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Management of acute low back pain

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This document provides guidelines for the management of acute low back pain. It recommends starting with acetaminophen or NSAIDs for two to four weeks. Physical therapy modalities like heat, cold packs, and massage can provide relief for the first two to four weeks. Bed rest is not generally recommended except for two to three days for acute radiculopathy; otherwise, activity modification is preferred. Exercise programs focusing on weight loss, trunk strengthening, and stretching can help alleviate back pain. Patient education on back protection and lifestyle changes is important. Surgery is only recommended for select groups with complications like cauda equina lesions or worsening/resistant neurologic symptoms.

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Management of Acute Low Back Pain PHARMACOLOGIC THERAPY The mainstay of pharmacologic therapy for acute low back pain is acetaminophen or a non- steroidal anti-inflammatory drug (NSAID). If no medical contraindications are present, a two- to four-week course of medication at anti-inflammatory levels is suggested. Adequate gastrointestinal prophylaxis, using a histamine H2 antagonist or misoprostol (Cytotec), should be prescribed for patients who are at risk for peptic ulcer disease. Two new NSAIDs with selective cyclooxygenase–2 inhibition—rofecoxib (Vioxx) and celecoxib (Celebrex)—recently have been labeled by the U.S. Food and Drug Administration. These agents have fewer gastrointestinal side effects, but they still should be used with caution in patients at risk for peptic ulcer disease. For relief of acute pain, short-term use of a narcotic may be considered. The need for prolonged narcotic therapy should prompt a reevaluation of the etiology of a patient's back pain. REST Previously, bed rest was frequently prescribed for patients with back pain. However, several studies have shown that this measure has an adverse effect on the course and outcome of treatment. One randomized clinical trial found that patients with two days of bed rest had clinical outcomes similar to those in patients with seven days of bed rest. The group with a shorter rest period missed 45 percent fewer days of work and presumably avoided the effects of deconditioning and the fostering of a dependent sick role. The current recommendation is two to three days of bed rest in a supine position for patients with acute radiculopathy. Sitting, even in a reclined position, actually raises intradiscal pressures and can theoretically worsen disc herniation and pain. Activity modification is now the preferred recommendation for patients with nonneurogenic pain. With activity restriction, the patient avoids painful arcs of motion and tasks that exacerbate the back pain. PHYSICAL THERAPY MODALITIES Superficial heat (hydrocolloid packs), ultrasound (deep heat), cold packs and massage are useful for relieving symptoms in the acute phase after the onset of low back pain. These modalities provide analgesia and muscle relaxation. However, their use should be limited to the first two to four weeks after the injury. The use of deep heat may be subject to a number of restrictions.
Selected Therapies for Low Back Pain Therapy Indications Contraindications Prescription Superficial heat (hydrocolloid packs) Analgesia Reduction in muscle spasm Increased tolerance for exercise Impaired sensation, circulation, cognition Edema Bleeding diatheses Apply to affected area for 20 to 30 minutes; inspect skin frequently during therapy; repeat application every 2 hours as needed. Ultrasound (deep heat) Analgesia Increased length of periarticular ligaments and tendons Same as for superficial heat Never use deep heat near cardiac pacemaker or fluid-filled cavities (e.g., eyes, uterus, testes, laminectomy sites). Avoid use of deep heat near open epiphyses, malignancies or joint arthroplasties. Apply 0.5 to 2.0 W per cm2 to affected area for 10 to 15 minutes before range-of-motion exercises are performed. Cold packs Analgesia Limitation of edema formation in acute musculoskeletal injury Impaired sensation, circulation, cognition History of cold intolerance Apply to affected area for 20 to 30 minutes; inspect skin frequently during therapy; repeat application every 2 hours for 48 hours after injury as needed. No convincing evidence has demonstrated the long-term effectiveness of lumbar traction and transcutaneous electrical stimulation in relieving symptoms or improving functional outcome in patients with acute low back pain. Therapy should emphasize the patient's responsibility for spine care and injury prevention. CORSETS The role of corsets (lumbosacral orthoses, braces, back supports and abdominal binders) in the treatment of patients with low back pain is controversial at best. Use of a corset for a short period (a few weeks) may be indicated in patients with osteoporotic compression fractures. EXERCISE Aerobic exercise has been reported to improve or prevent back pain. The mechanism of action is unclear, and the relationship between cardiovascular conditioning and rate of recovery is not universally accepted. Excess weight, however, has a direct effect on the likelihood of developing low back pain, as well as an adverse effect on recovery. In general, exercise programs that facilitate weight loss, trunk strengthening and the stretching of musculotendinous structures appear to be most helpful in alleviating low back pain. Exercises that promote the strengthening of muscles that support the spine (i.e., the oblique abdominal and
