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Low Back Pain: Eliminating Myths and Elucidating Realities

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Jennifer Kendall, PharmD, is busy, so the sound of children's laughter in the pharmacy just barely registers. Her technician rifles through the prescription orders that have been faxed in and extracts a couple. "Ms. Healow is here, and maybe we could do these first so her children don't take the place apart, hmm?" she says. 

 Low Back Pain: Eliminating Myths and Elucidating Realities


Guido R. Zanni, Jeannette Y. Wick 
J Am Pharm Assoc 43(3):357-362, 2003. © 2003 American Pharmaceutical Association

Posted 06/18/2003
Abstract and Introduction
Abstract
Most people have experienced the aches and inconvenience of low back pain. Although the causes can be hard to pin down, treatment can be very simple.

Introduction
Jennifer Kendall, PharmD, is busy, so the sound of children's laughter in the pharmacy just barely registers. Her technician rifles through the prescription orders that have been faxed in and extracts a couple. "Ms. Healow is here, and maybe we could do these first so her children don't take the place apart, hmm?" she says. Jennifer looks up and sees Ms. Healow perched awkwardly in a plastic chair, apparently oblivious to her two children, who are running up and down the aisles. "She was just here yesterday, wasn't she?" Jennifer asks, as she looks at orders for a different analgesic and a new muscle relaxant. "She was," Julia says, "but she said the prescriptions snowed her. She can't stay awake." Jennifer sighs. "Back pain. It's like the common cold this week. Between the folks who don't have time to see a doctor and those with prescriptions, we've seen about 20 people. At least there's no doubt that she really has a backache. An abuser wouldn't complain about sedation.

Like the common cold, low back pain (LBP) affects most everyone at one time or another; up to 85% of people suffer at least one bout of LBP during their lifetime.[1] Many sufferers do not seek medical attention, whereas others employ various and sundry home remedies. Acute LBP can be a minor inconvenience, a signal of serious pathology, or an excuse to maintain a drug habit. Its etiology is frequently cloaked in mystery and often baffling to clinicians. Despite treatment advances, myths abound (see Table 1).


A Common, Almost Inevitable Condition
LBP has been around for ages. An Egyptian papyrus from 1500 BC describes examination ("If thou examinest a man having a pain of the vertebra of his spinal column, thou shouldst say to him: Extend now your legs and contract them..."), diagnosis ("Thou shouldst say to him: One having a sprain in the vertebra of his spinal column and ailment I shall treat."), and then ends abruptly with a recommendation for treatment ("Thou shouldst place him prostrate on his back..."). At this tantalizing point, the unknown Egyptian scribe, copying a much older text, ceased his labors. Both he and the papyrus were buried in a tomb on the Upper Nile near Thebes, where they lay for almost 3,500 years until the papyrus was found by grave robbers and sold.[6]

Biblical references to LBP include the famous one in Genesis in which Jacob is described as wrestling with an angel and having the hollow of his thigh shrunk. The Latin translation of this passage suggests that Jacob suffered from sciatica; as a result of this divinely inflicted pain, Kosher dietary restrictions forbid "meat from the hollow of a thigh," interpreted strictly to be the sciatic nerve, and liberally to be the hindquarters.[7]

During the Middle Ages, people in pain turned to folk medicine for help. The Welsh called backache "shot of the elf," and the Germans called it "witch's shot," because they, too, believed external supernatural causes created this discomfort.[6]

Thomas Jefferson, especially while he was vice president beginning in 1797, suffered severe backaches that he attributed to doing heavy labor at Monticello.[7] Little was written about LBP until the 1800s, however. Until then, most physicians believed the pain was a form of rheumatism or lumbago. In the early 1800s physicians began to connect back pain with trauma or injury. Then, as now, visible pathology did not necessarily translate to predictable symptoms.

In the early 20th century, as societies struggled to develop social systems to address worker disability, physicians and politicians debated the reality of LBP. Some called it a "litigation symptom," and eminent psychiatrists of the day, including Sigmund Freud and Pierre Janet, went so far as to label back pain as a pathologic manifestation of unconscious conflict.[8 Back pain gained a reputation as a somatic or hysteric, rather than real, affliction.

