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Home > Library > Journal Issue > Article 3.0* CERP:A $24.95 Treatment Strategies for Low Back Pain Relief The Nurse Practitioner, April 2006 Clinical Topic: Advanced practice nursing Expires: 04/30/2008 CE Collection|Add to Planner | Take Test Treatment Strategies for Low Back Pain Relief D’Arcy MS, CRNP, CNS The Nurse Practitioner: The American Journal of Primary Health Care April 2006 Volume 31 Number 4 Pages 16 - 25 © 2006 Lippincott & Wilkins, Inc. Volume 31(4), April 2006, PP 16-25 Treatment Strategies for Low Back Pain Relief [MUSCULOSKELETAL CARE] D’Arcy, MS, CRNP, CNS ABOUT THE AUTHOR D’Arcy is a Pain and Palliative Care Nurse Practitioner/Outcomes Manager at Suburban Hospital, Bethesda Md. AUTHOR DISCLOSURE The author has disclosed that she has no significant relationship or financial interest in any commercial companies that pertain to this education activity. FIGURE. No caption available. One of the most frustrating patient groups for primary care practitioners (PCPs) to treat effectively are patients with low back pain (LBP). They come with high expectations for pain relief and expect prompt action. These patients come in all shapes, sizes, and ages, and the pain can be the result of a number of causes or pathologies. Low back pain is a symptom and may not have an attributable cause or related disease. Since the pain can come from overuse, lifting, or bending incorrectly, patients often blame themselves for not being more careful or for lifting an object that was too heavy. Because pain in the back can severely limit motion and functionality, patients can get very discouraged when the pain does not get better or it takes longer than anticipated to resolve. The effects of a seemingly minor injury can last for weeks, causing patients to try multiple solutions in an effort to get back to their normal activities. Approximately 50% to 80% of all adults experience LBP 1 , which affects more than two-thirds of the American public at some time in life. 2 Statistics show that LBP is the fifth most common reason that patients visit a PCP 1 , meaning PCPs spend a great deal of time helping patients with LBP. This article will review some common causes of LBP, both acute and chronic, and look at treatment strategies that can help busy PCPs manage patients with this common problem. The Weak Link: The Back Of all the structures in the human body, the spine seems to come with a unique set of problems and structural anomalies. Although it is designed to be the primary support and hold the body upright, it is not meant to support the obese bodies of modern-day patients, nor does it adapt to physical demands such as heavy lifting or overuse if the back muscles are not strong. The spine itself consists of the cervical spine, thoracic spine, and the lumbar spine. Each spinal segment includes a flattened spinal body with structures called facets that extend from each side. The nerve roots for each spine pass through foramina located in the facets. As people age, the facet space can narrow and impinge on the nerve roots with arthritic thickening and changes such as bone spurs. The normal spine has curvatures in the cervical and the lumbar region. If the normal curves are flattened (lordosis) or unnaturally curved (scoliosis) the musculature in these areas can tighten or stretch, which can result in pain. Postural correction, physical therapy, or in extreme cases, surgical intervention, can correct some of the physical changes seen with these conditions. Between each spinal body is a disc with cartilage. The disc is meant to help cushion the vertebral body and protect it from damage during movement. As we age, the disc space between each vertebral body narrows and the cushioning fluid decreases. This allows for more boney damage to the spine as the vertebral bodies lose the natural protection and separation. Compression injuries in which the spinal bodies come together with too much force can cause the disc material to compress and extend beyond the spinal column. This bulging disc or herniation can create pressure on nerve roots, causing extreme pain and in some instances, depending on the location, pain that radiates down the leg called radicular pain. With normal aging, cartilage erodes and the vertebral bodies themselves can lose calcium, resulting in osteoporosis. This loss of calcium in the boney structures can result in fractures of the spinal bodies called compression fractures. These fractures can impinge the nerve roots, which is particularly painful and difficult to treat. Causes of LBP Low back pain can be caused by musculoskeletal strain that is the result of overuse, structural damage to spinal processes caused by aging, infection, or a malignancy. FIGURE. Muscles of the Back Patients at risk for LBP 1 : * Are in poor physical condition and do not engage in regular exercise * Are over 55 years of age * Are workers who have engaged in hard physical labor over a period of time (e.g. construction workers) * Are obese * Have reduced spinal canal dimensions, spinal stenosis * Smoke or use other illegal substances * Are in a lower socioeconomic group There are