Severe Low Back Pain Treatment
The majority of patients with low back pain present with mild-to-moderate pain. A small group of patients present with acute onset of severe low back pain.
The aim of initial management of these patients is to reduce the pain and inflammation as rapidly as possible. When this is done, the management of these patients relies on the same principles as those with mild-to-moderate low back pain.
Acute onset of severe low back pain in the absence of nerve root signs may be due either to an acute tear of the anulus fibrosus of the disk or to an acute locked apophyseal joint. A locked apophyseal joint is thought to be due to entrapment of an intra-articular meniscus.
Clinical Features of Severe Acute Low Back Pain
- Acute low back pain is usually of sudden onset and is often triggered by a relatively minor movement such as bending to pick up an object.
- This minor incident may be more indicative of fatigue or lack of control, rather than tissue overload. The pain may increase over a period of hours due to the development of inflammation.
- Patients with chronic low back pain may also have acute exacerbations that may become more frequent and require less initiation over time.
- The pain is usually in the lower lumbar area and may be central, bilateral or unilateral.
- It may radiate to the buttocks, hamstrings or lower leg. Sharp, laminating pain in a narrow band down the leg is radicular pain and is associated with nerve root irritation, commonly as a result of intervertebral disk prolapsed.
- More commonly, the pain referred to the buttock and hamstring is somatic in nature, with the patient complaining of a deep-seated ache.
- The patient with acute, sudden onset of low back pain often adopts a fixed position and movements are severely restricted in all directions.
- Palpation of the lumbar spine reveals areas of marked tenderness with associated muscle spasm.
Management of Severe Acute Low Back Pain
- Encourage the patient to adopt the position of most comfort position varies considerably and may be lying prone, supine or, commonly, side-lying with a degree of lumbar flexion.
- Movements that aggravate pain should be avoided, whereas movements that reduce or have no effect on pain should be encouraged.
- Bed rest in the position of most comfort may be continued for up to 48 hours depending on the amount of pain.
- Bed rest longer than 48 hours has been shown to be detrimental.
- Taping of the low back can markedly reduce acute back pain and allow quicker functional restoration.
- Analgesics may control the pain and reflex muscle spasm. NSAIDs may help reduce inflammation.
- Electrotherapeutic modalities, for example, TENS, interferential stimulation and magnetic field therapy, may be helpful in reducing pain and muscle spasm in the acute stage. However, if access to these modalities in the acute stage requires any degree of travel, then bed rest alone may be preferable.
- Exercise in a direction away from the movement that aggravates the patient’s symptoms should be commenced as early as possible. For those patients in whom flexion aggravates their symptoms, extension exercises should be performed.
- The degree of extension should be determined by the level of pain. Initially, lying prone may be sufficient. Later, extension of the lumbar spine by pushing up onto the elbows may be possible. Eventually, further extension with straight arms can be achieved.
- Exercises should be immediately discontinued if peripheral symptoms develop.
- Prolonged posture involving flexion, such as sitting, should be avoided.
- In patients for whom extension movements aggravate their pain, flexion exercises or rotation (away from pain) exercises should be performed. For these patients, prolonged posture involving extension, such as standing with excessive lumbar lordosis, should be avoided.
Manual therapy has only a limited role in treating severe low back pain. Gentle mobilization techniques, for example, posteroanterior (PA) mobilization, may be performed and the patient’s response closely monitored. If there is any deterioration of symptoms, mobilization should be immediately ceased. The mobilization should be performed in the position of comfort adopted by the patient. Manipulation should not be attempted in the presence of marked muscle spasm. Similarly, gentle (grade I) soft tissue massage may be helpful in relieving pain and muscle spasm Traction has not been found to be helpful in patients with acute low back pain.
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