eMedicine Specialties > Physical Medicine and Rehabilitation > Lumbar Spine Disorders

Mechanical Low Back Pain: Follow-up

Author: Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Contributor Information and Disclosures

Updated: May 21, 2009

Follow-up

Further Inpatient Care

• Mechanical low back pain (LBP) generally is treated in an outpatient setting. Inpatient care may be appropriate in some cases when compelling evidence of neurological deficits is present along with an accompanying history of infection, malignancy, and/or trauma. The initial medical workup should be performed in the general acute hospital setting.
  • Patients who are elderly or severely disabled with no social support may need to be admitted into a medical setting for diagnostic studies and therapeutic interventions.
  • A comprehensive interdisciplinary approach combines the medical management of the pain with the functional restoration of motion and activities of daily living that is achieved through physical and occupational therapy.
  • More varied modalities can be used in the rehabilitation unit (eg, aquatic therapy, other physical modalities), as can counseling for the patient and his or her family. Psychological counseling may be more readily available in the rehabilitation unit, compared with the general medical or surgical unit.

Further Outpatient Care

• The proper application of physical therapy, analgesic medications, and selected injections (when warranted) can produce a positive impact on the functional outcome of mechanical low back pain (LBP).
• Careful and complete history gathering, objective physical examinations, and clearly prescribed therapeutic interventions are fundamental in the management of mechanical LBP.
• Patients may need regular follow-up and careful monitoring to ensure a positive outcome. Structured daily activity is crucial to encourage patients to realize that their efforts result in a positive outcome.
• The most successful management of mechanical LBP comes from an interdisciplinary team approach of physicians, therapists, counselors, and case managers.
• Sometimes, the physician needs to return to the history when if a puzzling clinical presentation that cannot be resolved.
• Ensuring care between the physicians and therapists is coordinated, evidence-based medical practices are being used, and certain published guidelines are being considered may help achieve the optimum treatment for LBP patients.

Inpatient & Outpatient Medications

• The most commonly prescribed medications for mechanical low back pain (LBP) are NSAIDs, muscle relaxants, opioid and nonopioid analgesics, and antidepressants.
  • NSAIDs provide satisfactory analgesic relief for most cases of mechanical LBP. NSAIDs are very easy to obtain in prescribed formulations and as over-the-counter preparations.
  • Muscle relaxants, in combination with the NSAIDs, may provide symptomatic relief to the low back musculature and promote more freedom of movement.
  • Opioid medications generally are not used as first-line treatments for mechanical LBP.
  • Nonopioid medications are being combined with NSAIDs to achieve adequate pain relief without the adverse effects of opioid medications.
  • Antidepressants are helpful adjuncts to the bio-psycho-social effects of chronic LBP.

Transfer

• Patients with mechanical low back pain (LBP) may present to their family physicians or to the emergency department of a hospital or clinic. After determining the patient has no life-threatening cause for the mechanical LBP (eg, tumor on the spine, fracture of the axial spine), consideration should be given to transferring the patient to an appropriate outpatient care facility or to an inpatient rehabilitation unit for pain management, reconditioning of muscles, and preventive treatment.

Deterrence

• Prevention of most cases of mechanical low back pain (LBP) can be achieved using good biomechanical principles when performing heavy manual labor. Deterrence and prevention information is mostly anecdotal and depends on education and raising the awareness levels of individuals at risk for developing mechanical LBP.

Complications

• Complex social, legal, and economic issues tend to produce most of the complications surrounding mechanical low back pain (LBP). A full account of these issues is beyond the scope of this article. The following complicating factors have been associated with extended care of LBP and should be viewed as "yellow flags" to help the physician explore other causes to the chronic spinal condition being presented:
  • Trauma
  • Greater than 4 separate episodes of LBP
  • Sciatica defined as pain extending below the knees
  • Skeletal anomalies
  • Heavy smoking
  • Multilevel degenerative joint disease
  • Job dissatisfaction
  • Job disability in previous 12 months
  • Psychological distress and abnormal illness behavior (eg, positive Waddell signs, pain consistently rated 9/10, pain avoidance behavior, symptom proliferation, total body pain, collapsing or inability to move)
• In an informal survey of chiropractors who were asked to rate the top 10 "back-breaking jobs," the number 1 job was heavy truck driving. Following, in no particular order, are the next 9 jobs:
  • Construction worker
  • Landscaper
  • Police officer (due to long hours sitting in a car then having to respond to a call for help)
  • Farmer (because self-employment, tend to respond rapidly to pain management interventions)
  • Roofers (often in awkward, bending positions for long periods)
  • Firefighters and emergency medical technicians
  • Delivery drivers
  • Nursing home workers
  • Auto mechanics

Prognosis

• The prognosis is good for recovery from mechanical low back pain (LBP). At 1 month, 35% of patients can be expected to recover; at 3 months, 85% have recovered; and at 6 months, 95% have recovered.
• Failure of a patient to recover should lead the clinician into a more thorough and extensive search into the cause of the back pain, including the possibility of recurrent back injuries.
• Recurrence at 1 year is 62%. At 2 years, 80% of patients have had 1 or more recurrences. The question remains whether this is the inevitable result of natural aging, continued pathologic processes, somatization, or a combination of all of these. Clearly, much more research is required.

