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Low-Back Pain: Consider Extension Education

Louis Kuritzky, MD with Jacqueline White


In Brief: Treatment of low-back pain has evolved in the past 15 years away from a reliance on x-rays for diagnosis, prolonged bed rest for pain relief, and surgery for treatment. Mechanical low-back pain is now recognized as a generally self-limiting condition, which for most patients resolves in a few weeks with conservative treatment. Early mobilization is helpful: The McKenzie technique can help identify appropriate rehabilitation exercises, which for most patients are not flexion but extension exercises.

Sedentary lifestyles have helped make low-back pain one of the most common patient complaints, but up to half of family practice physicians feel inadequately trained to manage this condition (1). Though a specific diagnosis is elusive in the vast majority of cases, once primary care physicians have ruled out nonmechanical causes that require specific corrective interventions, they can successfully manage almost all back pain patients.

What causes low-back pain?
Consider this experiment: Bend your index finger backwards until it's intensely painful. A biopsy of the finger won't reveal a tumor or an infection or an identifiable lesion, because there is none. But releasing the finger and letting it return to its "position of comfort" will allow the pain to subside.

As clinicians, we need to reorient ourselves to think about low-back pain in a similar way—functionally instead of pathoanatomically. The cause of low-back pain is elusive, but we are beginning to learn which postures and activities make the back "unhappy," and which return the back to functional happiness and normal activity. Rather than focusing on discovering the pathoanatomic disturbance leading to dysfunction, clinicians should strive to restore correct posture and normal productivity.

What do patients need to know about low-back pain?
Although patients often attribute the onset of their back pain to a specific injury, just as often as not the injury is quite trivial, like bending over, twisting, or sneezing. This is because much of the time onset of low-back pain represents the culmination of chronic injury or cumulative trauma.

If the arterial system has suffered the chronic insult of atherosclerosis, the acute event of shoveling snow may precipitate a myocardial infarction; in the same way, a lifetime of poor posture and poor lifting and bending habits may stress the posterior annulus area of the intervertebral disk to the point that even a minor stress precipitates frank herniation.

Excessive flexion activities are detrimental for most people, as is sedentary posture. Flexion causes the mobile nucleus pulposus to shift posteriorly and press against the annulus fibrosus at its thinnest, least-buttressed place. In some people, this leads to a full-scale herniated disk; in others, it just leads to pain. Sedentary posture causes stress because the highest measured pressure inside the disk occurs with sitting—it's even higher than with standing or walking (2). That's why the highest-risk groups for back pain in the United States are people who spend a lot of time sitting and leaning forward—truck drivers, clerks, dental hygienists, and such.

Once people know that the etiology of back pain appears to be cumulative trauma, especially cumulative flexion trauma from sedentary posture, then they can understand that the key, or the therapy, for back pain is activity—not pills or surgery. The problem has been that we've tended to intervene too quickly. Back pain is self-limiting in the majority of individuals: When treated conservatively, more than 90% of patients will recover after 2 months (3,4).

If low-back pain is usually due to cumulative trauma, does that mean it's most often mechanical?
Ninety-seven percent of back pain in the population seen by primary care physicians is mechanical in origin—there's something wrong with the muscles, ligaments, or connective tissues (5). Even a ruptured disk is a mechanical cause. Most people with back pain don't have ruptured disks, but it's notorious partly because x-rays dramatically overestimate the frequency. Two trials (6,7), one with magnetic resonance imaging and one with computed tomography, have shown that as many as one third to one half of healthy asymptomatic young men manifest signs consistent with disk bulge or herniation.

What are the nonmechanical causes of low-back pain?
Secondary causes of back pain include disorders such as neoplasia (primary or metastatic), ankylosing spondylitis, benign space-occupying lesions, hyperparathyroidism, pathologic fracture, disk-space infections, spinal infections (eg, tuberculosis), abdominal aortic aneurysm, nephrolithiasis, and cholelithiasis.

How does the primary care physician identify nonmechanical pain?
If the patient does not have neurologic deficits, and there are no signs of secondary disease, the physical examination is sufficient to rule out a nonmechanical cause of back pain. Secondary causes appear more frequently in people younger than 20 years and older than 50, so physicians should be especially alert for secondary causes in these age-groups.