Health statisticians began tracking the incidence of LBP only around the time of World War I. Antibiotics, insulin, and other improved interventions were making many illnesses less threatening, and increasing numbers of workers' compensation claims brought LBP to the forefront of analysis. Since then, the overall prevalence of LBP has been steady, with up to 85% of people suffering at least one bout during their lifetime.[1] Annually, 15% to 30% of adults experience back pain,[9] and up to 80% of sufferers eventually seek medical attention. Sedentary people between the ages of 45 and 60 are affected most, although LBP is the most common cause of inactivity for people younger than 45 years.[1,5] Often, sufferers either do not know what precipitated their attack or they remember some small thing as the cause, such as bending from the waist to lift an object instead of squatting down (i.e., lifting with the legs) or stepping off a curb too abruptly. Like our patient Ms. Healow, people experiencing LBP slouch, limp, list to one side, or reposition to accommodate pain or spasm. This profile of the back pain sufferer has been the same for over 100 years, when medical science first began linking LBP with pathology. Still, little is known about the real causes of LBP.

Recurrence rates are appreciable. The chance of LBP recurring within 1 year of a first episode is estimated to be between 20% and 44%; within 10 years, 80% of sufferers report recurrences.[1,10] Lifetime recurrence is estimated to be 85%.[10] Consequently, clinicians treating patients with LBP should focus on both alleviating symptoms and preventing future episodes.

Back pain affects both sexes about equally, but LBP secondary to disc disorders is more common in men. Incidence rates are generally higher among whites than among members of other racial groups.[10] Despite its preponderance, LBP sufferers' predisposing characteristics remain enigmatic, partly because no uniform and comprehensive tracking systems exist.[11,12] Although it is generally acknowledged that LBP is a serious problem, many people still give credence to lingering perceptions of malingering. It is still considered a workers' compensation nightmare because costs of LBP claims are exorbitant, and there is a perception that some workers exploit or abuse the system, mainly because pathology and symptoms are often unrelated.

LBP is among the top 10 reasons people seek medical attention (see Table 2 for general information about the prevalence and costs of LBP). Surgery to alleviate back pain has long been among the most common invasive medical procedures.[1,9] Serefeddin Sabuncuoglu, a 15th century surgeon, left three handwritten, illustrated manuscripts describing LBP, which, he said, "is generally caused by falling-related or direct traumatic injury. It is treated by the use of analgesic medications. If the pain is medically intractable, however, a cauterization procedure can be performed. The procedure of choice is to mark the painful area by the use of ink, and afterwards the painful area is cauterized" (Figure 1).[16]

Τι-είναι-η-ισχιαλγία-300x250Figure 1. In the 15th century, some used the highly questionable method of cauterization to treat low back pain. Image used by permission of the Turkish Historical Society.
Definition and Classification
Back pain is described by the length of time symptoms persist:

Acute LBP lasts less than 6 weeks.


Subacute LBP lasts between 6 and 12 weeks.


Chronic LBP persists for more than 12 weeks.[5]
LBP is also classified according to etiology. Mechanical or nonspecific LBP has no serious underlying pathology or nerve root compromise. A century of intense study has produced no clear understanding of commonplace back pain. Secondary LBP, occurring in fewer than 2% of patients, is associated with underlying pathology.[17] Metastatic cancer, spinal osteomyelitis, and epidural abscess account for 1% of back pain patients.[2] The most common neurologic impairment associated with back pain is herniated disc, and 95% of disc herniations occur at the lowest two lumbar intervertebral levels.[1]Table 3 lists red flags that suggest the need for further workup of patients presenting with LBP. This article addresses the 98% of people who suffer acute back pain.


Assessment and Treatment
When seeking medical attention, the majority of LBP sufferers (56%) see primary care physicians,[13] although one study[9] found that 54% turn to complementary and alternative care providers (e.g., chiropractors, massage therapists, acupuncturists). Regardless of the route of care chosen, recurrence rates and functional status during recovery are similar.[3] Also, many clinicians find LBP challenging, but even those clinicians who are confident in treating LBP do not not always achieve better outcomes.[17]

