USA TODAY International Edition
Explore options to treat back pain
After a recent ER shift, I was thinking about how often patients turn up because of acute low back pain. ERs across the country see more than 2.6 million visits annually for low back pain. One study showed that a whopping 84% of adults will suffer from low back pain at some point in their lives.
Most patients with acute low back pain are discharged from the ER with a diagnosis of “nonspecific back pain” or “lumbago,” meaning their symptoms are due to musculoskeletal strain/ spasm. Routine laboratory testing or imaging ( X- ray, CT, MRI), while often expected by patients, is time- and resource- consuming and is unhelpful in our evaluation. In fact, the American College of Emergency Physicians’ “Choosing Wisely” campaign recommends against lumbar spine imaging in the ER for adults with non- traumatic low back pain unless more dangerous causes are suspected. Such “red flags” include fever, major trauma, constant pain for more than six weeks, history of cancer, neurological deficits like numbness or weakness, night pain, or history of injection drug use.
But perhaps the most frustrating aspect of acute low back pain for both doctors and patients is that it’s notoriously difficult to satisfactorily treat in the ER setting.
I usually advise patients at the outset of their visit that my goal is to alleviate – not cure – their back pain. To that end, let’s look at the evidence for our current pain management options in the ER – and consider some nontraditional options that I often recommend for my patients.
Typically, doctors look inside the medicine cabinet to treat acute lower back pain. So what are the current options?
Multiple studies have looked at the effectiveness of treatment options for acute low back pain, including acetaminophen ( Tylenol), nonsteroidal anti- inflammatory drugs ( NSAIDs) such as ibuprofen ( Advil, Motrin), narcotics ( opioids) including oxycodone, and muscle relaxers, or a combination thereof.
A British Medical Journal metaanalysis of 13 studies including 5,400 patients found that acetaminophen was ineffective at reducing back pain. In fact, the study found that patients taking acetaminophen were four times more likely to have abnormal liver function tests, a possible side effect of longterm acetaminophen use.
Treatment with NSAIDs in the ER performed better; ibuprofen, ketorolac and diclofenac all proved effective in reducing low back pain in one randomized- control study. However, the addition of a muscle relaxer to ibuprofen did not generate improvement in low back pain symptoms or mobility, according to a 2019 study in Annals of Emergency Medicine. And prior studies found no benefit to adding narcotics or the muscle relaxer diazepam to NSAIDs.
Some doctors prescribe narcotics for moderate- to- severe acute low back pain. However, they are associated with both long- term addiction and a high rate of return to the ER within 30 days compared to other treatments.
Steroids – despite their powerful anti- inflammatory mechanism – also showed no benefit in multiple studies.
So NSAIDs perform the best in treating acute low back pain in adults.
Patients typically under- dose ibuprofen; aim for approximately 10mg/ kg every eight hours with food as needed for pain.
For an average adult, that’s 600mg- 800mg each dose.
But despite its research- demonstrated effectiveness in treating low back pain, not all patients can tolerate NSAIDs because of other medications they take.
If you have a history of acid reflux, gastritis, or peptic ulcer disease, you should not take NSAIDs. Patients with known coronary artery disease, asthma, heart disease, or kidney disease, or who take anticoagulant medications like warfarin and Eliquis should also avoid NSAIDs. Your risk of bleeding from NSAIDs also increases if you are over 60 years of age.
Epsom salt ( magnesium and sulfate) has moderate evidence to support its claimed reduction in inflammation and muscle aches and tension. I recommend adding two scoops of Epsom salt to a warm 15- 20 minute bath for almost all patients with low back pain – the main exception is diabetics. Rinse off with a cold shower.
Another option: Next time your lower back starts acting up, ask for a deep tissue massage to release the culprit muscle spasm. This therapeutic- focused massage will more effectively treat your pain.
Hand- held devices have risen in popularity recently. I recommend holding a percussive massager over a sore or inflamed muscle for 60 seconds at a time.
Ask your primary doctor to refer you to a physical therapist. Sessions are usually twice weekly for six weeks. Physical therapy sessions include manual therapy to release muscular spasms and guided mobility drills that you will be expected to continue between sessions as “homework.”
If you have no known contraindications to NSAIDs, over- the- counter weight- dosed ibuprofen is your best bet to treat acute low back pain.
But consider non- medication options as well and take an active role in your recovery from acute low back pain.
Always consult your doctor before starting a new medication or supplement.