Mechanical Low Back Pain Follow-up

  • Author: Everett C Hills, MD, MS; Chief Editor: Rene Cailliet, MD   more...
 
Updated: Jan 12, 2012
 

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.
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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.
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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.
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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.
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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.
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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
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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.
  • A prospective cohort study by Mehling et al reviewed outcome measures for recovery in primary-care patients with recent-onset acute LBP. Since a consensus does not exist about outcome definitions or how to identify when patients have failed to recover from an episode of LBP, the authors suggest that a combination of ratings from perceived recovery scales along with pain and disability measures be used as a highly accurate way to identify recovery.[27]
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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.
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Contributor Information and Disclosures
Author

Everett C Hills, MD, MS  Vice Chair, Department of Physical Medicine and Rehabilitation, Medical Director for Outpatient Services, Penn State Hershey Rehabilitation Hospital; Assistant Professor of Physical Medicine and Rehabilitation, Assistant Professor of Orthopaedics and Rehabilitation, Penn State Milton S Hershey Medical Center and Pennsylvania State University College of Medicine

Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

J Michael Wieting, DO, MEd  Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Program Development, Director of Sports Medicine, Associate Director of Physician Assistant Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Osteopathic Academy of Sports Medicine, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

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Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
Diskogram showing examples of an intact disk and a disrupted disk at the lumbar level.
Sagittal magnetic resonance image showing loss of intervertebral disk height at L5/S1. Herniations of the nucleus pulposus are noted at L4/5 and L5/S1.
Degenerative changes of the lumbar spine, including decreased signal intensity and disk bulging at the L-3/4, L-4/5 and L-5/S-1 disks.
The process of disk degeneration following internal disk disruption and herniation.
The various forces placed on the disks of the lumbar spine that can result in degenerative changes.
Table 1. Functional Muscle Testing
Nerve RootMotor ExaminationFunctional Test
L3Extend quadricepsSquat down and rise
L4Dorsiflex ankleWalk on heels
L5Dorsiflex great toeWalk on heels
S1Stand on toes*Walk on toes (plantarflex ankle)
*When testing the S1 innervated gastrocnemius muscle, the ability to stand on the toes once represents fair (3/5) strength. The patient must stand on his or her toes 5 times in a row to be rated normal (5/5) strength. Note that this approach should allow the physician to detect weakness at a much milder stage than if gastrocnemius strength were assessed only by using the examiner's hand to apply resistance to ankle plantar flexion.
Table 2. Dermatomal Sensory and Reflex Testing
Nerve RootPin-Prick SensationReflex
L3Lateral thigh and medial femoral condylePatellar tendon reflex
L4Medial leg and medial anklePatellar tendon reflex
L5Lateral leg and dorsum of footMedial hamstring
S1Sole of foot and lateral ankleAchilles tendon reflex
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