Treatment Of Lower Back Pain

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[edit] Treatment Of Lower Back Pain

(Shortcut to summary table of treatment)

Depending on what the underlying cause of the acute low back pain is, the therapy will vary considerably. Most of the back pains, as indicated above, are harmless and self-limiting, but extremely annoying to the patient. In the acute phase icing the back may give relief. Some patients have perhaps a weaker connective tissue.

For this reason they are more prone to recurrent acute lower back problems. They may benefit from a few chiropractic treatments. Minor malalignments of the facet joints can be treated very quickly and effectively this way. But some patients are very sensitive in their back, perhaps because they lean more towards developing fibromyalgia pain or myofascial pain when they have a lower back pain.

These patients will find out that they do better with physiotherapy and they should be sent there. Once the patient knows what works for them, they usually gravitate into the right treatment modality. It would be a mistake to recommend one therapy over another. Some patients also seem to respond best to a few acupuncture treatments combined with stretching exercises and subsequent reactivation.

If this is what it takes to overcome the acute back pain, go for it! After an initial one or two weeks of passive treatment modalities such as chiropractic, physiotherapy or acupuncture treatments it is important in all cases to switch over to a more active reactivation program with an exercise routine and stretching exercises. Work modifications should also be addressed to prevent repeat injuries.

If this is neglected, the patient gets into a muscle atrophy situation from disuse and this sets the patient up to get a chronic back pain, a fibromyalgia syndrome or a myofascial pain syndrome.

The following table lists the specific therapeutic recommendations for the more common underlying causes of back pain. Links are provided in the table for more details regarding these therapeutic modalities.

Treatment modalities for lower back pain
Cause or disease:	Treatment modalities:
Facet joint disease (lower back strain)	chiropractic or physiotherapy treatments initially followed by active exercises
Degenerative disc and facet joint disease	antiinflammatory medication and physiotherapy treatments, swimming; end stage intractible disease, if confined to one or two levels may respond to fusion surgery by spinal surgeon
spondyloarthropathies	treat underlying disease and use antiinflammatories; rheumatologist referral for more specific therapy
Osteoporosis	treat underlying hormone disbalance, if present; regular walking and swimming; avoid alcohol, caffeine, stop smoking; use calcium, biphosphonates, vitamin D
Scoliosis	bracing during growth spurts; good posture; strehgthening exercises; in severe cases corrective surgery with Harrington rods by spinal surgeon
Spinal stenosis	decompression surgery for severe cases to free spinal cord and nerve roots
Posttraumatic fibromyalgia	low dose antidepressants, cognitive therapy, mild physical exercises
Disc herniation with or without sciatica	only in 3% of all back pain is surgery indicated; many cases heal on their own
Spondylolisthesis and other congenital malformations	grade I to IIIA do not need surgery, stage IIIB and IV need fusion with instrumentation by spinal surgeon
Bone metastases	underlying cancer needs treatment, often chemotherapy required
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[edit] Treatment Of Spondyloarthropathies

The underlying disease such as Crohns disease, ulcerative colitis, psoriasis or ankylosing spondylitis that has lead to this inflammatory disease of the spinal column needs to be treated. Sulfasalazine in the case of Crohns disease and ulcerative colitis might also help the spondyloarthropathy. The COX-2 inhibitor (brand name: Celebrex) is also useful, as are the regular anti-inflammatories. Keep an eye on side-effects of the COX-2 inhibitory medications, which may be easier on the stomach than the regular anti-inflammatopries, but one of these drugs (VIOXX) was pulled from the market in October of 2004 due to serious cardiovascular side-effects. The VIOXX link explains this story in detail.

Otherwise reactivation, physical rehabilitation programs and postural improvements are helpful.

[edit] Osteoporosis Treatment

It is important that osteoporosis be diagnosed as early as possible and not only when a hip fracture, wrist fracture or compression fracture of a vertebral body happens with a fall. A physical exercise program involving swimming, walking and stretching exercises is combined with a good nutritional program. The affected person must ensure that enough calcium supplement is taken in by consuming both milk products and taking calcium supplements. Vitamin D taken at the same time helps to absorb more of the dietary calcium through the gut wall.

Calcitonin or a calcitonin analogue hormone by nasal spray can be given to build up stronger new bone. Sodium fluoride has been recommended in the past in an attempt to build up bone mass, but the bone that is built up with fluoride seems to be more brittle resulting in fractures again. Calcitonin hormone induces new bone growth that is identical to regular healthy bone and is preferred for this reason. Calcitonin is the hormone that stimulates bone cells called osteoblasts. These cells have been bone building when you grew up. It only makes sense that we would use the same cell mechanism to build up bone by using calcitonin when bone loss has occurred. Women in the post menopause time of their lives can use estrogen replacement (preferably low dose, discuss this with your physician) up to 5 years to preserve healthy bone structure. However, there is still a slightly higher than normal breast cancer risk. This risk is about 1.6 to 1.8-fold higher than without estrogen at the 5 year point of several studies. Many authorities feel that up to 5 years this risk would not show up to be significant and would be in favor of estrogen replacement as the death rate from hip fractures due to osteoporosis would be higher. In men testosterone levels need to be determined and if they are low, testosterone replacement therapy can be considered by the physician, again being cognisant that prostate cancer is the risk in that case, again likely more so the longer the replacement is taken. Discuss this with your physican.

References:

1. ABC of rheumatology, second edition, edited by Michael L. Snaith , M.D., BMJ Books, 1999.

2. The Merck Manual, 7^th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 52.

3. The Merck Manual, 7^th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 275,p.2429.

4. HA King Orthop Clin North Am 1988 Apr;19(2):247-255.

5. HA King Orthop Clin North Am 1999 Jul;30(3):467-474, ix.

6. The Merck Manual, 7^th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 59.

7. JA Smith Orthop Clin North Am Jul 1999; 30(3): 487-499.