Acute Back Pain – Causes, Symptoms, Diagnosis, Treatment

Acute Back Pain or short-term Back pain lasts a few days to a few weeks. Most low back pain is acute. It tends to resolve on its own within a few days with self-care and there is no residual loss of function. In some cases, a few months are required for the symptoms to disappear. Exercising, bed rest, and surgery are typically not recommended for acute back pain.

Acute Back Pain refers to pain that you feel in your lower back. You may also have back stiffness, decreased movement of the lower back, and difficulty standing straight. Acute back pain can last for a few days to a few weeks. Most back pain is what’s known as “non-specific” (there’s no obvious cause) or “mechanical” (the pain originates from the joints, bones, or soft tissues in and around the spine).

• inflammation or swelling on the back,
• constant back pain that doesn’t ease after lying down or resting,
• pain that travels to the chest or pain high up in your back,
• pain down the legs and below the knees,
• recent trauma or injury to your back,
• loss of bladder control,
• inability to pass urine,
• loss of bowel control, or
• numbness around the genitals, buttocks or anus.

Diagnosis of Back Pain

Diagnosis of back pain is following

• The physical exam – is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the review. The physical exam should include inspection, palpation, the range of motion, strength testing, provocative maneuvers, and neurologic (limb strength, sensation, and deep tendon reflex) assessments. Several provocative exercises help demonstrate or decrease suspicion of different processes.
• A straight leg raise (SLR) – can be complete by raising the patient’s leg to 30 to 70 degrees. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. The likelihood ratio (LR) of a straight leg raise is 2, with ave likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for a lumbar disk herniation with LR of 3.5 and NLR of 0.72.[rx][rx][rx]
• One leg hyperextension test/stork test – Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect.[rx]
• Adam test –  Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication of scoliosis.[rx]
• A straight leg raising – can be painful in lumbosacral radiculopathy. The mechanism of pain during a straight leg raise is increased dural tension placed upon the lumbosacral spine during the test. Patients are supine during the test. The physician will flex the patient’s quadriceps with the leg in extension as well as dorsiflex the patient’s foot on the symptomatic side. Pain or reproduction of paresthesias is considered a positive test (Lasegue sign). Separately, a Bowstring sign is a relief of this underlying radicular pain with flexion of the patient’s knee on the affected side. The straight leg raising test is most helpful in the diagnosis of L4 and S1 radiculopathies.[rx][rx]
• An internal hamstring reflex – for L5 radiculopathy has also been shown to be a useful test. Tapping either the semimembranosus or the semitendinosus tendons proximal to the popliteal fossa elicits the reflex. When there is an asymmetry of the reflex between legs, this can be significant for radiculopathy.[rx]
• A contralateral straight leg raising test – is the passive flexion of the quadriceps with the leg in extension and foot in dorsiflexion of the unaffected leg by the physician. This test is positive when the unaffected leg reproduces radicular symptoms in the patient’s affected limb. However, the straight leg raising test is more sensitive but less specific than the contralateral straight leg raising test.[rx][rx][rx]
• The prone instability test – The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso onto the couch.  The patient can hold onto the couch’s sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine, while the feet are off the floor, is considered positive. [rx]
• Prone Plank/Bridge – The patient is prone and elevates his / her entire body off the couch/mat on the forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.[rx]
• Supine Bridge – The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- the 30s. [rx]

Tests include

• Blood tests – are not routinely used to diagnose the cause of back pain but might be ordered to look for signs of inflammation, infection, cancer, and/or arthritis. Blood tests may include CBC, ESR, Hb, RBS, CRP, Serum Creatinine, Serum electrolytes.
• Bone scans – can detect and monitor an infection, fracture, or bone disorder. A small amount of radioactive material is injected into the bloodstream and collects in the bones, particularly in areas with some abnormality. Scanner-generated images can identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
• Discography – involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT scans taken following the injection.

Electrodiagnostics can identify problems related to the nerves in the back and legs. The procedures include:

• electromyography (EMG) – assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body.
• evoked potential studies – involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal transmissions to the brain.
• nerve conduction studies (NCS) – also use two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage.

Radiography

Suspected disk, nerve, tendon, and other problems – X-rays or some other imaging scan, such as a CT (computerized tomography) or MRI (magnetic resonance imaging) scan may be used to get a better view of the state of the soft tissues in the patient’s back.

• Myelograms
• Discography.
• Electrodiagnostics
• Bone scans
• Ultrasound imaging
• X-rays – can show the alignment of the bones and whether the patient has arthritis or broken bones. They are not ideal for detecting problems with muscles, the spinal cord, nerves or disks.
• MRI or CT scans – these are good for revealing herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
• Bone scan – a bone scan may be used for detecting bone tumors or compression fractures caused by brittle bones (osteoporosis). The patient receives an injection of a tracer (a radioactive substance) into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
• Electromyography or EMG – the electrical impulses produced by nerves in response to muscles is measured. This study can confirm nerve compression which may occur with a herniated disk or spinal stenosis (narrowing of the spinal canal).

Treatment of Acute Back Pain

Most cases of acute back pain can be treated using self-help techniques. These are discussed below.

