"A rational approach to the treatment of low back pain."
B Nelson, MD. Journal of Musculoskeletal Medicine 10(5): 67-82, 1993.
At the initial visit of a patient with low back pain, the physician must set a positive tone emphasizing that the problem is common in the human body and can be remedied. Initial treatment is 1 or 2 days of rest, a short course of analgesics, and stretches and other exercises. The 5% to 18% of patients who do not improve within 3 months (chronic pain patients) or have a relapse frequently require an active functional rehabilitation program. Exercises are helpful only if they focus on the lumbar extensors. Patients may need encouragement at the beginning of the program to tolerate discomfort. Expensive imaging studies are reserved for patients who become disabled or show no improvement. Only when a lesion is identified in a patient who has seriously tried and failed conservative rehabilitation is surgery considered.
I have read any number of review articles on the treatment of low back pain, most of them well written and technically accurate. Nevertheless, the next day in the office I'd see another patient complaining of low back pain, and again I would be uncertain of what to do.
As I once did, you may find it depressing to see on your schedule that the next patient's chief complaint is low back pain. Because these patients are so difficult to help, many of us become conditioned to dislike them, and we approach them with a negative attitude. None of us enjoys treating patients we can't help.
Despite this, for the past 3 years, I have limited my practice exclusively to the non-operative treatment of back and neck pain. I have supervised the treatment of more than 4,000 such patients. At one time, I used traditional treatment methods and had the traditionally poor success rate. Now I believe that most of these patients can be treated effectively. The secret is in knowing what to do (active rehabilitation) and what not to do (prolonged passive modalities).
In this article, I present a step by step approach to the patient with low back pain, beginning with history taking and a physical examination to rule out causes of back pain that require urgent measures. I describe the initial regimen of palliation and the criteria for progressing to an active, intensive program of functional rehabilitation exercises emphasizing lumbar extension. I also discuss the point at which advanced imaging studies are useful, when to consider surgery, and how to manage the patient with intractable back problems.
The initial visit may be the most important factor affecting the outcome of a. patient with low back problems. During that visit, a psychological template is often created in the patient's mind. If told the injury is serious, the patient easily falls into the sick role. Conversely, if told that back pain is a benign, self-limited condition ubiquitous in humans, the patient may be less likely to take on a seriously "sick" role.
No one knows what causes most back pain, and in only 10% to 15% of the patients can a precise, symptom-related diagnosis be made. 1-5 The rest of the time we simply do not know. But, reluctant to tell our patients "I don't know," many of us say some thing, and our reports are often contradictory.
The confused patient does not know whom to believe when the chiropractor says that the spine is out of alignment, the surgeon says that the disc has degenerated and vertebrae need to be fused, the physical therapist says that the muscles need electrical stimulation and hot packs, and a neighbor says to wear a copper bracelet and all the pain will go away. The clinician should anticipate this confusion and address it, thereby reducing the chances that the patient will be uncooperative or noncompliant.
The statistics are familiar: following an acute back injury, 70% of patients are significantly improved after 2 weeks, and 90% to 95% are recovered within 2 to 3 months. 5-8 Why is it, then, that most patients we see in our offices with acute back injuries do not follow that pattern? The answer, I believe, is that most per sons who injure their back never see a physician and never become patients.
Those who seek attention have already selected themselves and are more likely to have chronic problems, or to have more severe injury, or to have a hidden agenda. Whatever the reason, the person with low back pain who seeks medical advice often is among the 5% to 10% who have not improved within 3 months.
Given that a precise diagnosis usually cannot be made, a rational approach to the initial visit is to direct efforts at ruling out emergent causes of pain. Normally, by taking a thorough history and performing a thorough physical examination you can exclude tumor, infection, acute fracture, inflammatory arthritis, visceral sources of pain, or progressive neurologic deficit. With such critical diagnoses ruled out, you are able to concentrate on treatment.
The patient's history is probably the best tool for ruling out emergent causes of back pain.
Among the questions to ask are:
The answers to these questions may suggest the need for other diagnostic tests. For example, long-standing night pain unaltered by positional change suggests a space-occupying lesion, and imaging studies would be indicated to rule out tumor. A history of fever and chills with or without a previous infection any where in the body would indicate a bone scan to rule out low-grade infection. However, typically more than 90% of the patients will have non-emergent conditions, and in about 85%, an exact diagnosis cannot be made.
A great number of mistakes in caring for back pain relate to spinal imaging. When unsure of the cause of spinal pain, it may be tempting to blame a "spur" or "degenerated disc" seen on an x-ray film or to order another test. Such abnormalities are equally present in symptomatic and asymptomatic persons, however, and thus may be unrelated to the present symptoms. 9-12
Magnetic resonance imaging (MRI) studies are expensive ($600 to $1,200 each), their yield of clinically useful information is poor, and they should not be used as screening tools in these in stances. Furthermore, the vast majority of magnetic resonance scans are read as abnormal, with findings of bulging disc, desiccation at L5-SI, or facet arthrosis; unfortunately, the patient frequently is not told that abnormalities seen on spinal MRI may be unrelated to pain.
Moreover, we tend to forget how intimidating space-age technology may be for a layperson. Lying in an MRI scanner can be a stressful experience and may convince patients that their problem must be serious if such powerful equipment is required. When is a computed tomographic (CT) or MRI study indicated? Only when the results have the potential to change the treatment plan. The cost of a CT scan is approximately half that of a magnetic resonance scan. CT is better for visualizing bony lesions, whereas MRI is superior at depicting soft tissue.
Rest or exercise?
I am currently participating in a clinical study of chronic low back pain, involving the long-term follow-up of patients who have completed a rehabilitation program. More than one patient has criticized my care because a subsequent physician ordered an MRI study that showed the bulging disc or arthritis or degeneration that I "missed.' Had I discovered the "true" cause of the pain, they believe, I would not have pre- scribed exercise, stretching, and proper body mechanics. I would have told them to "take it easy."
But taking it easy does not work for chronic back pain. The Quebec Task Force on Spinal Disorders report, generally considered a balanced and fair evaluation of the passive treatment modalities for chronic back pain, concluded that no passive modalities appear to have any lasting effect. 3 Rest is simply another passive modality, with the added disadvantage that it promotes muscle atrophy, cartilage degeneration, stiffness, and depression. Passive modalities are appropriate in the early stages of an acute injury but have no place in the treatment of chronic pain.
Although there are certain spinal conditions that require a reduced activity level, in my experience, the far greater danger for most patients is in doing too little, not too much.
To make rational treatment choices, you must first understand the physiologic distinction between acute and chronic pain.
After a back injury, the body automatically begins the healing process, and soft-tissue healing usually is complete by 7 to 8 weeks. Nerve damage is generally secondary to another insult, such as pressure from a herniated disc or chemical irritation associated with inflammation. Treatment of nerve damage or irritation is therefore directed at the primary injury. Nerve tissue often takes longer than 7 to 8 weeks to heal. It is less resilient than many other human tissues and is more susceptible to permanent damage.
If pain persists beyond 7 to 8 weeks, it is properly labeled chronic. Since the body has the capacity to heal itself, the goals of treatment following acute injury are to:
These goals are met by using passive modalities, such as hot and cold packs, electrical stimulation, massage, and ultrasonography, in the acute phase to provide palliation while the healing process progresses. Bed rest beyond I or 2 days is avoided, to prevent rapid deconditioning. Also helpful is education for the patient about back protection strategies, including postural advice (lying supine with the hips and knees flexed to 90