A 43-year-old man comes to the office for follow up regarding back pain. He had acute onset of pain in the low back radiating to the buttocks 3 weeks ago after lifting heavy bags of fertilizer at his farm. The patient was treated with naproxen; with treatment, his pain has decreased from an 8/10 to 3/10 in severity, and he no longer has radiation of the pain. Medical history is notable only for 2 prior episodes of back pain in the last year. Vital signs are normal. BMI is 33 kg/m². Physical examination shows no spinal tenderness, normal lower extremity strength and reflexes, and a negative straight-leg raising test bilaterally. The patient asks what is needed to prevent future episodes of back pain. Which of the following is the most appropriate response to this patient's question?

Question

Quizplus · Accepted Answer

Explanation: This patient has acute, uncomplicated low back pain (LBP), which is improving with appropriate initial measures (eg, nonsteroidal anti-inflammatory drugs). In addition to reduced pain severity, he has experienced centralization of pain (ie, a reduction in the extent of referred pain), which carries a favorable prognosis. However, in his extended history, he has had recurrent episodes of LBP, which is associated with an increased risk for additional recurrences. In patients with LBP, physical activity is important for promoting resolution of the initial symptoms, as well as for lowering the risk of recurrence. During acute episodes of pain, patients should be counseled to maintain normal moderate activity. As pain improves, they should be advised to initiate (or resume) a regular exercise program to lower the risk of future episodes. Evidence supports a variety of exercise modalities, including stretching, core-strengthening exercises, and aerobic exercises (eg, walking). Although obesity is associated with an increased risk of LBP, it is not clear that weight loss apart from regular exercise lowers the risk of recurrence. (Choice A) Patients with acute LBP should be advised to continue normal moderate activity, which is associated with reduced duration of pain. However, normal activity alone without additional exercise is associated with a 1-year risk of recurrent pain of approximately 50%. This risk can be significantly reduced with a dedicated exercise program. (Choice B) Spinal manipulation is effective for short-term relief of acute LBP. However, it is not effective for preventing recurrent episodes. (Choice D) MRI is indicated for the evaluation of lumbosacral radiculopathy associated with significant or progressive neurologic deficits, LBP associated with features of cauda equina syndrome (eg, saddle anesthesia), or suspected epidural abscess (eg, fever, intravenous drug use). Otherwise, MRI does not improve outcomes or alter standard treatment advice. (Choice E) Lumbar support braces (back belts) are not associated with a decreased risk of recurrent LBP. In fact, some studies have noted an increased risk, possibly due to restricted mobility or muscular deconditioning. Educational objective: During an acute episode of low back pain, patients should be counseled to maintain normal moderate activity. As pain improves, they should be advised to initiate (or resume) a regular exercise program, which can decrease the risk of recurrent pain; modalities can include stretching, core-strengthening exercises, and aerobic exercises. References: Prevention of low back pain: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26752509)

A 43-Year-Old Man Comes to the Office for Follow Up