What is that management?
Well, certainly, it’s analgesics.
We’ve talked about those
a number of times.
I start with acetaminophen for safety
and then move up to non-steroidal anti-inflammatory drugs
and try to keep it safe and simple with those agents.
Physical therapy is probably the best means to
prevent the development of chronic low back pain,
which we’ll talk about in a minute.
There is not as much evidence
to support the use of
massage or spinal manipulation for the
majority of patients with low back pain.
It doesn't seem to add much to just
traditional medical management with analgesics.
and bed rest is
certainly not recommended.
You want these patients
mobile and start into a regimen
of rehabilitation with stretching
and strengthening exercises
to improve their current back pain,
but also to prevent chronic
low back pain as well.
So, hey, the case is coming back
as many cases of back pain do.
He returns nine months later,
his back pain has now become chronic
and he has moderate
difficulty in many activities.
He's tried to look for another type of work
because it is difficult to be in physical work
like construction with chronic back pain.
Luckily, his radiculopathy has resolved.
So, one thing I would note in the history here,
just be very –
I think it’s very important that there is an
assessment not just for his level of pain,
but also his function.
We are moving towards a system where
it's not so much just about
treating the number of pain.
Well, my pain is a 4 out of 10
and mine is an 8 out of 10.
It’s really about how does that
affect you in your life because
a 4 out of 10 pain can be
to somebody who works in a
physical job like construction.
But for someone who's
they may be –
they don't really have as
many physical activities.
They may be able to tolerate a
6 out of 10 or even a 7 out of 10 pain
because it’s not interfering
with their lifestyle at all.
But the question here is,
how common is this case?
What percentage of cases of
acute back pain become chronic?
The answer is 20%.
Approximately, 20% of low back
pain becomes chronic.
And when I see a patient with chronic back pain,
the first thing I’m going to look at is,
what are they doing in terms of
current therapy and its efficacy.
Maybe they improved after one
round of physical therapy.
It was pretty short
and then they kind of
forgot about it because,
hey, I feel better, and that's what you do.
And maybe it's time to then go back
and restart those exercises
and regain that confidence in
getting your back pain under control.
And then, of course,
looking at medications too.
So, look at the analgesics,
look at whether they’ve been doing
but particularly home exercise.
I think one of the most important
parts about physical therapy
is they can teach patients how to
take care of themselves at home.
So, if it's just four sessions,
it's likely that there are going to be
more problems down the road.
But patients who were able to continue
those therapeutic exercises over time,
that makes a big difference.
Look at function, as I mentioned.
That's a big factor.
And overall, if treatment isn't working
and you see decreased function,
that's when I consider imaging,
as I mentioned earlier,
and it’s time to think about doing something
a little bit more aggressive and invasive.
And so, less commonly,
many patients don't require this,
but they have been employed for many years
and often the next step in care
after just simple analgesics,
exercise, physical therapy fails
are epidural glucocorticoid injections.
Now, they don’t work that well for
non-specific low back pain,
but for pain that includes disability,
pain with radiculopathy,
these injections can be effective.
Unfortunately, it's usually a
fairly temporary relief
lasting three months or less.
One thing is that these injections should
always be applied with imaging.
It's been studied and those that don't
use imaging are frequently misplaced,
so therefore are may be ineffective
and potentially even dangerous.
There is a limit as well to
how many injections per year.
This isn’t a strong evidence-based guideline,
but the general consensus is certainly
up to six injections a year is a lot.
I generally don't want my patients
to go in more than four times.
And these injections also aren’t very effective
for cases of spinal stenosis as well.
So with that,
this is a broader view of an important subject.
Just understand that
low back pain is out there.
It's pretty common.
But the conservative therapy is going to work.
And about 80% of patients will improve.
Even with severe pain and radiculopathy (inaudible),
80% will get better within a couple of months.
So, you can be confident in that.
Many cases, one in five or so,
do become chronic and that's when it's
time to rethink about home exercises,
and then also consider imaging
and more aggressive therapy as well.