Medscape

Heidi Splete

Gerry Gajadharsingh writes:

The vast majority of acute low back pain will be categorised as mechanical, a combination of muscle and joint dysfunction. That means there is unlikely to be any underlying disease process, provoking the acute low back pain, especially in the absence of leg symptoms or other possible red flags. In the vast majority of cases, it is not necessary to organise imaging for straightforward, acute low back pain of a mechanical cause. Whilst these bouts of pain can be unbelievably painful, they’re normally managed conservatively and medication can certainly play its part.

Recurrent back pain and chronic back pain is different and often needs expert assessment from a clinician experienced in dealing with back pain.

The majority of patients with acute low back pain are able to take OTC  NSAID (over the counter, non-steroidal anti-inflammatory drugs), without side effects for short periods of time (patients with asthma and gastrointestinal problems are generally advised to take NSAID). Patients with cardiovascular problems, that often also advised not to take regular NSAID and NSAID can raise blood pressure.

Did you know that there is no drug that works 100% in all patients and therefore I tend to suggest an over-the-counter combination of NSAID and Paracetamol, and I’m glad that this is the preferred combination medication suggested in the research below. I also note that the paracetamol alone seems to be relatively ineffective, this has been something that has been reported by patients for many years.

Sometimes patients will need other medication such as prescription NSAID, Naproxen has a better safety profile than other NSAID, but Diclofenac is also prescribed commonly in many patients short-term with no adverse effects. Muscle relaxants can also sometimes be necessary in conjunction with NSAID, when there is a significant muscular spasm. They tend to be tranquilizers such as diazepam, lorazepam or temazepam et cetera, and therefore need to be used with caution and only for short periods of time. NHS GP’s often reluctant to prescribe these drugs, and if they do so, they generally only give the patient a few days’ supply, as they can become highly addictive.

I have never a big fan of codeine and given its risk of addiction and complications, I tend to advise patients to not take codeine. It often also causes constipation in many patients, the last thing you want to do is having to strain on the loo with acute low back pain!

However, acute low back pain can be excruciating and its causes a lot of panic and anxiety within patients. If over the counter NSAID and paracetamol has not started to reduce the symptoms within a couple of days, presenting to an experienced clinician in low back pain, such as an Osteopath, to make an assessment and advise on management treatment can often be reassuring to patients.

The research suggests using medications as a second line intervention, however, from a logistical and cost perspective I would generally advise a patient to wait a few days and try the OTC medications before presenting to a clinician, unless there are other associated more worrying symptoms, such as leg pain, tingling and numbness in your legs, weakness of muscles, change in bowel and bladder function, associated systemic upset, such as an infection, other potential red flags, such as a more elderly patient with acute onset of severe low back pain, unexplained weight loss or where there are other known comorbidities, which might contribute towards the acute low back pain presentation.

Muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) effectively improved symptoms of acute low back pain after 1 week of treatment, based on data from more than 3000 individuals.

Acute low back pain (LBP) remains a common cause of disability worldwide, with a high socioeconomic burden, write Alice Baroncini, MD, of RWTH University Hospital, Aachen, Germany, and colleagues.

The researchers identified 18 studies totaling 3478 patients with acute low back pain of less than 12 weeks’ duration. They selected studies that only investigated the lumbar spine, and studies involving opioids were excluded. The mean age of the patients across all the studies was 42.5 years, and 54% were women. The mean duration of symptoms before treatment was 15.1 days.

Overall, muscle relaxants and NSAIDs demonstrated effectiveness in reducing pain and disability for acute LBP patients after about 1 week of use.

In addition, studies of a combination of NSAIDs and paracetamol (also known as acetaminophen) showed a greater improvement than NSAIDs alone, but paracetamol/acetaminophen alone had no significant impact on LBP.

Most patients with acute LBP experience spontaneous recovery and reduction of symptoms, thus the real impact of most medications is uncertain, the researchers write in their discussion. The lack of a placebo effect in the selected studies reinforces the hypothesis that nonopioid medications improve LBP symptoms, they say.

However, “While this work only focuses on the pharmacological management of acute LBP, it is fundamental to highlight that the use of drugs should always be a second-line strategy once other nonpharmacological, non-invasive therapies have proved to be insufficient,” the researchers write.

The study findings were limited by several factors including the inability to distinguish among different NSAID classes, the inability to conduct a sub analysis of the best drug or treatment protocol for a given drug class, and the short follow-up period for the included studies, the researchers note.

More research is needed to address the effects of different drugs on LBP recurrence, they add.

However, the results support the current opinion that NSAIDs can be effectively used for LBP, strengthened by the large number of studies and relatively low risk of bias, the researchers conclude.

Study Supports Opioid Alternatives

The current study addresses a common cause of morbidity among patients and highlights alternatives to opioid analgesics for its management, Suman Pal, MBBS, a specialist in hospital medicine at the University of New Mexico, Albuquerque, said in an interview.

Pal said he was not surprised by the results. “The findings of the study mirror prior studies,” he said. “However, the lack of benefit of paracetamol alone needs to be highlighted as important to clinical practice.”

A key message for clinicians is the role of NSAIDs in LBP, Pal told Medscape. “NSAIDs, either alone or in combination with paracetamol or myorelaxants, can be effective therapy for select patients with acute LBP.” However, “Further research is needed to better identify which patients would derive most benefit from this approach,” he said.

Other research needs include more evidence to better understand the appropriate duration of therapy, given the potential for adverse effects with chronic NSAID use, Pal said.