“A
rational approach to the treatment of low back
pain." B
Nelson, MD. Journal of Musculoskeletal Medicine
10(5): 67-82, 1993.
ABSTRACT:
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.
INITIAL ENCOUNTER
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.
History
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.
Imaging
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.
Acute or chronic pain?
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° to reduce disc pressure), lifting
strategies (keeping objects close to the body and
lifting with the legs rather than the back), and
stabilization techniques (finding the body's neutral
position and tightening the trunk muscles to stabilize
that position).
Early introduction of stretches and back exercises
that emphasize the lumbar extensors can promote the
healing mechanism. These exercises include prone
lumbar extensions, prone lower trunk rotations, the
single knee to chest stretch, pelvic tilt, and diagonal
abdominal curl-up.
Most patients improve rapidly. The patient who is
not improving after 4 to 8 weeks is at high risk
for becoming a chronic-back pain patient. It is these
patients who generate about 85% of the costs associated
with back pain. 3 What can you do to prevent a chronic
condition from developing?
The choices for the next step are vast: more tests
(electromyogram, CT, MRI, discogram, dynamic roentgenogram);
more treatment (traction, aquatic therapy, epidural
injections, massage, transcutaneous electric nerve
stimulation); referral to a specialist (orthopedic
surgeon, neurosurgeon, neurologist, physiatrist);
or observe and recheck. Or you can prescribe functional
rehabilitation, which provides the best chance for
a good outcome and is also cost-effective.
LUMBAR OR PELVIC FUNCTION
It is possible for a body to be strong everywhere
except the back; to be in excellent physical condition
but still have a weak back.
Swimming, bicycling, weight lifting, jogging, and
walking all are excellent exercises, but none specifically
improve spinal function, nor do any strengthen a
spine that is weak, stiff, or atrophied. The back
can be meaningfully exercised only when the lumbar
spine is moving against resistance.
The difficulty in achieving true back exercise is
demonstrated by a "low back" exercise machine,
on which a patient sits, leans backward against a
thoracic pad attached to a stack of weights, and
performs multiple repetitions against resistance.
These machines do not exercise the lumbar spine.
Rather, they exercise the pelvic extensors, the hamstrings,
and glutei.
A patient with a sore back will reflexively change
body mechanics to protect the back, substituting
pelvic motion for lumbar motion. Even with a severe
lumbar injury, a patient may work out on an exercise
machine, all the while protecting the lumbar spine
from meaningful exercise.
A study at the University of Florida confirmed that
vigorous exercise on low-back machines does not build
strength in the lumbar spine. 13,14 Seventy-seven
volunteers were tested for isolated lumbar extensor
strength, then were divided into three groups: 41
completed a program of exercise on standard "back" exercise
machines typically found in physical therapy clinics;
21 exercised on equipment that isolated the lumbar
extensors by stabilizing the pelvis and allowing
no pelvic motion; 15 did no exercise and served as
a control group.
At the end of the 12 weeks there was no significant
difference (P < .05) in lumbar extensor strength
between the standard-machine group and the no-exercise
group. There was a large increase in back strength,
however, averaging 120% in the fully extended position,
in the group that did lumbar extension exercises
with the pelvis stabilized. The investigators concluded
that exercise without pelvic stabilization was not
effective for developing strength in the lumbar extensors.
Thus, while standard exercise machines may contribute
to a well-rounded rehabilitation program, they do
not exercise the lumbar extensors. Some patients
may be reluctant to exercise a painful lumbar spine,
but they must do so to produce true improvement in
lumbar function. Patients usually are willing to
work through the initial pain, provided they are
convinced that their effort will help their back
problem. They must be "sold" on exercise,
and this is a responsibility of both the physician
and the therapist. Without education and encouragement,
many patients quit with the first discomfort.
Meaningful lumbar strengthening can be done only
with the use of equipment that stabilizes the pelvis
and isolates the lumbar spine. Such equipment usually
is available only in professional settings. However,
patients can do exercises at home to maintain strength.
They will not make gains, but they can maintain current
strength with a home-based rehabilitation program.
FUNCTIONAL RESTORATION
For the vast majority of patients, the best approach
to rehabilitation of back problems is functional
restoration: treatment designed to restore spinal
strength, endurance, and flexibility to its normal
state. ("Functional restoration" as used
here does not include psychological, vocational,
social, and dietary interventions, as it does in
some centers.) A functional restoration program presupposes
that normal function is known and that the ability
to accurately measure function is available.
The goal of such treatment is to normalize function,
not to decrease pain, although pain relief is a desirable
byproduct. If function cannot be normalized, it should
at least be maximized, so that a patient reaches
as high a functional level as possible. Functional
restoration is best accomplished through a program
of progressive resistive exercise to strengthen the
trunk muscles, especially the lumbar extensors.
Such rehabilitative efforts may involve some patient
discomfort, especially in a previously sedentary
patient. However, provided the exercises are controlled
and supervised by a professional, no damage will
be done. Pain need not be interpreted as a warning
to stop exercising. Many investigators have found
that patients with chronic back pain have pain early
in a rehabilitation program and experience the benefits
only after a month or more. 15-18
An accurate baseline measure of functional ability
is established at the initial examination. Pain that
increases during a rehabilitation program can be
characterized as "bad" (pain associated
with deteriorating physical examination parameters
and decreasing spinal function as measured by a physical
therapist), or "good" (pain associated
with improvement in objective function and in physical
examination parameters, or at least with no negative
changes).
