Evaluation and treatment of acute low back pain

Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments.     

Nonopioid and adjuvant analgesics in chronic pain management: strategies for effective use

Nonopioid and adjuvant analgesics encompass a huge range of heterogenous drugs that differ chemically and mechanistically. These drugs generally are prescribed for mild-to-moderate pain, as coanalgesics for severe pain, or to target specific pain-generating mechanisms. This article provides an overview of some of the more commonly used nonopioid and adjuvant analgesics used to treat chronic pain, including salicylates, acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, N-Methyl-D-Aspartate receptor antagonists, lidocaine, skeletal muscle relaxants, and topical analgesics.     

Chronic low back pain: Progress in therapy

Low back pain is a common complaint in the primary care setting. Although most patients with acute low back pain will improve with conservative treatment, back pain often recurs, and a subset of patients will progress to chronic and sometimes disabling symptoms. A variety of treatments have been used for chronic low back pain; the best evidence supports intensive rehabilitation programs that include tailored exercise therapy in conjunction with cognitive behavioral interventions and education. The benefit of medications, including nonsteroidal anti-inflammatory drugs, analgesics, and possibly antidepressants or muscle relaxants, must be weighed against potential adverse effects. There is insufficient evidence regarding the effectiveness of many of the available therapies for chronic low back pain, and well-designed, randomized controlled trials are needed to clarify the role of these treatments.     

Pharmacologic pain treatment of musculoskeletal disorders: current perspectives and future prospects

OBJECTIVE: The authors aimed to provide an educational update on the current evidence of the effectiveness of drug therapy in the treatment of musculoskeletal pain and to offer a perspective of possible future developments. DESIGN: The authors used a pragmatic review of data provided by available systematic reviews and seminal controlled studies pertaining to the treatment of regional musculoskeletal pain problems. RESULTS: Epidural steroids may offer limited, short-term benefit for sciatica. Local injections of steroids are either ineffective or provide short-lasting benefits. Nonsteroidal anti-inflammatory drugs and opioids reduce pain, but the effect size is modest. The literature does not support convincingly the use of antidepressants. Certain muscle relaxants may be useful in the treatment of back pain. Hyaluronic acid, neutraceutical agents, avocado-soybean unsaponifiable agents, oxaceprol and diacerein may be effective in the treatment of osteoarthritis, but the information regarding these new agents does not allow wholesale endorsement of these substances. Selective epidural injection of steroids at a target nerve root approached through the intervertebral foramin has the potential to replace the traditional epidural approach. Long-acting, C--fiber-specific local anesthetics are under investigation and could provide long-lasting pain relief without motor or sensory impairment. In the future, central hypersensitivity in chronic musculoskeletal pain might be treated using antagonists of the N-methyl-D-aspartate receptor. Cannabinoid agents produce antinociception and prevent experimentally induced hyperalgesia in animals, and they may find a role in pain management. Methods to optimize drug combinations are available. CONCLUSIONS: The effectiveness of the currently available drugs in the treatment of musculoskeletal pain conditions is disappointing. Recent developments may open new perspectives in this area of pain medicine.     

A clinical and pharmacologic review of skeletal muscle relaxants for musculoskeletal conditions

Muscle strains and other musculoskeletal disorders (MSDs) are a leading cause of work absenteeism. Muscle pain, spasm, swelling, and inflammation are symptomatic of strains. The precise relationship between musculoskeletal pain and spasm is not well understood. The dictum that pain induces spasm, which causes more pain, is not substantiated by critical analysis. The painful muscle may not show EMG activity, and when there is, the timing and intensity often do not correlate with the pain. Clinical and physiologic studies show that pain tends to inhibit rather than facilitate reflex contractile activity. The decision to treat and choice of therapy are largely dictated by the duration, severity of symptoms, and degree of dysfunction. Trigger point injections are sometimes used with excellent results in the treatment of muscle spasm in myofacial pain and low-back pain. NSAIDs are used with much greater frequency than oral skeletal muscle relaxants (SMRs) or opioids in the treatment of acute MSDs. Unfortunately, remarkably little sound science guides the choice of drug for the treatment of acute, uncomplicated MSDs, and the evaluation of efficacy of one agent over another is complicated by numerous factors. Only a limited number of high-quality, randomized, controlled trials (RCTs) provide evidence of the effectiveness of NSAIDs or SMRs in the treatment of acute, uncomplicated MSDs. The quality of design, execution, and reporting of trials for the treatment of MSDs needs to be improved. The combination of an SMR and an NSAID or COX-2 inhibitor or the combination of SMR and tramadol/acetaminophen is superior to single agents alone.     

