Case study: As October gets underway, your schedule fills up with sports physicals for the local schoolchildren. But after a morning of catching up with healthy kids and teenagers you only see once or twice a year, you see the name of an adult you know well on your schedule. Rebecca is a 27-year-old elementary school teacher who lives down the street from you. She is coming in to be seen for back pain.
When you open the door to the exam room, you see an uncomfortable appearing young woman sitting gingerly in the chair. You greet your patient and ask her what’s wrong. Rebecca tells you she is here because she had been hauling boxes into her new classroom over the weekend and now has severe back pain. What else do you want to know?
You ask her if she has a history of back pain. She says she experienced back pain towards the end of her pregnancy several years ago, but she does not have any other history of back pain. She does not have any medical problems or previous surgeries. You ask her if she has a personal history of osteoporosis, ulcerative colitis, intravenous drug use or malignancies. She says, “No, I’m pretty sure this is an injury because I went to lift up a box of textbooks and felt sharp pains along my back. This is the first time I’ve been out of bed in two days. My sister drove me here because it hurts too much to drive.” She also denies any bowel or bladder incontinence, urinary retention, sensory or motor changes.
On physical exam, her vital signs are completely normal. Her heart rate and rhythm are regular and you do not hear any murmurs; her breath sounds are clear bilaterally; and she does not have any abdominal tenderness. However, she does have bilateral tenderness to palpation along the middle of her back. When you perform a lower extremity neurological exam, she does not have any referred pain. Strength, sensation and reflexes are equal and normal bilaterally. Her physical exam findings are consistent with an acute back injury caused by lifting heavy objects. What do you do next?
You do not identify any concerning red flags that would require imaging or blood work. Therefore, you reassure the patient that back pain is, well, painful, but that the prognosis for improvement in her case is very good. You ask Rebecca how she has been managing her back pain. She tells you that she has been taking ibuprofen and staying very still in bed. You counsel her that her pain will persist the longer she stays in bed. Instead, she should do her best to resume normal activity, though she might want to avoid bending, twisting, and lifting for a while. You also recommend that she schedule her NSAIDs throughout the day for the next 3-5 days instead of only taking them when she is in severe pain. You do not prescribe narcotic pain medications, but you counsel her to contact your office if her pain does not improve. Lastly, you give her a set of back stretching exercises and schedule her for physical therapy so she can strengthen her muscles and learn proper lifting techniques in order to prevent this type of injury in the future.
How do you manage your patients with back pain? Comment below.
Dr. V. Silverstein
Published on 10/4/18