If the pain is "bad," then treatment needs
to be modified. Exercise frequency or intensity may
need to be reduced or a certain exercise stopped.
Further diagnostic testing may be in order. If the
pain is "good"" rehabilitation continues.
Even if the patient experiences some discomfort
at the beginning of a vigorous rehabilitation program,
treatment should continue as long as the patient
is measurably, objectively increasing lumbar function.
On average, 18 sessions over 2 to 3 months are needed
to optimize function. 13, 19-21
CHOOSING A FACILITY
The clinician who refers back pain patients for
rehabilitation should become acquainted with the
facility and the therapists or physicians who will
be guiding the rehabilitation. A visit to the physical
therapy center may help ensure that patients are
well supervised in a program emphasizing functional
restoration.
It is important that the center accurately measures
strength, flexibility, and endurance. It should have
equipment to pro- vide valid and reproducible measurements
of lumbar function and exercise machines that stabilize
the pelvis, thus allowing for meaningful lumbar exercise.
The center should develop goals for each patient
and make clear to each patient that the purpose of
rehabilitation is to improve spinal function-not
to decrease pain. As mentioned previously, the majority
of patients able to improve spinal function will
also experience a decrease in pain, which is often
dramatic but which remains a secondary goal.
EDUCATION
A proper goal of treatment is for patients to learn
to manage back problems on their own. You may find
it helpful to make available patient bulletins on
various topics. Giving patients a page of information,
written in layman's terms, on such topics as the
incidence of false positive results of imaging studies,
when surgery is and is not indicated, and the importance
of and rationale for exercise, may save you time
and act as a reminder of important information for
the patient.
Dependence
In our zeal to help patients, we sometimes disable
them. They become dependent on our participation
and the medical system for pills, tests, permission
not to work, and continual therapy. But if from the
beginning of treatment the focus is on teaching patients
to be their own back doctors, dependence can be avoided.
First, explain to patients that back pain is a normal
part of human experience. To be alive is to know
back pain. Then guide them in maximizing their spinal
function, using aggressive, intensive exercise. Also,
teach lifelong strategies, such as body mechanics,
stabilization, and home exercises, for dealing with
the condition. Instilling these attitudes early fosters
independence and better outcomes. For an acute episode
of back pain, muscle relaxants and non-steroidal
anti-inflammatory drugs may have a place short term
but are to be avoided as long-term medication.
SURGERY
Even strong proponents of non- operative care for
most spinal conditions are not necessarily opposed
to surgery. However, surgical treatment, especially
fusion for chronic back pain, should be considered
only under the following circumstances:
The patient has failed a good functional restoration
program and has intractable pain significantly affecting
the activities of daily living.
The patient has shown a good-faith effort to get well and does not demonstrate
undue signs of symptom exaggeration.
A specific surgical lesion understood to be causing
the pain can be identified.
I have treated dozens of patients thought to be surgical candidates who,
after an aggressive functional restoration program, significantly improved
and were able to avoid surgery. Preliminary studies suggest that the improvement
is lasting. Among 950 patients who completed a rehabilitation program, 220
had entered the program believing they were surgical candidates, either because
of previous diagnosis or severity of the pain. At post program follow-up
averaging 13 months, 71% of these believed that rehabilitation had allowed
them to avoid surgery.
Surgery for a patient showing signs of symptom exaggeration
is not recommended. The outcome is usually poor,
with patients often continuing to complain of severe
symptoms. Similarly, patients treated surgically
for poorly defined back pain tend to do poorly. The
Quebec Task Force on Spinal Disorders reported that
surgery for back pain alone is an unproven remedy.
3 Surgery should he reserved for patients who meet
strict criteria.
Treatment with functional restoration, on the other
hand, is usually successful, especially in patients
with lumbar disc syndrome, spondylolysis, spondylolisthesis,
degenerative arthritis, degenerative disc disease,
lumbar strain, or mechanical low back pain. Elderly
patients with spinal stenosis and significant leg
pain may also achieve lasting relief through exercise.
These patients usually show significant and sometimes
dramatic increases in strength, flexibility, and
endurance.
THE INTRACTABLE PROBLEM
Despite our best efforts, physicians and patients
must recognize that some patients cannot be cured.
Some cannot even be helped to improve? The best strategy
to use with such patients is honesty and compassion,
along with time. Talk at length with the patient
and explain why more treatment or diagnostic testing
is not warranted. Counsel the patient on proper body
mechanics and exercise, explain that such injuries
cannot be effectively treated with rest and inactivity,
and provide reassurance that "hurt" does
not necessarily mean "harm."
If a patient fails an appropriate rehabilitation
program and does not have an identifiable surgical
lesion (fewer than 5% do), then further treatment
is, at best, palliative and will have no lasting
effect. Patients who accept the situation and try
to resume a normal life usually do best. A rational
strategy based on the known physiology of soft tissue
is most effective in treating back pain. Being able
to offer help to a patient with spinal pain may change
a depressing physician/ patient experience into a
rewarding one.
References
