Medications for low back pain
Low back pain (LBP) is a prevalent condition affecting millions worldwide, often prompting individuals to seek relief through medication. Understanding the array of options available and their respective efficacies is crucial for both patients and healthcare providers. Below we will provide three recommendations based on the current evidence. Then we will delve further into the most commonly prescribed and recommended medications for low back pain. This is based on the latest evidence, highlighting how effective they are for treating LBP and the associated risks for these medications. Based on the current research you can take away three recommendations. Acute/Sub-Acute (<3 months duration) Low Back Pain Recommendation: Considering that the majority of patients experiencing acute or subacute low back pain tend to recover spontaneously irrespective of treatment, patients are advised to opt for non-pharmacologic options. These may include superficial heat therapy, massage, acupuncture, or spinal manipulation. However, if medication is preferred, clinicians and patients should choose nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants for short-term use. For more information on what to do with a new episode of back pain, read Jess’s blog – navigating-a-new-episode-of-low-back-pain. Chronic (>3 months duration) Low Back Pain Recommendation Step 1: In the case of chronic low back pain, clinicians and patients are advised to first consider nonpharmacologic interventions. This is due to the adverse side effects from most of the medications recommended for chronic low back pain. These nonpharmacologic interventions include exercise, multidisciplinary rehabilitation, acupuncture or dry needling, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioural therapy, or spinal manipulation. For more information on the benefits of maintenance care for low back pain, read Jess’s blog – maintenance-care-for-chronic-low-back-pain Step 2: If non-pharmacologic therapy fails to adequately address chronic low back pain, clinicians and patients should contemplate pharmacologic options. Nonsteroidal anti-inflammatory drugs are recommended as the first-line treatment, followed by tramadol or duloxetine as second-line choices. Opioids should be considered only as a last resort for patients who haven’t responded to previous treatments. Also, this should only happen after an open discussion between the GP and patient. For more information on the different types of medication, see below: Acetaminophen (AKA paracetamol) e.g. Panadol Despite its widespread use, recent evidence suggests that paracetamol may not be as effective as once believed for acute LBP. Studies have shown no significant differences in pain relief between paracetamol and placebo, challenging its efficacy in managing this condition. While acetaminophen carries a lower risk of adverse events compared to NSAIDs, its effectiveness in chronic or radicular LBP remains uncertain. Non-steroidal anti-inflammatory drugs (NSAIDs) e.g. Ibuprofen, Naproxen, Advil, Voltaren NSAIDs are commonly recommended as the first-stop medication for low back pain due to their anti-inflammatory properties. Studies have demonstrated greater mean improvements in pain intensity with NSAIDs compared to placebo for both acute and chronic LBP. However, NSAIDs are associated with a higher risk of adverse effects, particularly gastrointestinal issues, emphasizing the importance of cautious use. Opioids e.g. Oxycodone, Morphine, Tramadol and Tapentadol Opioids are often prescribed for severe or chronic low back pain when other treatments have failed. While some trials suggest short-term relief with opioids, there is low quality and limited evidence to suggest long-term relief from pain. Furthermore, there are concerns regarding their safety and potential for addiction, overdose, or drug abuse. This highlighting the need for judicious prescribing and close monitoring. Systematic reviews also found short short-term use of opioids had an increased risk of nausea, dizziness, constipation, vomiting, drowsiness, and dry mouth. Skeletal muscle relaxants e.g. Methocarbamol, Cyclobenzaprine Skeletal muscle relaxants are sometimes recommended for short-term relief of acute LBP, albeit with a caveat of increased risk for adverse effects involving the central nervous system, particularly sedation. Studies have shown superior pain relief with skeletal muscle relaxants compared to placebo in the short termevidence for their efficacy in chronic LBP is lacking. Benzodiazepines e.g. Valium Benzodiazepines are occasionally prescribed for low back pain, although evidence supporting their effectiveness is limited, low quality and inconsistent. Research also suggests a greater risk for central nervous system adverse events, including drowsiness, fatigue, and lightheadedness. There are no clinical trials designed to evaluate the risk for addiction, abuse, or overdose, again suggesting against their use and prescription for back pain. Antidepressants e.g. Endep Low-dose tricyclic antidepressants, e.g. amitriptyline (Endep), and selective serotonin reuptake inhibitors (Lexapro), have limited evidence to suggest a difference in pain levels in individuals with chronic back pain. However, some studies found that the serotonin-norepinephrine reuptake inhibitor, duloxetine, has shown promise in providing modest relief for chronic low back pain. Recent trials suggest that duloxetine may be more effective than placebo in improving pain and function, albeit with increased risk of adverse events such