Medical Management of Back Pain
Low back pain is a complaint associated with 60 different illnesses. No one therapy works for all of these problems. The most common problems that people have are mechanical in origin. Mechanical disorders are associated with overuse of a structure like muscles, or changes associated with growing older.
Many individuals with mechanical forms of low back pain improve over a period of time measured in days to weeks. Both non-drug and drug therapies can be helpful in speeding recovery.
Rest is helpful, just not too much of it. Too much rest, especially without exercise, will contribute to muscle weakness and make back pain worse. Bed rest should be used for only a few days. When lying on one’s back, a small pillow under the knees can be helpful. Fetal position, with legs drawn up, is most comfortable for those who like lying on their side.
Movement is necessary to keep the back flexible and strong. Walking on land or in the water can be helpful without jarring the spine. One should do the kind of exercise that is comfortable without increasing pain significantly. A general 30-minute exercise program includes a warm-up period, aerobic exercise like a treadmill, core abdominal strengthening, and a cool-down period. Exercise programs are best done 3 times a week. Examples of the exercises can be seen as a video on www.drborenstein.com. Physical therapists, like ours at Arthritis and Rheumatism Associates, can tailor an exercise program to your specific needs. A frequently asked question is whether a physical therapist or a personal trainer is most appropriate to get fit. I recommend a physical therapist for individuals who are having pain. A therapist will get you back to a pain-free state. Personal trainers are good for improving function at a time when you are pain-free.
Where we are physically in space (standing, sitting, lying down) can have a significant impact of relieving pain. With sitting, the softest chair is not the best. The lack of support in the seat makes the muscles work continuously. That is why individuals feel stiff and sore after sitting on a soft seat. The seat should be firm and at a height that places your feet comfortably on the floor. If your feet do not reach the floor, you should have a little bench or stool that rests your legs so that your knees are slightly higher than your hips. A cushion behind the curve of the lower back helps with support. Ideally, you should not sit in one place for more than 30 minutes if your back is painful. Movement allows blood flow with oxygen to restore muscle function and decrease pain.
Standing requires even weight distribution on both legs. Flattening of the lumbar spine occurs when raising a foot onto a stool or rail resulting in decreased muscle tension and pain. Flat or low-heeled shoes are more comfortable when faced with standing for long periods of time.
A moderate firm mattress has been shown to be the preference for individuals with low back pain. Moderate firmness can be obtained with a very firm mattress by adding a pillow top that allows for a slight sinking of the body. I also suggest that low back pain individuals “test-drive” their mattresses when in the market for a new bed. Lie down on the mattress and remain there for at least 20 to 30 minutes. If you are uncomfortable in the first 5 minutes, an additional 20 probably will not make it better. A pillow between the legs when on your side is helpful. The pillow may be placed below the knees when on your back.
A cold compress can be used for 5 to 10 minutes on a painful area of the back. Cold is most helpful when back pain first occurs or after you exercise. Cold works as a pain reliever but does cause increased stiffness. Heat increases blood flow to muscles and decreases stiffness. Heat therapies are most useful later in the course of an episode of back pain, usually at 48 hours after the onset of pain. Some individuals will apply ice initially and then later will apply heat to an area of muscle stiffness.
A wide variety of drug therapies are available for the treatment of acute and chronic low back pain. Different drug therapies will be used depending on the length of time you have had the problem and the structures that are affected. Analgesics are medicines that are pain relievers. They may be purely pain relieving (acetaminophen, opioids) or anti-inflammatory as well (ibuprofen, naproxen). Some of these therapies are available without a prescription while others are prescription-only. Either of these therapies can be helpful depending on the circumstances of your condition.
Most commonly, nonsteroidal anti-inflammatory (aspirin-like) drugs are used to decrease pain and local inflammation in the structures in the lumbar spine. A number of these drugs are available with different characteristics. Different types are given between one to six times a day. All of these drugs have the potential to cause stomach upset, raise blood pressure or cause kidney dysfunction. That is why these medicines need to be monitored if you take them for a persistent period of time. You should speak to your doctor about all your medical conditions to limit the possibility of toxicity.
Some medicines are indicated for individuals who have back pain that has continued longer than the usual time of healing. Once low back pain becomes chronic, other drug therapies may be indicated. One of these is duloxitene (Cymbalta), an antidepressant medicine. This medicine increases signals in the pain inhibitory pathway in the central nervous system. An increase in the chemical messengers in this system suppresses pain signals from parts of the body. This medicine works to decrease pain in the absence of depression. The medicine is associated with a variety of possible toxicities including nausea and foggy thinking.
Muscle relaxants are a group of medicines used to decrease muscle tension when tightness is noted. This group of agents is useful to allow improved motion and decreased pain. The medicines work on the central nervous system by decreasing signals to the muscles causing spasm. As a group, these medicines can be associated with sleepiness. They are given most often at night to limit this toxicity.
Acupuncture, yoga, and stress management are among a number of complementary therapies associated with the treatment of low back pain. Some of these therapies are alternatives to exercise (yoga). Others are non-drug forms of pain management like acupuncture and massage therapy. None of these complementary therapies have been studied adequately to know their proven benefit for the treatment of low back pain. However, for the most part, these therapies have few associated toxicities. They may offer a reasonable option where the toxicities associated with drug therapies outweigh their benefits in specific individuals.