Low Back Pain Management

Aka: Low Back Pain Management, Lumbar Disc Disease Management

1. See Also
   1. Low Back Rehabilitation
   2. Low Back Muscle Fusion Rehabilitation
   3. Return to Work in Lumbar Back Pain
   4. Lumbar Disc Disease
   5. Sciatica
   6. Low Back Pain
   7. Lumbar Spine Anatomy
   8. Low Back Pain History
   9. Low Back Pain Red Flags
   10. Low Back Exam
   11. Low Back Imaging
   12. Differential Diagnosis of Low Back Pain
   13. Rheumatologic Conditions affecting the Low Back
   14. Low Back Pain in Children
   15. Low Back Pain in Teen Athletes
2. Management: General Measures
   1. Ice or heat applied to affected area
      1. Initial interval: 20-25 minutes per hour
      2. Later interval: three times daily
   2. Position of comfort
      1. Flexion relieves pressure on Posterior Columns
      2. Extension relieves pressure on anterior columns
   3. Body mechanics
      1. Ease transfers out of bed
      2. Ease moves to chair, car, toilet, and bathtub
   4. Stay active
      1. Early mobilization activities
         1. Slowly walk every 30 minutes
         2. Consider pool walking
      2. Improves outcomes
         1. Speeds recovery
         2. Reduces chronic Disability
         3. Reduces time off work
      3. Avoid exacerbating activities
         1. See Return to Work in Lumbar Back Pain
         2. Avoid prolonged standing or sitting
         3. Avoid forward flexion at waist (especially while lifting)
         4. Avoid prolonged bed rest (slows recovery)
            1. If absolutely needed, then limit to no more than 2 days
   5. Massage
      1. No affect on pain, functional status or mobility
   6. Physical Therapy
      1. See Low Back Rehabilitation
      2. See Low Back Muscle Fusion Rehabilitation
      3. Consider if no improvement in 2 to 4 weeks
      4. Consider traction or inversion table
      5. Little added benefit in early referral for Acute Low Back Pain
         1. Fritz (2015) JAMA 314(14): 1459-67 [PubMed]
   7. McKenzie Method
      1. http://www.mckenzieinstitute.org/clinicians/
      2. Initial assessment by methodology trained PT and then individualized self treatment
         1. Rosedale (2014) J Orthop Sports Phys Ther 44(3): 173-81 [PubMed]
         2. Dunsford (2011) J Multidiscip Healthc 4:393-402 [PubMed]
      3. Self-Directed McKenzie Method Book is available
         1. https://www.amazon.com/Treat-Your-Back-Robin-McKenzie/dp/0987650408
   8. Corset
      1. Stabilizes spine but does not immobilize back
      2. May allow patient to continue to work
      3. Reduces Exercise benefit of daily activities
3. Management: Acute Pain Control
   1. NSAIDs
      1. Effective for short-term symptomatic relief
         1. Griffin (2002) Am Fam Physician 65(7):1319-21 [PubMed]
      2. Other Analgesics do not offer significant additional benefit
         1. Acetaminophen offers little benefit in decreased pain and increased function
            1. Machado (2015) BMJ 350:h1225 [PubMed]
         2. Naproxen alone was as effective as when combined with an Opioid or Cyclobenzaprine
            1. Friedman (2015) JAMA 314(15): 1572-80 [PubMed]
   2. Opioids
      1. Use sparingly for refractory Acute Low Back Pain
      2. Limit to very short course (risk of Opioid misuse, Opioid Abuse and diversion)
      3. Patients improve faster without Opioids
   3. Muscle relaxants
      1. Efficacy studies
         1. Reduces Acute Low Back Pain
         2. Does not impact outcome
         3. No benefit over Placebo in chronic Low Back Pain
      2. Entire class acts centrally and causes sedation
      3. Greatest benefit may be at night to assist sleep
      4. Valium does not add benefit over Naprosyn alone for Low Back Pain
