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Management of Low Back Pain

Principals of Management

The main aims of management of your low back pain are to improve your pain and reduce the disability you are suffering because of the pain, allowing allow you to return to normal activities including work.

Most acute episodes of low back pain settle within 6 weeks and do not represent severe injury, so often simple reassurance is all that is required for you to feel confident to continue with everyday activities and remain at work.

If pain is still troublesome then it may be improved in a variety of ways including the giving of medication, dry needling and interventions such as cortisone injections and radiofrequency lesioning.

Treating the pain may be enough to also improve your disability (or loss of normal function) but other methods may be of additional help including exercise, manipulation and interventions such as prolotherapy.

Manipulation

Manipulation may be performed by a number of health professionals who have received specific training, such as osteopaths, chiropractors, manipulative physiotherapists and some doctors. Treatment aims to increase movement between adjacent vertebrae and is achieved by the therapist performing a high velocity thrust, a small movement of the spine performed at high speed. Often this is accompanied by an audible clunk which is probably caused by the facet joints between the vertebrae opening up (gapping) causing a small bubble of gas to come out of the fluid within the joint. The technique is employed when certain parts of the spine are found to be stiff. This may be due to posture or because the surrounding muscles have become very tight. The procedure is often repeated at intervals but if there is no perceivable benefit after 3 – 6 treatments then it is unlikely to make any difference. If there is benefit, this may be maintained by learning some exercises to keep that particular spinal segment mobile. Manipulation can be used at any stage in patients with back pain but seems to be more effective within the first few weeks of an episode. It is generally felt to be unwise to use forceful manipulations when there is evidence of new onset nerve root pain. It is common to feel sore for a day or two after each treatment.

Exercise

There are a variety of exercises that may help patients with low back pain problems. Exercises should be tailored to the individual’s need and may vary from one case to another. In general terms, if pain is worse when you bend but improves when you bend backwards, then exercises to encourage the less painful movement would be encouraged in the first instance. In patients with spinal instability, exercises to train the segmental, supporting muscles (which are commonly weak in these situations) may help to prevent further recurrences of pain. Exercises are usually taught by a trained physiotherapist but you may be able to improve your spinal stability by attending Pilates classes.

Acupuncture/dry needling

Dry needling involves the insertion of fine needles through the skin. Chinese acupuncture, involves insertion of needles at points in the body removed from where the pain is, whereas Western acupuncture tends to involve the insertion of needles into tender muscles (trigger points). The aim of dry needling is to cause relaxation of these tight trigger points, thereby reducing the pressure on the spine caused by chronically contracted muscle. These treatments are generally given as a course of 3 – 6 at intervals and may include the insertion of a number of needles (6 – 12) at a time. Different people react to acupuncture in different ways, some patients being strong responders and some who do not respond at all. Some patients need the needle left in for just a few seconds and in some they can be left in for many minutes. If there is no perceived benefit within 3 – 6 treatments then it is unlikely that this treatment will be of benefit to you. It is common to feel sore for a day or two after each treatment.

Medication

In most cases of back pain, it is important to maintain movement right from the very start. This may be difficult, particularly if there is a great deal of pain. Often people with back pain, are concerned about taking medication to mask the pain because they are concerned that they may cause themselves more damage by moving. All the evidence suggests that this is not true and it is now considered extremely important to get moving as soon as possible. In order to achieve this, it may be necessary to take sufficient painkillers. It is also important to take this medication regularly, particularly in the first instance.

Paracetamol

Paracetamol 500 mg tablets can be taken 2 tablets 4 times a day in adults. Within this dosage, there is often reasonable pain relief, particularly if pain is not too severe, and there are unlikely to be any significant side effects.

NSAID’s (non steroidal anti-inflammatory drugs).

This category of medication comprises drugs such as Ibuprofen, Nurofen and Diclofenac. These drugs have moderate anti inflammatory affects and can be useful in patients with mild to moderate back pain. Taken regularly for relatively short periods, there are unlikely to be significant effects but if there is a history of peptic ulcer, kidney disease or asthma, then advice should be sought. They can be taken in combination with paracetamol or codeine-based medication.