spinal extensor muscles) should be included in the physical therapy regimen. Aggressive exercise programs have been shown to reduce the need for surgical intervention. CHIROPRACTIC Patients with acute or chronic back pain frequently seek chiropractic intervention. The Agency for Healthcare Research and Quality (AHRQ), previously the Agency for Health Care Policy and Research (AHCPR), and the Clinical Standards Advisory Group acknowledge the potential value of a short course of spinal manipulation in patients with acute low back pain. However, further research is needed to clarify the subgroup of patients most likely to benefit from this intervention. PATIENT EDUCATION It is critical to solicit the active participation of patients in spine care. Successful treatment depends on the patient's understanding of the disorder and his or her role in avoiding re-injury. Many hospitals and large businesses offer programs on back protection. These programs emphasize measures for avoiding spinal injury and review appropriate postures for sitting, driving and lifting. Weight loss and healthy lifestyle classes are also widely available. PSYCHOLOGIC EVALUATION Psychosocial obstacles to recovery may exist and must be explored. Studies have shown that workers with lower job satisfaction are more likely to report back pain and to have a protracted recovery. Patients with an affective disorder (e.g., depression) or a history of substance abuse are more likely to have difficulties with pain resolution. It is important for the physician to find out whether litigation is pending, because this can often adversely affect the outcome of therapy. INDICATIONS FOR SURGICAL EVALUATION Of all industrialized nations, the United States has the highest rate of spinal surgery (e.g., five times that of Great Britain). Studies examining the outcomes of conservative and surgical treatment of back pain have revealed no clear advantage for surgery. In one prospective study of 280 patients with herniated nucleus pulposus diagnosed by myelography, the surgical group demonstrated more rapid initial recovery than the medical treatment group. However, after approximately four years, outcomes appeared to be roughly equivalent in both groups; by 10 years, no appreciable differences in outcome were found. Select groups of patients with acute low back pain should undergo immediate surgical evaluation. Patients with suspected cauda equina lesions (characterized by saddle anesthesia, sensorimotor changes in the legs and urinary retention) require immediate surgical investigation. Surgical evaluation is also indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment.

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Management of acute low back pain

  • 1. Management of Acute Low Back Pain PHARMACOLOGIC THERAPY The mainstay of pharmacologic therapy for acute low back pain is acetaminophen or a non- steroidal anti-inflammatory drug (NSAID). If no medical contraindications are present, a two- to four-week course of medication at anti-inflammatory levels is suggested. Adequate gastrointestinal prophylaxis, using a histamine H2 antagonist or misoprostol (Cytotec), should be prescribed for patients who are at risk for peptic ulcer disease. Two new NSAIDs with selective cyclooxygenase–2 inhibition—rofecoxib (Vioxx) and celecoxib (Celebrex)—recently have been labeled by the U.S. Food and Drug Administration. These agents have fewer gastrointestinal side effects, but they still should be used with caution in patients at risk for peptic ulcer disease. For relief of acute pain, short-term use of a narcotic may be considered. The need for prolonged narcotic therapy should prompt a reevaluation of the etiology of a patient's back pain. REST Previously, bed rest was frequently prescribed for patients with back pain. However, several studies have shown that this measure has an adverse effect on the course and outcome of treatment. One randomized clinical trial found that patients with two days of bed rest had clinical outcomes similar to those in patients with seven days of bed rest. The group with a shorter rest period missed 45 percent fewer days of work and presumably avoided the effects of deconditioning and the fostering of a dependent sick role. The current recommendation is two to three days of bed rest in a supine position for patients with acute radiculopathy. Sitting, even in a reclined position, actually raises intradiscal pressures and can theoretically worsen disc herniation and pain. Activity modification is now the preferred recommendation for patients with nonneurogenic pain. With activity restriction, the patient avoids painful arcs of motion and tasks that exacerbate the back pain. PHYSICAL THERAPY MODALITIES Superficial heat (hydrocolloid packs), ultrasound (deep heat), cold packs and massage are useful for relieving symptoms in the acute phase after the onset of low back pain. These modalities provide analgesia and muscle relaxation. However, their use should be limited to the first two to four weeks after the injury. The use of deep heat may be subject to a number of restrictions.