• Physiotherapy – Physiotherapy aims to improve human function and movement and maximizing potential: it uses physical approaches to promote, maintain and restore physical, psychological, and social well-being, through the use of manual therapy, electrotherapy, and exercise.
• Manual therapies – including manipulation, massage, mobilization.
• Heat and/or ice – may help ease pain, reduce inflammation, and improve mobility for some people
• Gentle stretching – (not vigorous exercise) upon advice by your healthcare professional
• Other non-pharmacological interventions – Including, laser, transcutaneous electrical nerve stimulation, traction, ultrasound, IRR, wax therapy.
• Back school – These include the components seen in some types of back school and multidisciplinary rehabilitation programs
• Percutaneous electrical nerve stimulation (PENS)- including acupuncture, electro-acupuncture, nerve blocks, neuro reflexotherapy, percutaneous electrical nerve stimulation (PENS), injection of a therapeutic substance into the spine.
• Hydrotherapy – An exercise treatment conducted within a specially designed pool so that water supports the patient’s body weight
• Interferential therapy – An electrical treatment that uses two medium frequency currents, simultaneously, so that their paths cross. Where they cross a beat frequency is generated which mimics a low-frequency stimulation
• Intra-Discal Electrothermal Therapy (IDET) – Use of a heating wire passed through a hollow needle into the lumbar disc intended to seal any ruptures in the disc.
• Lumbar supports – External devices designed to reduce spinal mobility, e.g. corsets
• Manipulation – Small amplitude high-velocity movement at the limit of joint range taking the joint beyond the available range of movement.
• Transcutaneous electrical nerve stimulation (TENS) – Electrodes are placed on the skin and different electrical pulse rates and intensities are used to stimulate the area. Low-frequency TENS (also referred to as acupuncture-like TENS) usually consists of pulses delivered at 1 to 4 Hz at high intensity, so they evoke visible muscle fiber contractions. High-frequency TENS (conventional TENS) usually consists of pulses delivered at 50 to 120 Hz at a low intensity, so there are no muscle contractions.
• McKenzie – A system of assessment and management for all musculoskeletal problems that uses classification into non-specific mechanical syndromes. Assessment involves the monitoring of symptomatic and mechanical responses during the use of repeated movements and sustained postures
• Neuroreflexotherapy – Temporary implantations of epidermal devices into trigger points at the site of each subject’s clinically involved dermatomes on the back and into referred tender points in the ear.
• Traction – Traction performed by utilizing the patient’s own body weight (for example by suspension via the lower limb) or through movement.
• Intra-Discal Electrothermal Therapy (IDET) – Use of a heating wire passed through a hollow needle into the lumbar disc intended to seal any ruptures in the disc.
• Prolotherapy – Injections of irritant solutions to strengthen lumbosacral ligaments.
• The Back Book – A widely used advice booklet for people with back pain.
• Psychological treatment – Psychological treatments include a range of talking therapies including both psychotherapy and counseling there a several different broad psychological approaches, including, for example, cognitive-behavioral therapy (CBT). The focus of these treatments is usually on health promotion rather than treating specific disorders
• Counseling – Counselling takes place when a counselor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life, or loss of a sense of direction and purpose. It is always at the request of the client as no one can properly be ’sent’ for counseling.

Medication

• Analgesics – with or without paracetamol may improve pain and function compared with placebo. However, long-term use of NSAIDs or opioids may be associated with well-recognized adverse effects.
• Over-the-counter (OTC) painkillers – Paracetamol is usually recommended to treat acute lower back pain. If paracetamol proves ineffective, a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen may be used instead.
• Stronger painkillers – If your back pain symptoms are severe, your GP may prescribe a mild opiate-based painkiller, such as codeine, which can be taken in combination with paracetamol or an NSAID.
• Muscle relaxants – If your back pain symptoms are very severe, your GP may prescribe a muscle relaxant such as diazepam. Diazepam can make you feel very sleepy, so do not drive if you have been prescribed this medication. After your course of diazepam has ended, you should wait at least 24 hours before driving. Diazepam will also make the effects of alcohol worse, so you should avoid alcohol while you are taking the medication.
• Antidepressants  – decrease chronic low back pain or improve function compared with placebo in people with or without depression. Antidepressants such as tricyclic antidepressants and SNRI’s, topical analgesics, muscle relaxers, N-methyl-d-aspartate (NMDA) receptor antagonists, and alpha 2 adrenergic agonists are also the most effective pharmacological therapies.
• Muscle Relaxant – Benzodiazepines may improve pain, but studies of non-benzodiazepine muscle relaxants have given conflicting results.
• Gabapentin –The initial treatment of neuropathic pain and chronic back pain is often with gabapentin or pregabalin.  It is Considere’s most effective treatments are in general recommended in chronic low back pain. They are indicated for postherpetic neuralgia, diabetic neuropathy, and mixed neuropathy.[rx]
• Oral systemic steroids tablet – are often prescribed for acute low back pain, and chronic low back pain although there is limited evidence to support their use. It is basically used to remove nerve-related inflammation, edema, hematoma.
• topical pain relief – such as creams, gels, patches, or sprays applied to the skin stimulates the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Common topical medications include capsaicin and lidocaine.