How to treat generalized low back pain

Now that we’ve covered how to evaluate patients with generalized low back pain, let’s jump into how to manage these patients. We’ll discuss recommendations for the management of acute low back pain and suggestions for managing more serious or chronic low back pain.

Medications

When a patient first presents with low back pain, start a course of nonsteroidal anti-inflammatory drugs (NSAIDs) which offer some analgesic and anti-inflammatory effects.

Generally speaking, muscle relaxants have not been overly successful in the treatment of low back pain. But, they can be tried in combination with NSAIDs during bouts of acute pain exacerbation.

Due to their addictive nature, do not prescribe benzodiazepines. Avoid narcotics and steroids; neither is indicated in this situation.

Rest

If the pain is intense and acute, recommend that the patient try 2–3 days of rest in a comfortable position. After this period of rest, they may start to gradually increase activities of daily living.

Prolonged rest is inadvisable because it deconditions the support muscles of the spine and has not been shown to successfully treat the condition. Instead, encourage gentle activity and light exercise.

Exercise

Patients with low back pain may benefit from exercising in a pool. They don’t have to exercise vigorously or do flip turns—just move around in the water in a comfortable fashion. The movement helps coordinate muscular support while unloading the back from the weight of gravity.

Provide the patient with low back care and rehabilitation literature. If available, have them enroll in back classes—group exercise classes that focus on strengthening the back and supporting musculature.

Physical therapy and exercise

If the patient has persistent back pain, refer them to a physical therapist for direct muscular therapy, range of motion, movement tolerance, core strengthening, and back education. Patients may also have success with pool therapy or simply moving around in a pool (and not necessarily swimming).

Steroid injections

If the patient with low back pain has definitive muscle regions where palpation reproduces their pain (and they don’t respond to therapy), you can ask a specialist to try a steroidal injection into the trigger points. Remember, these trigger points are rarely the prime pain generators.

Epidural steroid injections or facet injections may also be an option. However, without definitive targets, this treatment can be hit or miss and has little evidence-based support.

Diagnostic imaging

If the patient experiences pain that persists for more than four weeks, worsening symptoms, or severe and unabating symptoms, proceed with x-rays and non-contrast magnetic resonance imaging (MRI). The purpose of the MRI is to rule out more serious pathologies such as tumors, infection, deformity, and spinal injury.

Be aware that the patient’s MRI may show multiple degenerative findings such as herniated discs, stenosis, bone spurs, overgrown joints, and even various types of cysts. These are common in everyone (even those without pain) and do not define the pain generator unless they can be tied directly to the syndrome.

Physical therapy

If the patient’s pain continues to persist, they are entering a chronic stage of the syndrome. Most of these patients will not be surgical candidates, so continue with physical therapy, core strengthening, and work hardening (an individualized program structured to help patients return to a pre-injury level of work).

Bracing, corsets, traction, and transcutaneous electrical nerve stimulation (TENS) units have not been shown to significantly exceed placebo in relieving generalized low back pain (although some patients swear by them). Advise the patient to go with interventions that have previously worked for them.

Surgery

With chronic persistent pain, a spinal surgery evaluation should be obtained. But, be wary of surgeons who operate on patients without a definitive pathology.

Fusion surgery is seldom beneficial for patients with generalized low back pain unless they have a severe spinal deformity (degenerative scoliosis), significant vertebral subluxation (spondylolisthesis), or abnormal movement on flexion-extension x-rays. Obviously, patients with definitive spinal pathology on their studies should be evaluated by a spinal surgeon—urgently if need be.

Chiropractic care and osteopathy

If a patient has no definitive pathology or major neurological findings, spinal manipulation specialists can be consulted. Some patients respond well to chiropractic or osteopathic manipulation methods. However, the relief they experience is often temporary and multiple manipulations are required.

Chronic pain management

Management of low back pain is a tough business. The diagnosis of primary pain generators and direct therapy to manage back pain may be elusive. Personal habits and job descriptions can work against successful therapy. There may be significant secondary gain from lack of improvements such as workman’s compensation, litigation, malingering, narcotic abuse and sales, depression, or conversion disorder. As well, there may be significant psychological and psychosocial issues impeding improvement.

Prolonged intractable pain with no obvious etiology and no surgical options may need to be addressed by pain specialists with or without psychological evaluation and support. It is better to bring in these experts than to try treating long-term patients with low back pain by yourself.

Lifestyle changes

In the long run, many patients improve with significant lifestyle changes, weight loss, daily exercise, increased overall activity, postural correction, improved body mechanics, core strengthening, better nutrition, and healthier living overall. When achievable, such interventions can often improve the situation significantly. Unfortunately, such successes are the exception, and not the norm.

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