Diagnosis and treatment of acute low back pain

Acute low back pain is one of the most common reasons for adults to see a family physician. Although most patients recover quickly with minimal treatment, proper evaluation is imperative to identify rare cases of serious underlying pathology. Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required. Although there are numerous treatments for nonspecific acute low back pain, most have little evidence of benefit. Patient education and medications such as nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants are beneficial. Bed rest should be avoided if possible. Exercises directed by a physical therapist, such as the McKenzie method and spine stabilization exercises, may decrease recurrent pain and need for health care services. Spinal manipulation and chiropractic techniques are no more effective than established medical treatments, and adding them to established treatments does not improve outcomes. No substantial benefit has been shown with oral steroids, acupuncture, massage, traction, lumbar supports, or regular exercise programs.     

Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review

Skeletal muscle relaxants are a heterogeneous group of medications used to treat two different types of underlying conditions: spasticity from upper motor neuron syndromes and muscular pain or spasms from peripheral musculoskeletal conditions. Although widely used for these indications, there appear to be gaps in our understanding of the comparative efficacy and safety of different skeletal muscle relaxants. This systematic review summarizes and assesses the evidence for the comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions. Randomized trials (for comparative efficacy and adverse events) and observational studies (for adverse events only) that included oral medications classified as skeletal muscle relaxants by the FDA were sought using electronic databases, reference lists, and pharmaceutical company submissions. Searches were performed through January 2003. The validity of each included study was assessed using a data abstraction form and predefined criteria. An overall grade was allocated for the body of evidence for each key question. A total of 101 randomized trials were included in this review. No randomized trial was rated good quality, and there was little evidence of rigorous adverse event assessment in included trials or observational studies. There is fair evidence that baclofen, tizanidine, and dantrolene are effective compared to placebo in patients with spasticity (primarily multiple sclerosis). There is fair evidence that baclofen and tizanidine are roughly equivalent for efficacy in patients with spasticity, but insufficient evidence to determine the efficacy of dantrolene compared to baclofen or tizanidine. There is fair evidence that although the overall rate of adverse effects between tizanidine and baclofen is similar, tizanidine is associated with more dry mouth and baclofen with more weakness. There is fair evidence that cyclobenzaprine, carisoprodol, orphenadrine, and tizanidine are effective compared to placebo in patients with musculoskeletal conditions (primarily acute back or neck pain). Cyclobenzaprine has been evaluated in the most clinical trials and has consistently been found to be effective. There is very limited or inconsistent data regarding the effectiveness of metaxalone, methocarbamol, chlorzoxazone, baclofen, or dantrolene compared to placebo in patients with musculoskeletal conditions. There is insufficient evidence to determine the relative efficacy or safety of cyclobenzaprine, carisoprodol, orphenadrine, tizanidine, metaxalone, methocarbamol, and chlorzoxazone. Dantrolene, and to a lesser degree chlorzoxazone, have been associated with rare serious hepatotoxicity.     

A comprehensive review of clinical trials on the efficacy and safety of drugs for the treatment of low back pain

A systematic review involving 50 randomized controlled trials (4,863 patients) published since 1980 was undertaken with the objective of assessing efficacy and safety of low back pain (LBP) medications. The methodological quality of each trial was evaluated based on a standardized system. Quality scores ranged from 26 to 82 points on a 100-point scale (from 0 to 100), indicating an overall moderate quality of the trials reviewed. Limited evidence was found regarding the effectiveness of drug treatments for LBP and current studies focused on short-term usage of the therapies. Available evidence supported the effectiveness of non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) in acute and chronic LBP, of muscle relaxants in acute LBP, and of antidepressants in chronic LBP; safety results were heterogeneous. More rigorously designed trials should be implemented to establish comparative efficacy and safety of drugs used to treat chronic and acute LBP.     

Pain relief in terminally ill patients

A systematic approach to identifying the cause of pain and rational use of drug therapy are keys to providing pain relief to cancer patients. Aspirin, acetaminophen and nonsteroidal anti-inflammatory drugs are effective for mild to moderate pain, and they enhance the effectiveness of weak oral narcotics, such as codeine. For severe pain, morphine is the drug of choice. A variety of adjuvant drugs can be used to enhance the effect of narcotics and to treat specific side effects of the disease or of therapy. For the terminally ill patient, a peaceful death with dignity should always be possible.     

