low%20back%20pain
LOW BACK PAIN
Treatment Guideline Chart
It is pain, stiffness, or discomfort in the lower back area below the costal margin and above the gluteal creases.
Low back pain is also called spinal pain or lumbago.
Nonspecific low back pain is without identifiable specific causes and makes up 90-95% of all low back pain cases.  It also includes pain felt in the proximal lower extremities.
Patients with low back pain may have mobility deficits caused by severe or progressive neurologic disorders or comorbidities.
Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, or inflammatory disorders.
Low back pain associated with radiculopathy or spinal stenosis is dermatomal pain with or without neurologic deficits that is most often caused by nerve root compression.

Low%20back%20pain Treatment

Principles of Therapy

  • Includes treatment of symptoms and the underlying cause of low back pain
  • Tailor treatment to patient’s condition and needs

Pharmacotherapy

Analgesics (Non-Opioid)

  • Eg Paracetamol (Acetaminophen), Aspirin, Capsaicin (topical)
  • Recommended 1st-line treatment for acute, subacute and chronic low back pain
  • Also recommended for patients with chronic low back pain with or without radicular pain, especially if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated
  • A weaker analgesic but with less adverse effects compared to NSAIDs 
  • Paracetamol with weak opioid is recommended as alternative when NSAIDs or Paracetamol alone is ineffective in controlling pain
  • Aspirin is now used infrequently for the treatment of chronic pain and inflammation
    • May be used for patients with concomitant cardiovascular risk factors
  • Capsaicin (topical) is recommended for acute and subacute low back pain; may also be used for flare-ups of chronic back pain
    • Capsicum plaster may be used as an adjunct for short-term basis in patients with chronic low back pain

Anticonvulsants

  • Eg Carbamazepine, Gabapentin, Pregabalin, Topiramate
  • Topiramate may be used for patients with chronic low back pain as last-line therapy
    • Used in patients with concomitant anxiety or depression disorders
  • Carbamazepine is a treatment option for patients with radicular pain unresponsive to traditional treatments
  • Gabapentin may also be used for patients with radicular pain syndrome with severe neurogenic claudication and limited walking distance
  • Off-label use for chronic radicular and neuropathic pain

Antidepressants

  • Eg mixed serotonin and norepinephrine reuptake inhibitors/SNRIs (Duloxetine, Venlafaxine); tricyclic antidepressants/TCAs (Amitriptyline, Desipramine, Doxepin, Imipramine, Maprotiline, Nortriptyline)
  • Treatment option for pain alleviation in patients with acute, subacute and chronic low back pain

Benzodiazepines

  • Eg Diazepam
  • May be used for acute, subacute, and chronic low back pain for patients unresponsive to 1st-line treatments
    • Off-label use as a muscle relaxant in patients with subacute or chronic low back pain 
  • May also be given to patients with painful radiculopathy
  • Sedative, anxiolytic, and antiepileptic that acts on gaba-aminobutyric acid (GABA)
  • Should only be used  for <1 week
  • Avoid combination therapy with an opioid due to an increased risk of overdose compared with opioid monotherapy

Glucocorticoid Injections

  • Epidural steroid injections may be used by specialists for patients with acute or subacute severe radicular pain, spinal stenosis, sacroiliitis unresponsive to 2-6 weeks of non-invasive treatment
  • Should not be used as monotherapy
  • Further studies are needed to conclude the efficacy of steroid injections for chronic low back pain

Local Anesthetics

  • Eg Lidocaine patches
  • Further studies are needed to prove the efficacy of Lidocaine patches in chronic low back pain

Muscle Relaxants (Non-Benzodiazepine)

  • Eg Baclofen, Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Eperisone, Metaxalone, Methocarbamol, Orphenadrine, Tizanidine
  • Used as 2nd-line treatment for moderate-severe acute or subacute low back pain unresponsive to NSAID therapy, and for patients with acute exacerbations of chronic low back pain
  • Moderately effective compared to placebo for short-term pain relief of acute low back pain
  • Also recommended for patients with acute radicular pain syndrome
  • Should only be used for <4 weeks
  • Caution should be observed when using these as they may cause drowsiness, dizziness, addiction, liver disorders, and other adverse effects

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

  • Eg acetic acid derivatives (Aceclofenac, Diclofenac, Etodolac, Indomethacin, Sulindac); coxibs (Celecoxib, Etoricoxib); anthranilic acid derivatives (Meclofenamate, Mefenamic acid); oxicam derivatives (Meloxicam, Piroxicam, Tenoxicam); propionic acid derivatives (Ibuprofen, Ketoprofen, Loxoprofen, Naproxen); other NSAIDs (Nimesulide)
  • Recommended as 1st-line pharmacological treatment for acute, subacute and chronic low back pain
    • Provides moderate short-term analgesia for acute low back pain
    • Moderately more effective for chronic low back pain than placebo
  • Useful also for patients with acute lumbosacral radiculopathy 
  • Non-selective NSAIDs have increased risk for gastrointestinal complications
  • COX-2-selective NSAIDs produce lesser gastrointestinal symptoms compared to non-selective NSAIDs
    • Not recommended for patients with known cardiovascular risk factors 
  • Topical NSAIDs are also an effective option for mild cases
  • May be used in combination with proton pump inhibitors (PPIs)
    • Have gastroprotective properties against the adverse effects of NSAIDs

