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Clinicians should approach low back pain conservatively.
Acute low back pain (LPB)—a pain that varies from dull to stabbing, just worrisome to overtly preoccupying—generally forces patients to limp into the clinic or balance precariously on their seats to avoid aggravating it. It’s a common concern in retail health clinics because more than a quarter of adults indicate that they have experienced LBP during the previous 3 months. When LBP becomes disabling or causes people to miss work (as it often does), patients want relief.
Because clinicians of all types have tended to over-treat LPB, it’s critical to approach this condition conservatively.
Patients can sometimes identify precipitating factors like slipping or falling, or lifting something heavy. Just as often, though, they report that they just noticed it when they woke one day. People who operate machinery that vibrates or drive long distances are at elevated risk. Aging, obesity, lack of exercise, or inconsistent exercise (no exercise for days punctuated with bouts of weekend warrior-type exercise) can predispose to LBP.
Acute LPB is usually a mechanical problem that lasts few days to a few weeks, and then resolves completely. Once the spine, muscle, intervertebral discs, and nerves heal or realign, the pain and discomfort go away. If pain continues, the diagnosis changes to subacute low back pain (lasting between 4 and 12 weeks). Pain that persists for 3 months or more is considered chronic, occurs in about 15% of patients, and is treated differently.
During assessment, observation is imperative. Patients may place their flat hands on the back, indicating regional or diffuse pain, or point to an exact location. When taking a history and physical, retail health care providers should routinely ask about pain location and duration; symptom frequency; when it started; if the patient has had previous LPB, and if so, what worked to relieve pain.
Guidelines also recommend psychosocial assessment because it can identify patients whose recovery may be slow. Depression and anxiety often aggravate LBP, slowing its resolution.
Patients who lack coping skills or have a substance abuse disorder also are at risk of progressing to subacute or chronic LBP.
Nonspecific or a Bigger Problem?
Current guidelines divide back pain into:
Red flags for more aggressive diagnostics or referral include numbness or muscle weakness, or associated bowel pattern disruption. Fever and unusual weight loss indicate an underlying pathology. A positive straight leg raise (pain at an angle of 30oto 70o) or great toe and foot dorsiflexion indicates herniated disc.
Most LPB will be nonspecific, and early imaging or other diagnostic tests are completely unnecessary. Patients who undergo plain radiography or advanced imaging with computerized tomography (CT) or magnetic resonance imaging have no better outcomes than those who don’t.
Simple Remedies Work for Nonspecific LBP
When recommending interventions, retail healthcare providers need to explain the expected course to patients, advise them to remain active, and provide information about effective self-care options. Many of these interventions seem simple, but patients usually need detailed explanations.
Applying heat or cold packs may relieve pain in select patients. Patients need specifics when clinicians recommend these interventions, so they should qualify their advice:
Stepping Up to Medication
Patients who are having pain may find relief from OTC analgesics, starting with acetaminophen or the nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen or naproxen at recommended dosages. Scheduling doses around the clock for 3 to 4 days can break the pain cycle.
When recommending analgesics, remember that NSAIDs can increase cardiovascular risk, elevate blood pressure, and cause or contribute to gastrointestinal bleeding. Employ the lowest effective dose for the shortest period of time.
A short trial of muscle relaxant or a topical analgesic may help LBP. Reserve opioid analgesics, tramadol, or benzodiazepines for pain unrelieved by the non-opioid drugs.
Maintaining activity with light stretching and walking seems to speed healing. And alternatively, bedrest can worsen LBP, especially if it exceeds 4 days. Patients often need to be reminded that if they attempt movement and it hurts, they should stop.
Some patients’ pain responds to massage, and a skilled masseuse will know how to offer relief without aggravating the pain.
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.Ann Intern Med.2007;147(7):478-491.
D'Arcy Y. Is low back pain getting on your nerves?Nurse Pract.2009;34(5):10-17. doi: 10.1097/01.NPR.0000350564.15612.33.
Hills EC, Kishner S. Mechanical low back pain. Medscape website. emedicine.medscape.com/article/310353-overview. Published May 27, 2016. Accessed January 8, 2017.