11
Conservative Treatment: Drugs, Physiotherapy, and Alternative Medicine

Christopher C. Ornelas and Mona Zall

■ Introduction

Low back pain (LBP) has a high prevalence in the adult and geriatric population. Up to 70% of adults are affected at some point in their lives with LBP.¹ It is the second most common cause of disability in the developing world and has major social welfare and economic implications.^2,3 When evaluating a patient with LBP, the physician should elicit a thorough history and perform a detailed musculoskeletal and neurologic examination. If the diagnosis remains unclear or if the patient does not respond to initial treatments, imaging may be necessary. LBP is usually classified as acute, subacute, or chronic, and can be described as either axial or radicular. The differential diagnosis for axial LBP is broad, and the etiology can involve intervertebral disk syndromes, facet joint-mediated pain syndromes, sacroiliac joint arthritis or strain, and muscle strain involving the paraspinal musculature.⁴ Lumbar radiculopathy, or pain associated with irritation or injury to lumbosacral nerve roots, is also associated with a broad differential and can present as pain, numbness, or weakness in the affected extremity. Most episodes of acute LBP resolve, but some patients develop chronic or recurrent pain. Typically, those who have persistent LBP are older and have greater baseline pain and dysfunction, depression, an ongoing compensation claim, or fear of pain persistence.

This chapter discusses nonsurgical treatment options for patients with LBP, including physical therapy, exercise, pharmacotherapy, topical modalities, therapeutic steroid injections, and neuromodulation.

■ Etiology and Epidemiology of Axial and Radicular Low Back Pain

Facet or zygapophyseal joints in the lumbar spine are responsible for 15 to 45% of axial LBP.^5,6 Facet pain may also cause a local referred pain pattern, and is innervated by lumbar medial branch nerves of the lumbar dorsal rami nerves. Each facet joint is innervated by the medial branch nerves cephalad and caudal to the joint. The onset of facet pain is generally insidious, and it occurs more commonly in patients of ages 65 years and older. Typically, pain is worse with prolonged standing and extension of the lumbar spine, and is alleviated by sitting, forward flexion, or recumbency. No test is considered sensitive for the identification of facet pain, and it is not always associated with obvious X-ray evidence of facet arthritis. However, small studies have shown that pain with extension and rotation may be indicative of facet pain.⁴ Facet pain may be due to the intrinsic abnormalities of the joint or because of extrinsic compression of the descending root in the lateral recess or exiting nerve root in the intervertebral foramen. Facet pain can be managed in several ways, including physical therapy, intra-articular facet injections, medial branch nerve blocks, and medial branch nerve radiofrequency ablation (RFA).4

Radiculopathy is a type of neuropathic pain that results from a lesion or disease affecting the somatosensory system and is caused by nerve root irritation and lumbar stenosis. Radicular pain is generated by discharges from an irritated spinal nerves and presents as pain in a dermatomal distribution. Although radicular pain is most commonly associated with herniated disks, it can also be caused by ligamentum flavum thickening, facet arthropathy, body spurs, or trauma.⁴ Lumbar radicular pain is managed with physical therapy, medications, and epidural steroid injections.

Lumbar stenosis occurs when there is narrowing of the vertebral canal by surrounding bone and soft tissues, which in turn leads to compression of neural structures.⁴ The cause of lumbar stenosis is multifactorial, and usually involves the combination of intervertebral disk protrusion or herniation, facet joint hypertrophy, congenital narrowing of the central spinal canal, hypertrophy of the ligamentum flavum, and spondylolisthesis.⁴ Lumbar stenosis can be associated with both axial and radicular pain. The hallmark symptom of lumbar stenosis is neurogenic claudication. Patients with claudication have pain that increases with standing and walking and decreases with sitting. The pain is typically located in one or more dermatomes and often affects the lower extremities symmetrically. It is distinguished from vascular claudication due to peripheral vascular disease in that it may present with prolonged standing alone, whereas vascular claudication is usually associated with ambulation.

