eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Back Pain, Mechanical: Follow-up

Author: Debra G Perina, MD, Associate Professor, Director of Prehospital Care Division, Department of Emergency Medicine, University of Virginia Health Sciences Center
Contributor Information and Disclosures

Updated: Jul 16, 2009

Follow-up

Further Inpatient Care

  • Inpatient care for low back pain is typically not required.
  • Patients with cauda equina syndrome, epidural abscess, spinal tumor, systemic illnesses, or those with poor social support should be admitted for further evaluation and management.
    • Referral to an orthopedist or a neurosurgeon may be necessary. Whether an orthopedist or a neurosurgeon is selected for referral depends on local resources and customs.
    • The patient's primary physician should be contacted regarding the referral.

Further Outpatient Care

  • Outpatient follow-up is generally managed by the patient's private physician. Patients with true sciatica or nerve root findings may also require consultation with an orthopedic surgeon or a neurosurgeon.
  • Short-term physical therapy with gentle exercises may be of some benefit.
    • Short-term physical therapy has not been proven significantly more effective than self-care with instructions by the physician. However, patients appear to prefer therapy to self-care when surveyed.
    • Sertpoyraz et al compared isokinetic and standard exercise programs for chronic low back pain. Pain, mobility, disability, psychological status, and muscle strength was measured. Forty patients were randomly assigned to a program that took place in an outpatient rehabilitation clinic. Results showed an equal effect in the treatment of low back pain, with no statistically significant difference found between the two programs.18
    • Cost-benefit ratio should be considered prior to physical therapy referral from the ED.

Inpatient & Outpatient Medications

  • Outpatient therapy generally consists of a combination of muscle relaxants and NSAIDs. In certain cases, a short course of prednisone may also be helpful.

Transfer

  • Time-sensitive transfer to other facilities may be necessary in patients with suspected cauda equina syndrome if emergent MRI is not available at the treating hospital. All such patients should receive dexamethasone before transfer to avoid delays in treatment.
  • Patients with compressive tumors or abscesses should be transferred to a center that has a spine surgeon who can provide decompression in a timely manner if unavailable at the treating hospital.

Deterrence/Prevention

  • Back muscle strengthening exercises have value in preventing future episodes of low back strain.20
  • Weight loss in overweight patients results in less strain on back muscles.
  • Practicing proper lifting techniques results in less back strain.
  • General overall improvement of physical conditioning can decrease low back pain exacerbations.21

Prognosis

  • The prognosis is good for most patients who present with mechanical back pain.22,23
    • Overall, 70% of patients feel better in 1 week; 80%, in 2 weeks; and 90%, in 1 month.
    • Only 10% of all patients with low back pain have long-term problems.
    • A significant functional overlay or component of secondary gain is present in a subgroup of patients, who also account for the majority of office visits with low back pain complaints (see Causes section).
    • Recurrence is common and seen in up to 40% of patients within 6 months. Prevention methods should be discussed with patients with low back pain along with encouragement to monitor them when the acute period has resolved.
    • Psychosocial factors such as presence of posttraumatic stress disorder, use of a lawyer, presence of other chronic illnesses, and lower education levels appear to be positive predictors of development of chronic back pain in patients who sustain an initial injury to their back. Chronic back pain development was not associated with age, gender, occupation, or severity of original injury.

Patient Education

  • Patient education focuses on prevention and includes the following:
    • Promoting weight loss where indicated
    • Performing back strengthening exercises
    • Teaching proper lifting technique
    • Increasing overall physical conditioning
  • Back belts, which are commonly worn in occupations with heavy lifting, have not been proven to prevent back injury.
  • For excellent patient education resources, visit eMedicine's Bone Health Center; Back, Ribs, Neck, and Head Center; and Muscle Disorders Center. Also, see eMedicine's patient education articles Back Pain, Chronic Pain, and Sciatica.

Miscellaneous

Medicolegal Pitfalls

  • Work excuses deserve special mention
    • Most patients require some form of relief from work.
    • Prolonged work excuses often lead to functional disorders. It is generally recommended that excuses be limited to 2-3 days following an ED visit.
    • It is preferable that patients return to work as soon as possible. This may be facilitated by noting light or restricted duty upon their return for a short time period.
    • If work excuses are needed beyond this time, the patient's primary or referral physician should provide them.
    • When providing work excuses, patient confidentiality must always be protected. The only information employers are entitled to without explicit authorization by the patient is whether the work excuse is legitimate and whether the employee poses a health risk to others.
    • Be sure to include what activities the patient may engage in and the time period the restrictions are in effect.

Special Concerns

  • Back pain is an uncommon complaint in children. The cause of back pain is most often infectious or malignant in these patients.
  • Suspect malignancy if back pain has lasted for more than 1 month, is unrelieved by bed rest, and occurs at night (interrupting sleep in patients older than 50 years).
 