         1. Friedman (2017) Ann Emerg 70(2): 169-76 +PMID: 28187918 [PubMed]
   4. Systemic Corticosteroids (variable evidence)
      1. Variable proven benefit over NSAIDs and increased risk of adverse effects
      2. May reduce radicular pain
      3. Some studies have suggested treating for seven day course on fast taper
      4. Some studies demonstrating efficacy have used a 2 week taper (Prednisone 60, 40 then 20 mg)
         1. However most studies show no significant benefit in Acute Low Back Pain due to Herniated disc
         2. Goldberg (2015) JAMA 313(19):1915-23 +PMID:25988461 [PubMed]
4. Management: Spinal Manipulation
   1. Manipulation may improve Low Back Pain in up to 85% of patients when 2 criteria met
      1. Acute Low Back Pain less than 16 days and
      2. No symptoms distal to the knee
      3. Fritz (2005) BMC Fam Pract 6(1): 29 [PubMed]
   2. Effective in acute and chronic Low Back Pain
      1. (2005) Best Pract Res Clin Rheumatol 19(4):639-54 [PubMed]
   3. Equivalent efficacy to other conservative measures
      1. Analgesics
      2. Physical therapy
      3. Back school
      4. Assendelft (2003) Ann Intern Med 138:871-81 [PubMed]
5. Management: Chronic Pain Control - Effective Measures
   1. NSAIDs
      1. Less effective for long-term pain relief
      2. Risk of Peptic Ulcer Disease and renal injury
   2. Tricyclic or Tetracyclic Antidepressant (e.g. Amitriptyline, Nortriptyline)
      1. Mechanism related to Norepinephrine reuptake inhibition
      2. Reduces back pain symptoms
      3. SSRI medications do not appear to be effective
      4. Staiger (2003) Spine 28:2540-5 [PubMed]
   3. Serotonin Norepinephrine Reuptake Inhibitor
      1. Cymbalta (Duloxetine) appears more effective than Placebo in chronic Low Back Pain
      2. Sklijarevski (2009) Eur J Neurol 16(9): 1041-8 [PubMed]
   4. Anticonvulsants
      1. Consider for neuropathic, radicular pain
         1. Found to be more effective than Placebo
         2. However limited evidence in Low Back Pain and not found effective in Sciatica
      2. Gabapentin (Neurontin)
         1. Yildirim (2009) J Back Musculoskelet Rehabil 22(1): 17-20 [PubMed]
      3. Pregabalin (Lyrica)
      4. Topiramate (Topamax)
         1. Muehlbacher (2006) Clin J Pain 22(6): 526-31 [PubMed]
   5. Onabotulinum Toxin A (Botox)
      1. Effective in Low Back Pain with radiculopathy
      2. De Andres (2010) Reg Anesth Pain Med 35(3): 255-60 [PubMed]
   6. Cognitive Behavior Therapy
      1. Improves pain and Disability in chronic Low Back Pain
      2. Modifying attitude toward pain reduces Disability
         1. Normal functioning possible despite back pain
         2. Pain does not cause harm, and activity may hurt
         3. Goal is return to function, not eliminating pain
         4. Dramatically reduces time to return to work
         5. Staal (2004) Ann Intern Med 140:77-84 [PubMed]
   7. Yoga
      1. Short and longterm efficacy in chronic Low Back Pain
      2. Cramer (2013) Clin J Pain 29(5):450-60 [PubMed]
   8. Exercises and Therapy
      1. Perform daily back Exercises
      2. Consider back school
         1. Intensive low back educational sessions may be very effective
         2. Engers (2008) Cochrane Database Syst Rev (1): CD004057 [PubMed]
      3. Consider multidisciplinary treatment program (including Cognitive Behavioral Therapy)
         1. Kamper (2015) BMJ 350:h444 [PubMed]
      4. Consider Acupuncture
         1. Growing evidence for benefit, especially in chronic Low Back Pain
         2. See Acupunture for related studies
         3. Best used in combination with other standard measures
      5. Prescribed Walking Program (at least 4 days weekly)
         1. As effective as physical therapy in improved function and decreased pain