Traditionally, bed rest and inactivity were seen as crucial therapies for LBP, and this led to anxiety in people unable to comply with such recommendations. Research now suggests that inactivity is exactly the wrong response to back pain. In one study, for example, researchers randomly assigned acute nonspecific LBP sufferers to bed rest for 2 days, back-mobilizing exercises, or continuation of routine daily activities. Those assigned to bed rest recovered most slowly, while patients who continued normal daily activities recovered sooner.[18] Despite such evidence to the contrary, medical professionals still cling to the myth that bed rest is appropriate, and they prescribe it more liberally than they should. A survey published in 1995 revealed that 72% of responding physicians considered strict bed rest for more than 3 days appropriate for treating LBP.[19]


Pharmacotherapy
Pharmacotherapy for LBP is fairly simple. Analgesics, usually traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and/or skeletal muscle relaxants (SMRs), can enhance mobility and help patients with LBP resume physical activities during the natural recuperative period (see Table 4). Acetaminophen or any of the NSAIDs usually offers adequate short-term analgesia.[20-22] Our hypothetical community pharmacist, Dr. Kendall, might counsel the truck driver who asks about over-the-counter remedies that scheduled, by-the-clock dosing can interrupt a cycle of pain and increase the likelihood that therapy will be successful; patients should take analgesics before their pain becomes intense.[20]

In some specific cases, one drug may be preferred over another:

Celecoxib (Celebrex -- Pfizer) is a sulfonamide and is thus contraindicated in the sulfa-allergic patient.


Salsalates, choline and trisalicylate combination products, and COX-2 selective agents have no clinically significant effect on platelet aggregation.


NSAIDs available in liquid formulations (e.g., ibuprofen, naproxen, rofecoxib [Vioxx -- Merck]) are helpful for patients who have difficulty swallowing or who need doses titrated.
Occasionally, back pain is severe enough to warrant use of an opioid analgesic. If this is the case, analgesic agents in Schedules III and IV are generally strong enough to offer short-term relief. All of these agents have similar pharmacologic profiles, and dosages should be increased until analgesia is obtained.

Several studies have shown that the combination of SMRs with NSAIDs is superior to NSAIDs alone for relieving LBP.[23-25] Patients who have had LBP previously may ask for a specific SMR. All of the SMRs are equally efficacious, differing only in adverse effects and abuse potential. Thus, SMRs should be selected on the basis of these criteria. Some patients will want a sedative so they can sleep; others will have histories of drug abuse or dependence and want to avoid potential addiction. Still others, like Ms. Healow, will want or need to stay alert and awake.


Dynamics of Adherence
One might think that when a condition is painful, adherence to therapy would not be a problem. Unfortunately, LBP patients do experience obstacles to adhering to treatment, including the following:

Fear of addiction. Many patients believe that analgesics are addictive and avoid taking them and/or reduce doses. Other patients increase doses or attempt to manipulate clinicians to prescribe addictive substances. Note that many patients have inadvertently become addicted to medication when their physicians, unaware of a medication's abuse potential or a patient's propensity to abuse, prescribe pain medication or SMRs, so this fear is somewhat realistic.


Potential adverse effects. Often, busy LBP patients like Ms. Healow worry about sedation; unwanted drowsiness can interfere with everyday tasks or working. On the other hand, clinicians may exploit sedation-inducing effects so patients can sleep. Other medications, such as NSAIDs, have other adverse effects, such as gastrointestinal distress, that prove troublesome to patients.


Cost. For uninsured or marginally insured patients, medications and other back pain treatments may be too expensive. Patients who have prescription drug plans may prefer a prescription if an over-the-counter medication is suggested so they will not have to pay for it.


Patients' own risk-benefit assessments. Patients may not perceive treatment benefits as outweighing costs, either because clinicians communicate benefits poorly or because patients have conflicting beliefs.


Regimen complexity. Patients prefer medication regimens that are simple and easy to remember. The bad news here is that most NSAIDs and SMRs require several doses daily. On the other hand, patients' discomfort may serve as an adherence aid when pain or spasm recurs.
When dealing with patients who have comorbid conditions and who take other medications, it is important to try to schedule their analgesics and SMRs so they are not taking medications at odd hours or inconvenient times. A prescription to "take X tablets as needed" is neither simple nor prudent because patients vary greatly in their perception of "as needed." Pharmacists should advise patients to schedule doses, rather than waiting for pain or spasm to occur. It may be helpful to include specific times on the label.[26]

