Back Pain - Treatment and Prevention
Back pain is the most prevalent musculoskeletal disorder. Back pain and its associated disabilities - both permanent and temporary - place significant impact on individuals, families, and society in general. (It is estimated that eight out of ten people will experience, and require treatment for, some form of back pain in their lifetimes.)
CAUSAL FACTORS
Low back pain is caused by a number of differing factors, most of which are behavioural or environmental. Social and genetic factors also play a role. While most patients seek a single cause for their pain, the source of back pain is mostly multifactorial. The exceptions are patients presenting a clear-cut anatomical reason for back pain such as a herniated disk, tumour, or congenital abnormality.
Behavioural factors that contribute to pain in the lower back include poor posture, level of activity and recreational habits. Individuals who are sedentary tend to sit for extended periods and often adopt poor posture when they do so. This places stress on the supportive structures of the back and increases the risk for injury and pain. Highly active people may damage the soft tissues through overuse.
Overweight individuals tend to suffer more back pain due to stress on the spine. Lifestyle factors such as smoking and drinking also have an impact on the spine. (Smoking and alcohol consumption constrict the blood vessels that supply the spinal column.) Alcohol also dehydrates the body, making the tissues less resilient.
Occupational stressors such as lifting, bending and standing still for extended periods can give rise to chronic low back pain. Psychological stress from worry, tension and workplace pressures can cause the back muscles to tense up, resulting in strains and sprains. Over time, the tension in the soft tissues causes micro-tearing which gradually wears them down. Back pain is the result of this prolonged physical stress.
TREATMENT MODALITIES
Where back pain is not the result of a herniated disk, tumour or other clearly defined cause, lifestyle factors should be addressed. If the patient is in chronic or acute pain, analgesics and anti-inflammatories are normally prescribed. Treatment for back pain usually involves strengthening the back through special exercises and adjusting the lifestyle to avoid the stressors (physical and mental) that have contributed towards the injury.
PHYSICAL MANIPULATION TECHNIQUES
Physical manipulation via qualified healthcare professionals (sports medicine doctors, chiropractors, osteopaths, physiotherapists and others) has been shown to improve quality of life in many people suffering from back pain. The non-invasive manipulation techniques and the excercise and stretching protocols these healthcare professionals recommend can be very helpful.
Click here to view Back Pain Wellness Tips for your patients.
Surgery is considered a last resort for continuing, debilitating back pain.
MEDICATIONS
Although medications will not cure back pain of degenerative origin, they are routinely used to control pain, inflammation, muscle spasm, and associated disruption of sleep.
MEDICATIONS FOR SYMPTOMATIC RELIEF
Analgesics and Anti-inflammatories
Acetaminophen
Acetaminophen is often prescribed to relieve mild to moderate back pain. The drug possesses analgesic and antipyretic properties, but is not an anti-inflammatory. For this reason, it may usually be safely combined with an anti-inflammatory medication to relieve pain.
Overdosing can cause liver damage that may be severe enough to cause liver failure and death. This damage occurs in a dose-related manner and is the leading cause of rapid onset liver failure in the US, Canada and the UK.
For the average healthy adult, the recommended maximum dose of acetaminophen over a 24-hour period is four grams (4000 mg) or eight extra-strength pills. (Each extra-strength pill contains 500 mg and each regular strength pill contains 325 mg.) A patient who drinks more than two alcoholic beverages per day, however, should not take more than two grams of acetaminophen over 24 hours. For children, the dose is based on weight and age.
A single dose of 7 to 10 grams of acetaminophen (14 to 20 extra-strength tablets) can cause liver injury in the average healthy adult. (This amount is about twice the recommended maximum dose for a 24-hour period.) In children, a single dose of 140 mg/kg body weight of acetaminophen can result in liver injury. However, amounts of acetaminophen as low as 3 to 4 grams in a single dose or 4 to 6 grams over 24 hours, have been reported to cause severe liver injury, sometimes resulting in death. Certain individuals, for example, those who regularly drink alcohol or those with hepatitis C, are more prone than others to developing acetaminophen-induced liver damage.
NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of drugs commonly used to treat back pain because of their analgesic, anti-inflammatory, and antipyretic properties. NSAIDs inhibit the enzymes Cox-1 and Cox-2 (cyclooxygenase), which catalyze arachidonic acid to prostaglandins and leukotrienes. Arachidonic acid is released from membrane phospholipids as a response to inflammatory stimuli. The efficacy of NSAIDs differs from patient to patient. This is likely due to the pharmacokinetic differences among the various NSAIDs.
Through their inhibition of Cox-1 enzyme, NSAIDs can cause stomach irritation, bleeding, fluid retention, and decreased kidney function. Since NSAIDs bind to plasma proteins they may be displaced by or may displace other plasma-bound drugs such as coumadin, methotrexate, digoxin, cyclosporine, oral antidiabetic agents, and sulfa drugs. This interaction can enhance the therapeutic or toxic effects of either drug.
