It is estimated that 50% of working
adults suffer from back pain and 15-20% seek treatment.
This is an enormous strain on medical facilities, the
workplace, the individual, and society. Acute back pain
is defined as activity intolerance as a result of back
or back-related leg pain of < three months' duration.
About 90% of these individuals will recover spontaneously,
but the remainder will need special management. Chronic
back pain is a syndrome that has physical, psychological,
and social components. This is known as the biopsychosocial
There are many physical causes of back pain from trauma
to degeneration of the different anatomical structures
of the back. Initial management of these patients is
to determine the etiology of the pain and create a custom
treatment plan. If the condition is severe, such as
with a fracture, nerve involvement, cancer, tumor progression,
infection, inflammation, or recent onset of neurological
deficit, advanced therapy may be needed. If these severe
conditions are not present, then early return to work
should be facilitated.
If the back pain is simple, then treating with simple
analgesics is usually adequate. Medication side effects
should be monitored. Educating the patient on how to
walk, stand, lift, and general back care is extremely
important. Encouragement to return to work and normal
activities promotes healing. Walking and water exercises
are very helpful.
If there is nerve root compression, treatment will depend
on the severity. Less severe cases may respond to conservative
management. More severe pain may require physical therapy
(PT) to avoid debilitation. PT should focus on mobilization,
pacing of activities, and setting realistic goals for
the patient. Postures and movements that aggravate the
pain should be avoided and this may require some lifestyle
Gradual increase in activity is important. Conditioning
exercises for the back may be stressful initially and
should be avoided in the first few weeks. Patients with
sciatica will have longer recovery times and may need
more advice for back care than patients with less specific
Radiographic evaluation may be helpful if one remembers
that anyone > 30 y/o will have "abnormal"
findings. It does not always benefit the patient to
ascribe these changes as an etiology of the pain. Routine
blood work may show some medical condition as the cause
of the pain. If physical exam suggests tissue damage
or neural impairment then further radiological testing
Many patients with a disc problem will return to normal
activity within a month. There is nothing to indicate
that waiting for this period of time will make the condition
worse. Most of these patients improve whether or not
they have surgery. Surgery may speed the recovery but
only benefits about 40% of patients. Referral to a specialist
should be delayed until three months of conservative
therapy have failed unless severe symptoms occur. If
a patient has adverse neural tension of < six months'
duration, epidural steroids may help. If just one root
is involved, a single injection to that root may be
Lumbar facet and sacroiliac joint injections are indicated
when stressing these joints provokes pain. Post procedure
evaluation is important to differentiate between immediate
pain relief (which suggests pain arising from the joint,
responsive to radiofrequency denervation) and pain relief
of gradual onset peaking at 48 hrs (which suggests inflammation
of the surrounding tissues, and is more likely to benefit
from further steroid injections).
Treatment with botulinum toxin may be indicated for
patients with abnormal rigidity of the paraspinal muscles
that does not respond to medication management. Muscle
relaxation peaks at six weeks and lasts for up to three
months. Patients should be taught to maintain good posture,
movement, and activity management during this time.
Additionally, the multifaceted psychological needs of
the patient must be treated. Behavioral dysfunction
can be challenged and relaxation techniques, biofeedback,
and returning the "locus of control" to the
patient are all aims of intensive pain management programs.
These programs are combined with physical therapy, injections
and concurrent drug therapy.