Back Pain: Therapy

Counseling/education

  • The patient should be educated about the complaint and encouraged to actively cooperate.
  • Caveat. The patient should not fall into a protective posture, but continue to move actively!Bed rest as a treatment measure in patients with chronic non-specific low back pain is not recommended.
  • In chronic low back pain, the U.S. guidelines primarily advise more physical exercise and gymnastics, as well as multidisciplinary and non-drug methods (see below psychotherapy and “Complementary treatment methods”).

General measures

  • Resumption of normal physical activities as soon as possible should be a primary goal of the affected person.
  • Nicotine restriction (refraining from tobacco use) – smoking can contribute to pain in the long term; it slows healing processes, worsens blood circulation and increases the risk of degenerative disc processes, for example, and is thus often a cause of lumbalgia (back pain located in the lumbar region)
  • Alcohol restriction (abstaining from alcohol consumption) – Alcohol leads to non-deep sleep (reduces the important REM phases and leads to sleep-through problems). The result is not enough restful sleep.
  • Aim for normal weight! Determination of BMI (body mass index, body mass index) or body composition by means of electrical impedance analysis and, if necessary, participation in a medically supervised weight loss program or program for the underweight.
    • BMI ≥ 25 → participation in a medically supervised weight loss program.
    • Falling below the BMI lower limit (from the age of 19: 19; from the age of 25: 20; from the age of 35: 21; from the age of 45: 22; from the age of 55: 23; from the age of 65: 24) → Participation in a medically supervised program for the underweight.
  • Review of permanent medication due topossible effect on the existing disease.
  • Avoidance of psychosocial stress:
    • Stress

Conventional non-surgical therapy methods

  • Analgesics (pain relievers; acetaminophen: not for treatment of nonspecific low back pain), muscle relaxants (not for treatment of: acute nonspecific low back pain; chronic nonspecific low back pain), and glucocorticoids, if appropriate
  • Percutaneous therapy procedures should not be used to treat nonspecific low back pain [S-3 guideline: ⇓⇓]. Percutaneous therapy procedures are:
    • Injections
      • Botulinum toxin injection
      • Injections at the vertebral arch joints/in the sacroiliac joint (SIG).
      • Epidural injections and spinal nerve injections.
      • Intradiscal injections
      • Proliferation therapy, also known as sclerotherapy or prolotherapy – reparative and regenerative injection procedure for the treatment of pain in joints and musculoskeletal system.
      • Trigger point (TP) injections
    • Denervations with radio frequency (RF), electrothermal and other procedures.
      • Facet denervation
      • Intradiscal electrothermal procedures
      • Intrathecal opioid administration
      • Spinal Cord Stimulation (SCS)

      A large randomized trial demonstrated that radiofrequency denervation in addition to physiotherapy exercise therapy was no more effective than not doing so in patients with chronic low back pain.

  • Infiltration therapy or therapeutic local anesthesia (TLA; injection of local anesthetics to nerves, muscles, or painful regions) with and without the addition of glucocorticoids or glucose (proliferation therapy) is a possible therapeutic option. Performing TLA under X-ray or CT assistance increases the success rate. Indications (areas of application) for TLA are:
    • Epidural infiltrations in mediolateral prolapse, spinal stenosis (narrowing of the spinal canal).
    • Transforaminal injection in lateral (lateral) disc prolapse (herniated disc).
    • Facet joint infiltration (FGI) – interventional radiological procedure for the treatment of painful facet joints; this involves an injection of locally active drugs in the immediate vicinity (periarticular) to the facet joints, as well as in the joint capsule (intraarticular).
    • Sacroiliac joint injection (also used as a diagnostic nerve block).

Operative therapy

  • Surgical therapy is required in only 1-3% of all patients with degenerative spinal changes!

Nutritional medicine

  • Nutritional counseling based on nutritional analysis
  • Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
    • A total of 5 servings of fresh vegetables and fruit daily (≥ 400 g; 3 servings of vegetables and 2 servings of fruit).
    • High-fiber diet (whole grains, vegetables).
  • Observance of the following special dietary recommendations:
    • Diet rich in:
      • Omega-3 fatty acids – fresh sea fish once or twice a week, i.e. fatty sea fish such as salmon, herring, mackerel.
  • Selection of appropriate food based on the nutritional analysis
  • See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
  • Detailed information on nutritional medicine you will receive from us.

