No Evidence Muscle Relaxants Can Ease Low Back Pain

Alan Mozes wrote . . . . . . . . .

Although tens of millions of Americans turn to muscle relaxants for lower back pain relief, a new Australian review finds little evidence that such drugs actually work.

That’s the conclusion of a deep-dive into 31 prior investigations, which collectively enlisted more than 6,500 lower back pain patients. Enrolled patients had been treating lower back pain with a wide range of 18 different prescription muscle relaxants.

But while the studies suggested that muscle relaxants might ease pain in the short term, “on average, the effect is probably too small to be important,” said study author James McAuley. “And most patients wouldn’t be able to feel any difference in their pain compared to taking a placebo, or sugar pill.”

Another concern: Beyond their ineffectiveness, “there is also an increased risk of side effects,” cautioned McAuley, director of the Centre for Pain IMPACT with the University of New South Wales’ School of Health Sciences in Sydney.

Such side effects can include dizziness, drowsiness, headache and/or nausea, in addition to the risk that patients will develop a lingering addiction.

McAuley said his team was surprised by the findings, “as earlier research suggested that muscle relaxants did reduce pain intensity. But when we included all of the most up-to-date research the results became much less certain.”

One problem is that much of the research “wasn’t done very well, which means that we can’t be very certain in the results,” McAuley said.

For example, none of the studies explored long-term muscle relaxant use. That means the Australian team could only assess muscle relaxant effectiveness during two time frames: throughout an initial two-week regimen and between 3 to 13 weeks. In the first instance, they found low evidence of an insignificant pain relief benefit; in the second instance, they found no pain intensity or disability relief benefit whatsoever.

McAuley’s take-away: “There is a clear need to improve how research is done for low back pain, so that we better understand whether medicines can help people or not.

“Low back pain is extremely common. It is experienced by 7% of the global population at any one time. Most people, around 80%, will have at least one episode of low back pain during their life,” McAuley noted.

But because it’s often very difficult to isolate a precise cause, many treatments — including NSAIDs, opioids, exercise therapy and/or counseling — aim to control pain rather than provide a cure. Muscle relaxants — prescribed to 30 million Americans in 2020 — fall into that category, McAuley said.

Given that muscle relaxants provide neither a cure nor pain relief, there’s “a clear need to develop and test new effective and cost-effective treatments for people with low back pain,” he said.

In the meantime, McAuley says a move is underway to “de-medicalize” lower back pain treatment by embracing techniques that focus on alternatives to medicine or surgery.

For example, “we know that people with low back pain should avoid staying in bed,” he noted, “and they should try to be active, and continue with usual activities, including work, as much as they can.

“People with recent onset low back pain should be provided with advice and education about the low back pain,” McAuley added. “[And] they should be reassured that they do not have a serious condition, and that their low back pain is very likely to improve over time, whether or not they take medicines or other treatments.”

He and his colleagues reported their findings in the July 7 issue of BMJ.

“The problem is, back pain has so many causes,” said Dr. Daniel Park, an associate professor in the department of orthopedics with Oakland University’s William Beaumont School of Medicine in Rochester, Mich.

So when it comes to treatment, “there is no one-size-fits-all,” stressed Park, who is also a spine surgeon at Beaumont Hospital-Royal Oak.

Still, Park thinks that when it comes to muscle relaxants, “there probably is a place for short-term benefit to help patients manage severe pain.”

For example, he suggests patients with “muscle strain from overdoing it,” or those with a herniated disc may actually benefit from short-term muscle relaxant use.

But patients with garden-variety back pain from a degenerative disc? Not so much.

Regardless, long-term pain relief is unlikely, regardless of the source of the problem, Park noted.

“Long-term, therapy and core strengthening will be much more beneficial,” Park said, while every effort should be made to identify the specific cause, and to minimize the risk for a chronic condition, permanent damage and enduring discomfort.

Source: HealthDay

Got Sciatica? Stay Active and Start Early on Physical Therapy

Amy Norton wrote . . . . . . . . .

For people with back pain caused by sciatica, it might be a good idea to start physical therapy sooner rather than later, a new clinical trial suggests.

Sciatica refers to pain that radiates along the sciatic nerve, which runs from the lower back, through the hip and down the back of the leg. It’s often the result of a bulging spinal disc that compresses the nerve.