Sacroiliac (SI) joint pain is responsible for 15 to 30% of axial LBP in individuals; 40 to 50% of patients with SI joint pain develop the pain after an acute trauma. The two most common traumatic events that can lead to SI joint pain are motor vehicle collisions and falls.⁷ Pain is typically located in the gluteal or lower lumbar paraspinals and can be associated with or without radiation to the thigh or the knee.⁷ What makes SI joint pain different from other forms of axial pain LBP is that pain typically occurs with transitional movements and can occur while in a seated position.⁴

■ Physical Therapy and Exercise

Physical therapy (PT) has been used as a conservative treatment to help patients with LBP, and it is believed that PT may decrease the need for invasive and costly interventions.⁸ Not many studies have shown benefit for exercise in acute LBP, and in certain situations starting therapy and exercise should be delayed until appropriate analgesia is achieved. PT can be viewed as a continuous process with a focus on developing immediate, intermediate, and long-term goals. These goals are usually determined at the initial evaluation of the patient by the licensed therapist. When ordering PT, the physician should inform the patient of the expectations and goals of therapy, as well as the anticipated duration of therapy. In the initial evaluation, the patient’s current pain level and functional limitations are assessed. Initially, the therapist aims to decrease the pain level with a series of modalities, which may include heat, ice, transcutaneous electrical nerve stimulation (TENS), and message. The patient also should be given an exercise program to perform at home, because the number of therapy sessions is limited. Another option is a back school, which focuses on educating the patient on the anatomy of the spine, common causes of back pain, posture, and stability, and may include instruction on gait and balance. There is often emphasis on prevention of positions or activities that can elicit or worsen the pain and other symptoms. Once the patient is able to adequately participate in therapy, the patient’s gait and posture are evaluated.^8–10

According to a review conducted in 2010, TENS failed to provide relief for patients with LBP, so Medicare no longer covers it.¹¹ However, TENS is often used in combination with other modalities for pain relief early in the therapy process.

The modality of heat has two forms, superficial and deep. Examples of superficial heat include heating pads, warm compresses, and fluid therapy. The goal of superficial heat is to provide muscle relaxation and analgesia. These modalities can also be used at home. Deep heat, which is achieved with ultrasound, shortwave diathermy, and microwave are usually performed under the direction of the therapist. Although a useful treatment, heat can cause injury and often skin hyperpigmentation. Cold therapy is almost exclusively superficial, and is suggested to be superior to heat in the acute setting. It can also play a role in the intermediate to long-term treatment of LBP. Cold therapy for LBP is relatively safe but should be avoided in the extremities of patients with arterial insufficiency and decreased sensitivity in the extremities such as peripheral neuropathy and radiculopathy.10

Once patients have developed a general understanding of the principles of their back pain, lumbar stabilization will be emphasized. Various techniques have been described in the literature, but there is a general consensus on including combinations of core strengthening, back strengthening, and stretching. The McKenzie method involves focusing LBP toward the spinal midline. This is done by repetitive motions or sustained postures. Studies have failed to show the benefit of such exercises over flexion and extension exercises. The Alexander technique is a hands-on method to improve balance, posture, and coordination and to break poor habits.

Often persons who are not as active have a tendency to develop LBP, so there is a period of time where therapy can cause some soreness and worsening of pain because muscles that have become weak over time are now being retrained.⁹ Although therapy sessions are usually held two to three days per week, the patient is instructed to perform some limited home exercises and stretching on the other days. PT ends when patients have demonstrated the ability to independently perform their exercises and when they are no longer making significant functional gains.

Patients should then transition into a home exercise program, which has been useful for pain in the subacute and chronic periods after the onset of pain. The exact amount or type of exercise that provides the best results has not been determined; more studies need to be conducted. Typical programs involve a combination of core strengthening exercises, aerobic exercises, range of motion, and functional restoration programs. Patients should start aerobic exercises slowly, and gradually increase their frequency and intensity.

In a review of 43 trials, exercise therapy for patients with chronic LBP was slightly superior to no treatment in improving functional outcomes and pain.⁹ Incorporation of aerobic activities is recommended, and may include yoga, Pilates, tai chi, and aquatic therapy. Pilates focuses on core strengthening. In a study comparing PT, no treatment, and Pilates, patients had more relief with reduction of pain in chronic LBP with Pilates. Yoga has been shown to provide some benefit to patients with LBP depending on the type of yoga performed. Viniyoga has shown to be superior to typical treatments at 12 weeks, but showed no difference at 26 weeks. Tai chi is a form of Chinese martial arts that involves slow movements, breathing, and meditation. In a study of a 160 patients with LBP, those who performed tai chi had greater relief and functional improvement than those who underwent standard treatment. But the long-term efficacy of tai chi has yet to be studied.⁹ Aquatic therapy has been shown to be beneficial in patients with LBP, but has not been shown to be superior to other interventions for chronic LBP. To best determine the most beneficial therapy and exercises for patients with LBP, more studies need to be conducted.