NSAIDs (particularly indomethacin) can interfere with the pharmacologic control of hypertension and cardiac failure in patients who take beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, or diuretics.
The long-term use of NSAIDs may have a damaging effect on chondrocyte function.
Adverse effects of NSAIDs (which can occur at any time), include renal failure, hepatic dysfunction, bleeding, and gastric ulceration.
Cox-2 Inhibitors
A relatively new sub-class of NSAID, known as Cox-2 inhibitors, work by blocking cyclooxygenase 2 enzyme which is involved in the inflammation pathway. By sparing cyclooxygenase 1 (Cox-1) enzyme, gastrointestinal toxicity is purportedly reduced. Due to their proclaimed reduction of gastro-intestinal side effects, Cox-2 inhibitors have claimed a large marketshare.
Unfortunately, recent studies have indicated that Cox-2 inhibitors can increase the risk of cardiovascular problems including angina, myocardial and cerebral infarction, thrombosis and sudden death, to four times that of traditional NSAIDs. A review of more than 48,000 patients taking rofecoxib revealed that 0.52% of patients taking an inactive placebo pill had a heart attack each year. The annual rate of heart attack was 0.74% for patients taking rofecoxib. One theory for this holds that Cox-1 enzyme plays a role in preventing the clot formation that leads to cardiovascular problems.
The assertion that Cox-2 inhibitors (rofecoxib, celecoxib) do not induce haemorrhage in the upper gastro-intestinal tract, is also under dispute. While studies confirm that Cox-2 inhibitors cause fewer gastro-intestinal events than traditional NSAIDs in the short-term, it is not yet known what the long-term effects of these drugs will have on the gastric mucosa.
*Important News Release September 2004
Vioxx®, the cox-2 inhibitor made by Merck, has been pulled from the market because of severe lethal side effects due to heart attack and stroke.
Muscle relaxants
Muscle relaxants that address back pain are available as prescription and over-the-counter medications. Prescription medications include Soma® (carisoprodol), Flexeril® (cyclobenzaprine) and Valium® (diazepam). Soma is typically prescribed on a short-term basis and may be habit-forming, particularly if used with alcohol or other drugs that affect the mind. Flexeril may be used on a longer term basis. This drug may impair mental and physical function and can lead to urinary retention in men with enlarged prostates.
Valium is usually restricted to one to two weeks of use. Due to this drug's habit-forming potential, and its propensity to alter the sleep cycle, it is not prescribed for the long-term. Since valium is a depressant, it can worsen the depression often associated with chronic pain.
MEDICATIONS THAT MAY HELP MODIFY THE DISEASE PROCESS
Nutricol®, available as Recovery® in many pharmacies, is proposed to reduce the inflammation that is associated with back pain. Nutricol® (Recovery®) is an anti-catabolic agent that works at cellular level to help stabilize the tissues. Biomedica Laboratories, Inc., also believes that this proprietary blending of plant nutrients naturally increases the cells' receptivity to hormones such as insulin which are required to speed the repair of tissues.
Nutricol® (Recovery®) may be safely combined with other back pain medications or taken on its own to help counter pain and inflammation. It does not produce unpleasant side effects. Since this product works to modify the body's responses, it may take up to six weeks for the patient to experience relief, with most individuals noticing benefits within a month.
Biostructural® Medicine goes beyond simply addressing symptoms and focuses on the degenerative process and optimal healing.
Nutricol® (Recovery®) may be safely combined with other medications or taken on its own to help counter inflammation and improve the quality and rate of healing.
Information for Doctors: Print an 6-page detailed information package that provides the following:
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Click here to view feedback from health professionals and users about the results noted from Recovery® with Nutricol®.
A NOTE FOR CHIROPRACTIC PRACTITIONERS
Back pain is the reason for most chiropractic visits in Canada. (Some studies have estimated that the annual cost to the health care system, combined with lost productivity, amounts to $8 billion.)
Biostructural Medicine Recovery™ with Nutricol™ addresses inflammation gently, yet effectively. By reducing free radical action and inhibiting the release of inflammatory compounds such as histamine, serine proteases, prostaglandins and leukotrienes, Recovery stabilizes cellular membranes, helping to minimize both the area and the degree of inflammation. The resulting reduction of nociceptive input allows your patient to better tolerate adjustments. Recovery is therefore faster and more complete.
Epidural steroid injections
Epidural steroid injections may be administered when analgesics fail to work This procedure involves placing a small amount of cortisone into the spinal canal.
Cortisone's powerful anti-inflammatory action may help to bring the inflammation surrounding the nerves under control. Unfortunately, ESIs have a success rate of only 40 – 50 percent.
Surgery
Surgery is usually a last-resort solution for back pain. Each surgery is unique to the patient's specific symptoms and there is no procedure that "fits all." Common surgical procedures include diskectomy, complete laminectomy and spinal fusion.