The use of medication in low back pain

doi:10.1016/j.berh.2005.03.011

Best Practice & Research Clinical Rheumatology

Volume 19, Issue 4, August 2005, Pages 609-621

https://doi.org/10.1016/j.berh.2005.03.011 Get rights and content

The choice of medication for low back pain should be evidence based and tailored as much as possible to suit the individual patient. Acetaminophen (paracetamol), mild opioids and NSAIDs are the first-line drugs for low back pain but there is no evidence that one is more effective than the others. Non-benzodiazepine muscle relaxants (with or without pain medication) could be considered as second-line drugs in acute low back pain, and cyclic antidepressants in chronic low back pain. The risk of adverse side effects can be reduced by taking account of the patient's medical history and by using a test dose. The realization that symptoms other than pain are sometimes more important and/or easier to overcome can increase the benefits of medication. The long-term effects of medication can be improved when it is combined with non-drug interventions.

Section snippets

Analgesics and NSAIDs

In the US, 69% of patients who visited a physician for the first time for low back pain received a prescription for an NSAID and 4% for acetaminophen (paracetamol) (see Table 1).¹ In the Netherlands, general practitioners prescribed analgesics or NSAIDs in 45% of low back pain episodes (Table 2).²

The role of COX-2 selective NSAIDs in the treatment of low back pain is controversial. Some authors have suggested that they should be preferred over other NSAIDs because they are as effective but have

Antidepressants

About 23% of primary care physicians in the US routinely use antidepressants in acute low back pain, even though their use is controversial.¹¹ There are no trials of antidepressants for acute low back pain, and reviews of antidepressants in chronic low back pain reach different conclusions. In 1996, Turner and Denny concluded that there was insufficient evidence to recommend their use.¹² In 1997, van Tulder et al found that ‘there is moderate evidence that antidepressants are not effective’.¹³

Muscle relaxants

The prescription of muscle relaxants for acute low back pain is very popular in the US. One survey showed that 91% of primary care physicians say they prescribe muscle relaxants routinely in acute low back pain¹¹, whereas other surveys show that between 35 and 64% of patients with acute low back pain received muscle relaxants.1, 23 In cases of acute, severe pain, muscle relaxants are mostly used for a period of 7–14 days.1, 23 A survey in the Netherlands showed that 89% of the primary care

What is the value of medication for acute low back pain?

The prognosis of acute low back pain is good, even without treatment.²⁶ The purpose of prescribing medication is not to ‘cure’ the patient but to relieve severe symptoms. The optimal choice of medication will depend on various arguments. Medication is indicated when pain interferes with advice to stay active and when sleep is disturbed by pain. In chronic low back pain, patients are advised to take medication in a time-contingent way for a specified time period, mainly based on psychological

What is the value of medication in subacute low back pain?

The subacute period from about 7 to 12 weeks seems to be the optimal period for intervention to prevent the development of chronic pain and disability, so management during this period is most important. Yet there are few studies of medication for subacute low back pain. Moreover, it is not clear what the physician expects medication to do at this stage: is it to provide pain relief as at the acute stage, to control pain to enable the patient to get active and rehabilitate, or simply to control

What is the value of medication in chronic low back pain?

A prospective cohort study in the Netherlands showed that 21.6% of patients with chronic low back received medication during a 12-month follow up: 3.9% used acetaminophen or aspirin, 16.3% an NSAID, 3.3% a benzodiazepine and 0.7% a tranquillizer.³⁰

The aim of treatment for chronic low back pain is completely different from that of acute low back pain. Many patients with chronic low back pain continue to have persistent or recurrent symptoms, so expectations of ‘cure’ are probably unrealistic.

