Low Back Pain
Kelly Gonzales, PhD, APRN-NP, FNP-C
College of Nursing
Case Presentation
Low Back Pain
• A 35-year-old male painter presents to the clinic
with the complaint of low back pain. He recalls
lifting a 5-gallon paint can and felt an immediate
pull in the right side of his back.
• This happened a few days ago and he had the
weekend to rest, but after taking Motrin and using
heat, he has not seen any improvement. He
states he needs to be able to work.
• He is having right leg pain but no bowel or
bladder changes.
• His pain is sharp, stabbing, and he rates it a 9 out
of 10.
• He had a similar incident ~5 years ago but made
a complete recovery.
Low Back Pain
• 5th most common visit in primary care
• LPB occurs in 70% of adults at some point in their
life
• Vast majority (90%) are benign and will
spontaneously recover within 1 month
Important considerations:
• Localized pain that is worse with moving
due to muscle pain
• Trauma may cause a fracture and
requires an x-ray
• Radiating pain into the leg along a
dermatome indicates a ruptured disc
• Loss of bowel or bladder function
indicates an emergency
HPI •
•
•
OLDCARTS
Any numbness/tingling
Does the pain radiate?
• Any bowel or bladder issues?
• Difficulty with sleep?
• Problems with sitting or walking?
1.Mode and timing of onset: Abrupt or d. Sleep
insidious? 4.History
2.Characteristics: a. Similar or different pains recently or in
a. Specific location of pain the past
b. Course (progressive, decreasing, b. Prior treatment and effect
increasing, fluctuating, episodic) (medications, types of surgery,
c. Associated limb and/or neurological nonpharmacological management,
symptoms (pain, paresthesias, lifestyle and work modifications,
numbness, weakness, atrophy, cramps, litigation, or workers’ compensation
fasciculations) issues)
d. Provoking or aggravating factors 5.Associated symptoms
e. Relieving factors a. Urinary problems (frequency, urgency,
f. Severity retention, incontinence)
3.Effects of activities b. Bowel problems (incontinence or
a. Posture constipation)
b. Coughing, sneezing, straining
c. Exercise, exertion, rest
Cardinal Signs and Symptoms
Abdomen Other Associated Symptoms
• Pain • Fever
• Rectal bleeding • Rash – think shingles
• Bowel leakage
• Malaise
Urinary
• Enlarged lymph nodes in
• Incontinence groin
• Painful urination • Pelvic pain or discharge
(females)
Neurologic
• Radiculopathy
• Foot drop
• Motor weakness of LEs
Any foot drop or bowel/bladder changes need
immediate attention and possibly an MRI or
referral to neurosurgeon
TABLE 54.1 Red Flags When Assessing
a Patient With Low Back Pain
Suspect Fracture Suspect Malignancy Suspect Infection Suspect Cauda
Equina Syndrome
Recent trauma or Prior history of cancer (most New onset of back Saddle anesthesia
injury common: breast, lung, or pain with fever New-onset fecal
Older age (older prostate cancer) Recent infection incontinence
than 60–70 years) Older than 50 years or Recent spinal New-onset bladder
History of younger than 20 years procedure incontinence or
osteoporosis Persistent bone pain IV drug use urine retention
Use of Progressive pain at night— Immunocompromised Progressive
corticosteroids may wake patient from Pain at rest sensory loss
sleep Pain at night—may Progressive
Pain at rest wake from sleep weakness
Unintended weight loss Potential exposure to
Failure of back pain to person with
improve with therapy tuberculosis (Tb) or
endemic area
Physical Exam
General
Vital signs Lumbar spine
appearance
• Fever is • Observe • Inspect
ominous sign general gait • Palpate
• Pulse • Guarding or • ROM
• BP coordination • Strength
• Respirations problems • Neurologic
• Appearance • Special Tests
of comfort •
versus Vascular
distress • Rectal exam
• Overall • Pelvic exam
muscle tone,
alignment and
abnormalities
Case Study Findings
Subjective
• Abrupt onset, pain radiates down right leg, no N/T, no
difficulties with bowel/bladder, some pain when turning over in
bed but no real sleep difficulties, no problems sitting, slight
limp with walking
Objective
• VS normal
• General appearance: well-developed healthy male, no
deformities
• Chest: lungs clear. S1 and S2 with no murmur
• Musculoskeletal: no obvious deformities, masses or
discoloration. Palpable pain noted at the right lower lumbar
region. No palpable spasms. ROM limited to forward bending
10 inches from floor. Able to bend side to side. Had difficulty
twisting and going into extension due to pain.
