In the primary care setting, we often encounter visits regarding back pain in general. Amongst these visits, lower back pain is amongst the top reasons to visit a medical office in the United States, and is a leading cause of work-related disability.
When someone 'throws out their back', most often times, these symptoms arise from the spine, vertebral disks, or surrounding soft tissues. It is important to be evaluated and undergo a physical exam to understand the root cause of back pain.
Your doctor may reserve imaging on initial presentation unless there are symptoms concerning for more severe disease, including spinal cord compression, malignancy, fractures, or infections. For the sake of this article, we will focus on the more common cause of back pain which is usually nonspecific or mechanical in nature.
Back pain can be distinguished based on duration of symptoms, and location. This article will focus on acute lower back pain, which will help you understand how proper evaluation and management can help prevent recurrence of symptoms. When symptoms are on going and longer than 6 weeks in duration, this is called chronic back pain and management options slightly differ.
Most patients who experience severe lower back pain, go on to have recurrent episodes. Chronic lower back pain affects up to 23% of the population worldwide, often reoccurring yearly. To avoid this disabling occurrence of pain, it is important to have proper evaluation and treatment options with your primary care physician.
Acute Low Back Pain
Acute low back pain occurs with muscle tension, stiffness localized between the lower rib cage and buttocks. The symptoms often last less than 6 weeks in duration. Most patients who visit their family physician have no clear or identifiable cause of their pain.
The good news is that most episodes are mild in nature, with less than 10% of patients developing intense lower back pain. Most patients will have complete resolution of symptoms, but approximately 30% will have recurrence within 6 months of injury.
When reviewing data from primary care offices, about 1% of patients with acute lower back pain have a serious underlying cause of pain.
Risk Factors
It is important to understand the root causation of acute lower back pain to help prevent recurrence of injury and symptoms. Risk factors include:
Heavy physical work
Frequent bending, lifting, and twisting
Squatting/kneeling
Awkward lifting or with poor form/technique
Prolonged static postures
High television viewing times (>2 hours/day) - This one was surprising.
Prolonged standing
High psychosocial demand jobs
Psychological factors such as depression and anxiety
Causes Of Mechanical Low Back Pain
Mechanical low back pain can involve injury to the spine, intervertebral disks, or surrounding soft tissues. This includes:
Lumbosacral muscle strain (70% of injuries)
Disk herniation
lumbar spondylosis
spondylolisthesis
Spondylolysis
Vertebral compression fractures
Acute or chronic traumatic injury
Repetitive trauma and overuse are common causes of recurrence of pain and often times secondary to workplace injury.
Evaluation Of Lower Back Pain
These days patients opt for the convenience of telemedicine visits, but we request that patients be evaluated in office with a proper physical examination to help assess the root causes of low back pain.
Your physician will obtain a detailed history including many aspects of pain. It is important to also discuss risk factors and occupational hazards to help understand how to help prevent future occurrence of pain. One key aspect to take into consideration is mental health, as patients with psychosocial issues are more likely to develop chronic back pain and associated disability by their symptoms.
Once a detailed history is obtained, your physician will examine your back. Focusing on strength, range of motion, sensation and point tenderness associated with your injury. A common examination technique is called the straight leg raise test and crossed straight legs test to help determine if their is any disk herniation involved in the presentation of pain. This simple office examination is sensitive to help guide further treatment.
Imaging
Patients should know the evidence behind why we choose to do imaging. Unless there is a concern for cord compression, malignancy, fracture, or infection, obtaining images on initial assessment is not recommended based on the evidence.
The American College of Radiology recommends imaging only if there is no improvement after six weeks of conservative medical and physical therapy management. Of if there is high suspicion for more severe disease.
Unless indicated, it is appropriate to begin therapy without imaging in adults younger than 50 years. If your physician is not concerned for systemic disease, older adults may begin therapy as well prior to obtaining any imaging.
Treatment Options
Our practice approaches low back pain over two visits. Initial office visit is to identify any red flag symptoms which would prompt additional images to help diagnose. If none are identified, patients are given education, advice on pain control and referral to physical therapist trained in the McKenzie Method.
The McKenzie Method is also termed mechanical diagnosis and therapy management which is provided by a trained physical therapist. This is followed by an individualized self treatment program which has been shown to have moderate evidence for acute back pain. In terms of chronic back pain, there is no difference to outcomes when this method is applied.
We recommend to avoid the usage of opioids for acute low back pain, and find that most patients pain is improved with the usage of non steroidal anti-inflammatory drugs, which are considered first-line treatment to provide short term pain relief.
At times, skeletal muscle relaxants and corticosteroids can be added for symptomatic relief of acute low back pain. However, this needs to be discussed in detail with your doctor as these medications often come with side effects.
During their second visits to the office, we assess adherence to previously recommended therapy and re-evaluate for alternate diagnosis if treatment fails to improve symptoms.
Osteopathic Manipulative treatment, trigger point injection, acupuncture and massage therapy also show some benefit in acute back pain.
There is strong evidence to advice patients to stay active, avoid aggravating movements, and return to normal activity as soon as possible. This approach has been shown to be more effective for return to work and long-term pain control in patients with acute low back pain.
If pain is disabling and negatively impacting quality of life for more than one year, your physician may request a surgical evaluation for further management.
Additional treatment options
We believe in treating the underlying cause of pain and often incorporate cognitive behavior therapy into the treatment plan as this has shown greater improvement in back pain and functional limitations in chronic low back pain.
There is also strong evidence in both acute and chronic low back pain to implement yoga into the treatment plan.
When researched lumbar supports or back belts are considered ineffective in preventing low back pain, but their use during an acute injury may be beneficial. Instead strengthening the back with appropriate exercise help prevent recurrences of back pain.
Conclusion
When you 'throw out your back', it is important to be evaluated by your primary care physician. An appropriate history and physical examination helps direct treatment options and determines the need for prompt imaging. There are many approaches to treatment which includes medications, physical and cognitive therapy.
Recurrence of back pain can occur, and strengthening the core with appropriate exercises can help prevent recurrent injuries. Patients with nonspecific acute low back pain without sciatica (nerve pain) should be managed conservatively with non drug therapies including heat, massage, and advice to stay active.
Bed rest should be avoided.
Prevention of illness is the key to longevity in life. We, at Florida Advanced Medicine, are here to help you achieve your health and wellness goals. A good primary care doctor by your side is important to help keeping your health optimized.
Remember, prevention is better than cure. Learn more about services we offer in our Family Medicine clinic located in beautiful Orlando, Florida.