How can we improve the effects of medication? The art of prescription

Clinical trials show that various drugs are effective in low back pain but that the effect sizes are usually quite small. A systematic review of NSAIDs for acute low back pain showed that the relative risk (RR) for global improvement compared with placebo after 1 week was 2.0.³¹ Another systematic review showed that the RR of global improvement for muscle relaxants compared with placebo was again 2.0.²⁴ In comparison, the RR for relief of acute postoperative pain on a single dose of 400 mg

Summary

This chapter tries to combine the best evidence about the efficacy of medication for low back pain and the ‘art of prescription’. It has been shown that various drugs are more effective than placebo, but the effects are small. Based on efficacy, there is little to chose between acetaminophen, NSAIDs and mild opioids. In acute low back pain, it is worth considering pain medication with or without non-benzodiazepine muscle relaxants. In chronic low back pain, it is worth considering pain

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Recurrent low back pain or chronic low back pain?
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The reason for consultation “low back pain” is extremely common. It is a big consumer of time, waiting time for patients, energy for professionals involved in chronic pain. We receive in consultation many patients for whom, the recent knowledge, both of the disc physiology and sagittal balance of the spine, must enable us to extract them from the too global framework of “chronic low back pain”. This painful complaint, protean and invasive, is a source of errors of diagnosis and exhaustion on the part of therapists. But with the help of a focused and targeted interview, a rigorous clinical examination, we can respond quite easily to the patient. We will highlight the most common mechanical causes and in particular 2 little known entities and source of validated and relevant therapeutic solutions. Traumatic, inflammatory (rheumatic, infectious, tumoral…) causes are not the subject of our remarks. The transition to chronicity concerns only 10% of low back pain.
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Lumbar spinal stenosis is a common cause of low back pain and spine-related disability among older adults. Lumbar spinal stenosis is a condition which involves narrowing of the central spinal canal, lateral recess, or foramen, leading to reduced space available for the neural and vascular elements, which may result in back and leg pain, lower-extremity paresthesias, decreased walking capacity, and impaired quality of life. Clinical management and research of lumbar spinal stenosis is limited by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and the high rates of anatomic stenosis on imaging studies in asymptomatic older people. Conservative management options currently include medications, spinal interventions, and rehabilitation. However, as few high-quality randomized trials have evaluated conservative management options, systematic reviews have concluded that there is insufficient evidence to recommend any specific type of nonsurgical treatment. As the prevalence of lumbar spinal stenosis with neurogenic claudication is expected to rise exponentially, large high-quality trials are warranted. Surgical intervention has been shown to be helpful for patients with symptomatic spinal stenosis.
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Citation Excerpt :
Conservative therapy with medical management has been shown to be effective at reducing pain [3–8], yet no studies to date have shown the ability of oral or topical medications to completely eliminate lumbar zygapophysial joint pain. There is also little evidence to support the use of one medication over another [9–11]. Procedural interventions for zygapophysial joint pain are the second most common type of procedure performed in pain management centers throughout the United States [2].
Using diagnostic anesthetic blocks, the lumbar zygapophysial (facet) joint has been shown to be the primary cause of pain in approximately 15% of patients with chronic low back pain. Radiofrequency neurotomy (RFN) of the lumbar medial branch innervating the zygapophysial joint has been shown to provide a significant decrease in pain in patients selected by dual comparative anesthetic blocks, but quantitative improvements in mobility have not been fully elucidated. A theoretical concern with RFN is that the multifidus muscle, a stabilizing paraspinal muscle, is also denervated during this procedure, which may have adverse effects on mobility and spine stability.
The purpose of this study was to examine gait kinematics and muscle activity of the low back during treadmill walking both before and after RFN.
Case study.
One 33-year-old female, with 15 years of chronic left low back pain and a diagnosis of L4/L5 lumbar zygapophysial joint pain by dual comparative anesthetic blocks was studied.
Self-reported measures of perceived pain and effort; in addition to physiologic measures of heart rate, gait kinematics and surface electromyography (EMG) activity of the multifidus and erector spinae muscles were collected before and after the procedure.
The participant walked for 15 consecutive minutes on a treadmill. The first and last 5-minute intervals were at a self-selected pace, and the middle 5-minute interval was at a 50% increase of the self-selected pace. Gait kinematics and lumbar paraspinal surface EMG activity were recorded during the last minute of each walking interval. Heart rate, perceived effort, and perceived pain were also collected at the end of each walking interval. Data were collected both 7 and 1 days before RFN, and on the following days post-RFN: 0, 8, 14, 28, and 58.
Perceived effort did not change despite an increase in treadmill speed and heart rate. Pain decreased by 60% in the first two weeks and by 92% by 4 weeks post-RFN. There were also gradual positive changes in gait kinematics across all post-sessions and an immediate and sustained decrease in surface EMG activity over the left multifidus and erector spinae muscles following RFN.
The results of this pilot study are the first to show quantitative positive changes in gait and muscle activity post-RFN, suggesting that the relationship between this procedure and mobility warrant further investigation.
ALX 1393 inhibits spontaneous network activity by inducing glycinergic tonic currents in the spinal ventral horn
2013, Neuroscience
Citation Excerpt :
Taking these findings into account, it makes sense to test GlyT2 inhibition as a novel target for centrally acting muscle relaxants (Aragón and López-Corcuera, 2003). For the treatment of acute lower back pain currently used central muscle relaxants have a strong sedative component as side effect (Mens, 2005; Shen et al., 2006; Gonzalez et al., 2009). Sedation is primarily mediated by cortical networks (Rudolph and Antkowiak, 2004).
Strychnine-sensitive glycine receptors are activated by glycine and facilitate chloride influx into neurons. Glycinergic transmission might be either mediated by synaptic or extrasynaptic glycine receptors. While phasic neurotransmission is provided by a synaptic pathway, activation of extrasynaptic glycine receptors induces tonic inhibition. The glycine transporter 2 (GlyT2) regulates the uptake of glycine into presynaptic boutons. It is not determined yet, whether inhibition of GlyT2 by ALX 1393 can produce inhibition of spinal motoric networks and, whether phasic or tonic glycinergic inhibition is mostly enhanced.
We investigated the effect of ALX 1393 on spontaneous action potential firing activity by extracellular recordings in the ventral horn area of organotypic spinal cultures. Additionally, using the whole-cell patch-clamp technique, we defined the influence of GlyT2 inhibition on tonic and phasic glycinergic transmission in commissural interneurons of the ventral horn.
GlyT2 inhibition by ALX 1393 potently reduced neuronal action potential activity in a concentration-dependent manner (n = 211). The half maximal effect of ALX 1393 was observed at 100 ± 31 nM. Moreover, 88.3 ± 2.6% of the action potential activity was suppressed at 1 μM. Whole-cell patch-clamp recordings unveiled that ALX 1393 (200 nM) induced a tonic current (−45.7 ± 11.6 pA, n = 5) that was significantly reversed by application of the competitive glycine receptor antagonist strychnine. Contrastingly, phasic glycinergic transmission was not augmented by GlyT2 inhibition (charge transferred per time period for control conditions: 1.1 ± 0.1 pC, n = 7, for ALX 1393: 0.9 ± 0.2 pC, n = 7, p > 0.05).
GlyT2 inhibition induced glycinergic tonic currents, which might be the underlying mechanism for the observed suppression of spontaneous action potential activity by ALX 1393 in the spinal ventral horn. Silencing neuronal action potential activity by blocking GlyT2 might be a novel principle to inhibit locomotor circuits in the ventral horn area and to induce muscle relaxation.
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6The use of medication in low back pain

