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Low Back Pain Management
Aka: Low Back Pain Management, Lumbar Disc Disease Management, Lumbar Back Pain Management, Lumbosacral Back Pain Management
- See Also
- Low Back Rehabilitation
- Low Back Muscle Fusion Rehabilitation
- Return to Work in Lumbar Back Pain
- Lumbar Disc Disease
- Sciatica
- Low Back Pain
- Lumbar Spine Anatomy
- Low Back Pain History
- Low Back Pain Red Flags
- Low Back Exam
- Low Back Imaging
- Differential Diagnosis of Low Back Pain
- Rheumatologic Conditions affecting the Low Back
- Low Back Pain in Children
- Low Back Pain in Teen Athletes
- Management: General Measures
- Ice or heat applied to affected area
- Initial interval: 20-25 minutes per hour
- Later interval: three times daily
- Position of comfort
- Flexion relieves pressure on Posterior Columns
- Extension relieves pressure on anterior columns
- Body mechanics
- Ease transfers out of bed
- Ease moves to chair, car, toilet, and bathtub
- Stay active
- Early mobilization activities
- Slowly walk every 30 minutes
- Consider pool walking
- Improves outcomes
- Speeds recovery
- Reduces chronic Disability
- Reduces time off work
- Avoid exacerbating activities
- See Return to Work in Lumbar Back Pain
- Avoid prolonged standing or sitting
- Avoid forward flexion at waist (especially while lifting)
- Avoid prolonged bed rest (slows recovery)
- If absolutely needed, then limit to no more than 2 days
- Massage
- No affect on pain, functional status or mobility
- Physical Therapy
- See Low Back Rehabilitation
- See Low Back Muscle Fusion Rehabilitation
- Consider if no improvement in 2 to 4 weeks
- Consider traction or inversion table
- Little added benefit in early referral for Acute Low Back Pain
- Fritz (2015) JAMA 314(14): 1459-67 [PubMed]
- McKenzie Method
- http://www.mckenzieinstitute.org/clinicians/
- Initial assessment by methodology trained PT and then individualized self treatment
- Rosedale (2014) J Orthop Sports Phys Ther 44(3): 173-81 [PubMed]
- Dunsford (2011) J Multidiscip Healthc 4:393-402 [PubMed]
- Self-Directed McKenzie Method Book is available
- https://www.amazon.com/Treat-Your-Back-Robin-McKenzie/dp/0987650408
- Corset
- Stabilizes spine but does not immobilize back
- May allow patient to continue to work
- Reduces Exercise benefit of daily activities
- Management: Acute Pain Control
- NSAIDs
- Effective for short-term symptomatic relief
- Griffin (2002) Am Fam Physician 65(7):1319-21 [PubMed]
- Other Analgesics do not offer significant additional benefit
- Acetaminophen offers little benefit in decreased pain and increased function
- Machado (2015) BMJ 350:h1225 [PubMed]
- Naproxen alone was as effective as when combined with an Opioid or Cyclobenzaprine
- Friedman (2015) JAMA 314(15): 1572-80 [PubMed]
- Opioids
- Use sparingly for refractory Acute Low Back Pain
- Limit to very short course (risk of Opioid misuse, Opioid Abuse and diversion)
- Patients improve faster without Opioids
- Muscle relaxants or antispasmodics (Benzodiazepines and non-Benzodiazepines)
- Not recommended due to lack of benefit and increased adverse effects
- Cashin (2021) BMJ 374: n1446 [PubMed]
- Efficacy studies
- Reduces Acute Low Back Pain
- Does not impact outcome
- Minimal benefit over NSAIDs alone
- No benefit over Placebo in chronic Low Back Pain
- Entire class acts centrally and causes sedation
- Greatest benefit may be at night to assist sleep
- Valium does not add benefit over Naprosyn alone for Low Back Pain
- Friedman (2017) Ann Emerg 70(2): 169-76 +PMID: 28187918 [PubMed]
- Systemic Corticosteroids (variable evidence)
- Variable proven benefit over NSAIDs and increased risk of adverse effects
- May reduce radicular pain
- Some studies have suggested treating for seven day course on fast taper
- Some studies demonstrating efficacy have used a 2 week taper (Prednisone 60, 40 then 20 mg)
- However most studies show no significant benefit in Acute Low Back Pain due to Herniated disc
- Goldberg (2015) JAMA 313(19):1915-23 +PMID:25988461 [PubMed]
- Management: Spinal Manipulation
- Manipulation may improve Low Back Pain in up to 85% of patients when 2 criteria met
- Acute Low Back Pain less than 16 days and
- No symptoms distal to the knee
- Fritz (2005) BMC Fam Pract 6(1): 29 [PubMed]
- Effective in acute and chronic Low Back Pain
- (2005) Best Pract Res Clin Rheumatol 19(4):639-54 [PubMed]
- Equivalent efficacy to other conservative measures
- Analgesics
- Physical therapy
- Back school
- Assendelft (2003) Ann Intern Med 138:871-81 [PubMed]
- Management: Chronic Pain Control - Effective Measures
- NSAIDs
- Less effective for long-term pain relief
- Risk of Peptic Ulcer Disease and Renal Injury
- Tricyclic or Tetracyclic Antidepressant (e.g. Amitriptyline, Nortriptyline)
- Mechanism related to Norepinephrine reuptake inhibition
- Reduces back pain symptoms
- SSRI medications do not appear to be effective
- Staiger (2003) Spine 28:2540-5 [PubMed]
- Serotonin Norepinephrine Reuptake Inhibitor
