The Lowdown on Acute Low Back Pain

Whether one calls it lumbago,back strain, hyperextension,facet joint disorder, or adegenerative disk problem, low backpain (LBP) is common. Lifetime prevalencefor both genders approaches85%.^1,2 Recurrence approaches 20%within 1 year and 44% within 10 years,^1,2and approximately 15% to 20% ofpatients have related limitations for upto 1 year.³ Among young adults (<45years), it is the most frequent cause ofinactivity.^1,4 Despite its impact, approximately20% of those afflicted do notseek medical attention.

Contrary to updated information, certainmyths persist:

• One myth is that diagnosis is precise.In fact, 85% of diagnoses arenonspecific.
• Another myth is that diagnosticimaging is necessary. Actually, expertsrecommend imaging only ifpain persists for 6 weeks.
• Some think that bed rest and backexercises hasten recovery. After 2or 3 days, however, bed rest prolongsdisability, and specific exerciseshelp no more than other interventions.
• The utility of corsets, back braces, orlong-term lumbar traction is controversial,too.
• Seeing a specialist will not necessarilyspeed recovery. Care from primarycare providers is as good.^1,4-8

Classification and Assessment

Back pain is classified as acute (lastingless than 6 weeks), subacute (6-12weeks), and chronic(longer than12 weeks).⁴ Formost, LBP is acute,temporary, andminor. Less than2% of LBP islinked to seriouspathology, suchas metastatic cancer,osteomyelitis,or abscess.^5,9 Ifneurologic in origin,LBP mostoften is due toherniated disk.¹Pain associatedwith bladder orbowel incontinencemay reflectherniation, andunilateral painmay point to kidneyinfections orstones.¹¹ Table 1^9,10 lists red flags signalingserious problems.

Treatment

Treatment focuses on symptom alleviationand prevention. LBP rarely becomesa chronic condition, and mostcases resolve within 2 weeks.^12,13

Mild analgesics and/or skeletal musclerelaxants (SMRs) generally are used first.Acetaminophen or a nonsteroidal antiinflammatorydrug (NSAID) normally providesadequate short-term relief.^14-16 Inspecific cases, certain drugs may be preferredor contraindicated:

• In sulfa-allergic patients, celecoxib (asulfonamide) is contraindicated
• If platelet aggregation must be avoided,salsalate, choline magnesiumtrisalicylate, and cyclooxygenase-2selective agents are preferred
• If swallowing is problematic or if finetitration is necessary, liquid formulations of some NSAIDS are available

Severe pain warrants short-term opioidsfrom Schedules III and IV. All opioidshave similar pharmacologic profiles, soclinicians should use side-effect profileas the selection criterion and increasethe dose until pain relief occurs.

Combining an SMR and an NSAID maybe superior to using an NSAID alone.^17-19Patients with histories of LBP may ask fora specific NSAID or SMR (Table 2^10,20). TheSMRs differ only in adverse effect andabuse potential, and here too cliniciansshould work with patients to select drugswith acceptable potential or actual sideeffects.

Patient Counseling

Pain generally promotes adherence,but not always. Table 3 highlights adherenceissues.

?Begin counseling withthe basics. For 24hours, patients canapply ice, but if it isapplied directly to skinit can burn. Tellpatients to limit theapplication of ice to 15to 20 minutes 4 to 6times daily if it iswrapped in a toweland comfortable. Afterthat, suggest alternatingice and comfortableheat for 20 minutesevery 3 to 4hours.²¹

?If patients describepain inadequately orhave yet to see a prescribingclinician, suggesta symptom diary.Knowing the time,type, location, andduration of symptomshelps clinicians individualizetreatmentplans.¹⁴

?Patients should seekimmediate health careif pain radiates alongthe lower leg; if foot, groin, or rectumnumbness occurs; if nausea or vomiting,fever, weakness, sweating, orincontinence begins; or if intensepain prevents mobility. They alsoshould call a physician if LBP continuesafter 2 to 3 weeks.²²

?Active people recover most rapidly.Patients should avoid activities thatworsen pain but continue mild andgradually more strenuous exercise.^13,23

?Suggest sleeping flat on the back,propping the knee or leg comfortablywith a pillow¹⁴

?Provide written materials, such asthose available on MEDLINE plus(www.nlm.nih.gov/medlineplus/backpain.html)

?Analgesia works best before painintensifies.¹⁴ Remind patients toschedule analgesics and to takethem "by the clock" to break the paincycle. Labeling prescriptions withspecific, convenient times worksbest.

?Discuss potential side effects. If thepatient considers sedation to be aproblem, call the prescriber and suggesta less-sedating drug. Discussthe effects of sedation on driving.Some states prohibit driving whiletaking sedating agents.²⁴

?Many patients takemultiple medications.Scheduling analgesicsand SMRs at similartimes, not at odd orinconvenient hours,can improve adherence.Avoid directionssuch as "Take X tabletsas needed." Patientsvary greatly intheir perception of "asneeded."²⁵

Often, pharmacists associate"LBP" with "abuser."Unless other red flagsare present (lost prescriptions,frequent refills, manipulativebehavior), LBPpatients deserve adequatetreatment.

Final Thought

Good counseling beginswith dispelling myths andwatching for signals ofserious pathology whileassuring patients that it israre. Direct and simpleinstructions are oftenbest.

Dr. Zanni is a psychologist andhealth-systems consultant based inAlexandria,Va. Ms. Wick is a seniorclinical research pharmacist at theNational Cancer Institute, NationalInstitutes of Health, Bethesda, Md.The views expressed in this articleare those of the authors and notthose of any government agency.

For a list of references, send a stamped,self-addressed envelope to: ReferencesDepartment, Attn. A. Rybovic, PharmacyTimes, Ascend Media Healthcare, 103 CollegeRoad East, Princeton, NJ 08540; or send ane-mail request to: arybovic@ascendmedia.com.