Low Back Pain in Adults
TERMS
ankylosing spondylitis
annular tears
cyclobenzaprine
degenerative disc disease
disc herniation
facet syndrome
lumbosacral sprain
lumbosacral strain
myofascial
physiatrist
spondylolisthesis
spondylopathy
spondylosis
spondylolysis
zygapophyseal joints
QUICK LOOK AT THE CHAPTER AHEAD
A specific cause for low back pain is often difficult to diagnose, and therefore difficult to treat. Low back pain that lingers and develops into chronic pain can negatively impact all aspects of a person’s life, leading to depression and even suicide. Because primary care providers are often not skilled in providing effective treatment for chronic pain, it is imperative that they refer clients with unrelieved back pain to specialists knowledgeable in effective therapies.
CASE STUDY
Mrs. K. is a 30-year-old woman who works as a registered nurse in a community hospital. While caring for a patient in cardiac arrest, she injures her lower back. Mrs. K. is examined by an orthopedic surgeon, who finds no neurological deficits and no significant abnormalities on radiographic study of the spine. A diagnosis of lumbosacral strain is made, and Mrs. K. is provided with a plan of care consisting of bed rest for 3 days, ibuprofen 400 mg every 6 hours, cyclobenzaprine (Flexeril®) 10 mg three times a day, and moist heat as needed. She is also instructed not to return to work or perform strenuous activity (for example, lifting) until she has been cleared by the physician.
For more than 1 week, Mrs. K. remains on bed rest, walking to the bathroom as needed. Her pain initially improves with rest, so she continues to limit her activity as much as possible. She states she is afraid that any increase in her activity will cause disc herniation. She stops taking her cyclobenzaprine but increases the dose of ibuprofen to 600 mg every 6 hours.
On follow-up visits with her physician 4 and 8 weeks after injury, she informs the physician that her pain continues, and that she has new pain in her buttocks. He tells her that there is no evidence of a disc disorder and that she can return to work for 4-hour periods. There is no discussion about her pain experience, and no other recommendations for treatment or symptom relief are made.
When Mrs. K. returns to work, she finds that she is extremely stiff, with dull pain in her low back after 4 hours. After several days of work, much of her stiffness is relieved, but her pain continues. Ten weeks after injury, the orthopedic surgeon tells her she may return to work full-time and releases her from his care. Out of frustration, Mrs. K. makes an appointment with her primary care physician, who tells her there is nothing wrong neurologically and gives her a handout with instructions for pelvic tilt exercises. Mrs. K. performs the exercises as prescribed by the physician but finds that they do not help relieve the pain. Frustrated and concerned that she may not be performing the exercises properly, she refers herself to a physical therapist who is described as someone with expertise in back pain. The therapist urges Mrs. K. to increase the number of pelvic tilts she is doing and gives her additional exercises to strengthen her back.
Mrs. K. finds that one of the exercises (upper trunk extension) helps relieve her pain, but that the pelvic tilt (a flexion exercise) actually increases the pain intensity. Because she is concerned she will harm herself further, Mrs. K. stops doing the pelvic tilts. On sharing this information with the therapist, the therapist tells Mrs. K. that there is nothing more she can do for her if she is not going to do her exercises.
Concerned that she is not improving, Mrs. K. again contacts her primary care physician to request a computed tomography (CT scan). Before this is ordered, she is required to see her physician, who reassesses her neurological status and finds no deficits. The physician agrees to order a CT scan, which is performed 1 week later. Three weeks after the scan, the physician notifies Mrs. K. that the CT findings are normal. He gives her no further recommendations to help with her pain.
Identify three questions that Mrs. K. might have asked the orthopedic surgeon while he was caring for this client. Why do you think the orthopedic surgeon released Mrs. K. without ordering physical therapy and/or follow-up? Why do you think Mrs. K’s primary care physician gave her no further recommendation for treatment of her back pain? Which characteristic of Mrs. K’s pain support the diagnosis of myofascial pain?