Many LBP sufferers are concerned about work, fearing the effects of medications on driving and job performance. Additionally, workers with job-related LBP fear its recurrence and its potential impact on future employment. A medication's impairment of driving ability depends on its sedating effect. Good counsel might be to avoid driving; pharmacists should advise patients that their ability to drive safely is reduced before they are aware that they are sedated. Note that Oregon does not schedule carisoprodol but states that its use while operating a motor vehicle renders drivers as impaired and dangerous as does use of a controlled substance.[27]


Potential for Abuse
Listening to the prolific Beethoven's works, few would envision a composer tormented by various pains, including LBP. On autopsy, however, Dr. Johann Wagner diagnosed renal papillary necrosis in the composer, most likely secondary to analgesic abuse. Beethoven's secretary, Mr. Schindler, described his employer's heavy-handed analgesic use in these terms: "Indeed! What effect a teaspoonful of medicine can have! The patient swiftly corrects the prescription, as he would correct a slip of the pen in a score. A tablespoonful, it should be. That's how medicine is taken. And if he remembers to take it, the bottle is empty within a few hours, and a new supply is ordered." Lucky for Beethoven that his brother, Nickolaus Johann, was a pharmacist and probably kept him supplied.[28]

Often, when pharmacists think about LBP, the potential for abusing pain killers comes to mind. Most experienced pharmacists have dealt with an alleged LBP patient who dashed in at closing time with a prescription for a narcotic analgesic. Abuse of opioids and benzodiazepines is well documented.

Abuse of SMRs is also on the rise. In 1998, 14% of two-way drug combinations mentioned most frequently in emergency department episodes included an SMR.[29] Oregon includes 2 SMRs (diazepam and carisoprodol) on its top 10 list of most abused prescription drugs.[27]

Carisoprodol is controlled in Florida, Georgia, Hawaii, Kentucky, Massachusetts, New Mexico, and Oklahoma.[26] In other states, prescribers may be only marginally aware of the drug's danger, or it may be the only SMR on the formulary because of its reasonable price. The drug is commonly abused in combination with narcotic analgesics such as codeine, hydrocodone, oxycodone, and propoxyphene.[30] According to addicts, its use with other drugs (e.g., acetaminophen with codeine #3 and #4) induces a heroin-like high.

Carisoprodol, real and counterfeit, is also the most frequently encountered contraband pharmaceutical at the U.S.-Mexican border. Its volume was nearly three times greater than that of the number two pharmaceutical, diazepam, in a survey done in early 1998 at the San Ysidro Point of Entry. Illicit "DANs," "Ds," or "Dance" (from the imprint code DAN5513 on the generic tablets) can cost up to $12 each.[31]


Pharmacist's Role in Counseling
When LBP sufferers ask for advice, pharmacists should begin with the basics:

For 24 hours, patients can apply ice for 15 to 20 minutes 4 to 6 times. Warn patients that applying ice directly to the skin can burn; ice should be wrapped in a towel and left on the back only to the extent that it is comfortable. After 24 hours, patients should alternate ice and heat (again, removing the heat source when it becomes uncomfortable) for 20 minutes every 3 to 4 hours. Emphasize that patients should use either heat or cold, depending on what they perceive to be beneficial.[32]


When patients are vague about their pain and have not seen a physician, tell them to keep a symptom diary, detailing time, circumstances, location, and duration, so they will be prepared if they seek care later.[20]


Educate patients about recent scientific studies that indicate that active people enjoy the most rapid recovery from LBP. Advise common sense, saying, "Avoid activities that clearly worsen pain, but continue to move as long as it's comfortable." Stress that mild and gradually increasing exercise will help, but caution against starting a strenuous program immediately.[20,33]


Suggest sleeping flat on the back with a pillow beneath the knees, or on the side with the top leg flexed over a pillow or with a pillow placed between the thighs.[20]


Provide written materials (e.g., preprinted leaflets on managing and preventing LBP). Good information can help sufferers manage their LBP and change behaviors (e.g., begin to lift objects correctly) to prevent recurrences. Patients receiving such information report greater satisfaction with treatment and a greater sense of control over their condition.[34] Several excellent patient-oriented pamphlets are available on MEDLINEplus atwww.nlm.nih.gov/medlineplus/backpain.html.
Conclusion
LBP is a common problem. As with the common cold, patients often question pharmacists about home remedies. Despite treatment advances, myths about how best to alleviate LBP abound, and it behooves every pharmacist to help patients separate fact from fiction. Effective counseling need not be extensive or time-consuming; simple and direct instructions are highly effective in eradicating the myths about LBP.


