A condition of pain in the lower (lumbar-sacral) back region, with or without radiation of symptoms to the buttocks or lower extremities, in the non-pregnant patient.
Initial Diagnosis and management
- Elicitation of history and performance of physical examination. Special attention to presence or absence of "red flags" to include: age <18 or >55; history of malignancy, steroid use, or HIV positivity; weight loss or constitutional symptoms; structural deformity; anal or urethral sphincter disturbance; saddle anesthesia; gait disturbance; or widespread neurologic deficit.
- If red flags are present, diagnostic testing may include plain radiographs; CBC; ESR; bone scan; CT scan and/or MRI scan and electrodiagnosis as indicated.
- If red flags are absent a diagnostic workup is generally not necessary.
- Initial treatment for the first 2 weeks consists of: reassurance that most episodes resolve uneventfully within 6 weeks; encouragement to maintain as close to normal activity as is tolerable; avoidance of bed rest greater than 24 hours; NSAIDS (unless contraindicated); muscle relaxants for up to one week; acetaminophen as needed; weak opiates (codeine; propoxyphene) unless contraindicated; passive modalities (e.g. ice, heat) for symptomatic relief, profiling for active duty personnel or duty limitations.
Ongoing management and objectives
If pain has not improved in 2 weeks: re-evaluate for "red flags", change NSAID, and consider referral to Physical Therapy for evaluation and treatment while continuing to follow patient.
Indication a profile is needed
- Any limitations that affect strength, range of motion, and general efficiency of feet, legs, lower back and pelvic girdle.
- Slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects that may prevent hand-to-hand fighting and disqualifies for prolonged effort.
- Defects or impairments that require significant restriction of use
Specifications for the profile
- Weeks 1-2
- Run at own pace and distance
- No marching greater than 2 miles
- No sit ups
- No ruck sacks
- No lifting greater than 15lbs
- No repetitive bending
- Weeks 2-4
- Gradually return to normal activity
Patient/Soldier Education or Self care Information
- See attached sheet
- Demonstrate deficits that exist
- Describe/show soldier his/her limitations
- Explain injury and treatment methods
- Use diagram attached to describe injury, location and treatment.
- Instruct and demonstrate rehab techniques
- Demonstrate rehab exercises as shown in attached guide<
- Warm up before any sports activity
- Participate in a conditioning program to build muscle strength
- Do stretching exercises daily
- Ask the patient to demonstrate newly learned techniques and repeat any other instructions.
- Fine tune patient technique
- Correct any incorrect ROM/stretching demonstrations or instructions by repeating and demonstrating information or exercise correctly.
- Encourage questions
- Ask soldier if he or she has any questions
- Give supplements such as handouts
- Schedule follow up visit with primary care
- If pain persists or worsens
- The pain does not improve as expected
- Patient is having difficulty after three days of injury
- Increased pain or swelling after the first three days
- Patient has any questions regarding care
Indications for referral to specialty care
- Focal neurologic signs with abnormal imaging studies (urgent consult if worsening) - Orthopedics Spine referral with xrays done. Consider MRI prior to referral (without contrast unless tumor suspected).
- Focal neurologic signs with normal imaging studies (urgent if worsening) Orthopedic Spine referral.
- Incapacitating radiculopathy unresponsive to therapy - Orthopedic referral. MRI of lumbar spine prior to referral (without contrast usually).
- Abnormal plain radiographs associated with red flags - Orthopedics Spine referral. MRI of lumbar spine prior to referral (without contrast usually).
- Loss of bladder or bowel control - (urgent) Neurosurgery referral.
- Extra-spinal conditions such as, Urologic, GI, Gynecologic, Vascular, Neurologic, Rheumatologic, or Systemic - referral to subspecialty appropriate to affected organ system.
- If pain has not improved within 6 weeks, refer to Physical Medicine and Rehabilitation for evaluation and management.
Referral criteria for return to Primary Care
- Resolution of symptoms; or, implementation of continuing treatment program that can be managed in primary care portal with periodic subspecialty follow-up.
- Persistence of back pain without true radicular symptoms > 6 months – consider permanent profiling addressing such as lifting limitations and sit-up limitations.
- MEB referral goes to Tripler Army Medical Center Orthopedic MEB and Peblo MED regarding mechanical back pain.