Wednesday, July 12, 2017

Wisdom Wednesday: Guidelines on nonradicular low back pain by the American College of Physicians

Most patients with acute or subacute low back pain improve over time regardless of treatment and can avoid potentially harmful and costly treatments and tests. First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.

For chronic low back pain, consider nondrug therapy, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercises, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive-behavioral therapy, or spinal manipulation.

For chronic low back pain that does not respond to nondrug therapy, consider NSIADs as first-line therapy. For second-line consider tramadol or duloxetine. Consider opioids only in patients in whom first- and second-line therapy has failed, in whom risks are outweighed by benefits, and only after full discussion of the potential risks and benefits.

My Take – Nonradicular low back pain is well localized pain that does not radiate down either leg. Acute low back pain is limited to patients with an onset of 7-10 days maximum. Subacute low back pain extends from a week to six weeks and chronic low back pain is anything greater than subacute.

In general, I agree with these guidelines. For over 40 years, I have used spinal manipulation successfully in the treatment of acute, subacute and chronic low back pain.

However, I do disagree with a few of the recommendations. First, heat should never be used in the treatment of acute or subacute low back pain. Heat sedates the nervous system locally, so it does temporarily reduce some of the sensation of pain. But heat also increases circulation and therefore increases inflammation as well. About once every two weeks, I treat a patient with acute low back pain that probably would have resolved if they just didn’t use heat.

Ice is much preferred in the treatment of acute and subacute low back pain. The ice can be applied directly to the affected area for 20 minutes every hour. It is vital to allow 40 minutes between ice sessions to prevent a “hunting reaction” that increases circulation. Ice works best when sessions are grouped to cover a minimum of three hours.

First-line therapy should also include nondrug nutritional supplementation to reduce inflammation. Omega-3 fatty acids, Turmeric, ginger and other supplements can dramatically reduce inflammation without the side effects associated with NSAID therapy. Clinically, the use of NSAIDs should be restricted to 72 hours and I have rarely seen skeletal muscle relaxants provide any measure of relief.

Chronic low back pain is much more complicated. If you look at the recommended modalities, many of them involve neurological retraining. Injury reflexes triggered by low back injuries become ingrained as normal firing patterns in chronic patients. These patterns must be corrected or the patient returns to the chronic pain state as a “normal” neurological pattern.

The Bottom Line:
Don’t just reach for NSAIDs when your low back hurts. Try ice and some fish oil or Turmeric for 3-4 days. If your pain persists, seek nondrug therapy. My bias is toward spinal manipulation, but massage or acupuncture are viable alternatives.

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