Treatment of acute low back strain The pain of muscular and ligamentous strains is usually self-limiting, responding to simple measures in a relatively short period of time. The basic principle of therapy in both disorders is to avoid reinjury and reduce the discomfort of painful muscles. As a result of several studies that have failed to demonstrate a benefit of bed rest, the recent practice has been to allow activity if the patient is able and to prescribe exercises designed to stretch and strengthen trunk (especially abdominal) muscles, overcome faulty posture, and increase the mobility of the spinal joints (Hagen). Despite this modern approach, the authors can affirm from personal experience that some injuries produce such discomfort that arising from a bed or chair is simply not initially possible (see Vroomen et al). Lying on the side with knees and hips flexed or supine with a pillow under the knees favor relief of pain. With strains of the sacrospinalis muscles and sacroiliac ligaments, the optimal position is mild hyperextension, which is effected by having the patient lie with a small pillow under the lumbar portion of the spine or by lying prone. Local physical measures—such as application of ice in the acute phase and, later, heat and massage—may relieve pain temporarily. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given liberally during the first few days. It should be emphasized, however, the use of NSAIDs or narcotic analgesics for many months is hazardous and should also be avoided. Muscle relaxants (e.g., cyclobenzaprine, carisoprodol, metaxalone, and the diazepams) serve mainly to make bed rest more tolerable. Traction, formerly a popular treatment, is no longer used. When weight bearing is resumed, discomfort may be diminished by a light lumbosacral support, but many orthopedists refrain from prescribing this aid.
The use of spinal manipulation—practiced by chiropractors, osteopaths, and others—has always been a contentious matter partly because of unrealistic therapeutic claims relating to spinal alignment and adjustment made in treating diseases other than low back derangements. A type of slow muscle stretching and joint distraction (axial traction on a joint) administered by physiatrists and physical therapists is quite similar. It must be recognized that many patients seek chiropractic manipulation on their own for back complaints, often before seeing a physician and may not disclose this information to the physician. When the supporting elements of the spine (pedicles, facets, and ligaments) are not disrupted, chiropractic manipulation of the lumbar spine has undoubtedly provided acute relief to a number of our patients with low back strain or facet pain. At issue is the durability of the effect, particularly the need for repeated spinal adjustments. One randomized British trial has shown manipulation to be superior to analgesics and bed rest in returning patients to work after minor back injury (Meade et al). Some other trials have corroborated this finding (Hadler et al), whereas others have not, or, often, the results have been ambiguous. In the study by Cherkin and colleagues comparing chiropractic, physical therapy (McKenzie method), and simple instruction to the patient from a booklet, manipulation yielded a slightly better outcome at the end of a month.
Despite hypotheses offered by practitioners of spinal manipulation, the mechanism of pain relief is not known. The popping sound created by rapid and forceful distraction of the facet joints (and attributed to nitrogen coming out of solution in the joint fluid) seems not to be necessary for pain relief. It seems unlikely that mundane low back pain represents minor subluxation, as claimed by chiropractors.