some “red flags” that should not be overlooked when assessing a patient with LBP. If a patient has had a significant weight loss or complains of pain that worsens at night and does not resolve at rest while lying down, a malignancy may be the source of the pain. Neurologic symptoms, such as sudden bladder or bowel incontinence, or foot drop that worsens can indicate progression of a spinal cord impairment or a neurologic disease. Another red flag is severe or progressive neurologic deficit in the lower extremities and major motor weakness. This may be indicative of cauda equina syndrome. Other causes of LBP are kidney or urinary tract infection and gynecologic conditions such as cystic ovaries that can cause pain in the low back. Assessment When LBP is acute, most practitioners feel fairly confident about assessing pain. However, when pain becomes chronic, practitioners may begin to see patient presentation as identical, regardless of pain scale rating. Patients with chronic pain learn to cope with the pain and do not often appear to be in pain, which makes differentiating pain levels difficult. Additionally, chronic LBP patients can have vague and multifocal complaints, and may find it difficult to localize pain. Talking to family and friends constantly about their pain can strain relationships and patients with chronic pain learn when and to whom they can open up about their pain. For a basic pain assessment, the patient should be asked to: * Rate his pain intensity using a validated pain scale (0 to 10 numeric scale) and indicate any changes in pain with activity or movement * Point to the area of pain and any areas where the pain radiates * Tell the PCP how long the pain has lasted and any event that may have caused the pain, such as heavy lifting * Describe the quality of the pain (e.g. sharp, dull, achy, or shooting) * Indicate any functional impairment like inability to walk up or down steps impact of pain on sleep, diet, social relationships, etc. For long-term chronic LBP patients, a more formalized chronic pain assessment tool such as the Oswestry Brief Pain Inventory or Short-Form McGill Pain Questionnaire should be used. These expanded pain assessment tools have body diagrams for the patient to indicate the location and type of pain and have lists of pain descriptors that fully describe functional limitations and daily variations. 2,3 Chronic LBP is different from acute LBP. When patients have acute LBP, the pain resolves within 6 to 12 weeks regardless of treatment regime. 4 Patients who do not improve within that time period (about 15%), develop chronic LBP. 5 A newer term for chronic pain is persistent pain. This is pain that lasts beyond the expected normal healing period or greater than 3 months. The impact of chronic LBP is tremendous. It is the leading cause of work-related disability with 5% to 8% of individuals reporting pain of severe intensity. 6,7 Additionally, patients who have chronic LBP are significantly limited in their activities, may need time off from work to rehabilitate, and often experience depression related to the ongoing pain and disability. For many LBP patients, the ongoing stress of pain and depression strains relationships, and divorce is common. In a recent interview for USA Today , a chronic pain patient stated, “My husband describes pain as almost being a third person in our marriage.” 8 At least one in eight people with chronic LBP lose time from work. 9 The cost of chronic pain is about $62 billion/year from losses related to reduced performance alone. 8 Although the monetary effects on society are enormous, the personal costs and suffering take a much greater toll. Chronic pain is very difficult to manage and control. When ongoing pain is not relieved, patients report they cannot concentrate or sleep well, cannot engage in hobbies or help with chores at home, nor can they exercise or work effectively. 10 Given the impact of chronic pain on patients and families, it is not surprising that these individuals feel cranky and irritable, are unable to cope effectively, and often feel worthless and depressed. 10 FIGURE. Lower Spine (Lateral View) Case Study You are asked to see a 52-year-old female patient who originally hurt her back while lifting furniture. She complains of steady pain that worsens with activity, and tells you she has a really hard time standing for any period of time. She rates her constant pain as moderate-to-severe. The pain has been ongoing for 6 months. She is sure there must be something that will help her pain. The pain has made it impossible for her to care for her new home. When you examine the patient, she has very tender point areas. Her deep tendon reflexes are normal. She has great difficulty trying to bend forward and when she bends side to side, the stretch on the left side is very painful. She has impaired mobility. A straight leg raise reproduces pain in her back. Her magnetic resonance imaging examination shows a small herniated disc, but the surgeon has determined that she is not yet a surgical candidate. She has been sent for a physical therapy evaluation and a mental health evaluation where she was found to be depressed. She could