In general, people with sciatica should try to remain active and not take to bed, said study author Julie Fritz, a physical therapist and associate dean for research at the University of Utah’s College of Health, in Salt Lake City.

But it’s one thing to tell patients to stay active, and another to give them targeted exercises to deal with the condition, Fritz said.

So her team looked at whether starting physical therapy fairly soon after a sciatica diagnosis could speed people’s recovery.

On average, the 220 study patients had suffered sciatica pain for about a month. Half were randomly assigned to four weeks of physical therapy (PT), while the rest took a wait-and-see approach.

Six months later, patients who’d received early PT were reporting less disability in their daily activities, compared to the comparison group, the researchers report in the Oct. 6 issue of the Annals of Internal Medicine.

That does not mean everyone with sciatica should start PT right off the bat, according to Fritz.

“There really is no magic-bullet, slam-dunk therapy for everyone,” she said.

Some people with sciatica feel better within weeks, without any special intervention, while others have lingering pain. Even in this trial, 45% of patients in early PT said they were feeling “a great deal better” one year later. That was better than the comparison group, at just under 28% — but it also meant a majority did not feel that degree of improvement.

Unfortunately, Fritz said, there’s no way to predict which sciatica patients stand to benefit from early PT.

Low back pain is complicated, said Dr. Salvador Portugal, a physical medicine and rehabilitation specialist at NYU Langone Orthopedic Center in New York City.

Even when the source can be pegged to sciatica, there can be different “pain generators” for different people, said Portugal, who was not involved in the study.

And pain is not only physical, he pointed out, but involves psychological factors. People who become depressed or anxious, or tend to “catastrophize” pain, or become fearful of physical activity can be at risk of lasting pain.

“Some patients are afraid that physical activity will worsen the pain,” Portugal said. “But the opposite is true. You want to remain active.”

There are cases, he noted, where patients are in such severe pain that it makes sense to hold off on PT and use pain medication until exercise becomes more doable.

And while Portugal agreed there is no one-size-fits-all therapy for sciatica, he said the new findings do show the value of remaining physically active — in “a controlled way.”

While some sciatica patients fear activity, he noted, others adopt a “no pain, no gain” attitude. “That’s not what we want, either,” Portugal said.

For the trial, Fritz’s team recruited 220 patients ages 18 to 60 who had sciatica pain for less than three months.

Half were randomly assigned to four weeks of PT, which included exercise, manual therapy and individualized home exercises. The other half stuck with “usual care,” which included an education pamphlet on staying active.

Six months later, both groups were showing an improvement on a standard questionnaire that asked about difficulties with daily activities such as walking, sitting and lifting objects. But the improvement was greater in the PT group.

In the real world, even if people want PT, there can be obstacles, Fritz said. Not everyone has time to fit the sessions in, and insurance coverage varies.

Knowing when to start PT is tricky, too. “A fair number of patients will get better on their own pretty quickly,” Fritz said. “So we’re trying to balance. We don’t want to over-treat, and we don’t want to miss this window of opportunity where intervening can help recovery.”

On average, Fritz noted, patients in the PT group had only about five sessions. “That suggests a potential benefit of early PT is that it requires less effort to gain a benefit,” she said.

Source: HealthDay

Study Links Diabetes and Back Pain

People with diabetes have a 35 percent higher risk of experiencing low back pain and 24 percent higher risk of having neck pain than those without diabetes, a review by University of Sydney researchers has found.

Their findings, based on meta-analyses of studies that assess the links between diabetes and back or neck pain outcomes, were published in PLOS ONE.

Most adults experience low back pain during their lives and almost half suffer neck pain at some stage. Diabetes is an increasingly prevalent chronic condition; an estimated 382 million people live with type 2 diabetes, the most common form of this metabolic disease.

There was insufficient evidence in the review to establish a causal relationship between diabetes and back or neck pain, the paper’s senior author Associate Professor Manuela Ferreira from the University’s Institute of Bone and Joint Research said. But the findings warrant further investigation of the association.

“Diabetes and low back pain and neck pain seem to be somehow connected. We can’t say how but these findings suggest further research into the link is warranted,” Associate Professor Ferreira said.

“Type 2 diabetes and low back pain both have a strong relationship with obesity and lack of physical activity, so a logical progression of this research might be to examine these factors in more detail. Our analysis adds to the evidence that weight control and physical activity play fundamental roles in health maintenance.”

