low%20back%20pain
LOW BACK PAIN
It is pain, stiffness, or discomfort in the lower back area below the costal margin & above the gluteal creases.
Low back pain is also called spinal pain or lumbago.
Nonspecific low back pain is without identifiable specific causes that makes up 85-90% of all low back pain cases.  It also includes pain felt in the proximal lower extremities
Patients with low back pain maybe associated with mobility deficits caused by severe or progressive neurologic disorders or comorbidities.
Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, inflammatory disorders.
Low back pain associated w/ radiculopathy or spinal stenosis are dermatomal pain w/ or w/o neurologic deficits that most often caused by nerve root compression.

Principles of Therapy

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

Pharmacotherapy

Analgesics (Non-Opioid)

  • Eg Paracetamol (Acetaminophen), Aspirin, Capsaicin (topical)
  • Recommended first-line treatment for acute & chronic low back pain
  • Also recommended for patients w/ chronic low back pain w/ or w/o radicular pain, especially if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated
  • Capsaicin (topical) is recommended for acute & subacute low back pain; may also be used for flare-ups of chronic back pain
  • A weaker analgesic but w/ less adverse effects compared to NSAIDs
  • May be given w/ proton pump inhibitors (PPIs), or other gastric cytoprotective agents to counter possible gastrointestinal adverse effects

Anticonvulsants

  • Eg Carbamazepine, Gabapentin, Pregabalin, Topiramate
  • Topiramate may be used for patients w/ chronic low back pain as last-line therapy
  • Carbamazepine is a treatment option for patients w/ radicular pain unresponsive to traditional treatments
  • Gabapentin may also be used for patients w/ radicular pain syndrome w/ severe neurogenic claudication & limited walking distance

Antidepressants

  • Eg (Serotonin & Norepinephrine reuptake inhibitors/SNRIs) Duloxetine, Venlafaxine; (Selective serotonin reuptake inhibitors/SSRIs) Fluoxetine; (Tricyclic antidepressant/TCA) Amitriptyline, Doxepin, Imipramine, Maprotiline, Nortriptyline
  • Treatment option for pain alleviation in patients w/ subacute, & chronic low back pain
  • TCAs may be offered to patients w/ chronic low back pain if unresponsive to NSAIDs &/or analgesics, & w/o contraindications to TCAs

Benzodiazepines

  • Eg Diazepam
  • May be used for acute, subacute, & chronic low back pain for patients unresponsive to 1st line treatments
  • Effect: a sedative, anxiolytic, & antiepileptic that acts on gaba-aminobutyric acid (GABA)
  • Should only be used for a maximum duration of 2 weeks

Glucocorticoid Injections

  • Epidural steroid injections may be used for patients w/ 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
  • Reserved for patients w/ chronic low back pain
  • Further studies are needed to prove the efficacy of lidocaine patches in chronic low back pain

Muscle Relaxants (Non-Benzodiazepine)

  • Eg Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, Orphenadrine, Tizanidine
  • May be used as 2nd-line treatment for moderate-severe acute low back pain unresponsive to NSAID therapy, & for patients w/ 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 w/ acute radicular pain syndrome
  • Caution should be observed when using these as they may cause drowsiness, dizziness, addiction, liver disorders, & 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
  • Some institutions also suggest that NSAIDs be used as 1st-line treatment
    • Second to Paracetamol due to its gastrointestinal (GI) & renovascular adverse effects
  • Recommended for nonspecific acute, subacute, & exacerbations of chronic low back pain
  • Provides moderate short-term analgesia for acute low back pain
  • More effective for chronic low back pain than placebo
  • Non-selective NSAIDs have increased risk for gastrointestinal complications
  • COX-2 selective NSAIDs produce lesser gastrointestinal symptoms compared to non-selective NSAIDs
  • Topical NSAIDs are also an effective option for mild cases
  • May be used in combination w/ PPIs
    • Has gastroprotective properties against the adverse effects of NSAIDs

