The additional history that should be obtained is whether this episode of pain is similar to the current episode and whether the patient sought medical attention that time; if yes, what diagnosis was made. Previous treatment (medications or other interventions), surgical history, any history of arthritis or osteoporosis, any past traumas, acute hospital admissions, cancer, infections, mental illnesses (especially depression), sudden weight loss, work history, and family history of low back pain should be discussed should be ob(WebMD, 2015).
Specific examination techniques include vital signs (increased heart rate can indicate serious pain), gait observation (to assess its speed, any limitations), skin abnormalities at the lumbar spine area (can indicate inflammation), motion range, spine palpation (to assess whether there is any inflame in the bone and possibly detect compression fracture or metastatic disease), palpation of the costo-vertebral angle (pain in this area indicates the inflammation of kidneys), and straight leg raise test (can indicate nerve root irritation) (Goldberg, n.d.). It might be useful to ask the patient to show if there is any precise area of pain he can point to rule out pyelonephritis, spasm (para-spinal pain), or radiating down the legs (nerve root irritation) (Goldberg, n.d.).
An X-ray should be ordered to identify any skeletal defects or broken bones, as well as locate possible problems in the connective tissue; an MRI or a CT-scan can be helpful in determining whether the patient has soft-tissue or disc damage (WebMD, 2016). Furthermore, EMG can help detect nerve/muscle damage. The following red flags of low back pain can be the signs of malignancy (history of cancer, rapid weight loss, pain at night or rest, age over 50 years, rapid fatigue, fever), fracture (history of trauma, use of steroids, age over 50 or 60, sudden onset of pain, etc.), infection (fever, use of corticosteroids or immunosuppressants, drug addiction, intense night pain, previous back surgery), and cauda equina syndrome (CES) (perineal numbness, bladder dysfunction, progressive weakness in lower limbs, gait disturbance, fecal inconsistency, radiating pain in both legs) (Dunphy, Winland-Brown, Porter & Thomas, 2015; Verhagen, Downie, Popal, Maher, & Koes, 2016).
Suggested pharmacologic interventions are acetaminophen or nonsteroidal anti-inflammatory drugs, muscle relaxants, opiate pain relievers (if the pain is extreme), and antidepressants (such as amitriptyline and duloxetine) because they can help treat chronic back pain (WebMD, n.d.). Physical measures include walking (10-15 minutes every 2-3 hours), exercise (stretching and strengthening, performed gently and stopped if the pain increases), and sitting with a straight back when reading or watching TV. Complementary therapies include spinal manipulative therapy, acupuncture, yoga, ointment, and heat wrap therapy (Kizhakkeveettil, Rose, & Kadar, 2014). If combined with exercise suggested above and possibly medical interventions, they can mitigate the severity and longevity of the pain, as well as have a relaxing impact on the patient, improving his psychological well-being.
A Circle of Caring could help the patient approach the problem from a different point of view, sharing his experience with other patients like him and asking for advice from nurses. It could improve his self-management of the condition and provide psychological and spiritual support if needed. The follow-up should be regular to assess the progression (or a lack thereof) of the pain; if the pain becomes severe or any other symptoms appear, a referral to a physician is necessary. The patient should be educated about the importance of exercise, bed rest (if the pain is too severe), pain medications (the right dosage of over-the-counter and/or prescribed drugs), and potentially helpful complementary therapies (yoga). Exercises can include walking, stretching, and light aerobic activity. If the patient can avoid prolonged standing or sitting at work, he should return to it; if the pain is too severe or progresses, he should return for a follow-up and restrain from work.
References
Goldberg, C. (n.d.). Musculo-skeletal examination. Web.
Kizhakkeveettil, A., Rose, K., & Kadar, G. E. (2014). Integrative therapies for low back pain that include complementary and alternative medicine care: A systematic review. Global Advances in Health and Medicine, 3(5), 49-64.
Verhagen, A. P., Downie, A., Popal, N., Maher, C., & Koes, B. W. (2016). Red flags presented in current low back pain guidelines: A review. European Spine Journal, 25(9), 2788-2802.
WebMD. (2015). History and physical exam for low back pain. Web.
WebMD. (n.d.). Low back pain – topic overview. Web.
WebMD. (2016). What kind of back problem do you have? Web.