not engage in the physical therapy program because she found it too painful. Her former physician told her he would not give her any more opioid pain medications; he felt “she would just have to learn to live with the pain because she could become addicted to the opioids if she continued taking them.” Currently, she takes naproxen (Aleve) and uses a heating pad. This patient is typical of many chronic LBP patients. She hurt her back during a relatively benign activity. Now she is paying a penalty that has changed her life. She has evidence of an injury, but it is not significant enough to merit surgical intervention at this time. Treatment options such as physical therapy and coping support have not helped. She feels the therapy is too painful and her depression has not been addressed adequately. What can be done for this patient to help her regain a better quality of life and more functionality? Treatment Options: Overview The treatment options for acute LBP are fairly simple and straightforward. Current recommendations are: * Stay active. Bedrest is not indicated for acute LBP. Recovery is enhanced and functionality is maintained by staying as active as possible. 11,12,16 * If the patient is a good candidate, has no cardiovascular history, or history of gastrointestinal bleeding, a short course of nonsteroidal anti-inflammatory drugs (NSAIDs), either nonselective such as ibuprofen or naproxen, or the COX-2 inhibitor celecoxib (Celebrex) could be helpful in acute back pain. These medications should be used for the shortest period of time possible, at the lowest effective dose, and for patients who are deemed to be good candidates with a low-risk profile. 13 * Offer a pain medication that fits the level of pain the patient is reporting. 14 * Try heat, ice, analgesic balms such as Ben Gay, or massage if the patient is open to these types of therapies. Chronic LBP is a much more complicated condition to treat since it is persistent and will be present to some degree on a daily basis. Many patients with chronic LBP have physical injuries and the damage will not progress. In order to treat these patients, a multimodal approach will have to be used with a variety of therapies. * Patients with injuries will benefit from a physical therapy program that stresses improving mobility. 11,15 * There is no role for NSAIDs in chronic LBP. These medications are beneficial for short-term use in acute LBP at the lowest dose possible. The inflammatory effect in chronic LBP is not the same as with a patient who has acute LBP. 13 Acute injuries produce a swelling in the area and an inflammatory response. Imagine a person gets hit with a softball—the affected area swells, reddens, and becomes tender. Once the pain becomes chronic, the body adapts and the inflammatory response resolves and stops. Only the soft tissue injury or spinal injury remains, causing mechanical problems for the patient and ongoing pain. Again using the softball injury scenario, the swelling goes down, the red areas disappear (inflammatory response stops), but the area itself may be tender for months. * Many chronic LBP patients take opioids on a continuing basis and do not become addicted. When a patient takes opioids daily for pain relief, they are considered opioid-dependent. Addiction is a chronic, neurobiologic disease in which individuals misuse prescription pain medication or use illicit drugs. 16 Addicts have no control over their drug of choice. Chronic pain patients, on the other hand, are seeking pain relief and use prescription opioids under the direction of the prescriber to improve their functionality. It is important that the provider does not confuse opioid dependency with addiction. * Add medications for sleep and depression such as a selective serotonin norepinephrine reuptake inhibitor (SSNRI), a selective reuptake inhibitor (SSRI), or a tricyclic antide-pressant (TCA). * Refer the patient to a treatment program to help build coping skills and positive image. * Use nonpharmacologic interventions such as heat, ice, acupuncture, or analgesic balms if the patient is interested. * Consider referring the patient to an interventional pain management clinic to be evaluated for an epidural steroid injection directly on the nerve root being compressed by the disc. If the patient is found to be a candidate for this type of therapy, the pain clinician may perform a series of three injections that can significantly reduce the patient’s pain. Although research is lacking in this area, professionals continue to provide this therapy. For a select, well-screened patient population, this approach may have benefit. 15 Medication Management of Chronic LBP The World Health Organization’s (WHO) analgesic step approach to pain medication provides a general guide on how to choose a pain medication for a particular level of pain. Although it was originally developed for cancer pain, it is now commonly used for all types of pain. This step approach lists the types of pain medications and adjuvant medication that should be considered for use when patients complain of pain at certain levels (see Figure : “WHO’s Pain Relief Ladder”). FIGURE. WHO’s Pain Relief Ladder A chronic pain patient in need of pain relief over a 24-hour period may require a pain medication that provides extended relief. There are several extended-release pain medications for severe pain including morphine (MS Contin, Kadian), extended-release morphine (Avinza), oxycodone (OxyContin), methadone, and fentanyl patches (Duragesic). 