Other clues to a nonmechanical cause are fever, unexplained weight loss, substantial trauma, history of osteoporosis, point tenderness, history of cancer, chronic corticosteroid therapy, risk factors for significant vascular disease, and inability to find a position of comfort.

When are x-rays indicated?
For most low-back pain, x-rays are not necessary. In fact, they should be discouraged: The female gonads receive a substantial dose of radiation because they cannot be shielded for lumbosacral films. There's no reason for plain x-rays in the management of back pain unless the physician suspects a secondary cause. If a patient with mechanical low-back pain doesn't respond to therapy or the physician is contemplating early surgical intervention, radiologic imaging is reasonable. Magnetic resonance imaging is the most sensitive and specific.

But haven't x-rays been a common diagnostic tool for low-back pain?
Yes. Consider the back x-ray of our prototypical patient with low-back pain, a 45-year-old man. His films will very typically show three findings: loss of normal lumbar lordosis, which is evidence of muscle spasm; arthritic changes called degenerative joint disease; and a narrowed disc space, which shows that the cushion between the vertebral bodies has eroded with time.

The patient could understand that these findings would explain his back pain. It made good sense. Unfortunately, it was wrong. The lordosis of the spine does change with muscle spasm, but a loss of lordosis is seen too often in normal individuals to be a true discriminator. Studies of completely healthy individuals have shown that by age 40 most people will have some degenerative joint disease but that the degree does not correlate with symptoms. Narrowed disk space also appears to be a natural aging process that is unrelated to the presence, absence, or severity of back pain.

What are the indications for surgery?
There are four absolute indications for back surgery: cauda equina syndrome, intractable pain (with appropriate corroborative radiographic findings), progressive neurologic deficit, and new-onset incontinence (fecal or urinary).

Relative indications become a negotiated decision between clinician and patient. That low-back pain typically resolves within a few months is little solace to the financial head of a household who faces the prospect of economic disaster or to a professional athlete who risks losing valuable playing time. Surgical intervention is an option for such patients, even though conservative measures are likely to be just as effective if the patient is willing to endure a more lengthy recuperative course.

Is the use of surgery for back pain declining?
The last 15 years probably saw more surgery than was optimum. But studies now show that for mechanical back pain, conservative measures are just as effective as surgery, even in cases of frank disk herniation with an extravasated disk fragment (8) and of spinal stenosis (9). In addition, the growing number of individuals for whom postoperative disability proves devastating has dampened enthusiasm for surgery. Because patients who undergo laminectomy often don't address the lifestyle factors that contribute to their condition, they frequently undergo laminectomy at another disk level later. So it's important for physicians to address the underlying mechanisms, such as poor posture, that are creating the back pain.

As part of conservative treatment, should physicians recommend bed rest?
An evolution has occurred. Studies in the early 1980s did show some benefit from bed rest (10), and these were refined in the mid-1980s to show that 2 days of bed rest is just as beneficial as 7 for most patients (11). Our most recent data, which compare bed rest with physical therapy or resumption of normal activities as tolerated, show that those who resume normal activities fared as well as the others (12). This is not to say that some patients do not require or benefit from limited bed rest, but rather that bed rest should be employed sparingly. Physicians need to impart the philosophy that activity is usually the cornerstone of low-back rehabilitation. (See "Extend Yourself for Low-Back Pain Relief".)

What kind of activity is therapeutic?
The physician should encourage progressive activity and early mobilization. From the very onset of back pain, an individualized exercise program, designed by someone well versed in physical therapy, is recommended. Physicians can learn enough about mechanisms of back pain that they can prescribe exercise themselves, if they wish.

One method designed to treat acute back pain (which has increasing documentation of its efficacy) is the McKenzie system (13). Patients are put through various ranges of motion to find out which motions centralize their pain. If you take a patient who has pain that goes down the leg, then move the patient into a particular position and find that the pain retreats toward the midline or goes less distally, that's called centralization, which is considered a favorable sign.

