Chapter 016. Back and Neck Pain (Part 12)

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Algorithms for management of acute low back pain, age ≥18 years. A. Symptoms

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Chapter 016. Back and Neck Pain (Part 12) Algorithms for management of acute low back pain, age ≥18 years. A. Symptoms
Clinical trials have shown no benefit of >2 days of bed rest for uncomplicated ALBP. There is evidence that bed rest is also ineffective for patients with sciatica or for acute back pain with signs of nerve root injury. Similarly, traction is not effective for ALBP. Possible advantages of early ambulation for ALBP include maintenance of cardiovascular conditioning, improved disk and cartilage nutrition, improved bone and muscle strength, and increased endorphin levels. One trial of early vigorous exercise was negative, but the value of less vigorous exercise or other exercise programs are unknown. Early resumption of normal physical activity (without heavy manual labor) is likely to be beneficial. Proof is lacking to support the treatment of acute back and neck pain with acupuncture, transcutaneous electrical nerve stimulation, massage, ultrasound, diathermy, magnets, or electrical stimulation. Cervical collars can be modestly helpful by limiting spontaneous and reflex neck movements that exacerbate pain. Evidence regarding the efficacy of ice is lacking; heat may provide a short-term reduction in pain and disability. These interventions are optional given the lack of negative evidence, low cost, and low risk. Biofeedback has not been studied rigorously. Facet joint, trigger point, and ligament injections are not recommended for acute treatment.
A role for modification of posture has not been validated by rigorous clinical studies. As a practical matter, temporary suspension of activity known to increase mechanical stress on the spine (heavy lifting, prolonged sitting, bending or twisting, straining at stool) may be helpful. Education is an important part of treatment. Satisfaction and the likelihood of follow-up increase when patients are educated about prognosis, treatment methods, activity modifications, and strategies to prevent future exacerbations. In one study, patients who felt they did not receive an adequate explanation for their symptoms wanted further diagnostic tests. Evidence for the efficacy of structured education programs ("back school") is inconclusive; there is modest evidence for a short-term benefit, but evidence for a long-term benefit is lacking. Randomized studies of back school for primary prevention of low back injury and pain have failed to demonstrate any benefit. NSAIDs and acetaminophen (see Table 12-1) are effective over-the-counter agents for ALBP. Muscle relaxants (cyclobenzaprine, 10 mg PO qhs as initial dose, up to 10 mg PO tid) provide short-term (4–7 days) benefit, particularly at night if sleep is affected, but drowsiness limits daytime use. Opioid analgesics are no more effective than NSAIDs or acetaminophen for initial treatment of ALBP, nor do they increase the likelihood of return to work. Short-term use of opioids may be necessary in patients unresponsive to or
intolerant of acetaminophen or NSAIDs. There is no evidence to support the use of oral glucocorticoids or tricyclic antidepressants for ALBP. Epidural glucocorticoids may occasionally produce short-term pain relief in ALBP with radiculopathy, but proof is lacking for pain relief beyond 1 month. Epidural glucocorticoids, anesthetics, or opioids are not indicated in the initial treatment of ALBP without radiculopathy. Diagnostic nerve root blocks have been advocated to determine if pain originates from a specific nerve root. However, improvement may result even when the nerve root is not responsible for the pain; this may occur as a placebo effect, from a pain-generating lesion located distally along the peripheral nerve, or from anesthesia of the sinuvertebral nerve. Therapeutic nerve root blocks with injection of glucocorticoids and a local anesthetic should be considered only after conservative measures fail, particularly when temporary relief of pain is necessary. A short course of lumbar spinal manipulation or physical therapy (PT) for symptomatic relief of uncomplicated ALBP is a reasonable option. Prospective, randomized studies are difficult to perform in part because there is no consensus about what constitutes an adequate placebo control. Specific PT or chiropractic protocols that may provide benefit have not been fully defined.