acute thoracic back pain

[marie]

Patient 45 year old male, presented with R thoracic-lumbar back pain. Pain started 4 days ago after lifting heavy object. Pain was not immediately but an hour later when he tried to sweep the floor. He rested for the next three days and then saw dr. which prescribed anti-inflammatories. He felt better getting up the next day but a wrong movement ( he is not sure what specifically) set his pain of again. When the pain starts it is debilitating and he can't move - feels if muscle goes into uncontrollable spasm. No referred pain. Gets some relief when lying on the painful side - can't lie on the opposite side at all
On examination: He was standing in lumbar flexion but could straighten up when asked to without aggravating symptoms. When asked to do lumbar flexion this flared up his pain at the beginning of the movement and was so bad that he had to sit down before the pain settled and he could straighten up. It was decided not to continue with further assessment as any movement after this was painful.
Very tender on T10 on R. No pain on deep breathing Overlying muscle spasm T7 - L3 mainly on right.
My question is, how do you treat this patient without making him worse - any suggestions

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[linbin]

hi all
i feel the first preference should be given for symptomatic relief.once the irritability becomes less go for impairment assessment and see what is causing symptoms.the treat the sourse.
so pain relieving modalities and movement restriction should be the first line of treatment

[annelizeferreira]

Hi there

Do you have any provisional diagnosis yet? What is rotation like? Side Flexion?? Repeated movements? Is it a capsular or non capsular pattern of movement? Have you screened him for red flags? Does the pain spread anywhere? Is there a preferantial direction of movement?....Sorry for the quickfiring....would be good to have more info on assessment.

[gabrieljosh]

Shoulder and Back Pain are common because these areas are vulnerable to injury, such as sprains and strains. Other disorders that may cause back pain include herniated disc, degenerative disc disease, pinched nerves, scoliosis and sciatica. There is no way to avoid shoulder pain entirely. There are ways to make it less likely, though, such as regular stretching and taking proper advantage of ergonomically-designed furniture and office equipment.

[Physio Dace]

Hi,

If you've found the comparable spinal level (?T10 or thereabouts) then I'd start with very gentle or slow sustained mobilisations centrally thru the spinous process but directed laterally towards the painful side (usually most comfortable) and slowly redirect the angle more centrally and then towards non-painful side as pain allows. Gentle jiggles (?gr IV--) often work very well for Tx pain. The key is to position the patient in a non-painful position (most likely right side lying or prone on some flexion) and slowly work into less comfortable positions. Soft tissue massage either pre or post mobilisation tends to help alot too.

Low lumbar (R) rotations sustained may also work.

Good luck.

[Lachlan]

Often there are conditions which require time before physiotherapy exercises are effective.

From what you have described the patient would be too irritable to start moving around doing assessments. Pushing on their back or giving them exercises would most likely just aggravate their symptoms even more.

If i were to encounter that my advice would be:

-The patient should speak to doctor about more pain medications (anti inflams and muscle relaxants have evidence for acute back pain)

- Heat packs- May reduce some muscle spasm, unlikely to go deep enough to actually exacerbate any inflammation.

-Light soft tissue massage (if not too irritable and able to lay on their stomach, or even on their side if appropriate).

Im sure in a few days time the pain levels and irritibility would have settled to help you make an accurate diagnosis and treatment from there on out.

[thabiso]

Sometimes its difficult to go in and work on an area with cases of very bad pain. And I do agree, get a bit of reduction in the pain/irritability first. Cold (acute) or heat, IFT, or a gentle massage. That should allow you to get in and be more effective in your assessment and later treatment. The patient may benefit from a thoracolumbar support also (though I am not a fan for their continued use for too long-once they are over the initial bad pain curve I feel they should use it but rather develop good core stability)

all the best