All patients with acute back pain can be put through a series of exercises to discover which activities centralize their pain, and then do those activities repetitively in an effort to reduce their pain. After the acute episode is over, patients can continue the same exercises to help condition the spine. The likelihood is that the injurious repetitive activities will continue to be traumatic and the healing ones will continue to be helpful.

In the McKenzie method, the exercise that appears most beneficial for most individuals is extension, not flexion. It's not true for everyone, but it is for the majority of patients. In the most recent federal guidelines, conditioning of the trunk musculature is recommended, especially the extensors (14).

How useful is the McKenzie system for the active patient?
Say your patient is a golfer who has a swing that he practices a lot so it'll be consistent, fluid, and repetitively accurate. Although this repetitive pattern may be successful for his golf, it may be detrimental for his back. If he has back pain, he can go to a McKenzie therapist and demonstrate what his repetitive activities are. The therapist can suggest he try certain actions to see which ones relieve his pain.

This is not something that an athlete could do preventively—the McKenzie system requires a symptomatic patient. Although even the highly fit athlete is subject to acute low-back pain, aerobic conditioning and appropriate posture are appropriate preventives for most individuals.

Does activity protect against back pain?
Individuals who are most aerobically fit have the least back pain. A trial in firefighters in Los Angeles inversely correlated the frequency of back pain with fitness (15). These are individuals who obviously encounter stressful physical situations that could produce acute back pain. Those with the greatest level of fitness had the least back pain. Aerobic conditioning appears to be beneficial.

As a matter of fact, most physical activity programs appear to benefit low-back pain sufferers. What we're trying to do now is find out which is the most crucial ingredient of physical activity—that's the elusive part.

Should primary care physicians consider providing or referring for manual therapy?
A number of manual methods are effective in back pain. Manual medicine should not be defined only as chiropractic care: Both osteopathic physicians (DOs) and allopathic physicians (MDs), in particular physiatrists, employ manual medicine. Also, manual medicine should not just be considered the high-velocity thrust mechanisms we typically think of when we think of neck manipulations.

In studies that compare the outcomes of patients treated by a family doctor, orthopedist, or chiropractor, the outcomes are all about the same, with the orthopedist being the most expensive and the chiropractor's patients being the most satisfied with their care (16). Patients feel chiropractors give them a much more satisfactory explanation of why they have back pain. And, evidently, insight contributes to healing.

Apparently, manual medicine does work at least as well as traditional allopathic care. The published literature suggests that manual medicine should be considered for incorporation into the treatment provided by primary care physicians (14). When referring, seek a provider whose philosophy regarding returning the patient to activity matches your own.

What medication issues should physicians be aware of?
Medications are indicated to help patients optimize their activity. Treatment should initially be acetaminophen or nonsteroidal anti-inflammatory drugs. There is no best drug; in general, the shorter-acting drugs are better because any adverse effects don't last as long.

How can we avoid having patients feel they've been handed the old "Just take a couple aspirin and call me in the morning" line?
Obviously, that's a concern. We don't want them to go someplace else and get narcotics they don't need because they perceive we haven't taken them seriously. It's crucial that we convey to patients that narcotics are only indicated for severe pain—they should be considered "rescue medicine." If a person has severe pain, 99% of the time they can find a position of comfort in which their pain is not bothering them. They can keep that sleep, respite, or rescue position until the pain subsides.

Some patients find muscle relaxants a useful adjunct to analgesics or an effective agent when pain interrupts sleep. Yet any agent that hinders a patient's ability to function on the job or to progressively mobilize must be used sparingly.

You've suffered from low-back pain yourself. What did you learn?
I want practitioners to understand that surgery is a last resort. If we prescribe mobilization and allow sufficient time, with rare exceptions people will get better. I didn't know this when I experienced my own back pain (which is described elsewhere (17)). I've addressed literally thousands of primary care physicians, and they all tell me the same thing: They didn't know either.


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Dr Kuritzky is courtesy clinical assistant professor of family medicine at the University of Florida in Gainesville. Ms White is a contributing editor for The Physician and Sportsmedicine. Address correspondence to Louis Kuritzky, MD, 4510 NW 17th Pl, Gainesville, FL 32605.



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