More on Back Pain, Mechanical

Overview: Back Pain, Mechanical
Differential Diagnoses & Workup: Back Pain, Mechanical
Treatment & Medication: Back Pain, Mechanical
Follow-up: Back Pain, Mechanical
References
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References

  1. Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. Apr 15, 2007;74(8):1181-8. [Medline].

  2. Atlas SJ, Chang Y, Kammann E, Keller RB, Deyo RA, Singer DE. Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation. J Bone Joint Surg Am. Jan 2000;82(1):4-15. [Medline].

  3. de Inocencio J. Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits. Pediatrics. Dec 1998;102(6):E63. [Medline].

  4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?. JAMA. Aug 12 1992;268(6):760-5. [Medline].

  5. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. Mar 1990;72(3):403-8. [Medline].

  6. Hadjipaviou AG, Tzermiadianos MN, Bogduk N, Zindrick MR. The pathophysiology of disc degeneration: a critical review. J Bone Joint Surg Br. Oct 2008;90(10):1261-70. [Medline].

  7. van Tulder M, Koes B. Low back pain and sciatica (chronic). Clin Evid. Dec 2003;(10):1359-76. [Medline].

  8. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. Feb 1 2001;344(5):363-70. [Medline].

  9. Borenstein D. Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol. Mar 1996;8(2):124-9. [Medline].

  10. Marriott A, Newman NM, Gracovetsky SA, Richards MP, Asselin S. Improving the evaluation of benign low back pain. Spine. May 15 1999;24(10):952-60. [Medline].

  11. Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force classification. Int J Clin Pract. Dec 2000;54(10):639-44. [Medline].

  12. Lurie JD. What diagnostic tests are useful for low back pain?. Best Pract Res Clin Rheumatol. Aug 2005;19(4):557-75. [Medline].

  13. Kuritzky L. Current management of acute musculoskeletal pain in the ambulatory care setting. Am J Ther. Nov-Dec 2008;Suppl 10:S7-11. [Medline].

  14. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine. Sep 15 1997;22(18):2128-56. [Medline].

  15. Cherkin D, Sherman KJ. Conceptualization and evaluation of an optimal healing environment for chronic low-back pain in primary care. J Altern Complement Med. 2004;10 Suppl 1:S171-8. [Medline].

  16. Nelson L, Aspegren D, Bova C. The use of epidural steroid injection and manipulation on patients with chronic low back pain. J Manipulative Physiol Ther. May 1997;20(4):263-6. [Medline].

  17. Moffett JK, Torgerson D, Bell-Syer S, Jackson D, Llewlyn-Phillips H, Farrin A, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ. Jul 31 1999;319(7205):279-83. [Medline].

  18. [Best Evidence] Sertpoyraz F, Eyigor S, Karapolat H, Capaci K, Kirazli Y. Comparison of isokinetic exercise versus standard exercise training in patients with chronic low back pain: a randomized controlled study. Clin Rehabil. Mar 2009;23(3):238-47. [Medline].

  19. [Guideline] Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. May 1 2009;34(10):1066-77. [Medline].

  20. Hodges P, van den Hoorn W, Dawson A, Cholewicki J. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. J Biomech. Jan 5, 2009;42(1):61-6.

  21. Lotz JC. The biomechanics of prevention and treatment for low back pain: 2nd international workshop. Clin Biomech (Bristol, Avon). Mar 1999;14(3):220-3. [Medline].

  22. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ. Feb 26 1994;308(6928):577-80. [Medline].

  23. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ. May 2 1998;316(7141):1356-9. [Medline].

  24. Harris IA, Young JM, Rae H, Jalaludin BB, Solomon MJ. Factors associated with back pain after physical injury: a survey of consecutive major trauma patients. Spine. Jun 15 2007;32(14):1561-5. [Medline].

  25. Panjabi MM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol. Aug 2003;13(4):371-9. [Medline].

  26. Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. Aug 2008;16(8):471-9. [Medline].

  27. Tauney PJW, Siegel CB, LaBan MM. Thoracic and lumbar pain syndromes. In: Tintinalli, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. 2000:1866-1873.

  28. van Poppel MN, Hooftman WE, Koes BW. An update of a systematic review of controlled clinical trials on the primary prevention of back pain at the workplace. Occup Med (Lond). Aug 2004;54(5):345-52. [Medline].

  29. Walsh MJ. Evaluation of orthopedic testing of the low back for nonspecific lower back pain. J Manipulative Physiol Ther. May 1998;21(4):232-6. [Medline].

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Further Reading

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Keywords

low back pain, mechanical low back pain, low back pain treatment, low back pain causes, musculoligamentous injury, classic nerve root syndrome, musculoskeletal pain syndrome, impingement syndrome, herniated disk, herniated disc, spinal degeneration, cauda equina syndrome, myofascial pain syndrome, fibromyalgia, osteomyelitis, sacroiliitis, spinal stenosis, degenerative joint disease, straight leg test

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Contributor Information and Disclosures

Author

Debra G Perina, MD, Associate Professor, Director of Prehospital Care Division, Department of Emergency Medicine, University of Virginia Health Sciences Center
Debra G Perina, MD is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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