- Cymbalta (Duloxetine) appears more effective than Placebo in chronic Low Back Pain
- Sklijarevski (2009) Eur J Neurol 16(9): 1041-8 [PubMed]
- Anticonvulsants
- Consider for neuropathic, radicular pain
- Found to be more effective than Placebo
- However limited evidence in Low Back Pain and not found effective in Sciatica
- Gabapentin (Neurontin)
- Yildirim (2009) J Back Musculoskelet Rehabil 22(1): 17-20 [PubMed]
- Pregabalin (Lyrica)
- Topiramate (Topamax)
- Muehlbacher (2006) Clin J Pain 22(6): 526-31 [PubMed]
- Onabotulinum Toxin A (Botox)
- Effective in Low Back Pain with radiculopathy
- De Andres (2010) Reg Anesth Pain Med 35(3): 255-60 [PubMed]
- Cognitive Behavior Therapy
- Improves pain and Disability in chronic Low Back Pain
- Modifying attitude toward pain reduces Disability
- Normal functioning possible despite back pain
- Pain does not cause harm, and activity may hurt
- Goal is return to function, not eliminating pain
- Dramatically reduces time to return to work
- Staal (2004) Ann Intern Med 140:77-84 [PubMed]
- Yoga
- Short and longterm efficacy in chronic Low Back Pain
- Cramer (2013) Clin J Pain 29(5):450-60 [PubMed]
- Exercises and Therapy
- Perform daily back Exercises
- Consider back school
- Intensive low back educational sessions may be very effective
- Engers (2008) Cochrane Database Syst Rev (1): CD004057 [PubMed]
- Consider multidisciplinary treatment program (including Cognitive Behavioral Therapy)
- Kamper (2015) BMJ 350:h444 [PubMed]
- Consider Acupuncture
- Growing evidence for benefit, especially in chronic Low Back Pain
- See Acupunture for related studies
- Best used in combination with other standard measures
- Prescribed Walking Program (at least 4 days weekly)
- As effective as physical therapy in improved function and decreased pain
- Hurley (2015) Pain 156(1): 131-47 [PubMed]
- Management: Chronic Low Back Pain Control - Ineffective Measures (when compared with Placebo)
- Acetaminophen (Tylenol)
- Not more effective than Placebo in chronic Low Back Pain
- Williams (2014) Lancet 384(9954): 1586-96 [PubMed]
- However, reasonable low risk intervention (if within dosing limits) that may spare Opioids
- Dose: 1000 mg orally twice daily (maximum 4000 mg/day)
- Serotonin Norepinephrine Reuptake Inhibitors
- Not more effective than Placebo in chronic Low Back Pain
- Consider with comorbid depression or anxiety
- Trigger Point Injection
- No proven benefit in Low Back Pain
- Modalities
- Local Anesthetic injections
- Spray or ice followed by stretch
- TENS Unit
- No more effective than Placebo
- Khadikar (2008) Cochrane Database Syst Rev (4):CD003008 [PubMed]
- Epidural Corticosteroid Injection
- Efficacy
- No longterm benefit over Placebo in chronic Low Back Pain
- Choi (2013) Int J Technol Assess Health Care 29(3): 244-53 [PubMed]
- Friedly (2014) N Engl J Med 371(1):11-21 [PubMed]
- Manchikanti (2014) Pain Physician 17(4): E489-501 [PubMed]
- Novak (2008) Arch Phys Med Rahabil 89(3): 543-52 [PubMed]
- Indications (if used despite lower efficacy)
- Lumbar Disc Herniation with moderate to severe radiculopathy
- Symptoms should be refractory to 2-3 weeks of conservative therapy
- Preparation
- Typically follows MRI
- However classic symptoms and signs may direct ESI to best level when imaging is not possible
- Performed under fluoroscopy to optimize injection site
- Discuss significant neurologic deficits with spine surgery prior to epidural steroid injection
- Other measures without benefit over Placebo in chronic Low Back Pain
- Facet Joint Injections offer no proven benefit
- Sacroiliac Joint Injections are rarely indicated
- Lidocaine Patch (5%)
- Hashmi (2012) Mol Pain 8:29 [PubMed]
- Opioids and Tramadol should be avoided for chronic back pain as much as possible
- Try to save Opioids for acute exacerbations
- Management: Lumbar Surgery
- Common surgical procedures
- Spinal Fusion
- Lumbar Disc Replacement
- Surgery Indications
- Cauda Equina Syndrome (emergent surgery)
- Progressive Motor Weakness (urgent surgical evaluation)
- Disabling Low Back Pain impacting quality of life for >1 year and refractory to conservative measures
- Efficacy
- No significant benefit for spinal fusion after 13 years
- Hedlund (2016) Spine J 16(5): 579-87 [PubMed]
- Prognosis: Factors associated with Chronic Pain (more factors increase risk)
- Background
- Of those with Acute Low Back Pain, 20% will still have functional deficit at 3 months
- Affect
- Anxiety Disorder
- Major Depression
- Feeling of Uselessness
- Behavior
- Adverse coping strategies
- Impaired sleep
- Passive role
- Beliefs
- Belief that pain is harmful and must be eliminated
- Social
- Drug Abuse, physical abuse or sexual abuse
- Poor social support
- Work
- Anticipating that pain will increase with work
- Pending litigation
- References
- Last (2009) Am Fam Physician 79(12):1067-1074. [PubMed]
- References
- Atlas (2001) J Gen Intern Med 16:120-31 [PubMed]
- Herndon (2015) Am Fam Physician 91(10): 708-14 [PubMed]
- Tulder (2002) Am Fam Physician 65(5):925-8 [PubMed]
- Will (2018) Am Fam Physician 98(7):421-8 [PubMed]