Mechanical Back Pain Follow-up

  • Author: Debra G Perina, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 3, 2011
 

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.
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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.

Spinal manipulation is not recommended. Rubinstein et al, in an evidence based review of published literature, did not support any significant benefits from spinal manipulation.[24]

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.[21]
  • Cost-benefit ratio should be considered prior to physical therapy referral from the ED.

Studies of back pain patients in England suggest that a stratified management approach including prognostic screening, and a treatment approach targeting primary care efficiency and physiotherapy, leads to greater health gains for patients with back pain. Significant improvements were noted in the stratified management group at both 4- and 12-month follow-up with respect to physical and emotional wellbeing, pain intensity, work days missed, and quality of life.[25]

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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.
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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.
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Deterrence/Prevention

  • Back muscle strengthening exercises have value in preventing future episodes of low back strain.[26]
  • 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.[27]
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Prognosis

The prognosis is good for most patients who present with mechanical back pain.[28, 29]

  • 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.
  • A systematic review by Chou and Shekelle found that the following factors were most helpful for predicting which patients would experience persistent disabling low back pain: maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities. Factors related to the patient's work environment, baseline pain, and presence of radiculopathy are less useful for predicting worse outcomes.[30]
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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.
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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: Air Medical Physician Association, 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.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

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.

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

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; 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.

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  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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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