Wisdom Wednesday: Acute Low Back Pain – A Brief Case History

This is the first in a series of typical case histories taken from my office notes. They will appear in the Wisdom Wednesday blog slot intermittently. I hope they will give the reader some insight into managing and guiding a patient through a health issue.

A 66-year old female returns to my office for the first time in six years with complaints of acute low back pain. She has been struggling with chronic bilateral knee pain and has had a couple of orthopedic opinions on treatment ranging from medication management to total joint replacement. She denies radiating pain from the back to the legs and believes the onset is related to compensating for the knee pain. She is currently on the following medications: Atenolol, Celexa, Benacar, Zyrtec, Eliquis, Prempro, Simustatin, Armour Thyroid, Flecainide and 2 baby aspirin per day. (The average American takes 4 prescription medications daily, so this patient is taking twice that amount. I commonly see patients taking 16 different prescription medications on a daily basis).

Autogenic Facilitation (AF) was intact, using a weak left gluteus medius as an indicator muscle. (This indicates no body wide injury response by the nervous system. Her body has either resolved the injury neurologically, or there was no body wide injury stimulation to begin with - the later fits her history) Oral challenge with a mix of NSAIDS resulted in strengthening of the weak muscle. A favorable response to oral challenge with fish oil was noted. (These tests indicate that her primary inflammatory response is the production of prostaglandins despite taking aspirin daily which tends to block this pathway) Challenge of the left ilio-lumbar ligament was positive in weight bearing only, corrected by Injury Recall Technique (IRT). (This is a local injury reflex and is the most common source of ongoing neurological stimulation in low back pain) Gait assessment was intact. (Despite her contention that this low back episode is the result of compensating for her knee pain, no altered gait mechanism was indicated)

Tylenol ‘does not ease low-back pain’

Low back pain is the main cause of disability worldwide and acetaminophen (brand name Tylenol) is currently the first port of call in terms of reducing pain and speeding recovery.

However, a large randomized trial published in The Lancer investigates the efficacy of acetaminophen for acute low back pain and finds it performs no better than a placebo.

The researchers, led by Dr. Christopher Williams from the George Institute for Global Health at the University of Sydney, Australia, say their findings bring into question the “universal endorsement” of acetaminophen as the main painkiller for low back pain.

After conducting a systematic review of previous studies assessing the effectiveness of acetaminophen for low back pain, the team found no evidence to support its use. “All seven of the included trials had substantial methodological flaws, and only one trial included more than 25 participants per group,” they write. Additionally, they say no trial has compared acetaminophen with a placebo or compared dosing.

Their study randomly assigned 1,652 participants, of an average age of 45 years, with low back pain to receive regular doses of acetaminophen (3,990 mg per day) for up to 4 weeks; a second group was given acetaminophen as needed, and the third group a placebo. Results showed that between the treatment groups, there were no differences in the number of days to recovery; the median time to recovery was 17 days for the regular dose group, 17 days for the as needed group and 16 days for the placebo group.