Acute back Pain Patient Advice

[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.

[friendlypain]

Fantastic post alophysio. I agree with everything here.

It is very hard to base advice on the unknown as there are several mechanisms of injury for the lumbar/thoracic spine. So... If it hurts... dont do it.

[Shravan nath yogi]

advice to the acute low back ache patient: -

hot or cold therapy to relive the pain