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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 nonsteroidal 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 cyclooxygenase2 inhibitionrofecoxib (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
Superficial heat Analgesia Reduction Impaired sensation, circulation,
(hydrocolloid in muscle spasm
cognition Edema Bleeding
packs)
Increased tolerance diatheses
for exercise
Ultrasound
(deep heat)

Cold packs

Prescription
Apply to affected area
for 20 to 30 minutes;
inspect skin frequently
during therapy; repeat
application every 2
hours as needed.
Analgesia Increased Same as for superficial heat Never Apply 0.5 to 2.0 W per
length of
use deep heat near cardiac
cm2 to affected area for
periarticular
pacemaker or fluid-filled cavities 10 to 15 minutes before
ligaments and
(e.g., eyes, uterus, testes,
range-of-motion
tendons
laminectomy sites). Avoid use of exercises are performed.
deep heat near open epiphyses,
malignancies or joint
arthroplasties.
Analgesia
Impaired sensation, circulation,
Apply to affected area
Limitation of edema cognition History of cold
for 20 to 30 minutes;
formation in acute intolerance
inspect skin frequently
musculoskeletal
during therapy; repeat
injury
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.