Codeine based medication

These medications comprise medication such as Codydramol, Co-codamol, Codeine Phosphate, Dihydrocodeine and Tramadol. Side effects of these drugs can include drowsiness, nausea and vomiting and constipation. They may be effective in more severe episodes of low back pain.

Amitriptyline/Dothiepin

In larger doses, these medications have historically been used to treat depression. However, they have also been found to be useful in some patients who have chronic pain, particularly when this is associated with sleep disturbance and in these instances can generally be given much in lower doses. Side effects can include dry mouth, blurred vision and morning drowsiness but often these side affects tend be less intrusive with regular usage. These medications need to be taken regularly and may take several weeks to work.

Gabapentin/Pregabalin

These medications are often used when chronic pain is felt to be neuropathic (caused by disordered function of nerves). Tablets need to be taken on a regular basis and can take several weeks to work. Side effects may include dizziness, dry mouth, blurred vision and altered concentration.

Diazepam

Diazepam in large doses can be used as a sedative but in small doses, such as 2 mg three times a day, may be very effective in relieving muscle spasm associated with low back pain. It is best used within the first few hours/days of an episode of back pain associated with spasm and can help shorten the duration of an attack. This medication should not be taken on a long term basis as after as little as 10 days, it may become addictive. However, taking it in short bursts followed by intervals without may be appropriate if episodes of back pain are not too frequent. Side effects may include drowsiness.

Cortisone Injections

In certain scenarios, particularly when pain remains significant and prevents return to normal function, sport or work, the source of pain can be diagnosed and treated using injections. In principal this involves injecting a local anaesthetic and corticosteroid into a specific area that is thought to be causing pain. See Diagnostic Injections. In practice, this involves the insertion of a fine needle through the skin and under the guidance of Xray images, is passed into a suspected painful joint, (such as a facet joint, or sacroiliac joint) or around an irritated nerve (nerve root injection or epidural injection). Cortisone is a strong anti-inflammatory agent and so can potentially provide significant pain relief for a variable length of time (averaging a few weeks). For more information about these Therapeutic Injections and other procedures please see our Spinal Medical Patient Information Guides in the Patient Downloads section.

Radiofrequency Lesioning

When the source of pain is known to be the facet or sacroiliac joint, and when the above methods have not controlled pain, the small nerves that pass the pain signals from the point of pain to the spinal nerve roots (and thence to the spinal cord) can be heated via a radiofrequency technique through a needle. This causes these small nerves to stop firing and the pain messages cannot get through. See Radiofrequency Neurotomy. For more information about Radiofrequency Lesioning and other procedures please see our Spinal Medical Patient Information Guides in the Patient Downloads section.

Prolotherapy

Prolotherapy is also known as sclerosant injections or sclerotherapy. It is used in cases of low back pain due to segmental instability or sacroiliac instability. The aim of this treatment is to improve the stability of the low back by strengthening the ligaments that support it. The procedure involves a number of injections given to the ligaments of the low back and sacroiliac joint as they attach into bone. Small volumes of irritant are injected causing a local inflammation. This causes, amongst other things, new cells to migrate to the area of inflammation where they produce and lay down new ligament tissue (collagen). In practice the procedure tends to be repeated at intervals. A normal course will involve 3 sets of injections separated by 1-4 weeks. It often takes 6 weeks or more before the benefits start to be noticed and improvement may continue for several months. For more information about Prolotherapy and other procedures please see our Spinal Medical Patient Information Guides in the Patient Downloads section.

Surgery

Surgery for prolapsed intervertebral disc by way of microdiscectomy can be very rewarding in terms of pain control if the usual measures have not controlled the pain from nerve root irritation/ compression. The procedure requires a hospital stay of 1-3 days and recovery can take up to six weeks. The surgery is performed through a small incision on the low back and under a microscope to minimize complications. Risks include a 1-2% risk of nerve injury or infection, and a small risk of headache due to leakage of fluid from around the spinal nerves which settles usually within ten days. Surgery for chronic low back pain is less rewarding but in well-selected cases (such as those with proven disc pain who have an otherwise healthy spine), a fusion (where two spinal vertebrae are prevented from moving using bone grafts or metalwork) can be helpful. Risks again include infection, nerve injury and headache. About 70% of patients achieve 70% pain relief with 10% feeling either no benefit or worse symptoms.