In certain patients, such as those who sustained occupational injuries, further evaluation of work-specific tasks, ergonomics, home and workstation modifications, and work hardening programs may have to be explored to limit the return of pain and prevent further or future injury.

■ Pharmacotherapy

Several medication treatment options are available for patients with nonspecific LBP. The choice of medication depends largely on the patient’s symptoms, the etiology of the pain, the severity of pain, the patient’s previous response to medication, the patient’s medical comorbidities, and adverse side-effect profiles.12 Some medications have been shown to be more efficacious in acute LBP versus subacute and chronic pain LBP.

Acetaminophen

The American Pain Society recommends acetaminophen as a first-line pharmacological option for LBP, because of its safety profile. The major concern with acetaminophen is hepatotoxicity. In patients with a history of alcohol abuse or other risk factor for hepatotoxicity, the maximum dose advised is 2 g per day. In patients without such risk factors, the maximum dose is 4 g per day. Acetaminophen does not contain significant anti-inflammatory properties, and has been shown to be inferior to nonsteroidal anti-inflammatory drugs (NSAIDs) in several studies.¹³

Nonsteroidal Anti-Inflammatory Drugs

The NSAIDs exert their anti-inflammatory properties and analgesic effects by blocking cyclooxygenase (Cox) enzymes. They are also considered as a first-line treatment, but they are associated with gastrointestinal and renal adverse effects. Studies have shown that nonselective NSAIDs and Cox-2 inhibitors have been associated with a twofold increase in myocardial infarctions. Naprosyn has the lowest cardiac risk and is available over the counter.¹³ No study has shown a significant difference between traditional NSAIDs versus Cox-2 NSAIDs in the treatment of LBP, but traditional NSAIDs cause more side effects.¹⁴ There is no evidence that switching from one NSAID to another provides superior analgesia.

Muscle Relaxants

Muscle relaxants have been shown to be more effective than placebo in patients with nonspecific back pain. Data shows that they typically work better in acute versus chronic pain.⁴ In the United States, the muscle relaxants that are approved for musculoskeletal conditions are carisoprodol, cyclobenzaprine, chlorzoxazone, methocarbamol, and orphenadrine. Approved medications for spasticity include diazepam, dantrolene, tizanidine, and baclofen. Muscle relaxants are not considered first-line treatments due to the high prevalence of adverse side effects. They are commonly associated with central nervous system (CNS)-related adverse events including drowsiness, dizziness, fatigue, and headache. No study thus far has shown one muscle relaxant to be superior to another. Carisoprodol should be avoided because of its high potential for abuse and addiction. In 2007, the European Medicines Agency recommended the suspension of all carisoprodol-containing medications. In patients who do not respond to first-line treatments such as acetaminophen or NSAIDs, there has been evidence to suggest that the addition of a muscle relaxant was superior to monotherapy for short-term pain relief.¹³

Antidepressants

The role of antidepressants in the treatment of axial or radicular LBP is controversial. Antidepressants are not considered a first-line treatment due to the lack of evidence of their effectiveness for LBP, and they can be associated with QRS prolongation and arrhythmias. Some antidepressants require laboratory testing to assess therapeutic drug levels and routine electrocardiograms (ECGs). Tricyclic antidepressants (TCAs) have been shown to be superior to serotonin-norepinephrine reuptake inhibitors (SNRIs), which are more efficacious than selective serotonin reuptake inhibitors (SSRIs).⁴ Tertiary amines such as amitriptyline and imipramine have a higher risk of adverse events compared with secondary amines such as nortriptyline and desipramine. Some SNRIs such as venlafaxine, duloxetine, and milnacipran have demonstrated some benefit in patients with LBP that may or may not have had a neuropathic component.13

Synthetic Opioids

Tramadol, a synthetically derived analgesic, binds to mu-opioid receptors and weakly inhibits norepinephrine and serotonin reuptake. However, it is not recommended as a first-line treatment because of limited evidence of their effectiveness for LBP and the lack of data to suggest an advantage over NSAIDs. Moreover, although not a true opioid, tramadol does entail the potential for abuse. In a review conducted by Chung et al, it was found that tramadol did not have statistically significant pain relief when compared with placebo, but there was improvement in function associated with its use.⁴ One must use caution when prescribing tramadol to patients who are also taking an SSRI antidepressant medication because of the potential for developing a potentially life-threatening condition known as serotonin syndrome.¹³ Mild symptoms of serotonin syndrome include agitation, confusion, elevated blood pressure or heart rate, diarrhea, and headache. Severe symptoms include fever, arrhythmia, seizures, and unconsciousness.

