Back Pain: A Painful Pill To Swallow

13. June 2017
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Back pain is among the most common medical complaints. According to current studies, however, the medications used hardly show any effect. US guidelines now recommend non-drug measures. German experts advise that multimodal pain therapy be used.

Back pain refers to pain of the muscles, nerves, bone or other structures in the back or spine area. Some 85 percent of people suffer from it at least once in their lives. Women and people of lower social status (measured in terms of education, occupation and income) are slightly more often affected than men and people of middle or high social status. For most (90%), the symptoms disappear within six weeks, while for 10% they persist. If one however tracks the progressive pain patterns [Paywall], according to patient data 65 percent of the patients concerned still suffer from back pains even one year after first occurrence.

Medicines have little effect

Non-steroidal anti-inflammatory drugs (NSAID) and paracetamol are most frequently prescribed for back pain. Up until the current study update was published, these drugs were viewed as the first choice medications, as according to the clinical guideline of The American College of Physicians And the American Pain Society (from 2007). Other common painkillers used in the instance of lower back pain include muscle relaxants, antidepressants, opioids, systemic corticosteroids and benzodiazepines,

In order to examine the efficacy of these different substances with regard to low-back pain, a medical team led by Dr. Roger Chou from the University of Portland evaluated 46 publications, most of these being meta-analyses. The result was sobering.

  • According to one large, placebo-controlled study, paracetamol does not perform better than a placebo.
  • According to recent studies, NSAIDs are less beneficial than stated by older publications, yet cause more side effects than placebos.
  • Whereas earlier reviews revealed that tricyclic antidepressants are moderately effective with chronic low-back pain, a recent meta-analysis did not reveal any difference to placebo. In the case of duloxetine, a medication belonging to the selective serotonin-noradrenaline reuptake inhibitors class, some studies showed minor efficacy.
  • According to a study from 2010, benzodiazepines have no influence on radiculopathy, but do cause more pain than placebo. (For information purposes: a radiculopathy denotes that a nerve root is chronically or acutely irritated or damaged. Those affected suffer from pain, sensory disturbances or paralysis.)

Other conclusions, however, remained relatively unchanged compared to previous analyses. Muscle relaxants do free the patient of acute low back pain, however they also act as a sedative. Systemic corticosteroids do not seem to be effective and the evidence for benzodiazepines is sparse.

Opioids, on the other hand, performed better than placebos in short-term therapy, but the studies had some methodological weaknesses: the risk of overdosing and dependency was not assessed, this being due among other things to the relatively small number of participants and the short follow-up periods.

Limitations of study analysis

On account of the large volume of literature, it was impossible for the authors to include all studies in their evaluation. Newer systematic reviews were included, as were a few primary studies. Some of the studies had errors in their methodology. For example, important patient characteristics, such as the duration of the symptoms or whether radiculopathy was present, were missing. In addition, most studies were sponsored by industry.

The American College Of Physicians primarily recommends non-drug therapy

The American College Of Physicians has in accordance with the results obtained by the medical team led by Chou revised its guideline. “Doctors should assure their patients that acute and subacute lower-back pains usually improve over the course of time, regardless of the therapy”, Nitin S. Damle, President of the American College of Physicians, says. “They should therefore avoid unnecessary testing and costly and potentially harmful drugs, especially narcotics”.

In the case of chronic back pain, the specialist recommends not only gymnastics but also acupuncture, yoga, tai-chi, progressive muscle relaxation or low-energy laser therapy. If this non-drug therapy does not work, doctors may consider treatment using NSAIDs.

The American College of Physicians recommends the weakly effective opioid tramadol or duloxetine as a second option. Opioids however should only be prescribed if other therapies have failed, the benefit of the therapy has been exceeded and the patient has been informed about the benefits and risks of the substances.

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In the case of chronic back pain, doctors should choose therapies that are the least expensive and do not cause harm, according to the President of the American College of Physicians. © WolfBlur, pixabay

Multimodal therapy approach

The fact that drug therapy is only moderately effective for acute and, in particular, for chronic non-specific (cause-unclear) cross-pain is also shown by the current German treatment guide on lower back pain (2017). In particular, long-term application would involve relevant risks, with considerable health consequences.

Dr. Ariane Burtscher, Head of the Centre for Pain Therapy at the Schön Klinik Harthausen in Bad Aibling (Germany), therefore follows a multimodal therapy approach, in which the pain is interpreted as a multidimensional problem, in the treatment of their patients,. An exclusively drug based therapy for chronic back pain is unsuitable. Rather, psychosocial risk factors need to be identified and the patient trained with regard to this.

The basis of multimodal pain therapy is the so-called bio-psycho social disease model. Here the terms bio and/or psycho and/or social refer among other things to body-structural damage and/or disease setting, depression, or family and work place. The aim is to reduce the pain-promoting factors and to learn strategies to deal with the pain. Alongside various non-drug therapy approaches, such as sports therapy, occupational therapy and relaxation procedures, chronic pain is also treated with medicines. The main agents employed are NSAIDs, antiepileptics in cases of nerve pain, as well as antidepressants for concomitant conditions.

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3 comments:

Dr. med. Andreas Wüest
Dr. med. Andreas Wüest

What’s about interventional pain-therapy ?

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Dr Franz Nanni
Dr Franz Nanni

Whats about “manual therapy”… ???!

#2 |
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marcelo vaz
marcelo vaz

nice to know bout we must separate somatic from neuropathic pain, with appropriated tool like pain detect, DN4 and so thus gabapentinoids with paracetamol will reduce the intensity or severity of pain

#1 |
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