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The Physiatrist’s Corner: Healing Low Back Pain (Part I)

This is the first article in our three-part series on low back pain (read Part II here) written by Dr. Danielle Sarno, a board-certified physiatrist with a sub-specialty in interventional pain management at Brigham and Women’s Hospital (BWH). In this series, Dr. Sarno addresses key points in the recently updated guidelines from The American College of Physicians, and discusses her own diagnostic and treatment approaches for patients with low back pain. For a description of physiatry, see “Why You Should See a Physiatrist.”     

Acute low back pain often resolves with self-care

Low back pain is one of the most common disorders in the United States. Approximately 80 percent of people will experience at least one episode of low back pain in their lifetime. 

Most low back pain is mechanical in nature, meaning the pain is triggered by movement of the spine and the source of pain may involve the intervertebral discs, vertebrae, facet joints, nerves, or soft tissues. Less frequently, low back pain may be due to an underlying medical condition. 

According to the National Institute of Health, most low back pain is acute, or short-term, lasting a few days to a few weeks. With self-care, which includes a short period of rest, heat and cold therapy, exercise, stress relief, and over-the-counter pain medication, this pain tends to resolve without loss of function.

Acute low back pain lasts less than 4 weeks, whereas subacute back pain lasts between 4 and 12 weeks. Approximately 20 percent of people with low back pain develop chronic low back pain (>12 weeks).

Those with chronic low back pain experience persistent symptoms, even after an initial injury or underlying cause of pain has been treated. 

What causes lower back pain? 

The following factors can increase the risk of developing low back pain: 

  • Older age: leads to degeneration of the spine, including joints, intervertebral discs, and bones.
  • Overweight/obesity: may cause strain on joints and structural changes to compensate for the weight.
  • Physically strenuous work: may cause sprain of ligaments, strain of tendons or muscles, and wearing down of joints.
  • Sedentary work: may promote postural imbalances.
  • Mental health factors: stress, anxiety, or depression may contribute to the cycle of pain.
  • Smoking: may damage vascular structures within discs and joints.

All patients are evaluated with a thorough history and physical examination

Before providing treatment options, I evaluate each patient with a comprehensive history and physical examination. 

Although it may not be possible to determine the exact cause of low back pain in many patients, the evaluation for evidence of specific causes of back pain is important.

I care for many patients who have mechanical low back pain without associated neurological deficits. Such patients do not require imaging studies. 

However, there are “red flags” (concerning signs and symptoms) that indicate need for further investigation.  

If you have any of the following, please seek an evaluation by a physician: 

  • New back pain if you are 70 years or older
  • Pain that persists, even at night or when lying down
  • Weakness in one or both legs or problems with bladder, bowel, or sexual function
  • Back pain accompanied by unexplained fever or weight loss
  • A history of cancer, a weakened immune system, osteoporosis, or the use of corticosteroids (e.g., prednisone) for a prolonged period
  • Back pain from a fall or an accident, especially if you are older than 50
  • Pain that spreads into the lower leg, particularly if accompanied by weakness in the leg
  • Back pain that does not improve within four weeks  

Imaging tests, including plain radiographs, magnetic resonance imaging (MRI), and electrodiagnostic studies, may be recommended for people with certain conditions.

Patients who have low back pain with neurological deficits, such as weakness and numbness, may require diagnostic studies to help determine the cause of their pain, especially before moving forward with an interventional procedure, such as an epidural steroid injection.

Imaging studies do not improve outcomes for acute, mechanical low back pain

Most patients with acute, mechanical low back pain do not require imaging studies, as the pain usually is self-limited and the findings may not change the treatment plan. 

According to the American Board of Internal Medicine, imaging studies within six weeks of pain onset are not recommended, unless red flags are present. Studies have shown that imaging of the lumbar spine before six weeks does not improve outcomes, but does increase healthcare costs.

Furthermore, structural abnormalities are common even among people without low back pain. For example, a herniated disc can be seen on MRI in 25 percent of people who do not have low back pain.

After reviewing the results, some patients may become fixated on the structural abnormality, such as mild arthritis or disc degeneration, which may not even be the source of their pain.

Treatment options 

While taking the ACP guidelines, other evidence-based recommendations, and patient preferences into account, I offer individualized treatment plans. 

For people with acute, mechanical low back pain, I often prescribe a non-steroidal anti-inflammatory drug (NSAID) for a short-course, and a skeletal muscle relaxant as needed. 

However, before I provide any prescription, I consider an individual’s medical history, such as cardiac, gastrointestinal, and renal disease, allergies, potential side effects, and medication interactions.

Non-pharmacologic treatment options, such as physical therapy (including therapeutic exercise), massage, acupuncture, and spinal manipulation (such as Osteopathic Manipulative Treatment), often are helpful, but cost and access to the patient must be considered. 

A lumbar epidural steroid injection may be appropriate for patients with low back and leg pain caused by irritation of a spinal nerve. An epidural steroid injection may reduce pain, allowing the patient to better tolerate physical therapy and a home exercise program. 

Other procedures, such as lumbar medial branch nerve blocks, or radiofrequency lesioning, may be offered for patients with back pain that arises from other causes, such as facet joint-mediated pain. 

For a more comprehensive discussion of non-pharmacologic treatment options, please see Part III. 

Movement is better than bedrest

A person with acute, mechanical low back pain should return to normal physical activity as soon as possible. Bed rest or inactivity longer than 48 hours can make the initial injury worse.

Inactivity leads to weakening of the core muscles. When core muscles are weak, other muscles compensate, which can contribute to poor posture and further exacerbation of pain (see the Osher Center’s Core Integration Course for Low Back Pain).

According to the National Institute of Health:

“Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain.

Strong evidence shows that people who continue their activities without bed rest following onset of low back pain appear to have better back flexibility than those who rested in bed for a week.

Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs.”  

Physical therapy helps people overcome fear of activity 

It’s common for people to think that movement may further injure their back and exacerbate their pain. They may fear and avoid certain activities, even simple movements such as bending over to tie their shoes.

To overcome this fear of injuring themselves through physical activity, I recommend that patients work with a physical therapist who can help ease them back into their daily activities or exercise routine. Patients may consider starting with aquatherapy (physical therapy in a pool), and gradually transitioning to land-based physical therapy. 

A physical therapist addresses soft-tissue impairments, strength and flexibility deficits, as well as postural and ergonomic issues that contribute to pain. 

By equipping patients with a home exercise program in addition to self-management education, physical therapy empowers people to take control of their pain. 

-- This is Part I of a three-part series. Read Part II here