Tables
Table 1. Common Myths Surrounding Acute Low Back Pain


Myth: A precise diagnosis can often be made.

Fact: Approximately 85% of cases cannot be diagnosed precisely. 
Myth: Imaging (x-rays, MRI, etc.) usually reveals etiology.

Fact: Routine radiographic diagnostic tests fail to clarify etiology and may confuse diagnosis. Experts generally recommend imaging only if pain persists for 6 weeks. Low back pain's exact cause frequently remains unknown. 
Myth: Bed rest facilitates recovery.

Fact: Bed rest of more than 2 or 3 days actually prolongs recovery. 
Myth: Patients seen by specialists or multiple providers improve faster.

Fact: Patients seen by one primary care provider improve as well as those who are referred. 
Myth: Back exercises facilitate recovery.

Fact: Back exercises are no more beneficial than other interventions, so clinical specialists rarely recommend specific exercises for acute episodes.

MRI = magnetic resonance imaging. Sources: References 1-5.

Table 2. Annual Back Pain Statistics at a Glance


Number of office visits: 15 million 
Direct diagnosis and treatment costs: $25 billion 
Indirect costs (absenteeism, lost wages, decreased productivity, and worker's compensation): $100 billion 
Number of workers affected in 1999: 1 million 
Percentage of cases that consume 3/4 of costs: 25 
Percentage of sufferers who recover within 6 weeks: 60 to 70 
Percentage who recover within 12 weeks, regardless of the intervention used: 80 to 90

Sources: References 1,5,10,12-15.

Table 3. Symptoms Signaling a Potentially Serious Condition in Patients Presenting With Low Back Pain


Fever 
Age < 20 or > 60 years 
History of malignancy 
Incontinence 
Loss of balance or strength 
Nocturnal or resting pain, with or without night sweats 
Saddle anesthesia, or perineal or perianal sensory loss 
Substance abuse 
Systemic corticosteroid use 
Trauma 
Unintentional weight loss

Source: Reference 17.

Table 4. Common Medications Used to Treat Low Back Pain


Drug Dose Sedationa Gastrointestinal Adverse Effects Addiction Potential 
Carisoprodol 350 mg 3 to 4 times a day† +++† ++† +++b‡ 
Chlorzoxazone 250 mg 3 to 4 times a day† ++† +* --* 
Cyclobenzaprine 10 mg 3 to 4 times a dayc† +++ (~41%)‡ +d* --* 
Diazepam 2-10 mg 3 to 4 times a day† +++ (> 50%)‡ --* +++* 
Metaxalone (Skelaxin -- Elan) 800 mg 3 to 4 times a day† + (~4%)e* +* --* 
Methocarbamol 1-1.5 grams 4 times a day† ++‡ --‡ --‡ 
Narcotic analgesics Varies† +++† +++f* +++* 
Nonsteroidal anti-inflammatory drugs Varies† Varies† --* ++* 
Orphenadrine 100 mg twice a day* ++* --* --* 
Tizanidine (Zanaflex -- Athena Neurosciences) 4-8 mg every 6 to 8 hours, max 24 mg/24 hours† +++‡ --* --*

+ = mild 
++ = moderate 
+++ = severe 
* = less adherence concern 
† = medium adherence concern 
‡ = high adherence concern 
a When available, incidence rates are included. 
b Metabolizes to meprobamate; associated with drug-seeking behavior. 
c Cyclobenzaprine's structure is similar to that of a tricyclic antidepressant; similar adverse events may occur. 
d Strongly anticholinergic; may cause dry mouth and/or constipation. 
e See reference 35. 
f Often associated with constipation.

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Disclaimer

The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria.

The views expressed in this article are those of the authors and not those of the National Cancer Institute.


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Guido R. Zanni, PhD, is a health systems consultant based in Alexandria, Va. Jeannette Y. Wick, RPh, MBA, is senior clinical research pharmacist, National Cancer Institute, National Institutes of Health, Bethesda, Md.

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