What are the phases of nonoperative treatment for low back pain (LBP) and sciatica?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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In general, nonoperative treatment can be divided into 3 phases based on the duration of symptoms. Primary nonoperative care consists of passively applied physical therapy during the acute phase of soft-tissue healing (< 6 wk). Secondary treatment includes spine care education and active exercise programs during the subacute phase between 6-12 weeks with physical therapy—driven goals to achieve preinjury levels of physical function and a return to work. After 12 weeks, if the patient remains symptomatic, treatment focuses on interdisciplinary care using cognitive-behavioral methods to address physical and psychological deconditioning and disability that typically develops as a result of chronic spinal pain and dysfunction. [52]

When spinal pain persists into the chronic phase, therapeutic interventions shift from rest and applied therapies to active exercise and physical restoration. This shift is primarily a behavioral evolution with the responsibility of care passed from doctor and therapist to patient. [18, 53] Bed rest should be used sparingly for chronic spinal pain to treat a severe exacerbation of symptoms. Therapeutic injections, manual therapy, and other externally applied therapies should be used adjunctively to reduce pain so that strength and flexibility training can continue. When spinal pain is chronic or recurrent, traction or modalities, such as heat and ice, can be self-administered by patients for flare-ups to provide temporary relief. [18, 53]

Rational physical, medical, and surgical therapies can be selected by determining the relevant pathoanatomy and causal pain generators. Acute spinal injuries are first managed by the elimination of biomechanical stressors, using short-term rest, supplemented by physical and pharmacological therapies aimed directly at the nociceptive or neuropathic lesion(s).

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