Back pain conservative treatment

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This term has regrettably come to be used for non-surgical management. With minor modification, similar approaches can be used for mechanical low back pain, as well as for acute radiculopathy from disc herniation.

Recommendations (based on AHCPR findings ¹⁾ in the absence of “red flags”; note: some key literature citations are given here, primarily those from the better studies that support the Agency for Healthcare Policy and Research [AHCPR] panel recommendations. However, refer to Bigos et al ²⁾ for full analysis and list of references:

No studies were found that met the panel’s review criteria for adequate evidence. However, the following information was felt to be useful:

For 2–3 days maximum

● the theoretical objective is to reduce symptoms by reducing pressure on the nerve roots and/or intradiscal pressures, which is lowest in the supine semi-Fowler position ³⁾ and also to reduce movements which are experienced as painful by the patient

● deactivation from prolonged bed rest (> 4 days) appears to be worse for patients (producing weakness, stiffness, and increased pain) than a gradual return to normal activities ⁴⁾ recommendations: the majority of patients with low back problems will not require bed rest. Bed rest for 2–4 days may be an option for those with severe initial radicular symptoms; however, this may be no better than watchful waiting ⁵⁾ and may be harmful ⁶⁾.

● the goal is to achieve a tolerable level of discomfort while continuing sufficient physical activity to minimize disruption of daily activities

● risk factors: although there is no agreement on their exact role, the following were identified as having an increased incidence of low back problems. Jobs requiring heavy or repetitive lifting, total body vibration (from vehicles or industrial machinery), asymmetric postures, or postures sustained for long periods (including prolonged sitting).

● recommendations: temporarily limit heavy lifting, prolonged sitting, and bending or twist- ing of the back. Establish activity goals to help focus attention on an expected return to fully functional status.

(may be part of a physical therapy program):

● during the 1st month of symptoms, low-stress aerobic exercise can minimize debility due to inactivity. In the first 2 weeks, utilize exercises that minimally stress the back: walking, bicycling, or swimming

● conditioning exercises for trunk muscles (especially back extensors, and possibly abdominal muscles) are helpful if symptoms persist (during the first 2 weeks, these exercises may aggravate symptoms)

● there is no evidence to support stretching of back muscles or to recommend back-specific exercise machines over traditional exercise

● recommended exercise quotas that are gradually escalated results in better outcome than having patients simply stop when pain occurs ⁷⁾.

see Back pain medical treatment.

Education: (may be provided as part of a physical therapy program)

a) explanation of the condition to the patient ⁸⁾ in understandable terms, and positive reassurance that the condition will almost certainly subside ⁹⁾ have been shown to be more effective than many other forms of treatment

b) proper posture,sleeping positions,lifting techniques…should be conveyed to the patient. Formal “back school” seems to be marginally effective. ¹⁰⁾ There may be some early benefit, but long-term efficacy could not be shown ¹¹⁾.

The quality and expense of such programs varies widely ¹²⁾.

Defined as manual therapy in which loads are applied to the spine using long or short lever methods with the selected joint being taken to its end range of voluntary motion, followed by application of an impulse loading (may be part of a physical therapy program)

a) may be helpful for patients with acute low back problems without radiculopathy when used in the first month of symptoms (efficacy after 1 month is unproven) for a period not to exceed 1 month.

One study ¹³⁾ found no added benefit to APA + standard education

b) there is insufficient evidence to recommend SMT in the presence of radiculopathy

c) SMT should not be used in the face of severe or progressive neurologic deficit until serious conditions have been ruled out

d) ✖ reports of arterial dissection: especially vertebral artery and stroke, myelopathy & subdural hematoma with cervical SMT and cauda equina syndrome with lumbar SMT ^{14) 15) 16)} and the uncertainty of benefits have led to the questioning of the use of SMT ¹⁷⁾ (especially cervical)

see Epidural injection for back pain.

see Physiotherapy for low back pain

It has been proposed that replacing chairs with stability balls can diminish LBP in those who sit for prolonged periods. Research on the topic is sparse and inconclusive.

A total of 90 subjects (university students, staff, and faculty, ages 18-65, who sit ≥4 hr/d) were randomly assigned to the intervention or control group for the first part of the study. Baseline data were collected: Oswestry Disability Index, a numerical pain rating scale for LBP, and four core muscle endurance tests. For 8 weeks, the control group sat on their usual chair. The intervention group sat on stability balls 5 d/wk, increasing up to 90 min/d. Baseline measurements were repeated postintervention. After a washout period, subjects switched groups, and the procedures were repeated-70 completed participation in control group and 76 in intervention group.

There were no statistically significant differences for pain or disability in either group (P > 0.05). Changes in isometric trunk flexion (P = 0.001), nondominant side plank (P = 0.008), and Sorensen (P = 0.006) endurance scores were significant within the intervention group but not the control group. Between-group comparisons revealed a significant difference for isometric trunk flexion (P = 0.005) and Sorensen endurance times (P = 0.010). Analysis also showed that ball-sitting did not prevent an increase in LBP over the 8-week period.

Ball-sitting had no significant effects on LBP or associated disability, but did improve core endurance in the sagittal plane. Although ball-sitting may be useful as an adjunct treatment for LBP when core muscles are involved, clinicians should rely on other, evidence-based treatments for LBP ¹⁸⁾.

Current United States practice guidelines suggest an initial “wait and see” approach following onset of musculoskeletal pain, particularly for spinal pain.

Preliminary evidence is suggestive of decreased cost without compromising outcomes with early receipt of Physical Therapy (PT). The primary limitation of the current research on this topic is in study design. Additional high quality research involving prospective randomized designs and economic impact analyses is required to further investigate the outcomes with early initiation of PT. Level of Evidence Therapy, Level 1a ¹⁹⁾.