Acute back Pain Patient Advice

[C1086]

Dear All,
I would be very interested in what type of home advice you give to patients who are in acute pain whether it is lower back,neck or thoracic. What do you get your patients to do between treatments or before they can come for there first appointment with you.Your comments and pearls of wisdom would be greatly appreciated
C1086

[junior_physiotherapist]

Originally Posted by C1086

Dear All,
I would be very interested in what type of home advice you give to patients who are in acute pain whether it is lower back,neck or thoracic. What do you get your patients to do between treatments or before they can come for there first appointment with you.Your comments and pearls of wisdom would be greatly appreciated
C1086

Nonoperative treatments
Hot or cold: Hot or cold packs – or sometimes a combination of the two – can be soothing to chronically sore, stiff backs. Heat dilates the blood vessels, improving the supply of oxygen that the blood takes to the back and reducing muscle spasms. Heat also alters the sensation of pain. Cold may reduce inflammation by decreasing the size of blood vessels and the flow of blood to the area. Although cold may feel painful against the skin, it numbs deep pain. Applying heat or cold may relieve pain, but it does not cure the cause of chronic back pain.

[junior_physiotherapist]

Exercise: Although exercise is usually not advisable for acute back pain, proper exercise can help ease chronic pain and perhaps reduce its risk of returning. The following four types of exercise are important to general physical fitness and may be helpful for certain specific causes of back pain:
Flexion: The purposes of flexion exercises, which are exercises in which you bend forward, are to 1) widen the spaces between the vertebrae, thereby reducing pressure on the nerves; 2) stretch muscles of the back and hips; and 3) strengthen abdominal and buttock muscles. Many doctors think that strengthening the muscles of the abdomen will reduce the load on the spine. One word of caution: If your back pain is caused by a herniated disc, check with your doctor before performing flexion exercises because they may increase pressure within the discs, making the problem worse.

[junior_physiotherapist]

Extension: With extension exercises, you bend backward. They may minimize radiating pain, which is pain you can feel in other parts of the body besides where it originates. Examples of extension exercises are leg lifting while lying prone and raising the trunk while lying prone. The theory behind these exercises is that they open up the spinal canal in places and develop muscles that support the spine.

[junior_physiotherapist]

Stretching: The goal of stretching exercises, as their name suggests, is to stretch and improve the extension of muscles and other soft tissues of the back. This can reduce back stiffness and improve range of motion.
Aerobic: Aerobic exercise is the type that gets your heart pumping faster and keeps your heart rate elevated for a while. For fitness, it is important to get at least 30 minutes of aerobic (also called cardiovascular) exercise three times a week. Aerobic exercises work the large muscles of the body and include brisk walking, jogging, and swimming.

[junior_physiotherapist]

For back problems, you should avoid exercise that requires twisting or vigorous forward flexion, such as aerobic dancing and rowing, because these actions may raise pressure in the discs and actually do more harm than good. In addition, avoid high-impact activities if you have disc disease. If back pain or your fitness level makes it impossible to exercise 30 minutes at a time, try three 10-minute sessions to start with and work up to your goal. But first, speak with your doctor or physical therapist about the safest aerobic exercise for you.
Medications: A wide range of medications are used to treat chronic back pain. Some you can try on your own. Others are available only with a doctor’s prescription.

[C1086]

Thank you very much for your message. My question is really what sort of things do you advise a patient in acute pain to do so they don't get worse. For instance you have just treated them and they go home, then what do they do ?? Contrast bathing is fine, but what else would you recommend ? Eg it is generally agreed not to spend ages in bed, but supposing the patient is really acute, all they want is to get better and fast, what would you recommend they do to speed up there recovery and get better quicker.
Anyone else out there have any pearls that they find really helpful in this type of situation.
C1086

[sdkashif]

There has been already a lot of discussion on the topic of back pain with general over view for planning effective treatment strategies. When a patient comes to you to get help from physiotherapist, it is the resposnsibility of the physiotherapist to assess him properly to find out the possible cause for pt's back pain or spinal pain. In however, majority of the cases it is not possible to find the exact cause of low back pain. In other words after ruling out the red flags and yellow flags for Spinal pain or ruling out the serious causes of spinal pain, it is always clinician responsibility to find a possible cause for pt's pain. But as I have already mentioned that a possible cause is not found in majority of cases and patient back pain is labelled as acute non specific Back pain in acute cases. The acute non specific Back pain accounts for almost 80% cases of back pain. There are many empirical rules to treat this non specific back pain. The rest of 20% cases of Back may have other causes to be indentified and labelled in pt's treatment plan, so here you will be able to plan any suitable physiotherapy management plan. The best plan here is to use the evidence based guidelines of physiotherapy that you may use effectively. For you as a beginner, it is better to have a look over Danish Health and technology Guidelines which are very empirical and effective. You may have a look over them at Danish Health Technology Assessment 1999; 1(1) Low Back Pain

Another effective source of information for you is EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARE

Another good review is the norwegian Guidelines and you may have a look over that Acute low back pain-Interdisciplinary clinical guidelines developed by The Norwegian Back Pain Network

You may also have a look over the Gudelines developed in the USA at USA - Department of Health and Human Services, Agency for Health Care Policy and Research, Acute Low Back Problems in Adults; AHCPR Publication No. 95-0642

In my opinion this will help you to start as a beginner to get a better idea.