         2. Hurley (2015) Pain 156(1): 131-47 [PubMed]
6. Management: Chronic Low Back Pain Control - Ineffective Measures (when compared with Placebo)
   1. Acetaminophen (Tylenol)
      1. Not more effective than Placebo in chronic Low Back Pain
         1. Williams (2014) Lancet 384(9954): 1586-96 [PubMed]
      2. However, reasonable low risk intervention (if within dosing limits) that may spare Opioids
      3. Dose: 1000 mg orally twice daily (maximum 4000 mg/day)
   2. Serotonin Norepinephrine Reuptake Inhibitors
      1. Not more effective than Placebo in chronic Low Back Pain
      2. Consider with comorbid depression or anxiety
   3. Trigger Point Injection
      1. No proven benefit in Low Back Pain
      2. Modalities
         1. Local anesthetic injections
         2. Spray or ice followed by stretch
   4. TENS Unit
      1. No more effective than Placebo
      2. Khadikar (2008) Cochrane Database Syst Rev (4):CD003008 [PubMed]
   5. Epidural Corticosteroid Injection
      1. Efficacy
         1. No longterm benefit over Placebo in chronic Low Back Pain
         2. Choi (2013) Int J Technol Assess Health Care 29(3): 244-53 [PubMed]
         3. Friedly (2014) N Engl J Med 371(1):11-21 [PubMed]
         4. Manchikanti (2014) Pain Physician 17(4): E489-501 [PubMed]
         5. Novak (2008) Arch Phys Med Rahabil 89(3): 543-52 [PubMed]
      2. Indications (if used despite lower efficacy)
         1. Lumbar Disc Herniation with moderate to severe radiculopathy
         2. Symptoms should be refractory to 2-3 weeks of conservative therapy
      3. Preparation
         1. Typically follows MRI
         2. However classic symptoms and signs may direct ESI to best level when imaging is not possible
         3. Performed under fluoroscopy to optimize injection site
         4. Discuss significant neurologic deficits with spine surgery prior to epidural steroid injection
   6. Other measures without benefit over Placebo in chronic Low Back Pain
      1. Facet Joint Injections offer no proven benefit
      2. Sacroiliac Joint Injections are rarely indicated
      3. Lidocaine Patch (5%)
         1. Hashmi (2012) Mol Pain 8:29 [PubMed]
      4. Opioids and Tramadol should be avoided for chronic back pain as much as possible
         1. Try to save Opioids for acute exacerbations
7. Management: Lumbar Surgery
   1. Common surgical procedures
      1. Spinal Fusion
      2. Lumbar Disc Replacement
   2. Surgery Indications
      1. Cauda Equina Syndrome (emergent surgery)
      2. Progressive Motor Weakness (urgent surgical evaluation)
      3. Disabling Low Back Pain impacting quality of life for >1 year and refractory to conservative measures
   3. Efficacy
      1. No significant benefit for spinal fusion after 13 years
         1. Hedlund (2016) Spine J 16(5): 579-87 [PubMed]
8. Prognosis: Factors associated with Chronic Pain (more factors increase risk)
   1. Background
      1. Of those with Acute Low Back Pain, 20% will still have functional deficit at 3 months
   2. Affect
      1. Anxiety Disorder
      2. Major Depression
      3. Feeling of Uselessness
   3. Behavior
      1. Adverse coping strategies
      2. Impaired sleep
      3. Passive role
   4. Beliefs
      1. Belief that pain is harmful and must be eliminated
   5. Social
      1. Drug Abuse, physical abuse or sexual abuse
      2. Poor social support
   6. Work
      1. Anticipating that pain will increase with work
      2. Pending litigation
   7. References
      1. Last (2009) Am Fam Physician 79(12):1067-1074. [PubMed]
9. References
   1. Atlas (2001) J Gen Intern Med 16:120-31 [PubMed]
   2. Herndon (2015) Am Fam Physician 91(10): 708-14 [PubMed]
   3. Tulder (2002) Am Fam Physician 65(5):925-8 [PubMed]
   4. Will (2018) Am Fam Physician 98(7):421-8 [PubMed]