Opioids

Opioids remain controversial for LBP. They are considered a potent class of analgesics and carry a risk of respiratory depression, abuse potential, and addiction. The more common side effects associated with opioids include constipation, nausea, somnolence, pruritus, and myoclonus. The American Pain Society recommends the usage of opioids in severe, debilitating LBP that is not controlled by either acetaminophen or NSAIDs or when a patient has a high risk of complications on NSAIDs. For acute short-term use, short-acting opioids are generally recommended, whereas long-acting opioids are recommended for long-term use.¹³ A review by Chung et al¹⁴ found that opioids were able to provide statistically significant pain relief in patients with chronic nonspecific LBP. Many opioid medications such as hydrocodone and oxycodone are available in forms containing acetaminophen; physicians must counsel patients on their potential for hepatotoxicity, according to the same guidelines as acetaminophen monotherapy.

Glucocorticoids

Although commonly prescribed in an acute setting such as an urgent care or emergency care department, systemic glucocorticoids are not recommended for the treatment of LBP associated with or without radiculopathy because they have not been shown to be more efficacious than placebo.¹²

Antiepileptic Drugs

There is insufficient evidence to support the usage of antiepileptic drugs in LBP. Gabapentin has been efficacious in a few studies for chronic LBP with associated radiculopathy, but it is not approved by the Food and Drug Administration (FDA) for this indication.¹⁴ There is some evidence to suggest that antiepileptic drugs such as gabapentin have a potential to prevent central sensitization when prescribed early in radiculopathy.

Topical Analgesics and Ointments

The benefit of topical analgesics is that they do not entail the risk of systemic side effects. They may be used alone or with other medications. Side effects are typically mild and include allergic reaction or skin irritation. Capsaicin works by depleting substance P from the sensory afferent nerve fibers. There has been some evidence, although not strong, that capsaicin can be useful in the treatment of both neuropathic and musculoskeletal pain. Most patients tolerate capsaicin well. The most commonly reported side effect is an intolerable burning sensation.¹¹ Lidocaine 5% patches may be another option, but there are no data supporting the utilization of lidocaine for acute or chronic LBP. A few studies have shown its benefit for myofascial pain syndromes. Generally, lidocaine patches are well tolerated.11

■ Alternative Medicine

Herbal Medicine

Short-term studies have shown that herbal preparations such as devil’s claw, white willow bark, and cayenne may have a role in the treatment of LBP.¹¹ A 2014 Cochrane review addressed the usage of herbal medication for LBP. It found that Solidago chilensis Meyen (Brazilian arnica) may improve flexibility when applied twice a day. Capsicum frutescens cream or plaster showed effectiveness in treating chronic LBP in three separate trials, yet it is unclear if it provides relief in acute back pain. Harpagophytum (devil’s claw) was found to be better than placebo in providing short-term relief. Another study found that it was equivalent to 12.5 mg of rofecoxib. White willow bark (Salix alba) was shown to be better than placebo for short-term improvements in pain and rescue medication. Aromatic lavender essential oil, when applied by acupressure, reduced pain intensity and improved lateral spine flexion and walking time, compared with controls.¹⁵ These studies show promise in utilization of herbal medications, but some of the trials are not of the best quality, and there are few comprehensive large trials.

Acupuncture

Patients often turn to complementary or alternative medicine for the treatment of LBP. An option that patients frequently consider is acupuncture, which is based on the concepts of Chinese medicine. According to the Chinese, there are twelve main meridians in the body, which the Qi energy must flow through. Needles are inserted along the meridians to activate the body’s natural healing process. Acupuncture exerts its effect by inhibition at the dorsal horn, by activating the descending inhibitory pathways, and by stimulating the release of opioids and serotonin.¹⁶ There are mixed data regarding the efficacy of acupuncture in the treatment of LBP. A 2015 review by Liu et al¹⁷ found that in acute phases acupuncture was inconsistent in its ability to provide relief. But in patients with chronic LBP, acupuncture as an adjunct to conventional therapy provided patients with short-term relief and functional improvement. Better studies need to be conducted before acupuncture can be recommended as a standard of care.

Injections

Another form of conservative management for LBP is steroid injections. Epidural steroid injections are used in patients who have radicular pain and pain secondary to disk herniation, spinal stenosis, postlaminectomy syndrome, and diskogenic pain. The different approaches to injecting epidurals include transforaminal, interlaminar, and caudal. The response to epidural injections varies with the pathology.¹⁸ Typically, steroid and local anesthetics or local anesthetics alone are administered. The steroids exert anti-inflammatory effects. Multiple high-quality randomized controlled trials have shown grade I evidence that supports the utilization of caudal epidurals for lumbar disk herniation, diskogenic pain, spinal stenosis, and postlaminectomy syndrome. A review by Manchikanti et al¹⁸ analyzed several studies for lumbar transforaminal epidurals in patients with disk herniation and lumbar stenosis. They found that there was level I evidence that local anesthetics with steroids or local anesthetics alone provided significant pain relief in patients. There was also grade II evidence in two studies that showed some patients were able to avoid surgery after the injections.

Lumbar facet-mediated pain is treated by intra-articular injections, lumbar medial branch nerve blocks, and sometimes RFA. There are conflicting data regarding the efficacy of such interventions. Facet joint injections have been studied using saline, local anesthetics, and steroids. Injections can be both diagnostic and therapeutic depending on whether or not steroids are utilized. The most recent guidelines by the American Society of Interventional Pain Physicians does not recommend intra-articular injections for therapeutic purposes, but anesthetic-only facet injections may provide diagnostic utility and may aid in spine surgery planning.6 Medial branch nerve blocks can be diagnostic or diagnostic and therapeutic. Therapeutic medial branch nerve blocks entail administering 1 to 2 cc of a combination of steroid and anesthetic at each nerve. However, for diagnostic injections, only 0.5 cc of anesthetic is used. A diagnostic block confirms the diagnosis of facet-mediated pain; it is also used if therapeutic injections offer only short-term relief and RFA is being considered. After a double-positive diagnostic block, RFA can be performed and may provide patients with longer relief. A diagnostic nerve block is considered successful or positive if there is a reduction in pain by 80%.⁶ RFA has been demonstrated to provide significant pain relief in patients for 6 to 12 months, and even for more than 3 years in some patients in a retrospective study conducted by McCormick et al.¹⁹ It should be considered only in patients who demonstrate two positive diagnostic blocks.

Trigger point injections involve dry needling in the muscle and soft tissue. They can be performed with anesthetic or in a combination of anesthetic and corticosteroid. Although they are a nonspecific treatment, there is some evidence to suggest improvement in patients with chronic LBP.¹⁰

Spinal Cord Stimulators

Spinal cord stimulators (SCSs) are another option for patients who have LBP due to failed back syndrome or who have refractory neuropathic pain despite extensive medical and interventional therapies. Sanders et al²⁰ performed a retrospective study in patients with failed back syndrome and complex regional pain syndrome who had received SCS, and they found that patients had significant and sustained pain reduction and opioid medication utilization. SCS therapy is used after a successful trial period in which percutaneous stimulator leads (typically two) are placed into the epidural space and connected to an external pulse generator. A successful trial is defined as pain improvement such that the patient reports a reduction in oral analgesic medications, a reduction of pain of at least 50%, and improvement in quality of life and participation in activities of daily living. After a successful trial usually lasting about 1 week, an implantable pulse generator and permanent leads or paddle arrays are placed surgically. The device is then programmed remotely and charged percutaneously. The exact mechanism of spinal cord stimulators is not completely understood.

■ Chapter Summary

Low back pain is a common cause of pain in the adult and geriatric population and is a major cause of debility. A comprehensive history and detailed neurologic examination is key in understanding LBP, as the differential is broad. In the absence of neurologic compromise, imaging is not necessary, but it should be considered when the diagnosis of LBP is unclear or the patient fails to response to initial treatment. Conservative treatment options include combinations of physical therapy and first-line medications such as acetaminophen and NSAIDs. Physical therapy is a goal-driven process that ultimately educates the patient and develops a long-term home exercise program. If a patient fails to respond to initial treatments, medications such as muscle relaxants, antidepressants, and opioids can be considered. Image-guided injections can be useful not only to aid in the diagnosis of the patient’s pain but also to treat pain. Identifying the etiology of LBP is crucial to determine which type of injection should be used. Alternative treatments such as acupuncture, herbal medications, and exercise programs such as yoga and Pilates may also be used to help treat LBP, but they are not considered first-line treatments. Physical therapy is indicated in treating LBP before and after surgery. Spinal cord stimulators can be used in patients with persistent neuropathic pain after surgery.

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