• Neuro: DTRs 2+. Negative straight leg raises. Sensory intact
to light touch. Able to toe and heel walk. Gait stable and no
limping.
Differential Diagnoses
Lumbar Herniated Sacroiliac Osteoarth. Malignancy
Strain Disc
Onset Abrupt Either Abrupt Gradual Gradual
Duration < 2 weeks Varies Acute sxs Many years Many years
Location Lumbar Lumbar or Buttocks Lumbar Varies
Thoracic
Pain Can radiate Can radiate Can radiate Can vary Can vary
N/T Sometimes Often Sometimes Not often Varies
B/B changes No Possibly No No Possibly
DTR Normal Maybe Normal Normal Maybe
asymm. asymm.
Toe / heel Normal Maybe Diff Difficulty Normal Normal
walk
Straight Leg Negative Positive Negative Negative Negative
Raise
Final Diagnosis
Lumbar Strain
Pharmacological Pain
Management
• Continue with Motrin 600 mg TID for 2 weeks, then take every 8
hours PRN
• Higher risk of GI ulcers and hemorrhage
• Caution in GI, cardiac, or renal disorders
• Affects renal prostaglandins and may cause fluid retention and edema – monitor
for weight gain
• What to do if patient can’t take NSAIDs – can use Tylenol
• Other medication classes to consider
• Steroids
• ibuprofen vs. naproxen (BID dosing)
• TCA for shingles pain
• Gabapentin – for chronic LBP
• Cyclobenzaprine 5 mg at bedtime PRN, can advance to TID
PRN as tolerated
• CNS depressant --> drowsiness and dizziness
• Review side effects and caution with operating heavy machinery
Plan
Conservative Therapy
• Heating pad & ice for 15 minutes TID
• Avoid heavy lifting and any activities that exacerbate
pain (i.e. twisting)
• Review importance of maintaining normal activity to
include walking and avoid bedrest and/or excessive
sitting
• Follow up appointment in ~2-3 weeks
• If symptoms persist or worsen, consider Physical
Therapy and/or diagnostic tests to include x-ray and
possible CT or MRI
• nonspecific LBP typically only needs radiographs when they have failed to
improve after 6 to 8 weeks of conservative therapy
• Unless
1. You suspect a pathology that you would manage differently than nonspecific LBP
2. The patient has red flag signs or symptoms
• fracture; a malignancy; a spinal infection; or a progressive, severe neurological
Other Thoughts
• Don’t overlook other differential diagnoses that should be
considered based upon patient presentation or medical history
• UTI may present as back pain
• Shingles in the elderly – always consider this! Even if there is no rash!
• Patient requests a controlled substance
• Opioids may be used on a time-limited basis for severe pain
• Smallest dose, limited quantity
• Do not enhance a patient’s ability to return to full activity sooner than NSAIDs
• High risk of dependence and misuse/abuse
• Other non-pharmacologic approaches
• Massage, relaxation, yoga, meditation, spinal manipulation
• Lifestyle
• physically demanding job
• Obesity– what else will you counsel the patient on?
• Increase activity – complete whatever activities are tolerable
• Weight loss, physical activities, and exercise for 30 minutes a day (walking or biking with lumbar
flexion and/or extension exercises) are also important
• Consider psychosocial factors such as fear avoidance, financial problems,
anxiety, depression, job dissatisfaction, PTSD, or poor coping behaviors that
can contribute to prolonged disability and greater risk for chronic pain.
Non-pharmacological management
• Avoiding bedrest if possible, no
more than 1 to 2 days if needed
• Physical therapy or gentle home
exercise program
• Activity as tolerated
• Cognitive behavioral therapy or
mindfulness-based activities
• Tai chi
• Yoga
• Superficial heat
• Acupuncture
• Spinal manipulation or chiropractor
• Multidisciplinary rehabilitation
• Shoe inserts or lifts for patients with
leg length discrepancies greater
than 2 cm
• Massage, traction, transcutaneous
electrical nerve stimulation (TENS)
unit, ultrasound, and lumbar
supports have little or no evidence
in the literature to demonstrate their
benefit.