17 When used for pain management, methadone does not require special licensure and is a cheaper alternative for extended pain relief than other extended-release formulations. It does need to be carefully titrated when increasing dosages because of it’s extended half-life. Shorter-acting pain medications such as hydrocodone-acetaminophen (Vicodin, Lortab) are problematic at higher doses since the acetaminophen component of the medication creates a dose ceiling. For normal, healthy patients with no organ impairment, the total daily dose of acetaminophen should not exceed 4 000 mg per day. For those who consume alcohol regularly or who have impaired drug clearance, doses should be lowered and liver functions monitored. Duragesic patches are an extended-release form of fentanyl delivered via a small patch. The medication patch is placed in an area with little friction such as the abdomen, shoulder, or back, and the opioid diffuses through a membrane into the dermis, creating a medication depot in the subdermal fat layer. From there it is absorbed into the vascular system at a controlled rate for dispersal to the opioid receptors located throughout the body. It takes approximately 12 to 18 hours for onset of action, and it can take as long as 48 hours for a steady state to begin. The patches last for 72 hours and are then removed and replaced, rotating the sites. There are some important patient education issues involved with fentanyl patches. The patient should never apply heat to the area where the patch is placed because this causes the medication to absorb faster. Fevers also cause increased absorption and another type of pain relief should be substituted. The patches should never be cut or folded when applying them. Cutting makes the entire 3-day dose of medication available at once. Folding causes irregular absorption. TABLE. Medication Tips Patients should be taught to dispose of the patches by folding them in half and placing them into a closed container. There is enough residual opioid in a used patch to yield a lethal dose for a small child or pet. If a patient is using extended-release pain medication, he will need breakthrough medication for the times during the day when the pain escalates. Shorter-acting pain medications such as hydrocodone-acetaminophen, oxycodone-acetaminophen (Percocet), or oral morphine or hydromorphone injection (Dilaudid) are options. Adjuvant Pain Medications Adjuvant pain medications have additive effects for pain relief though they are not considered primary pain relievers. Chronic pain patients often take several medications. When the pain has a neuropathic component, described by patients as a burning, painful tingling, shooting-type pain, there are different pain medications that provide the best relief (see Table : “LBP Patients with a Radicular Component”). TABLE. LBP Patients with a Radicular Component All of the medications listed above have special considerations when used for adjuvant pain relief. The antidepressant medications that have the most research support and the highest potential for side effects such as morning hypotension are the TCAs. The SSNRIs seem to provide effective pain relief; the SSRIs are less effective for pain relief. Duloxetine is the newest neuropathic pain medication and the nausea and vomiting listed as side effects are dose-related, so starting at a low dose and titrating upward carefully can minimize the adverse effects. The most commonly seen adjuvant medication for neuropathic pain is gabapentin, but it is often not dosed high enough for adequate pain relief. The effective dose of gabapentin for pain relief is approximately 1,800 mg per day. 18 Although medications are the mainstay of treating LBP, there are nonpharmacologic options that can be used as adjunct pain relief. Over-the-counter analgesic creams can provide increased circulation to the painful area, helping to decrease the level of pain. Newer formulations of these medications are sold as patches over the counter. Capsaicin cream is made from hot peppers and is especially helpful for neuropathic pain. The drawback of capsaicin is that it needs to be applied three or four times per day for several weeks to see a significant decrease in pain levels. Topical lidocaine at 5% strength is available in a patch formulation called Lidoderm. Though this medication was originally formulated for use in neuropathic pain, recent research indicates its success for other pain conditions such as osteoarthritis. Though not recommended for use with LBP, if the pain can be localized a trial of lidocaine patches placed directly onto the painful site might prove helpful. The patient can use up to three patches per day 12 hours on and 12 hours off. TABLE. Case Study: Acute LBP For most LBP patients, one type of medication alone is not sufficient. Combining different