/publications/issue/2003/2003-02/2003-02-7093

Helping the Patient With Back Pain

Author: L. Kendall Shaw, PharmD

Back pain is second only to headache as the most frequent cause of pain for which health professionals are consulted. Back pain affects approximately 65 million people in the United States each year. Because the pharmacist is frequently among the first to be consulted, it is wise to be able to advise patients knowledgeably. Such pain can be a simple result of strain, appropriately treated by application of cold and heat and by a few days of rest. It can, however, be considerably more complicated. Therefore, the astute clinician should be able to differentiate various causes that might be more serious and require immediate consultation with a diagnostician.

Recommendations should be based on presenting symptoms, coupled with a history of the current problem and the overall health history of the patient. A young woman, for instance, presenting with pain in the kidney area, fever, and urinary frequency and urgency, may be suffering from a urinary tract infection (UTI) of almost any severity, or a vaginal infection, which can produce many of those same symptoms. The time-honored recommendations of ingestion of copious amounts of cranberry juice and some nonpre-scription phenazopyridine may be in order for a possible UTI. On the other hand, if a vaginal infection is suspected, a nonprescription yeast fighter may be appropriate, along with a supplement of lactobacillus culture, either orally or vaginally.

Most women are at least familiar with such symptoms, which typically affect the soft-tissue areas of the back and usually produce bladder or urethral pain as well. Thus, these are usually easily differentiated. Although rarer, similar symptoms can affect males (usually middle-aged to elderly) who are experiencing prostatitis, which is more common in men than urethritis. In any event, these problems tend to require rapid follow-up with thorough diagnostic measures if symptoms are not significantly improved within a day or so. General recommendations to minimize caffeine (and decongestant) intake and sugar intake also are usually appropriate in such cases.

Muscular spasms are actually more common causes of back pain and usually result from recent acute injury, although spasms can suddenly appear as a result of long-standing underlying postural or even musculoskeletal problems such as scoliosis or kyphosis. In acute injury, usually in males overex-tending weakened musculature at work or play, alternating cold and heat packs (15 to 20 minutes each), accompanied by a few days of rest, can help reduce inflammatory processes and speed healing. A nonsteroidal anti-inflammatory drug (NSAID) in appropriate patients also can be beneficial, both assuaging the pain and speeding the healing process. The pharmacist should query the patient regarding a history of gastroesophageal reflux disease or gastritis, as well as regarding possible concurrent NSAIDs being taken for other problems.

The danger here is that the injury may be more severe than simply a strain or sprain of a few muscle groups. As patients approach middle age, especially men and overweight and sedentary/underconditioned patients, the danger of spinal disk problems is high. Not only sports injuries, but also improper lifting and even a simple misstep can jar the spine sufficiently to cause a bulge or even a rupture of a disk weakened by age or decondition-ing. Such an injury opens the door for impingement syndrome, inflammation, or injury to the nerves exiting the spine or the spinal cord itself. Impingement syndrome often causes not only the pain and spasms associated with muscular strain and sprain (which are probably coexistent and indistinguishable initially), but numbness, tingling, and/or weakness in the extremities supported by these nerves.

Conclusion
In short, pharmacists should encourage the obvious emergency palliative measures of (1) cold compresses for the first 48 to 72 hours; (2) alternating cold and heat after that; (3) NSAIDs for appropriate patients (and acetamino-phen for those who are not but have adequate liver function); and (4) encouraging a thorough medical examination of the injury by a practitioner able to properly diagnose and treat it, in the event that it is more severe than it might appear. Back pain can be merely annoying in many cases; but it can be the source of lifelong agony and disability if not properly recognized and treated.