Expert consensus of Chinese Association for the Study of Pain on the non-opioid analgesics for chronic musculoskeletal pain

Chronic musculoskeletal pain (CMP) is a common occurrence in clinical practice and there are a variety of options for the treatment of it. However, the pharmacological therapy is still considered to be a primary treatment. The recent years have witnessed the emergence of opioid crisis, yet there are no relevant guidelines on how to treat CMP with non-opioid analgesics properly. The Chinese Medical Association for the Study of Pain convened a panel meeting to develop clinical practice consensus for the treatment of CMP with non-opioid analgesics. The purpose of this consensus is to present the application of nonsteroidal anti-inflammatory drugs, serotonin norepinephrine reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, muscle relaxants, ion channel drugs and topical drugs in CMP.     

Diagnosis and management of endometriosis

Signs and symptoms of endometriosis are nonspecific, and an acceptably accurate noninvasive diagnostic test has yet to be reported. Serum markers do not provide adequate diagnostic accuracy. The preferred method for diagnosis of endometriosis is surgical visual inspection of pelvic organs with histologic confirmation. Such diagnosis requires an experienced surgeon because the varied appearance of the disease allows less-obvious lesions to be overlooked. Empiric use of nonsteroidal anti-inflammatory drugs or acetaminophen is a reasonable symptomatic treatment, but the effectiveness of these agents has not been well-studied. Oral contraceptive pills, medroxyprogesterone acetate, and intrauterine levonorgestrel are relatively effective for pain relief. Danazol and various gonadotropin-releasing hormone analogues also are effective but may have significant side effects. There is limited evidence that surgical ablation of endometriotic deposits may decrease pain and increase fertility rates in women with endometriosis. Presacral neurectomy is particularly beneficial in women with midline pelvic pain. Hysterectomy and bilateral salpingo-oophorectomy definitively treat pain from endometriosis at 10 years in 90 percent of patients.     

Die Behandlung von Rückenschmerzen

QUESTION: Which are the most effective treatments for acute and chronic low back pain? METHODS: Systematic reviews were conducted including identification and selection of relevant trials, assessment of the methodological quality, data extraction (study populations, interventions, and outcomes), and data analysis. RESULTS: acute low back pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants relieve pain more than placebo; advice to stay active speeds up recovery and reduces chronic disability; bed rest and specific back exercises are not effective. RESULTS: chronic low back pain. Exercise therapy, back schools, behavioral therapy, and multidisciplinary programs are effective. CONCLUSIONS: Scientific evidence shows that an active approach to low back pain patients is effective.     

Physiotherapy in lumbar disc herniation

Physiotherapy is the treatment of choice in patients with symptoms caused by a lumbar disc herniation. In clinical practice a broad range of physiotherapeutic modalities has been revealed to be helpful. During the acute stage the efficacy of the McKenzie-concept, mobilisation therapies and traction has been demonstrated in randomized controlled trials with a blind assessor. In addition, pain reducing physical therapies such as cold or electrotherapy and non-steroidal anti-inflammatory drugs, analgesics and/or muscle relaxants are sensible initial accompanying treatments. The effectiveness of active physiotherapies such as training of local strength endurance of back and abdominal muscles has been proven in patients during the chronic stage. The indications for a in-patient rehabilitation programme, for surgery and the danger of developing chronic low back pain are discussed.     