types of medications such as opioids, antidepressants, and topical applications may reduce the pain to a level at which the patient can be functional. Cognitive behavioral programs can also be beneficial since patients with chronic LBP need to develop coping styles and techniques that will help them live with daily pain. Prevention There is very little that can help prevent LBP except regular conditioning exercises designed to increase support for the muscles in the low back. 15 Patients who are overweight and deconditioned are prime candidates for LBP. Helping a patient commit to weight control and exercise programs is the best health maintenance. For patients who are very obese, water exercise programs offer an option with very little stress on the joints and back. A surgical option for pain relief in LBP patients is total disc replacement, however not all aspects of this technique have been adequately studied. 21 Some studies indicate that there is movement in the operative segments and degenerative changes in adjoining spinal segments. These effects are hard to isolate and may add to the outcomes in the studies under review. Each patient needs to be evaluated and considered for this option by a surgeon. REFERENCES 1. Dorsi MJ, Belzberg AJ. Low Back Pain. In: Wallace MS, Staats P. Pain Medicine and Management . New York, NY: McGraw-Hill; 2005:141–146. [Context Link] 2. D’Arcy YM. Pain Assessment. Pain Assessment in Medical-Legal Aspects of Pain and Suffering. In: Iyer, ed. Tucson, AZ: Lawyers and Judges Publishing Company Inc: 2003. [Context Link] 3. D’Arcy, Y. Pain management and assessment. In: Iyer, P, Levin, B, Shea, MA. Medical Legal Aspects of Medical Records . Tucson, AZ: Tucson, Lawyers and Judges Publishing Company Inc: 2006. [Context Link] 4. Hagen KB, Hilde G. Jamvedt G, Winnem M. Bed rest for acute low back pain and sciatica. The Cochrane Database of Systematic Reviews . 2006 (1). Available at: http://www.cochrane.org/reviews/en/ab001254.html . Accessed March 10, 2006. [Context Link] 5. Von Korff M, Saunders K. The course of back pain in primary care. Spine . 1996;21:2833–2837. [Context Link] 6. Tullberg T, Blomberg S, Branth B, sson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen sterophotogrammetric analysis. Spine . 1998; 5(23):1124–8; discussion 1129. [Context Link] 7. Elliott AM, BH, Penny KI, et al. The epidemiology of chronic pain in the community. Lancet .1999;354:1248–1252. [Context Link] 8. Chronic pain: The enemy within. USA Today . May 9, 2005:1A–4A [Context Link] 9. WF, Ricci JA, Chee E, et al. Lost productive time and cost due to common pain conditions in the US workforce. JAMA . 2003;290:2443–2454. [Context Link] 10. Chronic Pain in America: Roadblocks to Relief. Conducted for the American Pain Society, the American Academy of Pain Medicine, and Janssen Pharmaceutica. 1999. Available at: http://www.ampainsoc.org . Accessed March 9, 2006. [Context Link] 11. Rozenberg S, Deval C, Rezvani Y, et al. Bedrest or normal activity for patients with acute low back pain: A randomized controlled trial. Spine . 2002; 27:1487. [Context Link] 12. Hagan KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute Low back pain and sciatica. Cochrane Database of Systemic Reviews 3. 2005 [Context Link] 13. Van Tulder MW, Scholten, RJPM, Koes BW, Deyo RA. Non-steroidal and anti-inflammatory drugs for low-back pain. Cochrane Database of Systemic Reviews. Volume 3, 2005. [Context Link] 14. Berry PH, Chapman CR, Covington ED, et al. Pain: Current Understanding of Assessment, Management, and Treatment. Reston VA: National Pharmaceutical Council, Inc. 2001. [Context Link] 15. Nelemans Pj, de Bie RA, deVet HC, Sturmans, F. Injection therapy for subacute and chronic benign low back pain. Cochrane Review, 1999. ACP Journal Club. V. 133(1):27, Jul–Aug, 2000. [Context Link] 16. American Society of Pain Management Nurses (ASPMN). ASPMN Position Statement. Pain Management in Patients with Addictive Disease. ASPMN: Pensacola FL. 2002. Available at: http://www.aspmn.org . Accessed February 16, 2006. [Context Link] 17. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. Glenview IL. 2003. [Context Link] 18. Staats P, Argoff C, Brewer R, D’Arcy Y, Gallagher r, McCarberg W, Reisner L. Neuropathic Pain: Incorporating new consensus guidelines into the reality of practice. Advanced Studies in Medicine. s Hopkins University School of Medicine Volume 4 (7B) July 2004. [Context Link] 19. Waddell G. Low Back Pain. In: Mersky H, Loeser J., Dubner R., eds. Low back pain in the paths of pain . Seattle, Wash.: IASP Press; 2005:379–390. 20. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain-bed rest, exercises or normal activity? New England Journal of Medicine 1995;335:351–355. 21. De Keluver M, Oner FC, s WC. Total disc replacement for chronic low back pain: background and a systemic review of the literature. European Spine Journal . 2003;12(2):108–116. [Context Link] CE Collection|Add to Planner | Take Test *Contact Hours; Contact Hours/Advanced Pharmacology Hours For more information about taking CE on NursingCenter, view our Help and Accreditation Information. 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