What to do about Back Pain: 5 Recommendations for Clinicians and Patients

What to do about Back Pain: 5 Recommendations for Clinicians and Patients

By: Rob Rowland

We have all the heard the statistics on back pain and chances are you have dealt with it yourself.  The problem is that with the prevalence of back pain, most people are still clueless on how they should deal with it. I encounter patients regularly who demand that they need a MRI so they can figure out exactly what is going on in their back.  They want to know where their “bulging disc” is, like that will somehow change their course of treatment. It has been shown that abnormal MRI’s as just as common in those without back pain as they are in those with back pain. This means that there are plenty of people walking around with “bulging discs” and have absolutely no pain or symptoms.  If an MRI shows your have a disc herniation, there is a good chance that the herniation isn’t even the cause of your pain.   I empathize with the physicians who fight the battle daily of explaining why expensive imaging like MRI of the back is not necessary for most back pain.

In 2007, the American College of Physicians and the American Pain Society published a set of guidelines for diagnosis and treatment of low back pain. It is written to an audience of clinicians, but being aware of current clinical guidelines makes the patient a much smarter “consumer”. They appraised the most appropriate literature on the diagnosis and treatment of low back pain and came up with seven recommendations of varying strengths (paraphrased here):

Recommendation 1: Clinicians should categorize patients into one of three categories: nonspecific low back pain, back pain potentially associated with radicular symptoms/ spinal stenosis, or back pain possibly associated with another specific cause.

About 85% of low back pain patients fall into the category of nonspecific low back pain.  You need to be aware of your symptoms. If your pain came on acutely with a specific event (grinding a lockout on a deadlift) then you probably fall into the first category, which also has the best outcomes. If your pain is waking you up in the middle of the night, you’re having incontinence issues, or you start tripping over your own foot, then it is probably time to seek medical attention.

Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific low back pain.

There most likely isn’t a need for imaging if you fall into the first category of back pain.  There is no evidence that imaging improves patient outcomes in the nonspecific low back pain group. Now if you’re playing offensive line, doing gymnastic moves, or regularly loading your spine in extension, then a radiograph may be useful to rule out a spondylolysis/spondylolisthesis.

Recommendation 3: Clinicians should perform diagnostic imaging and testing when severe or progressive neurological deficits are present (e.g. gross muscle weakness, persistent numbness) or when serious underlying pathology is suspected (e.g. compression fracture in elderly/osteoporotic, malignancy).

Again, if you find yourself having incontinence issues or you develop a foot drop then imaging is recommended. Risk factors for cancer, infection, and compression fractures should also be considered when deciding whether or not imaging is needed.

Recommendation 4: Clinicians should evaluate patients with persistent symptoms of radiculopathy or spinal stenosis with MRI or CT only if they are potential candidates for surgery or injection.

Even if a patient has symptoms of disc herniation, research shows the natural history results in marked improvement within the first month of non-invasive care. If your symptoms have not shown any improvement in that time frame, then it may be time to consider more invasive treatment where advanced imaging will be needed.

Recommendation 5: Patients should be provided with evidence-based information on low back pain with regard to their expected course…encourage patients to stay active.

This is true for most pathology these days. The idea of bed rest has become antiquated in recent years now that we know about the secondary complications associated with immobilization. Normal activity should be resumed as soon as it can be tolerated by the patients. For the active population, this means being creative in your training. If you can’t back squat because of back pain, switch to heavy unilateral training until your back is ready to squat again. If you can’t press, switch your upper body workouts to all pulls until the pain subsides. Just please don’t bench with your feet in the air though–even if it makes your back feel better. You’re not working on “core strength” and you’re just risking another injury.


Don’t be this guy

Recommendation 6: Medications with proven benefits only should be prescribed for patients with low back pain. Acetaminophen and NSAID’s are typically first-line medications.

Should be self-explanatory here… Just keep in mind these medicines are temporary.  Non-pharmacologic methods are preferred given possible side-effects of medication.

Recommendation 7: For patients who do not improve with self-care options, nonpharmacologic therapy with proven benefits should be included.

If you’re not improving after a couple weeks of self-care it may be time to seek out a health care professional. I may be biased, but if you live in a direct access state, go see a PT.

Each recommendation is given a strength based on the available research. More
detailed explanations of how the research was appraised and further explanation of each recommendation can be found in the original article listed below.

Chou et al. (2007) Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine; 147, 478-491.

In a time where people are looking for a “quick fix” and surgery rates are increasing, make sure you are knowledgeable about your own health.

Rob earned his Doctorate in Physical Therapy from the University of Delaware and now practices in MD specializing in orthopedics and sports medicine. He is also a Certified Strength and Conditioning Specialist through the NSCA. He is a competitive strongman athlete and who has qualified for the NAS national championships several times.  He can be contacted at robwrowland@gmail.com.

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