The paper also found diabetes medication could influence pain, possiby via its effect on blood glucose levels, and this connection should also be investigated. It also recommended health care professionals should consider screening for unknown diabetes in patients seeking care for neck pain or low back pain.

“Neck and back pain, and diabetes, are afflicting more and more people,” said co-author and collaborator Associate Professor Paulo Ferreira from the Faculty of Health Sciences and Charles Perkins Centre. “It’s worth committing more resources to investigate their interrelationship. It may be that altering treatment interventions for diabetes could reduce the incidence of back pain, and vice versa.”

Source: The University of Sydney


Today’s Comic

An Expert’s Guide to Avoiding Back Pain

Back pain is a common problem in the United States, but there are ways to protect yourself, an expert says.

“The back is a complex structure with many delicate parts, but with good judgment and healthy lifestyle habits — including proper lifting, good posture and exercise — it’s possible to avoid common back pain caused by strained muscles,” said Dr. Lawrence Lenke. He is director of spinal deformity surgery at the Spine Hospital at New York-Presbyterian in New York City.

For more complicated spinal problems such as scoliosis, stenosis, fractures or injuries, medical intervention is usually necessary, Lenke said.

“But each person with or without spinal problems can benefit from adopting healthier lifestyle habits to keep your spine as strong as possible,” he said.

Lenke offered this advice:

  • Maintain a healthy weight, don’t smoke, do stretching and strengthening exercises that increase back and abdomen flexibility, and get regular cardiovascular exercise. If your job involves a lot of sitting, get up and walk around every 15 to 30 minutes.
  • Maintain good posture even while sitting. Don’t slouch or hold your head too far forward. Be sure your feet are supported, hips are level with or slightly above the knees and your spine is slightly reclined. There should be a small arch in the lower back.
  • When sitting at a computer, your shoulders should be relaxed and away from the ears. Your elbows should be at the sides, bent to about 90 degrees, and your wrists should be neutral — not bent up, down or away from each other. Your head should face ahead without being too far forward.
  • When using a mobile device for non-voice activities, hold it up instead of bending your neck to look down. At just 45 degrees, the work your neck muscles are doing is equal to lifting a 50-pound bag of potatoes.
  • When lifting, make sure objects are properly balanced and packed correctly so weight won’t shift. Keep the weight close to your body. And take your time. Bend at the hips and knees and use your legs to lift. Maintain proper posture with your back straight and head up.

Source : HealthDay

The 3-Step Guide to Beating Back Pain

Hallie Levine wrote . . . . . . . .

Aching lower backs, either acute or chronic, affect nearly half of healthy, active people older than 60, according to a February study in the Journal of the American Geriatrics Society.

“Lower back pain is one of the most common pain problems for older adults and one of the most frustrating because there are no easy fixes,” says Roger Chou, M.D., a professor of medicine at Oregon Health & Science University in Portland.

Traditional treatments such as opioid pain pills, steroid injections, and surgery are not necessarily very effective and can have significant downsides.

But some good evidence supports certain nondrug and nonsurgical options. That’s why 2017 guidelines from the American College of Physicians (ACP) recommend them—and suggest drugs or surgery only when other therapies fail.

That advice is backed up by a nationally representative Consumer Reports survey of 3,562 back-pain sufferers.

More than 80 percent who tried yoga or tai chi, massage therapy, or chiropractic said it had helped them, as did more than 60 percent of respondents who tried acupuncture or physical therapy.

But experts agree that a personalized plan is best. “Everyone responds to pain differently,” says Jack Ende, M.D., immediate past president of the ACP. “And what works for one person may fall flat in another.”

So which steps should you take when your back starts aching, and in what order? Here’s what the research and our experts recommend.

When Back Pain First Strikes

Back pain is considered acute when a new episode lasts for less than four weeks. If your back begins to hurt, experts suggest starting with the following:

Heat or ice. For instance, a warm shower, hot-water bottle, or heating pad can reduce pain. Ice may also feel good.

Gentle activity. It’s best to resume normal activity. (If you can’t, walk for a few minutes every few hours, Ende says.) If you’re able, try easy stretches. A 2017 Cochrane Collaboration review found that people with back pain who were told to stay somewhat active reported less discomfort and recovered faster than those advised to stay in bed.

OTC pain relievers if needed. While the ACP emphasizes nondrug measures, Ende says over-the-counter ibuprofen (Advil or generic) or naproxen (Aleve and generic) can be used for a week or two.

