Complaint: Acute severe Mid-Back pain x 1 day in a 60 y.o. male who works in the stockroom (lifting boxes)
Incidence and
Risk Factors Signs and Symptoms Diagnostic Studies Gold Standard of Diagnosis Treatment Goal
Intervention or RX Patient Education
and Follow-Up
Differential DX 1
Muscle Strain
Most common mechanism of back muscle strain is sudden extension of the spine in combination with rotational movement.
Other causes of back strains are associated with chronic faulty posture. 1(p.506)
Risk factors include excessive lifting, poor posture, improper lifting technique, smoking, and obesity 2,3
Pain and discomfort present with active extension and passive flexion.
Pain with coughing and deep breathing may be present.
Swelling, heat, and point tenderness may be present over area of injury. 3,4
In depth history of mechanism of injury needed to determine location/type of injury.
Physical and neurological examination of cervical, thoracic, lumbar and sacral spine including range of motion (flexion, extension, lateral bending, rotation) and palpation of bilateral back muscles for point tenderness. Neurologic examination of extremities for radiculopathy such as temperature, Magnetic Resonance Imaging can determine the location and severity of a muscular strain. 3
Non-Pharmacological: Initial ice packs or ice massage to reduce swelling for first 72 hours post injury.
Rest, avoid movements that cause pain, and avoid heavy lifting.
Alternating with heat and ice may reduce pain.
Physical therapy may be indicated depending on the severity of strain. 1(p.506),2,3
Pharmacologic: NSAID such as Ibuprofen or Naproxen may be utilized to reduce inflammation Prognosis of acute mechanical back injuries is good. 70% heal within 1 week, 80% within 2 weeks, and 90% within a month. 2
Follow up to assess progress and consideration of further intervention such as the need for physical therapy will be scheduled for 4 weeks. 2
Re-occurance is common. Patient education will include proper lifting technique, encouragement of weight loss, encourage regular exercise including
vibratory, sharp/dull discrimination, and drop leg test.
Radiographic studies such as MRI will determine location and severity of strain. Spinal radiograph will help rule out skeletal injury as source of pain 3,4,5
and pain.
Analgesics indicated for severe pain include Vicodin or Tramadol
Muscle relaxers such as Soma and Flexeril provide short term benefit to pain management especially for muscle strains. 2.4
back strengthening and stretching. 2
The patient will be instructed to seek emergency medical attention if pain becomes increasingly worse or spreads to the neck and extremities. Patient will also be instructed to seek medical attention if he feels shortness of breath, weakness, or lightheadedness. 4
Differential DX 2
Herniated Disk
60-80% of people will have at least transient episodes of back problems in their lifetime.
Risk Factors include smoking, chronic coughing, stresses, not using lumbar support, sitting for prolonged periods, and lifting. 6
Mid to low back pain, along with various locations/ manifestations of potential neurological damage depending primarily on if nerve compression exists, and if so, how severe it is. Thorough history, physical examination, including neurologic examination.
Radiographic studies, including MRI if suspected neurological damage. CT scan as initial study. MRI if neurologic abnormalities or ligamentous/muscul ar concerns. These Magnetic Resonance Imaging if neurological deficits are seen. 7
Initial conservative management: analgesic (NSAIDs or opioids if severe) and education. Muscle relaxants may be considered. 48 hours of bedrest is appropriate. 8(p1636)
Epidural corticosteroids may be used for short term relief. If a major neurological function develops or continues surgery should be considered. 8(p798)
Patient will be taught to avoid movements which cause nerve compressions, and proper lifting techniques. Patient will be advised to return promptly to light activity after short period of bedrest. 9(p1274),8(pp798 ,1636) Advise patient to return if pain is not relieved, or if neurological symptoms develop.
serve in both ruling in and ruling out many problems. 7 May also use straight leg raise test. 5(p703)
Differential DX 3
Vertebral Fracture
Two groups with highest risks are those with osteoporosis or with bone cancer Age over 50, lifting heavy objects,and smoking increase risk.
Compression fractures are more common in thin women with early menopause. Other vertebral fractures are 4 times more common in males. 10
Neuro deficit occurs in 15-20% of thoracolumbar injuries. If sudden may feel severe pain in back, may continue to extremities. If it is gradual pain will be more mild. There may be weakness and numbness if nerves are involved.
If it is a compression fracture then point tenderness may be demonstrated on involved vertebrae. 11
Thorough history, physical exam, and neurologic examination. Begin with plain film x- rays (both anteroposterior and lateral radiographs), if any fracture is noted it necessitates radiographic analysis of the entire spine. CT may be ordered for osseus evaluation. 10,12
Plain film x-ray and CT scan for osseus structures. MRI for soft tissue injury. Goal consists of protecting neural elements, and prevention of instability or deformity. If severe, surgery may be needed to accomplish these goals. 10 For non surgical: consider bracing along with analgesics, along with patient education.
If neurological damage is seen, early treatment with methylprednisolone is indicated. 9(p1289)
If compression is severe may consider vertebroplasty or kyphoplasty to restore some degree of vertebral structure. May send patient for a DEXA scan to check for osteoporotic bone changes. 10
Instruction on lifting techniques is important. If pain does not decrease, or if neurological symptoms develop patient should return to clinic.
If surgical correction was utilized, early follow-up examination to assess wound healing should happen within first few weeks, along with radiographic followup over the first year.
If non operative tx is chosen we must monitor closely with frequent clinical and radiographic follow up, watching for changes. 10
References:
1. Prentice WE. Essentials of Athletic Injury Management. 7 th ed. The McGraw Hill Companies. 2010.
2. Perina DG. Mechanical Back Pain. 2012. http://emedicine.medscape.com/article/822462-overview Accessed April 20, 2013.
3. Wheeler SG, Wipf JE, Staiger TO, Deyo RA. Approach to the diagnosis and evaluation of low back pain in adults. 2013. http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults Accessed April 20, 2013.
4. University of Minnesota Medical Center. THORACIC SPINE STRAIN. 2013. http://www.uofmmedicalcenter.org/HealthLibrary/Article/116608EN Accessed April 20, 2013.
5. Bickley LS. Bates Guide to Physical Examination and History Taking. 10 th ed. Lippincot Williams and Wilkins. 2009.
6. Foster MR. Herniated Nucleus Pulposus. 2012. http://emedicine.medscape.com/article/1263961-overview#aw2aab6b8 Accessed April 20, 2013
7. American College of Radiology. Appropriateness Criteria. 2013. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedSpineTrauma.pdf Accessed April 20, 2013.
8. McPhee SJ, Papadakis MA. Current Medical Diagnosis & Treatment. 51 st ed. The McGraw-Hill Companies, Inc; 2012
9. Porth CM, Matfin G. Pathophysiology: Concepts of Altered Health States. 8 th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009
10. Leahy M. Thoracic Spine Fractures and Dislocations. 2012. http://emedicine.medscape.com/article/1267029-overview Accessed April 20, 2013
11. Southwest Scoliosis Institute. A Patients Guide to Thoracic Compression Fractures. 2013. http://www.consultingorthopedists.com/Compression-Fracture.php Accessed April 20, 2013
12. University of Maryland Medical Center. A Patients Guide to Thoracic Compression Fractures. 2012. http://www.umm.edu/spinecenter/education/thoracic_compression_fractures.htm Accessed April 20, 2013
The immediate effects of specific-myofascial release technique versus Proprioceptive neuromuscular facilitation Hold-relax technique on hamstring flexibility in sub-acute and chronic stroke patients–An experimental study
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