Section snippets

Analgesics and NSAIDs

Antidepressants

Muscle relaxants

What is the value of medication for acute low back pain?

What is the value of medication in subacute low back pain?

What is the value of medication in chronic low back pain?

How can we improve the effects of medication? The art of prescription

Summary

Clinical Therapeutics

Pain

Psychosomatics

Clinical Therapeutics

Pain

Gastroenterology

Lancet

The American Journal of Medicine

Pain

Journal of Psychiatric Research

Medication use for low back pain in primary care

Spine

Lage-rugpijn en benzodiazepine: een relatie vol spanning

Huisarts & Wetenschap

A systematic review of COX-2 inhibitors compared with traditional NSAIDs, or different COX-2 inhibitors for post-operative pain

Acta Anaesthesiologica

Do cyclooxygenase-2 inhibitors provide benefits similar to those of traditional nonsteroidal anti-inflammatory drugs, with less gastrointestinal toxicity?

Annals of Internal Medicine

Are Rofecoxib and Celecoxib safer NSAIDs?

Drug and Therapeutics Bulletin

Drug safety. Withdrawal of Vioxx casts a shadow over COX-2 inhibitors

Science

Non-steroidal anti-inflammatory drugs for low back pain

Dexketoprofen-trometamol and tramadol in acute lumbago

Fortschritte der Medizin. Originalien

6
The use of medication in low back pain