  • 2. Selected Therapies for Low Back Pain Therapy Indications Contraindications Prescription Superficial heat (hydrocolloid packs) Analgesia Reduction in muscle spasm Increased tolerance for exercise Impaired sensation, circulation, cognition Edema Bleeding diatheses Apply to affected area for 20 to 30 minutes; inspect skin frequently during therapy; repeat application every 2 hours as needed. Ultrasound (deep heat) Analgesia Increased length of periarticular ligaments and tendons Same as for superficial heat Never use deep heat near cardiac pacemaker or fluid-filled cavities (e.g., eyes, uterus, testes, laminectomy sites). Avoid use of deep heat near open epiphyses, malignancies or joint arthroplasties. Apply 0.5 to 2.0 W per cm2 to affected area for 10 to 15 minutes before range-of-motion exercises are performed. Cold packs Analgesia Limitation of edema formation in acute musculoskeletal injury Impaired sensation, circulation, cognition History of cold intolerance Apply to affected area for 20 to 30 minutes; inspect skin frequently during therapy; repeat application every 2 hours for 48 hours after injury as needed. No convincing evidence has demonstrated the long-term effectiveness of lumbar traction and transcutaneous electrical stimulation in relieving symptoms or improving functional outcome in patients with acute low back pain. Therapy should emphasize the patient's responsibility for spine care and injury prevention. CORSETS The role of corsets (lumbosacral orthoses, braces, back supports and abdominal binders) in the treatment of patients with low back pain is controversial at best. Use of a corset for a short period (a few weeks) may be indicated in patients with osteoporotic compression fractures. EXERCISE Aerobic exercise has been reported to improve or prevent back pain. The mechanism of action is unclear, and the relationship between cardiovascular conditioning and rate of recovery is not universally accepted. Excess weight, however, has a direct effect on the likelihood of developing low back pain, as well as an adverse effect on recovery. In general, exercise programs that facilitate weight loss, trunk strengthening and the stretching of musculotendinous structures appear to be most helpful in alleviating low back pain. Exercises that promote the strengthening of muscles that support the spine (i.e., the oblique abdominal and
  • 3. spinal extensor muscles) should be included in the physical therapy regimen. Aggressive exercise programs have been shown to reduce the need for surgical intervention. CHIROPRACTIC Patients with acute or chronic back pain frequently seek chiropractic intervention. The Agency for Healthcare Research and Quality (AHRQ), previously the Agency for Health Care Policy and Research (AHCPR), and the Clinical Standards Advisory Group acknowledge the potential value of a short course of spinal manipulation in patients with acute low back pain. However, further research is needed to clarify the subgroup of patients most likely to benefit from this intervention. PATIENT EDUCATION It is critical to solicit the active participation of patients in spine care. Successful treatment depends on the patient's understanding of the disorder and his or her role in avoiding re-injury. Many hospitals and large businesses offer programs on back protection. These programs emphasize measures for avoiding spinal injury and review appropriate postures for sitting, driving and lifting. Weight loss and healthy lifestyle classes are also widely available. PSYCHOLOGIC EVALUATION Psychosocial obstacles to recovery may exist and must be explored. Studies have shown that workers with lower job satisfaction are more likely to report back pain and to have a protracted recovery. Patients with an affective disorder (e.g., depression) or a history of substance abuse are more likely to have difficulties with pain resolution. It is important for the physician to find out whether litigation is pending, because this can often adversely affect the outcome of therapy. INDICATIONS FOR SURGICAL EVALUATION Of all industrialized nations, the United States has the highest rate of spinal surgery (e.g., five times that of Great Britain). Studies examining the outcomes of conservative and surgical treatment of back pain have revealed no clear advantage for surgery. In one prospective study of 280 patients with herniated nucleus pulposus diagnosed by myelography, the surgical group demonstrated more rapid initial recovery than the medical treatment group. However, after approximately four years, outcomes appeared to be roughly equivalent in both groups; by 10 years, no appreciable differences in outcome were found. Select groups of patients with acute low back pain should undergo immediate surgical evaluation. Patients with suspected cauda equina lesions (characterized by saddle anesthesia, sensorimotor changes in the legs and urinary retention) require immediate surgical investigation. Surgical evaluation is also indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment.