable medication may be used to manage
back pain. Dr. Frank advises, “in cases of chronic
pain in compliant patients, don’t be afraid to
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,” Dr. Frank adds,
“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. Unfortunately, patient
compliance with the exercise portion of treatment is
notoriously poor. A 1993 study of adherence to physiotherapists’
exercise recommendations found that of 1178 patients,
only 35% reported full adherence, 41% partial adherence
and 22% non-adherence.(9)
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.(10) Additionally, therapist
and patient views of ability to perform a particular
exercise may differ, leading to patient non-compliance.(11)
Dr. Frank has his own hypothesis: “Everybody wants
a quick fix. That’s not unexpected, but an exercise
program takes motivation and commitment.” Whereas
standard medication-based treatment is passive and requires
no more of the patient than swallowing a pill, exercise
is an active approach, requiring patients to set aside
time to do their exercise program. “We need to
help patients understand that there is no quick fix
for back pain, not even surgery,” Dr. Frank advises.
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.(12)
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.(13)
It is imperative that patients be convinced that active
participation in the prescribed physical therapy is
necessary to facilitate their recovery.
Prescribing Physical Therapy
As a firm advocate of physical therapy to treat lower
back pain, Dr. Christine M. Villoch, physiatrist and
interventional spine care specialist at CINN, agrees
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,” she says. Dr. Villoch finds that 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 is to keep
the spine in as neutral a position as possible,”
Villoch explains.
“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.”(14)
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.(15)
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 LBP, 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.(16)
For acute flexion-based LBP, McKenzie exercises and
those that emphasize stretching of the hamstrings are
often best. For acute extension-based LBP, 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.17
Throughout these treatments, it is recommended that
the lines of communication between specialists and the
patient’s general practitioner be kept open. Dr.
Villoch reports, “in my 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.”
Lower 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 LBP sufferers. “Exercise
empowers patients to take an active role in their treatment,”
notes Dr. Frank. “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.”
|
