Acute Low Back Pain

Introduction

Acute low back pain treatment requires the practitioner to determine which motion or position decreases the patient’s symptoms.

Lumbar radiculopathies are commonly due to nerve impingement by facet joint dysfunction, spasm of the piriformis muscle, and degenerative pathologies such as spinal stenosis. These symptoms often lessen when the patient is in a more flexed position, also called a flexion bias. When symptoms are due to lumbar disc dysfunction and protrusion, the patient’s symptoms improve when they lean backward and extend the spine. This is called an extension bias.

The muscles involved in maintaining the lower back’s stability include the psoas, quadratus lumborum, abdominal muscles, latissimus dorsi, paraspinal and oblique muscles (Figure 10-1). These muscles, often called “the core,” contract to help stabilize the spine. When these muscles are appropriately engaged, they dissipate the stresses on the spine.

Figure 10-1 • Muscles involved in the lower back’s stability. (Reprinted from Moore KL, Agur AM, Dalley F. Essential Clinical Anatomy. 5th ed. Baltimore: Wolters Kluwer; 2014 with permission.)

Figure 10-2 • Muscles of the hip that can contribute to back pain. (Reprinted from Archer PA, Nelson LA. Applied Anatomy & Physiology for Manual Therapists. Baltimore: Wolters Kluwer; 2012 with permission.)

Improving range of motion of these muscles and the joints they serve is referred to as joint mobilization. Providing manual techniques to joints with limited movement promotes joint mobilization, decreases pain, and improves range of motion.

Dysfunction of other muscle groups that contribute to supporting the back can also lead to back pain. Tightness of the muscles of the hip (iliacus, piriformis, rectus femoris) can cause back pain and sciatica (Figure 10-2). Weakness of the core muscles, such as the abdominal muscles and obliques, may cause instability around the spine and lead to pain symptoms.

The goal of treating acute low back pain is to move the patient to a posture that reduces their pain and helps regain conscious control of their core muscles.

Box 10-1 Rule Out Red Flags

In patients who:

are younger than 18 years or older than 50 years,
with fever,
weight loss,
recent trauma,
urinary incontinence,
perineal anesthesia or
history of cancer,

consider a full evaluation to rule out conditions such as bone disease, tumor, and infection. This includes complete blood count with differential; a metabolic profile, alkaline phosphatase; erythrocyte sedimentation rate or C-reactive protein; plain films of the lumbosacral spine; or, if urinary or bowel incontinence is present, urgent neurosurgery referral.

Physical Examination

Palpate bony structures for point tenderness, palpate muscles for spasm and trigger points, check patellar reflexes for symmetry, and have the patient plantar and dorsiflex the foot against resistance.
Determine the position that decreases the patient’s pain.
- Forward flexion bias: Sitting and leaning forward reduces symptoms.
  - Common causes: piriformis spasm, degenerative disease such as spinal stenosis.
  - The lumbar spine is often flattened to maintain posture and reduce pain (Figure 10-3A).
  - Goal of treatment: Increase the patient’s ability to flex forward by stretching the posterior muscle groups of the back and lengthening the hamstrings.
- Backward extension bias: Standing and/or lying prone reduces symptoms.
  - Common causes: disc bulging or herniation.
  - The lumbar spine commonly has an exaggerated lordosis (concavity) (Figure 10-3B).
  - Goal of treatment: Increase the patient’s ability to extend their back by lengthening their hip flexors.

Figure 10-3 • Flexion and extension bias versus neutral back.

Range-of-Motion Testing

While standing, have patient put their hands on the anterior thighs for support and slowly forward flex. (If the patient cannot do this standing, have them sit.)
Ask the patient how the pain changes from upright to forward flexed.
Have the patient put the hands on the hips and extend the back, moving the back and shoulders posteriorly.
Ask the patient how the pain changes from upright to extension.
With the patient’s hands relaxed at their sides, have the patient side bend to one side, then the other, asking how the pain changes based on each side.

Treatment

Treatment is based on bias.

Techniques for Flexion Bias (Forward Flexion Reduces Pain)

These techniques are for when a patient prefers for their low back to be in a state of flexion.
Patients with flexion bias may be more comfortable sitting than standing and tend to lean forward when they go to stand or walk.
Goal of treatment is to increase joint and muscle range of motion in flexion; muscles to stretch include paraspinal muscles of the back and hamstrings.

Cannonball

Have the patient lie supine and pull the knee on the affected side up to chest as far as able and then place their foot under your arm.
The clinician grasps their mid-calf in one hand and around their knee with the other.
Move the knee toward the axilla on the involved side to the limit.
Have the patient attempt to extend the leg using 10% effort against resistance while taking three belly breaths and then relax.
Move the patient’s knee into greater hip flexion and repeat the above-mentioned steps for a total of three stretch-relax cycles.

Assisted Posterior Pelvic Tilt

With the patient supine, flex the hip and knee, placing the knee over your shoulder.
Pull the patient’s proximal thigh toward the clinician and ask the patient to try to bring the leg back to the table using 10% effort while taking three belly breaths.
As the patient relaxes, move the hip into increased flexion.
Repeat these steps for a total of three stretch-relax cycles.

Straight-Leg Raise With Traction

Have the patient lie on a lowered table. Alternatively, the clinician stands on a step stool.
Assist the patient to raise the straightened leg to 45 degrees.
Grasp the ankle and provide a caudal traction (away from the hip) while the patient takes three belly breaths, then relaxes.
Increase hip flexion and repeat these steps for a total of three stretch-relax cycles.

Hamstring Stretch

Have the patient flex the hip and knee to 90/90 position.
Grasp the patient’s thigh just proximal to the knee and at the ankle.
Assist the patient in extending the knee until it is maximally stretched.
Ask the patient to use 10% effort to push the heel down into your shoulder or hand while taking three belly breaths.
Have the patient relax while you move the knee into further extension.
Repeat these steps for a total of three stretch-relax cycles.

Techniques for Exension Bias (Backward Extension Reduces Pain)

These techniques are used when the patient’s preferred position is with the spine straightened and an increased lordosis in the lower back.
Patients tend to feel better standing than sitting.
Symptoms are often correlated with herniated discs and/or tight hip flexors.
Goal of treatment is to increase extension through joint mobilization and lengthening the hip flexors (quadriceps, psoas, and piriformis).

Lumbar Glide

Have the patient lie on their stomach. Palpate for a tender lumbar spinous process.
Apply pressure downward (from posterior to anterior) to the lumbar spine while you direct the patient to move up onto their elbows. Hold for three belly breaths.
Have the patient return to prone.
Move your hands to the next tender spinous process area and repeat the process.

Supine Psoas and Rectus Femoris Stretch

Ask the patient to sit as close to the end of the table as possible.
Have the patient to flex the hip and knee on the uninvolved side and draw the knee toward the chest.
With your assistance, have the patient lie supine on the table; this will leave the leg on the involved side hanging off the table.
Stabilize the uninvolved knee with your chest and hold resistance against the involved knee toward the floor.
Ask the patient to flex the involved hip, using 10% effort, and to take three belly breaths then relax.
Move the involved hip into further extension.
Repeat these steps for a total of three stretch-relax cycles.