TYPES OF LOW BACK PAINThe causes of low back pain are many and varied. In a study evaluating the pathophysiology of back pain, 4% of patients had a compression fracture, 3% had spondylolisthesis, 0.7% had a tumor or metastasis, 0.3% had ankylosing spondylitis, and 0.01% had an infection. The most common cause of back pain was (and remains) nonspecific, and attributed to the degenerative process of the spine, known as spondylosis. Muscular and ligament inflammation are causes of low back pain in another large percentage of Americans.
The most common cause of back pain is nonspecific, and it is attributed to the degenerative process of the spine. Muscular and ligament inflammation cause low back pain in another large percentage of Americans.Specific causes of low back pain are difficult to diagnose. Radiographic studies (x-rays) will show the bony anatomy of the spine, and can rule in or rule out fractures, tumors, and congenital abnormalities, but these
are not the major causes of back pain. Degenerative disc disease is often seen on x-rays. However, simply finding evidence of this on x-ray does not explain back pain, because degenerative disease occurs in almost half the population, yet most of these people are asymptomatic. Diagnostic tests such as magnetic resonance imaging (MRI) are more valuable for diagnosing soft tissue, muscle, and ligament abnormalities. However, MRIs are not routinely performed on clients with acute low back pain. They are generally reserved for clients who have back pain lasting more than 1 month that does not respond to treatment.
are not the major causes of back pain. Degenerative disc disease is often seen on x-rays. However, simply finding evidence of this on x-ray does not explain back pain, because degenerative disease occurs in almost half the population, yet most of these people are asymptomatic. Diagnostic tests such as magnetic resonance imaging (MRI) are more valuable for diagnosing soft tissue, muscle, and ligament abnormalities. However, MRIs are not routinely performed on clients with acute low back pain. They are generally reserved for clients who have back pain lasting more than 1 month that does not respond to treatment.
Degenerative disc disease is often seen on x-rays, but simply finding evidence of this on x-ray does not explain back pain because degenerative disease occurs in almost half the population, and most of these people are asymptomatic.When diagnostic tests, physical examination findings, and the client’s history rule in or rule out certain abnormalities, more specific diagnoses for low back pain can sometimes be made. Diagnostic labels (Table 8-1) for specific types of degenerative disc disease or muscular or ligamentous causes of low back pain include:
♦ lumbosacral strain or sprain
♦ disc herniation/herniated intervertebral disk
♦ discogenic syndrome
♦ facet syndrome
♦ spinal stenosis
♦ spondylolysis
♦ spondylolisthesis
♦ spondylosis
Because evidence to support one of these specific diagnoses is often lacking, low back pain is frequently described in terms of its duration (for example, acute versus chronic) and site (for example, lumbosacral spine), as opposed to its cause.
Acute Low Back Pain
Most occurrences of low back pain are acute, self-limiting, and benign, lasting less than 1 month. Some occurrences last longer, but most resolve within 3 months. Patients with low back pain should have a history and physical examination, with an emphasis on the severity of pain and
neurological function below the level of the pain. Severe pain or pain considered to be related to trauma, metastatic disease, or neurological dysfunction will likely prompt the physician to obtain x-rays of the spine, MRI, and a consultation with a back specialist. A CT scan may be of some value in diagnosing the source of pain, but CT scans are limited by the fact that they do not show soft tissue injury. MRI is often the test of choice because it not only shows soft tissue injury, but also shows disc herniation with great accuracy.
neurological function below the level of the pain. Severe pain or pain considered to be related to trauma, metastatic disease, or neurological dysfunction will likely prompt the physician to obtain x-rays of the spine, MRI, and a consultation with a back specialist. A CT scan may be of some value in diagnosing the source of pain, but CT scans are limited by the fact that they do not show soft tissue injury. MRI is often the test of choice because it not only shows soft tissue injury, but also shows disc herniation with great accuracy.
Table 8-1 Diagnostic Labels for Low Back Pain | ||||||||||
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