Medikamentöse Therapie bei Rückenschmerzen

Today, a wide range of efficient analgesic and non-analgesic drugs for the treatment of back pain are available. However, drugs should never be the only mainstay of a back pain treatment program. Non-steroidal antiinflammatory drugs (NSAID) are widely used in acute back pain. NSAIDs prescribed at regular intervals are effective to reduce simple back pain. The different NSAIDs are effective for the reduction of this pain. They have serious adverse effects, particularly at high doses, in the elderly, and on long-term administration. The new cyclooxygenase II-inhibitors have less gastrointestinal complications. But the long-term experiences are limited up to now. Considerable controversy exists about the use of opioid analgesics in chronic noncancer pain. Many physicians are concerned about the effectiveness and adverse effects of opioids. Other clinicians argue that there is a role for opioid therapy in chronic noncancer pain, e. g. especially in chronic low back pain. There is a low incidence of organ toxicity in patients who respond to opioids. The incidence of abuse and addiction is likewise relatively low. The potential for increased function and improved quality of life seems to outweigh the risks. However, there is a lack of randomised controlled trials (RCT) on opioid therapy in a multimodal pain treatment approach. Clinical experience and some studies suggest administration of sustained release opioids because of better comfort for the patient and less risks for addiction. The opioids should be selected due to the specific side effects of the different drugs. For patients with pre-existing constipation transdermal fentanyl should be preferred. Antidepressant medications have been used for the treatment of chronic back pain, though there is only little scientific evidence for their effectiveness. There is no evidence for the use of antidepressants in acute low back pain. Trials of muscle relaxants for patients with acute back pain have used a wide range of agents, e. g. benzodiazepines. They mostly reduce acute back pain, but they have significant adverse effects including drowsiness and psychological and physical dependence even after relatively short treatment. Benzodiazepines are not indicated in the treatment of chronic back pain. Drugs are sometimes necessary for the patients to begin and persevere a multimodal treatment program. Drug therapy should be terminated as soon as other treatment strategies succeed. Unfortunately, no studies exist evaluating the place of analgesics within a multimodal treatment program.     

Interventions Available Over the Counter and Advice for Acute Low Back Pain: Systematic Review and Meta-Analysis

This systematic review evaluated evidence from randomized controlled trials investigating interventions available over the counter and advice that could be provided to people with acute low back pain. Searches were conducted on MEDLINE, Embase, Cochrane Database of Systematic Reviews, AMED, CENTRAL, and PsycINFO for eligible randomized controlled trials. The primary outcome measure was pain. Eligible controls included placebo, no treatment, or usual care. Two reviewers extracted data and rated study quality. A random effects model was used to pool trial effects with the overall strength of evidence described using the GRADE criteria. Thirteen randomized controlled trials (2,847 participants) evaluating advice, bed rest, simple analgesics (paracetamol, nonsteroidal anti-inflammatory drugs), heat application, and a topical rubefacient were included. There was low-quality evidence that bed rest is ineffective and very-low-quality evidence that advice is ineffective in the short, intermediate, and long terms. There was very-low-quality evidence that nonsteroidal anti-inflammatory drugs (ibuprofen and diclofenac “when required” dosing) provide an immediate analgesic effect (mean differences −10.9 [95% confidence interval = −17.6 to −4.2] and −11.3 [95% confidence interval = −17.8 to −4.9], respectively). There is very-low-quality evidence that heat wrap and a capsicum-based rubefacient provide an immediate analgesic effect (mean differences −13.5 [95% confidence interval = −21.3 to −5.7] and 17.5, P < .001, respectively), but there was no information on longer-term outcomes.PerspectiveThere is limited evidence that nonsteroidal anti-inflammatory drugs, heat wrap, and rubefacients provide immediate pain relief for acute back pain and that bed rest and advice are both ineffective. Future research is needed to provide evidence to support rational use of over-the-counter remedies and advice for people with acute low back pain.     

The role of rofecoxib, a cyclooxygenase-2-specific inhibitor, for the treatment of non-cancer pain: a review.

Rofecoxib was the first specific inhibitor of cyclooxygenase-2 (COX-2) approved for the treatment of acute pain. It has been shown to provide analgesia that is significantly better than placebo and has an onset of action and efficacy similar to that of traditional nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen. In addition, the analgesic efficacy of rofecoxib has been demonstrated to be superior to that of the opioid combination of codeine 60 mg/acetaminophen 600 mg in an acute dental pain model. For the treatment of acute pain, the efficacy of rofecoxib was further demonstrated in a study of patients who had undergone orthopedic surgery. Rofecoxib has been found to be as effective as naproxen sodium and more effective than placebo in studies evaluating its use for the treatment of primary dysmenorrhea. In patients with osteoarthritis (OA) of the knee or hip, rofecoxib is superior to placebo and similar to diclofenac and ibuprofen in relieving OA pain and improving physical function. Rofecoxib has also been shown to be superior to acetaminophen and celecoxib after 6 weeks of treatment for OA. The efficacy of rofecoxib has also been demonstrated in patients with rheumatoid arthritis and low back pain. The advantages of using COX-2-specific NSAIDs include convenient once-daily dosing schedule and improved safety compared with traditional NSAIDs. Two large outcomes studies, VIGOR and CLASS, have shown that gastric mucosal ulceration occurs significantly less often in patients taking COX-2-specific inhibitors than in those treated with ibuprofen, diclofenac, or naproxen and occurs with a similar incidence to that of placebo. Absence of any effect on platelet aggregation and bleeding time further distinguishes these agents from traditional NSAIDs. Because COX-2-specific inhibitors do not have an antiplatelet effect, they cannot be used as a substitute for low-dose aspirin for cardiovascular prophylaxis. Rofecoxib is a safe and highly effective alternative to previously available NSAIDs and should be considered for the treatment of acute pain conditions in adult patients, especially those at risk for developing gastrointestinal complications. It is preferred in the perioperative setting because of its analgesic efficacy and lack of platelet effects. Because of its more favorable gastrointestinal toxicity profile compared with nonselective NSAIDs, rofecoxib is safer in patients, especially older patients, for whom chronic anti-inflammatory or analgesic therapy is indicated.     

