Back Out – Low Back Pain

Back pain, especially low back pain (LBP), is an extremely common condition and leads to many doctor and ER visits. According to this recent study from Journal of Spine in 2012, there were:

An estimated 2.06 million episodes of low back pain occurred among a population at risk of over 1.48 billion person-years for an incidence rate of 1.39 per 1,000 person-years in the United States. Low back pain accounted for 3.15% of all emergency visits. Injuries sustained at home (65%) accounted for most patients presenting with low back pain. Low back pain demonstrates a bimodal distribution with peaks between 25 and 29 years of age (2.58/1,000 person-years) and 95 to 99 years of age (1.47/1,000)

With this condition being this common you would think that everyone would have a good understanding of what to do. But must don’t and with the evidence being so vague I’ll try to go over the evidence for medical and alternative therapies.

Medical Therapy

NSAIDS – there is significant evidence to support NSAIDS in acute LBP. And some evidence that it may be better than acetaminophen. Also there is evidence that intramuscular ketorolac (Toradol) is as good as intramuscular demerol. Avoid if you have any kidney disease as NSAIDs are toxic to kidneys and if you are an otherwise healthy adult it is recommended to take less than 2400 mg/day.

Tylenol – the use of acetaminophen in acute back pain is also supported more by experience than by evidence. There have been no randomized controlled trials intended to test the efficacy of acetaminophen in back pain. A systematic review of acetaminophen in osteoarthritis found it to be less effective than NSAIDs but this can’t only partially be applied to LBP. Tylenol is toxic to the liver and if you have liver disease you should take no more than 2 g/day and if you are otherwise healthy adult you can take 4 grams/day (4000 mg/dy).

Muscle Relaxants – centrally acting skeletal muscle relaxants provide analgesia and sedation. The non-benzodiazepines  (cyclobenzaprine, methocarbamol, carisoprodol, baclofen, chlorzoxazone, metaxalone, orphenadrine, and tizanidine) are somewhat effective in acute LBP. The combination of a muscle relaxant and an NSAID provided the most effective symptom relief in patients with their first episode of LBP. Side effects of this class mainly include sedation and dizziness.

Steroids – The 2007 joint guidelines from the American College of Physicians and the American Pain Society recommend against use of systemic steroids because of lack of proven benefit over placebo

Opiates – Misuse and abuse are a concern with opiates and use will be based on the clinical judgement of your doctor. A good alternative is a non-opiate drug that acts on the opiod receptor is tramadol. There are studies that show tramadol/acetaminophen is comparable to codeine/acetaminophen

Alternative Therapy

Spinal Manipulation – Spinal manipulation therapy is provided by a number of health professionals: chiropractors, osteopaths, massage therapists, and many physical therapists. Manipulative therapy may involve low-velocity mobilization or manipulation with a high velocity thrust that stretches a joint (spinal structures, in the case of back pain) beyond the normal end-range of voluntary movement. Based upon the available evidence, manipulation is as effective as conventional medical therapy for acute low back pain. Integrating it into the therapeutic plan for individual patients should depend upon their preferences and access to this type of intervention.

Exercise and Exercise Therapy – Patients should be encouraged to walk and resume normal daily activities as quickly as possible. Bed-rest and inactivity slow recovery. As far a early physical therapy in acute LBP, there isn’t much data to support it. Exercises specifically targeting the back are not indicated, as there is little evidence to suggest that exercise therapy is effective for patients with acute low back pain. Once the acute phase has subsided, exercise may help prevent recurrences.

Accupuncture, Massage, & Yoga -Patient expectations may play an important role in the benefit of these and other treatments. Acupuncture, massage, and yoga have only been evaluated in patients with chronic back pain, and evidence-based recommendations cannot be made for acute back pain.

Cold and HeatThis systematic review was unable to find sufficient evidence for a benefit of cold in treating low back pain but some improvement with heat:

The evidence base to support the common practice of superficial heat and cold for low back pain is limited and there is a need for future higher-quality randomized controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and sub-acute low-back pain, and that the addition of exercise further reduces pain and improves function. The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain. There is conflicting evidence to determine the differences between heat and cold for low-back pain.

Mattress Recommendations – There isn’t any data on mattress firmness for acute back pain but the old  thought of a firm mattress may be challenged as this study showed that a mattress of medium firmness improves pain and disability among patients with chronic non-specific low-back pain.

Back Braces – No evidence was found on the effectiveness of lumbar supports for prevention of future back injury after an initial episode of acute LBP. Also there have been no good studies to show that lumbar supports are more effective than other interventions for treatment of low back pain and very limited evidence to show that they are even better than not wearing them.