Sports Medicine

  • Endurance training (cardio training) and strength training (muscle training).
  • Physical activity in leisure time (exercise therapy, sports therapy) reduces the risk of chronic low back pain.
  • Strength exercises lead to pain reduction and improve function.
  • Chronic low back pain: programs with an emphasis on strength/resistance and coordination/stabilization are effective therapeutic approaches.
  • Aqua gymnastics (water gymnastics).
  • Pilates – systematic whole-body training to strengthen muscles, primarily pelvic floor, abdominal and back muscles; indication: nonspecific back pain; a Cochrane review confirms Pilates training moderate effectiveness in the short term and low effectiveness in the medium term with regard to pain intensity and physical limitations.
  • Preparation of a fitness plan with suitable sports disciplines based on a medical check (health check or athlete check).
  • Detailed information on sports medicine you will receive from us.

Physical therapy (including physiotherapy)

Education on improving strength as well as endurance. The following are recommended for uncomplicated back pain:

  • Exercise therapy – as a primary non-drug therapy measure is recommended for patients with subacute and chronic low back pain (esp. also for back pain in old age).
  • Physiotherapy measures: These contribute to pain reduction and improvement of function. (insb. also for back pain in old age).
  • Thermotherapy [not suitable for the treatment of chronic low back pain]:
    • Heat applications (hot bath or red light applications) [Not suitable for the treatment of non-specific low back pain].
    • Cold applications – gel or ice pack in the temperature range of ideally 10 to 15 degrees; several times a day for about 3 minutes to cool the painful area [Not suitable for the treatment of non-specific low back pain].
  • Massage in combination with exercise therapy – for the treatment of subacute and chronic non-specific low back pain in combination with activating measures Note: Massage alone should not be used to treat acute non-specific low back pain.
  • Remedial gymnastics or physiotherapy (compensation of individual deficits: e.g., limited mobility; reduced muscle strength, etc.).

Psychotherapy

  • Psychotherapy if necessary
  • Stress management (including relaxation techniques, e.g., progressive muscle relaxation, PMR); for treatment:
    • Acute and subacute non-specific low back pain.
    • Chronic low back pain
  • Cognitive behavioral therapy (CBT) – In the presence of psychosocial risk factors, cognitive behavioral therapy based on the individual risk profile should be offered for subacute nonspecific low back pain (S-3 guideline: ⇑ ⇑).
  • Mindfulness-Based Stress Reduction (MBSR): mindfulness-based stress reduction: program to manage stress by directing specific attention and by developing, practicing, and stabilizing.
  • For detailed information on psychosomatic medicine (including stress management), please contact us.

Complementary treatment methods

  • Acupuncture, acupressure, and cupping may be helpful in treating chronic low back pain.
    • Ear acupuncture is a promising therapy for the treatment of chronic low back pain in adults
  • Chiropractic – Chiropractic method to release spinal blockages; meta-analysis sees limited effect on low back pain; first-time complications were not mentioned in any of the studies.
  • Light therapy – The patient looks into a very strong light source for about 30 minutes. The intensity of the illumination is between 2,500 and 10,000 lux. This is roughly equivalent to a sunny spring day and is 5-20 times more intense than average room lighting. Indication: chronic back pain with / without depressive symptoms.
  • Manual therapy combined with exercise therapy – can improve mobility and reduce pain in patients with subacute and chronic low back pain. Note: Manual therapy should not be used to treat nonspecific low back pain (S3 guideline).
    • Manual therapy in children with acute low back pain: according to one study, the combination of conservative and manual therapy did not perform better than conservative therapy alone.
  • Osteopathy – using the hands to release tension to relieve patient pain [current guideline “Non-specific low back pain” does not advise against this treatment method].
  • Transcutaneous electrical nerve stimulation (TENS) – The efficacy of this method in acute pain is not yet sufficiently clarified. Case reports provide evidence for a good effect with TENS in lumbago. Not suitable for patients with chronic low back pain.
  • Yoga (Iyengar, Hatha or Viniyoga).
    • For nonspecific lumbago (low back pain); small symptom reduction in the first six to twelve months compared with patients who did no back exercises at all
    • For chronic low back pain, yoga relieves pain and improves function to the same degree as physical therapy
  • Treatment methods that should not be used to treat nonspecific low back pain (S3 guideline):
    • Interferential current therapy
    • Kinesio-Taping
    • Shortwave diathermy
    • Laser therapy
    • Magnetic field therapy
    • Manual therapy (manipulation / mobilization)
    • Percutaneous electrical nerve stimulation (PENS).
    • Therapeutic ultrasound

Training

  • Back school or back exercise Back school based on a biopsychosocial approach can be used for prolonged (> six weeks) or recurrent nonspecific low back pain.