PEER systematic review of randomized controlled trials: Management of chronic low back pain in primary care

ObjectiveTo determine the proportion of chronic low back pain patients who achieve a clinically meaningful response from different pharmacologic and nonpharmacologic treatments.Data sourcesMEDLINE, EMBASE, Cochrane Library, and gray literature search.Study selectionPublished randomized controlled trials (RCTs) that reported a responder analysis of adults with chronic low back pain treated with any of the following 15 interventions: oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, acupuncture, spinal manipulation therapy, corticosteroid injections, acetaminophen, oral opioids, anticonvulsants, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors, cannabinoids, oral muscle relaxants, or topical rubefacients.SynthesisA total of 63 RCTs were included. There was moderate certainty that exercise (risk ratio [RR] of 1.71; 95% CI 1.37 to 2.15; number needed to treat [NNT] of 7), oral NSAIDs (RR = 1.44; 95% CI 1.17 to 1.78; NNT = 6), and SNRIs (duloxetine; RR = 1.25; 95% CI 1.13 to 1.38; NNT = 10) provide clinically meaningful benefits to patients with chronic low back pain. Exercise was the only intervention with sustained benefit (up to 48 weeks). There was low certainty that spinal manipulation therapy and topical rubefacients benefit patients. The benefit of acupuncture disappeared in higher-quality, longer (> 4 weeks) trials. Very low-quality evidence demonstrated that corticosteroid injections are ineffective. Patients treated with opioids had a greater likelihood of discontinuing treatment owing to an adverse event (number needed to harm of 5) than continuing treatment to derive any clinically meaningful benefit (NNT = 16), while those treated with SNRIs (duloxetine) had a similar likelihood of continuing treatment to attain benefit (NNT = 10) as those discontinuing the medication owing to an adverse event (number need to harm of 11). One trial each of anticonvulsants and topical NSAIDs found similar benefit to that of placebo. No RCTs of acetaminophen, cannabinoids, muscle relaxants, selective serotonin reuptake inhibitors, or tricyclic antidepressants met the inclusion criteria.ConclusionExercise, oral NSAIDs, and SNRIs (duloxetine) provide a clinically meaningful reduction in pain, with exercise being the only intervention that demonstrated sustained benefit after the intervention ended. Future high-quality trials that report responder analyses are required to provide a better understanding of the benefits and harms of interventions for patients with chronic low back pain.     

Sacroiliac sprain: an overlooked cause of back pain.

Since sacroiliac sprain syndrome is not a common disorder, it may be overlooked as a cause of low back pain. Even though the sacroiliac joint is very strong, it can incur painful injury. The diagnosis of sacroiliac sprain syndrome requires more than just tenderness on palpation of the sacroiliac area. Certain maneuvers, such as Patrick's test and the sacroiliac compression test, are useful in establishing the diagnosis. Proper treatment consists of bed rest, heat, nonsteroidal anti-inflammatory drugs and muscle relaxants. Physical therapy and manipulation may also help. In recalcitrant cases, injection of the sacroiliac joint with a corticosteroid and a local anesthetic can be effective.     

Managing Osteoarthritis Pain in the Older Population

ABSTRACT

Challenges to pharmacological management in this patient group include treatment concordance, comorbidity, polypharmacy, and age-related physiological changes affecting pharmacokinetics. Paracetamol (acetaminophen) is generally recommended as a first-choice analgesic in osteoarthritis pain. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral formulations, and prescribing NSAIDs for older people requires careful consideration. There are some data relating to opioid use for noncancer pain in older people.