Opioid Analgesics

  • Eg Buprenorphine, Codeine, Diamorphine, Dihydrocodeine, Fentanyl, Oxycodone, Tramadol
  • Recommended for severe acute, subacute and chronic low back pain and radiculopathy not controlled by NSAIDs and non-opioid analgesics
  • Some studies argue that the efficacy of opioid analgesics is similar to that of NSAIDs and non-opioid analgesics but should only be used if former treatments were ineffective
  • Tramadol is recommended as 2nd-line pharmacological therapy for chronic low back pain 
  • Weak opioids help relieve pain and disability in patients with non-specific chronic low back pain
  • Duration of treatment should be limited to <2 weeks to decrease the risk of dependency and the potential for misuse and abuse

Non-Pharmacological Therapy

Exercise

  • Recommended 1st-line non-pharmacological treatment for chronic low back pain 
  • A tailored exercise regimen for up to 8 times in 12 weeks may be beneficial
  • Stretching, strengthening, stabilization, directional and aerobic exercises are recommended for patients with acute, subacute, and chronic low back pain
    • Aerobic exercise is recommended in patients with non-specific low back pain to improve pain, disability and mental health
  • Aquatic exercise may be advised in selected patients with subacute and chronic low back pain
  • Gradually transitioning into moderate-higher stress exercises may improve outcome 
  • Low-stress exercises may be started during the 1st 2 weeks of acute low back pain attack
    • Effectively prevents debilitation due to inactivity 
  • Yoga is recommended for patients with acute, subacute, or chronic low back pain of >1 year
    • Several studies have shown that viniyoga is superior to traditional exercises, self-care educational books, and medications for the management of chronic low back pain
  • Studies suggest tai chi resulted in improvement of moderate pain 
  • May also help improve pain and function in patients with radicular low back pain

Functional Restoration

  • Involves physical conditioning, work conditioning, or work hardening programs
  • May be considered in patients with chronic low back pain when with cognitive-behavioral techniques

Physical Modalities

Electrical Nerve Stimulation

  • Eg transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS)
  • Recommended as an adjunct therapy for patients with chronic non-specific low back pain and chronic radicular pain, and sciatica
  • TENS utilizes continuous electrical impulses to deliver temporary pain relief
    • Uses a small battery-operated device that delivers the impulses via surface electrodes
    • Not recommended for acute low back pain
  • PENS uses slim needles inserted into the skin to be able to deliver low-level electrical stimulation to target tissues/organs
    • Targets pathological tissues via dermatomal levels
  • PENS is moderately superior to TENS when based on pain relief and functional outcome

Low-level Laser Therapy (LLLT)

  • May be considered for temporary pain alleviation in acute low back pain if combined with exercise
  • Provides moderate pain relief in patients with acute or subacute low back pain when coupled with NSAID therapy
  • Studies showed pain relief and improved function in chronic low back pain with LLLT compared with sham laser
  • Utilizes dermal application of electromagnetic energy with laser wavelengths ranging from 632-904 nm

High-Intensity Laser Therapy (HILT)

  • Effective for short-term pain relief when combined with exercise

Thermotherapy

  • Application of hot and/or cold compress/wrap provides short-term relief of acute low back pain
  • Low-tech cryotherapies may be helpful for acute, subacute, and chronic low back pain
  • Radiofrequency ablation may provide improvement in pain relief, intake of pain medications, and quality of life in patients with chronic lumbar facet joint back pain
  • Intradiscal electrothermal therapy (IDET) has been found to be effective for treating discogenic low back pain

Ultrasound

  • Usually done together with other physical modalities  
  • Beneficial effect is derived from the heating of the deep tissues  
  • A few studies have shown it to be effective for chronic low back pain

Spinal Manipulation/Spinal Manipulative Therapy (SMT)

  • May be considered for acute, subacute, and chronic low back pain only after serious pathology has been ruled out
  • When used for acute low back pain, therapy should be given within the 1st month of appearance of symptom
    • Effective for short-term pain management
  • Studies showed that manipulation/mobilization of the cervical/thoracic spine for patients with chronic low back pain may be effective for temporary symptom alleviation and improvement of function
  • 12-18 sessions are suggested for better treatment effects

Psychological Therapies

  • Eg cognitive behavior therapy, electromyography (EMG) biofeedback, relaxation training (eg mindfulness-based stress reduction), hypnosis, fear avoidance belief training (FABT)/kinesiophobia
  • May help patients with issues regarding emotional, behavioral and cognitive aspects of dealing with pain
  • When combined with other therapies, psychological therapy is highly recommended for patients with chronic low back pain
  • Further studies are needed to prove the efficacy of biofeedback for patients with acute low back pain

Alternative Therapies

  • Eg devil’s claw (Harpagophytum procumbens) root, white willow bark (Salix alba), cayenne (Capsicum frutescens), comfrey (Symphytum officinale) root extract, and topical lavender essential oil
  • Studies show moderate benefit from herbal therapies

Other Options

Acupuncture

  • May be considered for persistent non-specific low back pain and for some patients with moderate-severe low back pain and chronic low back pain
  • Considered to be more effective for temporary relief of chronic low back pain compared to nontreatment and sham acupuncture
  • A maximum of 10 sessions in 12 weeks is suggested

Dry Needling/Needlestick

  • May help alleviate pain coming from a specific trigger point in patients with chronic low back pain
  • Studies showed that dry needling exhibits better pain relief for chronic low back pain when given in conjunction with other interventions

Massage

  • Moderately helps provide short-term pain relief in patients with acute, subacute and chronic low back pain compared to other non-pharmacological interventions
    • Massage coupled with exercise and/or education is superior in efficacy compared when done alone when used in patients with subacute to chronic low back pain

Spa

  • May help patients with chronic low back pain
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