as nausea and withdrawal symptoms once ceasing the drug’s use. Due to conflicting findings and the associated adverse effects, further research is needed to elucidate the role of antidepressants in managing low back pain and to explore their comparative effectiveness with other medications. Anti-seizure medications e.g. Pregabalin, Gabapentin Anti-seizure medications, such as pregabalin and gabapentin, have been evaluated for their efficacy in low back pain, particularly in cases of radiculopathy. However, evidence for their effectiveness remains inconclusive, with some studies reporting inconsistent results and methodological shortcomings. Overall evidence suggests no effect on pain levels and functions for both acute and chronic low back pain. Additional research is warranted to determine the optimal use of antiseizure medications in the management of low back pain. Systemic corticosteroids e.g. Prednisone Systemic corticosteroids do not appear to be effective for treating acute non-radicular low back pain or spinal stenosis. There is insufficient evidence to support their use for chronic non-radicular pain. For radicular low back pain which is back pain that refers to one or both legs, several trials consistently found no significant differences in pain relief between systemic corticosteroids and placebo, although one large trial suggested a small improvement in function with corticosteroids at 52 weeks. However, corticosteroid use was associated with an increased risk
Navigating a New Episode of Low Back Pain
Are you experiencing a flare-up or a new episode of low back pain? Here’s how to navigate it. Low back pain (LBP) is a prevalent condition, often causing discomfort and disruption to daily life. Understanding the best practices for managing LBP is essential for achieving effective relief and preventing further complications. Using clinical practice guidelines, this blog aims to provide actionable advice for when you experience LBP. Before we go any further, it’s important to seek help from a professional when you experience a new episode of pain or intense pain, to determine the need for immediate medical relief. This blog post is targeted to ‘non-specific low back pain’, which is pain that does not have a known patho-anatomical cause. In other words: not caused by serious conditions such as a tumour, infection, spinal cord compression, etc. So with that in mind, let’s discuss how to manage it and when it’s appropriate to see a chiropractor! How you can manage a new episode of back pain by yourself: Avoid bed rest: Most research advises against prolonged bed rest for acute LBP, recommending maintaining normal activities to promote healing. Medication and superficial heat: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for pain relief, e.g. neurofen (ibuprofen). It’s important to read the label when taking these drugs and consult with the pharmacist to ensure they are right for you. Additionally, heat packs or heat creams can help when experiencing an acute episode of low back pain. For more information on the different medications for back pain read Jess’s blog – medications for low back pain. Exercise Therapy: Exercise is universally endorsed, particularly for chronic LBP, although the type and delivery mode may vary. The recommended exercise varies from person to person, but generally speaking, while suffering from a painful episode of low back pain, gentler exercises will be more beneficial. For example, light swimming, walking, or pilates. Psychosocial Strategies: Cognitive-behavioral therapy (CBT) is widely recommended, addressing psychosocial factors that may contribute to LBP. Generally, CBT strategies are performed by a psychologist and are useful if you frequently suffer from low back pain episodes. Alongside that, regular mindfulness practice is encouraged to decrease the intensity and frequency of back pain. How can a chiropractor help you if you experience a new episode of low back pain? If symptoms persist or worsen, consider consulting a healthcare provider within the first 1 – 2 weeks of the pain for further evaluation and personalised treatment recommendations. Chiropractors can develop individualised exercise programs and provide hands-on interventions to address pain and promote recovery. Additionally, research shows the significance of receiving reassurance from a professional that improvement is achievable while experiencing low back pain. Chiropractors can also discuss with you the strategies that will be most effective when managing the pain at home or outside of the clinic. For chronic LBP, multidisciplinary rehabilitation may be beneficial, involving a coordinated approach with various healthcare professionals. Chiropractors can offer referrals to specialists if you need to look at other options. However invasive treatments such as injections or surgery are generally discouraged unless conservative measures have been ineffective, and specific criteria are met. Long-term management and prevention of back pain Once you have managed to settle down the pain it’s good to implement long-term strategies to avoid another flare-up. Some simple ways include: Lifestyle modifications: Regularly change the position you’re in – making sure you’re not staying in the same position for too long e.g. sitting or standing for too long, engage in regular exercise, and manage stress to reduce the risk of recurrent LBP episodes. Education and self-management: Research shows that when you understand how pain is perceived in the body you are less likely to catastrophise a flare-up, subsequently