[C1086]

Thank you very much for those references. They are excellent and will be usefull. But what I really want to know is what do you tell your acutely painful patient while in your treatment room, what to do after his treatment when he gets home.
European Guidelines are not much immidiate help to him at this moment in time, all he wants is to be out of pain, as much as possible for as long as possible. Should he do exercises (which ones ?), should he go for a swim, should he go home and do nothing etc etc

Happy New Year

C1086

[junior_physiotherapist]

Hi colleague:

i'll give u this link and i think it'll help u ,really it's very interisting link


www.spine-health.com/topics

hope to be useful

all best

[angela929]

Beside all those that have metioned above, I believe posture education and core stabilization exercise for back are also important to prevent recurrence of back pain. Transverse Abdominals can be as a target for training with draw in manouver technique.

[C1086]

Dear Angela,
Thank you for your reply. But really this advice is best given when the patient has got over the acute attack. What do you advise a patient does when he goes home after his first visit to you ? Surely not the drawing in manoevre ? Regards C1086

[sdkashif]

Originally Posted by angela929

posture education and core stabilization exercise for back are also important to prevent recurrence of back pain.

It is good to give the patient an exercise plan to do at home when the problem is mechanical in nature. But when there are other causes of LBP as I already mention, other appropraite strategies should be adopted and followed as described in the guidelines above.

[alophysio]

Hi C1086,

[edit: I agree completely with sdkashif's last comment]...

Your question relates to exercise after the first treatment for an acute attack of LBP right?

First of all, I wouldn't give an exercise usually after the first visit. I ahve just done a S/E then an objective exam, formulated a diagnosis and treatment plan, implemented treatment and reassessed. Now i would expect a significant difference after that treatment intervention.

If i give the patient an exercise at home (and how many really do it properly when it is tacked onto the end of all the assessment and treatment?), how will i know what made them better or worse when they come back. Plus, if it is tacked on at the end, the idea the patient may get (consciously or unconsciously) is that it is not as important as all the things i did to them.

Therefore i would argue that exercises should be commenced at the second session wherever possible.

Also, as a therapist (i am guessing manual therapist), you are treating their immediate problem if it is acute. Exercise may in fact be detrimental to the patient in the acute phase (i am not advocating bed rest!). It has been clearly shown many times over that pain during exercise leads to muscle inhibition (i.e. you won't work the muscles you want anyway) and probably leads to poor muscle patterning because of compensatory movements.

Therefore, if they have a mechanical pain, treat it. If they have chemically mediated pain, get the doctor to treat it. Deal with their immediate needs first. Bring the pain down, get their movement back. (**Remember - this is an acute patient or actue-on-chronic patient - this does not apply to chronic pain**). You can deal with their exercises soon.

As for giving advice while they are waiting for your appointment...I like the simple "Do whatever feels good". How can you give a responsible answer without an assessment? If you tell them heat and they have an underlying infection, you just gave them bad advice. If you tell them to put ice on it but didn't show them how, they may get an ice burn. If you give them extension exercises to do but they have a facet joint injury, they are going to hate you!

So my recommendation is "Whatever feels good". It is what we go by anyway - we ask them their aggravating factors and their easing factors. We then use the easing factors to help relieve pain and avoid the aggravating factors - the aggs become our functional goals of treatment.

Lastly, reciepe based advice is not the best path for our profession. People have individual problems so need individual advice and exercise. Not everyone needs "core-stability" exercises (believe it or not!). In fact, some people have an overactive "core".

Make your assessment, do your treatment, evaluate the effect of your treatment, start the exercises as a session in itself to highlight the importance of the exercises....in my humble opinion...

[asha]

I would be very interested in what type of home advice you give to patients who are in acute pain whether it is lower back,neck or thoracic. What do you get your patients to do between treatments or before they can come for there first appointment with you.Your comments and pearls of wisdom would be greatly appreciated
C1086

There can be no advice one can give to a patient before he can come for his first appt. advices would depend on the assessment findings. Sometimes what makes them better or worse may also put you in the wrong track. A patient who has a huge post central disc may feel better with a slump or with slight flexion ,(because the disc gets accomadated) but does not remain better. In such a case advising him flexion would make him worse. A patient who has facetal dysfunction in flexion would again feel better in flexion, but if he has been in this situation for sometime, he may have secondary derangements which make him worse if advice of flexion is given & extension would again have him not forgiving you for it. So its not easy to give a straight answer as there can be no straight answer. The only answer would be, a good assessment is the mainstay of treatment.