Patients with acute back pain turn into a number of OTC treatments to find relief, including analgesics, topical ointments, hot and cold presses, and back support garments.
Reducing Pain and Inflammation Is Key, But Not All OTC Remedies Are Created Equal
Back pain is the second most common neurologic ailment in the United States—only headache is more common. Within a given year, up to 50% of adults suffer from back pain and 85% of people younger than 50 years will experience at least 1 back pain episode each year.1-3
Acute lower back pain (LBP) lasts from 1 day to 3 months; longer durations are classified as chronic. Common causes include nerve irritation, bone and joint arthritic conditions, lumbar radiculopathy (nerve irritation caused by herniated or damaged discs), and bony encroachment (vertebrae can shift, pressing against the spinal cord and nerves).4 Other causes may include kidney stones, obesity, smoking, stress, poor posture, and poor sleeping conditions.
Acute back pain’s most common cause, however, is lumbar strain—a stretch injury to the lower back’s ligaments, tendons, and/or muscles. The injury creates microscopic tears in these tissues, causing pain and inflammation.4
Most back pain is self-limiting, dissipating within days. Treatment usually involves drugs that reduce pain and inflammation, and muscle-strengthening exercises to restore proper function and prevent recurrence.
Most people turn to analgesics, topical ointments, hot and cold presses, and/or back support garments to find relief.
OTC analgesics—nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen—can reduce pain and inflammation quickly.
Ibuprofen, naproxen, and aspirin tend to work best when taken on a regular schedule rather than waiting until pain is severe. Choice is guided by assessing benefits and gastrointestinal (GI) and cardiovascular risks associated with each agent. Although aspirin is associated with cardiovascular benefits, it has higher GI toxicity and is generally avoided as a first-line treatment.5,6
Coadministration of aspirin with ibuprofen or naproxen is contraindicated, as it increases risk for serious NSAID-related adverse effects. Regardless of the NSAID used, risk for GI effects is highest among those 65 years and older.6 Table 1 highlights profiles for ibuprofen and naproxen along with acetaminophen.
Meta-analysis finds no differences between NSAIDs and acetaminophen in achieving pain relief.9 Practice guidelines of the American College of Physicians and the American Pain Society conclude that acetaminophen is a slightly weaker analgesic, but endorses it as a first-line treatment option because of its more favorable side-effect profile and cost. These guidelines recommend the lowest dose possible for all NSAIDs because of their association with GI and cardiovascular disorders.5
As new data emerged on acetaminophen’s side-effect profile, the FDA issued a directive in January 2011 limiting the amount of acetaminophen in prescription combinations. Although the limit of 325 mg per tablet or capsule only applies to prescription drugs, consumers of OTC products need to take notice. Generally, healthy adults should not exceed a maximum daily dose of 4 g daily (2.6 g for the elderly).10
A Word of Caution
Some people, especially athletes, take NSAIDs routinely before exercising, believing they will ease muscle strain that may occur when engaging in vigorous activity. Many people assume they are safe and are naive about life-threatening effects, including liver failure and death. When discussing NSAIDs with patients, emphasize that they should never be used prophylactically unless directed by a physician.
Most OTC rubefacients direct the patient to rub the agent directly on the tender area. They appear to relieve pain by causing a counterirritant effect, producing either a burning or cooling sensation. The most common active ingredient in OTC rubefacient products is capsaicin, which is derived from chili peppers. Once the skin absorbs capsaicin, it desensitizes the individual to pain by interfering with neural signals that transmit pain sensations to the brain. Other products contain methyl salicylates, wintergreen, or eucalyptus oil. Although many people achieve comfort with these products, a recent Cochrane review found little evidence that topical creams and ointments affect pain and recovery.11
Although some people find them helpful, the use of wide elastic belts and other support garments that can be tightened to “pull in” lumbar and abdominal muscles remains controversial. One landmark study found no evidence that elastic belts and similar garments reduced and/or prevented back injury or back pain.1
People with LBP who continue their normal routine function better than those assigned to bed rest. A Cochrane report concludes, “Advice to rest in bed is less effective than advice to stay active.”12 Activity is also associated with modest improvements in pain and function.13 Bed rest alone may exacerbate back pain because it decreases muscle tone and increases risk for blood clots.
Because back pain is a recurring condition for many, it helps to focus on prevention (Table). Exercise strengthens back muscles and is the most effective way to a speedy recovery and preventing future muscle strain. Walking is perhaps the best exercise for preventing LBP.1,14
Dr. Zanni is a psychologist and health systems consultant based in Alexandria, Virginia.
1. National Institute of Neurological Disorders and Stroke. Low back pain fact sheet. www.ninds.nih.gov/disorders/backpain/detail_backpain.htm. Accessed January 8, 2011.
2. US Spine Care. Facts about back pain. www.usspinecare.com/back-pain-facts.html. Accessed January 10, 2011.
3. Perina D. Back pain, mechanical. http://emedicine.medscape.com/article/822462-overview. Accessed January 10, 2011.
4. Shiel W. Lower back pain (lumbar back pain). www.medicinenet.com/low_back_pain/article.htm. Accessed January 8, 2011.
5. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
6. Herndon CM, Hutchison RW, Berdine HJ, et al. Management of chronic nonmalignant pain with nonsteroidal antiinflammatory drugs. Joint opinion statement of the Ambulatory Care, Cardiology, and Pain and Palliative Care Practice and Research Networks of the American College of Clinical Pharmacy. Pharmacotherapy. 2008;28:788-805.
7. Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ. 2011;342:c7086. doi: 10.1136/bmj.c7086.
8. Gandey A. All nonsteroidal anti-inflammatory drugs have cardiovascular risks. www.medscape.com/viewarticle/735672.
9. Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine. 2008;33:1766-1774.
10. Lowes R. FDA limits acetaminophen in prescription analgesics. www.medscape.com/viewarticle/735738. Accessed January 18, 2011.
11. Matthews P, Derry S, Moore RA, McQuay HJ. Topical rubefacients for acute and chronic pain in adults. Cochrane Database Syst Rev. 2009(3):CD007403. DOI: 10.1002/14651858.CD007403.pub2. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007403/frame.html.
12. Hagen KB, Hilde G, Jamtvedt G, Winnem M. WITHDRAWN: Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010(6):CD001254.
13. Vega C. For acute low back pain, staying active may be better than bed rest. http:/medscape.org/viewarticle/724386. Accessed January 10, 2011.
14. WebMD. Low back pain - treatment overview. www.webmd.com/back-pain/tc/low-back-pain-treatment-overview. Accessed January 10, 2011.