As I sat down today to work on this month's blog for our website here at Summit Spine, I found myself having significant difficulty focusing because I currently have back pain. Yep, classic acute back pain. I hurt myself 2 days ago and now, as my wife told me this morning, I am a little irritable. I have had very fitful sleep and daytime pain, but fortunately heavy doses of ibuprofen have been helpful. At this point, I am questioning whether I should avoid exercise over the next week and if I should add any additional medication. Maybe I should cancel this afternoon’s clinic and go back to bed? I treat back pain every day, but I found myself wondering if I am up to date with the latest recommendations.
Lower back pain is now the #1 reason patients seek treatment from their primary providers. According to the American College of Physicians (ACP), 1 in 4 people in the United States will experience back pain in the next 3 months. I can’t argue with that! Well, it just so happened that the ACP released their new recommendations for acute and chronic lower back pain in February and there are some interesting changes.
First, there are a few details and terms we should review. In medicine, treatment is constantly evolving based on the latest research, clinical findings and technological advances. This ongoing effort allows us to offer patients the most effective and cost efficient treatment, and is the foundation for evidence based medicine. Today I will be discussing a “treatment guideline” which is a tool we use to help direct care in the most effective manner. Guidelines are provided by internationally respected organizations composed of highly reputable researchers, who have done much of the leg work for us. They often spend several years compiling data and reviewing, sometimes thousands of studies, as the basis of these guidelines.
In this guideline from the ACP there are a few terms we should also discuss. When dealing with back pain, the ACP defines acute as lasting up to 4 weeks, subacute as 4 to 12 weeks and chronic as longer than 12 weeks. There are 2 important points to make here. First, the overwhelming majority of patients will NEVER get to the chronic phase of injury and most of us accomplish this without any intervention from the medical community. I guess that means I should stick around for clinic this afternoon. Secondly, as your pain transitions to a different phase, so does your treatment. I make this point because what may or may not be indicated during the acute or subacute phase may be considered beneficial during the chronic phase. Acetaminophen is a good example of this.
For me the most significant change is the use of Acetaminophen. For as long as I can remember this was a first line drug for back pain and was reinforced by the ACP in their previous guidelines from 2007. In its latest edition, the ACP found that it did not perform better than a placebo and only offered a weak recommendation for acute and subacute back pain. Remember though for chronic pain this is a different story and it is still a first line medication for the treatment of arthritis.
A second significant change is a very solid reinforcement of the benefits of NSAIDS. These are medications such as Ibuprofen, Advil, Alieve, Naproxin, and Celebrex. These medications have again proven to be very beneficial and received a strong recommendation. I can attest to that! This is not necessarily a change, but this class of medications now seems to take center stage in early treatment. In addition, muscle relaxants have been endorsed by the ACP as a first line medication during the acute and subacute phase. Prior to this the consensus had been mixed.
What I appreciate the most about this new guideline is more focused attention towards non-surgical and non-pharmacological treatment options. First line treatment includes exercise, physical therapy, multidisciplinary rehabilitation, acupuncture, stress reduction, tai chi, yoga and spinal manipulation. Each of these areas showed benefit, but one was not more beneficial than others.
You may have noticed I have not mentioned Narcotics. Narcotics are not indicated with most acute low back pain and are not beneficial in long term back pain management. Narcotics work by overwhelming the entire central nervous system. These effects decrease overall function and can lead to increased dependency, depression, pain and even death. We will talk more about this in future blogs.
You may have also noticed this guideline does not include back pain with other symptoms such as leg pain, weakness, or certain times of associated bowel and bladder dysfunction. These symptoms suggest a completely different problem which can be much more severe and you should see a provider as soon as possible.
I have included a link if you would like to review the entire article and guideline published in the Annals of Internal Medicine but I also added the summary recommendations below if you want a quick review. Well I am off to do some light tai chi and take my NSAIDS before clinic, but if you have any additional questions please come see us at Summit Spine. We are here to help!
Sean Brown PA-C
Director of Patient Education & Clinical Research
Annals of Internal Medicine ACP Low Back Pain Recommendations February 14, 2017
Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)