Opioid Analgesics

  • Eg (weak opioids) Codeine, Dihydrocodeine; (strong opioids) Buprenorphine, Diamorphine, Fentanyl, Oxycodone; Tramadol
  • Recommended for severe acute, severe subacute, & chronic severe low back pain not controlled by NSAIDs & non-opioid analgesics
  • Some studies argue that the efficacy of opioid analgesics are similar to that of NSAIDs & non-opioid analgesics & should only be used if former treatments were ineffective
  • Tramadol is moderately more effective than placebo for short-term chronic low back pain analgesia & improvement in quality of life assessments
  • Weak opioids help relieve pain & disability in patients w/ nonspecific chronic low back pain
  • Duration of treatment should be limited to <2 weeks

Non-Pharmacological Therapy

Exercise

  • A tailored exercise regimen for up to 8 times in 12 weeks may be beneficial
  • Stretching, strengthening, & aerobic exercises are recommended for patients w/ acute, subacute, & chronic low back pain
  • Recommended 1st-line non-pharmacological treatment for chronic low back pain
  • Low stress exercises may be started during the 1st 2 weeks of acute low back pain attack
    • Effectively prevents debilitation due to inactivity 
  • Gradually transitioning into moderate-higher stress exercises may improve outcome
  • Yoga is recommended for patients w/ chronic low back pain of >1 year
    • Several studies have shown that viniyoga is superior to traditional exercises, self-care educational books, & medications for the management of chronic low back pain

Functional Restoration

  • Involves physical conditioning, work conditioning, or work hardening programs
  • May be considered in patients w/ chronic low back pain when w/ 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 w/ chronic nonspecific low back pain & chronic radicular pain, & sciatica
  • TENS utilizes continuous electrical impulses to deliver temporary pain relief
    • Uses a small battery-operated device that delivers the impulses via surface electrodes
  • 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 & functional outcome

Low-level laser therapy

  • May be considered for temporary pain alleviation in acute low back pain, but further studies are needed to establish efficacy
  • Utilizes dermal application of electromagnetic energy w/ laser wavelengths ranging from 632-904 nm

Shortwave diathermy

  • May be considered for temporary pain alleviation in acute low back pain, but further studies are needed to establish efficacy
  • Utilizes shortwave electromagnetic radiation ranging from 10-100 MHz used as a form of thermotherapy to increase deep tissue temperature, providing pain relief

Thermotherapy

  • Application of hot &/or cold compress/wrap provides short-term relief of acute low back pain
  • Low tech cryotherapies may be helpful for acute, subacute, & chronic low back pain

Traction

  • The drawing & pulling movements used to stretch the lumbar spine may help relieve acute low back pain
  • Further studies are needed to determine the effect of traction for chronic low back pain

Spinal Manipulation/Spinal Manipulative Therapy (SMT)

  • May be considered for acute, subacute, & chronic low back pain only after serious pathology has been ruled out
  • When used for acute low back pain, therapy should be given w/in the 1st month of appearance of symptom
  • Studies showed that manipulation/mobilization of the cervical/thoracic spine for patients w/ chronic low back pain may be effective for temporary symptom alleviation

Psychological Therapies

  • Eg cognitive behavior therapy, electromyography (EMG) biofeedback, relaxation training, hypnosis
  • May help patients w/ issues regarding emotional, behavioral, & cognitive aspects of dealing w/ pain
  • When combined w/ other therapies, psychological therapy is highly recommended for patients w/ chronic low back pain

Alternative Therapies

  • Eg Devil’s claw (Harpagophytum procumbens) root, white willow bark (Salix alba)
  • Studies show moderate benefit from herbal therapies

Other Options

Acupuncture

  • May be considered for persistent nonspecific low back pain & for some patients w/ moderate-severe low back pain, & chronic low back pain
  • Considered to be more effective for temporary relief of chronic low back pain compared to nontreatment & 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 w/ chronic low back pain
  • Studies showed that dry needling exhibits better pain relief for chronic low back pain when given in conjunction w/ other interventions

Massage

  • May help patients w/ acute, subacute & chronic low back pain

Spa

  • May help patients w/ chronic low back pain
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