Patient Education

• Patient education should begin with reassurance and a management plan, even though a precise pathoanatomic diagnosis may not be possible.
• The importance of educating patients to understand that uncomplicated mechanical low back pain (LBP) has a natural course of recovery cannot be overemphasized.
• One consistent finding from a review of the literature is that people who are depressed, have poor job satisfaction, and can receive compensation as long as their backs hurt have an increased prevalence of mechanical LBP that develops into chronic disability.
• Deal with external factors that influence recovery, including anxiety, and increase the patient's understanding of the expectations of key players (eg, family, physician, employer) compared with his or her own goals.
• Posture, reconditioning, proper nutrition, and stress management also should be addressed.
• For excellent patient education resources, visit eMedicine's Osteoporosis and Bone Health Center and Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Back Pain, Sprains and Strains, and Pain Medications.

Miscellaneous

Medicolegal Pitfalls

• The potential medical and legal pitfalls in cases of mechanical low back pain (LBP) are numerous and varied. The foremost medical pitfall is failure to correctly diagnose the cause of LBP. Legal pitfalls occur when attempting to establish causality for the LBP, especially in the presence of preexisting conditions.
• To the primary care physician, mechanical LBP is usually a benign illness. The clinician must be careful to rule out any congenital, metabolic, infectious, or malignant processes as the cause because these medical conditions could lead to more serious disease.
• In the absence of any underlying medical cause for the LBP, the goal of treatment is reduction of pain and maximization of function, but this may be very difficult to achieve in cases of mechanical LBP that occurred in work-related injuries or motor vehicle collisions.
• When recovery is delayed or questions arise over a case of mechanical LBP, an independent medical evaluation (IME) may be requested.
  • An IME is usually requested by either the defense or plaintiff's attorney, claims adjuster for an insurance company, administrative adjudicator, or their representatives.
  • No physician-patient confidentiality exists because all parties have access to the report.
  • No physician-patient relationship is established because the IME is performed to answer questions about the case and not for the purposes of medical treatment.
• The workers' compensation system was set up on the basic premise that an employee injured on the job would receive appropriate medical services free of charge. The employer or his designated agent would pay these medical services; however, several basic flaws exist in the workers' compensation system.
  • Workers' compensation systems vary from state to state.
  • Over the years, a great deal of mistrust has developed between injured employees and their employers, mainly over each party's responsibilities.
  • Compensation for patients remaining injured and unable to work may be sufficiently more attractive to the injured employee than returning to work, especially in situations of low job satisfaction or poor social support.
  • The costs of compensating work-related injuries in terms of lost wages and productivity add significant costs to employers who may be unable to pass these costs on to their customers.

Special Concerns

• Patients presenting with work-related mechanical low back pain (LBP) may require a determination that maximum medical improvement was reached before they can be released to return to work. Maximum medical improvement is a term used to indicate that no further recovery of restoration of function is anticipated to occur within the next 12 months.
• The following terms have unique legal definitions and the terminology may vary in different jurisdictions. The physician is advised to check the acceptable terminology in the appropriate jurisdiction.
  • Exacerbation refers to a temporary increase in symptoms of a preexisting condition. Exacerbation is generally seen as a flare-up of symptoms.
  • Aggravation refers to a long-standing factor due to an event that alters the course or progression of the medical impairment. The aggravation results in worsening, hastening, or deterioration of a condition.
  • Causation is defined as an identifiable factor that results in a medically identifiable condition.
  • Apportionment represents the distribution of causation among many factors that caused or contributed significantly to the impairment.
• Depending on the date of onset, most patients can be encouraged to return to work in some capacity (eg, sedentary, light) with lifting restrictions.
• Establishing time-limited and functionally oriented goals with the patient and the physical therapist is important. If goals cannot be met, then the treatment program should be modified.
• Close communication between the physician and physical therapist is essential. The patient may report continued pain with certain exercises. If these persist, the patient should be referred back to the physician for further evaluation.

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