If You’re Still in Pain After a Week or Two

If you still have a lot of pain at this point, your doctor may provide a home-based exercise program or refer you to physical therapy for supervised exercise. (Some sessions are usually covered by insurance.)

PT may include massage or low-level laser therapy, but the exercise component is key. People who get PT within 90 days of the onset of pain get fewer imaging tests and questionable treatments, according to a study published in 2015 in the journal BMC Health Services Research.

After a month or two, you may feel well enough to get back to—or start—a normal exercise program.

And that’s important: People who have had lower back pain but are active are about one-third less likely to see it recur, according to a review published in 2017 in the American Journal of Epidemiology.

When Pain Persists for Months

For pain that continues even after a couple of months of home-based exercise or PT, the ACP recommends considering these (some may be covered by insurance):

Yoga and tai chi. They strengthen core muscles, relieving pressure on your back, says Benjamin Kligler, M.D., national director of the Integrative Health Coordinating Center for the Veterans Health Administration.

A 2017 Cochrane review of studies concluded that yoga improved back function. And research used as a basis for the ACP guidelines found that tai chi was useful for chronic back pain. It can also help with shorter-term pain, but it may take several weeks for you to see results, Kligler says.

Your doctor may be able to refer you to a local class for yoga (opt for a gentle form) or tai chi. YMCAs and fitness centers may also offer them.

Or find a list of certified instructors through the American Tai Chi and Qigong Association, the Yoga Alliance, or the International Association of Yoga Therapists.

Cognitive behavioral therapy or mindfulness-based stress reduction. If back pain has you feeling depressed or anxious, CBT—which focuses on circumventing negative thought patterns—may help. MBSR increases awareness and acceptance of pain with practices such as yoga and meditation.

Adults with chronic back pain who did either technique for 2 hours a week for eight weeks reported significant relief, according to a study published in 2016 in the Journal of the American Medical Association. Ask your doctor for the names of cognitive behavioral therapists, or check the website of the Association for Behavioral and Cognitive Therapies.

Spinal manipulation. Used by chiropractors, osteopaths, physical therapists, and some massage therapists, it involves moving the joints of the spine. A review published last year in JAMA found that spinal manipulation significantly improved pain and function for those with acute lower back pain. A Cochrane review concluded that it works as well as exercise, PT, or standard medical care for chronic back pain.

Check your health insurer’s website for licensed chiropractors and doctors of osteopathic medicine (D.O.), then ask your primary care doctor for a referral. (Our survey found that spinal manipulation is more likely than most nondrug treatments to be covered by insurance, at least partly.) Roger Chou at Oregon Health & Science University advises trying it for three to four weeks but moving on if it’s not helping.

Acupuncture. This involves inserting very fine needles into specific points on the body. “I usually have people with chronic back pain try a course of PT because it’s usually covered by insurance, and if that doesn’t seem to help, recommend they try acupuncture for six to eight sessions,” says Joseph Herrera, D.O., system chair for rehabilitation medicine at the Mount Sinai Health System in New York.

A large review of studies found that acupuncture outperformed sham treatment and no treatment for all kinds of chronic pain, including back pain. But it may cost you $100 or more per session. Make sure any acupuncturist you see is licensed by the state. Find listings on the National Certification Commission for Acupuncture and Oriental Medicine’s website.

What About Meds and Surgery?

If none of the above help or you’re in significant pain while starting a treatment like PT, a week or two of medication is reasonable, Chou says. The ACP recommends over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.

If you can’t take an NSAID or need stronger relief, consider the prescription pain pill tramadol (Ultram and generic) or the antidepressant duloxetine (Cymbalta and generic). Both have only a small effect on back pain, so you’ll need nondrug methods as well.

The nerve-pain drug gabapentin (Neurontin, Gralise, Horizant, and generic) is often prescribed for muscle pain, but research suggests that it’s not very effective and causes side effects such as dizziness.

And groups such as the ACP and the American Academy of Family Physicians strongly advise against the use of opioid painkillers such as oxycodone (Oxycontin and generic).

“These drugs are very problematic in seniors because they increase the risk of falls, as well as other concerns such as addiction and overdose,” Chou says.

Should surgery ever be an option? Only for persistent pain, numbness, and tingling that radiates down a leg from a herniated disk; severe or progressive weakness in a foot or leg; or spinal stenosis that hasn’t responded to therapies such as PT, