Little treatments, lots of time best for back pain

It's critical to spend time talking to patients about their history, check for red flags that could identify the etiology, and encourage patients not to stay bedridden.

At any given time, 12% of adults suffer from low back pain, which is the #1 cause of disability worldwide, speaker O. Kenrik Duru, MD, explained during his Thursday session. The condition costs employers $7.4 billion annually, mostly from presenteeism rather than absenteeism, said Dr. Duru, professor-in-residence at the University of California, Los Angeles (UCLA).

While those are large numbers, it's the little things that matter in treatment. “Different things with small effects over time will add up,” Dr. Duru told the audience.

Reassurance is perhaps the best treatment, he said. It's critical to spend time talking to patients about their history, check for red flags that could identify the etiology, and encourage patients not to stay bedridden. “It's worth taking two minutes to do this before the other treatments I'll recommend,” he said.

Dr. Duru reviewed a few of the red flags that could be identified while taking a history. Long-term steroid use can result in compression fracture. Morning stiffness that improves with exercise but not rest could be ankylosing spondylitis. The very rare cause of cauda equina is easily identified with the questions, “Are you able to pee when you want, and are you able to hold it when you want?” Also, ask the patient if wiping with toilet paper feels different or numb.

As for treatment, most patients, 93% to be exact, don't benefit from imaging if their low back pain is less than six weeks in duration. So it's important to figure out what an MRI might reveal: 4% of patients might be found to have a compression fracture; 2%, pain radiating from other tissues or organs; 0.7%, cancer; 0.01%, osteomyelitis; and 0.00003%, cauda equina (which is why Dr. Duru said most internists will never see a patient with this).

Two-thirds of low back pain improves by six weeks. Warning signs that a patient won't be in that majority include experiencing prior episodes (particularly of prolonged low back pain), catastrophizing, avoiding activities out of fear (of further injury, for example), and having depression, anxiety, obesity, comorbidities such as diabetes, headaches, or asthma, or a physically demanding job, Dr. Duru said.

Given that most patients improve over time regardless of treatment, internists can recommend heat, massage, acupuncture, or spinal manipulation. These work equally well, so “Whatever the patient thinks will work, I tend to go with,” he said. Next, add NSAIDs or muscle relaxants, such as a regimen of ibuprofen, 400 to 600 mg four times a day, or naproxen, 250 to 500 mg four times a day.

Avoid prescribing acetaminophen or narcotics, he said. Between 1% and 1.5% of patients taking opioids will become dependent, and risks are higher for patients with neck, shoulder, and knee pain or multiple comorbidities. If opioids are necessary, CDC guidelines recommend starting immediate-release opioids at the lowest dose for the shortest duration, usually less than three days of supply, Dr. Duru noted.

Other options include multidisciplinary rehabilitation, which a show of hands revealed that about 25% of the audience had recommended to patients. Far fewer had tried mindfulness-based stress reduction, but more had recommended cognitive behavioral therapy, which Dr. Duru said he frequently recommends to patients because it's available at UCLA.

“The choice comes down to what's available in your local environment,” he said.

About two-thirds of the audience also indicated they had recommended epidural steroidal injections for low back pain, and Dr. Duru reported that use of this treatment has increased from fewer than 1 million procedures in 2000 to more than 2.2 million performed in 2011. But, Dr. Duru said, it is minimally effective. That's also an off-label use by FDA standards and can carry rare but significant adverse risks.

“There is no magic bullet. Low back pain gradually improves with time, so time is your friend,” Dr. Duru said. “There are a lot of things we can do. Each has a little beneficial effect, so we do several of them, and while we wait we reassure the patient that they will get better over six to 12 weeks.”