decreasing the intensity and duration of that flare-up. Empower yourself with knowledge about LBP management strategies and adopt self-management techniques to address symptoms proactively. If you regularly get pain flare-ups have a look at Lorimer Moseley’s Ted talk on YouTube called “Why Things Hurt”. Regular follow-ups with healthcare providers such as chiropractors can help monitor progress, adjust treatment plans as needed, and address any new concerns or symptoms. Experiencing low back pain can be challenging, but with the right approach, relief and recovery are achievable. By adhering to evidence-based recommendations such as those discussed in this blog, individuals can navigate LBP with confidence and take proactive steps towards improved health and well-being. Remember, you are not alone in your journey, and there are resources and healthcare professionals available to support you every step of the way. Stay informed, stay proactive, and prioritize your health for a brighter, pain-free future. References: Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CC, Chenot JF, van Tulder M, Koes BW. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018 Nov;27(11):2791-2803. doi: 10.1007/s00586-018-5673-2. Epub 2018 Jul 3. PMID: 29971708. Chou R, Côté P, Randhawa K, Torres P, Yu H, Nordin M, Hurwitz EL, Haldeman S, Cedraschi C. The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):851-860. doi: 10.1007/s00586-017-5433-8. Epub 2018 Feb 19. PMID: 29460009. Ladeira CE. Evidence based practice guidelines for management of low back pain: physical therapy implications. Rev Bras Fisioter. 2011 May-Jun;15(3):190-9. doi: 10.1590/s1413-35552011000300004. PMID: 21829982. Wong JJ, Côté P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017 Feb;21(2):201-216. doi: 10.1002/ejp.931. Epub 2016 Oct 6. PMID: 27712027. Lorimer Moseley G, Leake HB, Beetsma AJ, Watson JA, Butler DS, van der Mee A, Stinson JN, Harvie D, Palermo TM, Meeus M, Ryan CG. Teaching Patients About Pain: The Emergence
Maintenance care for chronic low back pain
Low back pain (LBP) is a common and burdensome health issue affecting millions worldwide. Its recurrence and persistence pose significant challenges, often leading individuals down a frustrating path of pain and reduced mobility. A lot of chiropractic treatment helps to decrease pain intensity but a proactive approach decreases the likelihood of pain flare-ups. Chronic LBP has a ripple effect on individuals, affecting their families, work, lifestyle and society. It is the leading cause of work absence and activity limitation globally. Its recurrent nature increases this burden, highlighting the critical need for preventive strategies. Alongside hands-on chiropractic treatment, exercise and education play pivotal roles, offering hope for individuals grappling with recurrent LBP. Have you had a recent flare-up? Read Jess’s blog on how to deal with a new episode of low back pain. Chiropractors, skilled in musculoskeletal assessment and treatment, play a pivotal role in managing LBP. Manual therapies, including spinal manipulation and mobilization, are commonly employed to alleviate pain and improve function. Additionally, chiropractors often recommend maintenance care — a preventive approach aimed at reducing the risk of relapse and optimizing long-term well-being. Current Research A 2018 randomised controlled trial by Eklund et al. investigated the effectiveness of maintenance compared to symptom-guided care in individuals with recurrent or persistent LBP. The study replicated real-world clinical practices, offering valuable insights into its efficacy. The trial compared maintenance against symptom-guided care. The maintenance care group aimed to schedule chiropractic appointments before substantial pain, meaning appointments were pre-booked and controlled by the clinician. In the control group, the patients were instructed to book when pain occurred, meaning the appointments were not pre-booked and were controlled by the patient. The trial revealed that maintenance care was more effective than symptom-guided care in reducing the total number of days with bothersome LBP over 52 weeks. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, maintenance care should be considered an option for long-term prevention. In the struggle against recurrent LBP, exercise, education, and chiropractic emerge formidable allies. By embracing proactive strategies and evidence-based interventions, individuals can reclaim control over their well-being and navigate the journey of recovery with resilience and optimism. As chiropractors continue to champion holistic approaches to musculoskeletal health, the promise of maintenance care shines brightly, offering hope and healing to those in need. References Eklund A, Jensen I, Lohela-Karlsson M, Hagberg J, Leboeuf-Yde C, Kongsted A, Bodin L, Axén I. The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain – A pragmatic randomized controlled trial. 2018 Sep 12;13(9):e0203029.Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(6):968–74. 10.1136/annrheumdis-2013-204428da Silva TM, Mills K, Brown BT, Herbert RD, Maher CG, Hancock MJ. Risk of Recurrence of Low Back Pain: A Systematic Review. J Orthop Sports Phys Ther. 2017:1–27.Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(2):199–208. 10.1001/jamainternmed.2015.7431ringsli M, Berntzen A, Olsen DB, Leboeuf-Yde C, Hestbaek L. The Nordic Maintenance Care Program: Maintenance care—what happens during the consultation? Observations and patient questionnaires. Chiropr Man Therap. 2012;20(1):25 10.1186/2045-709X-20-25
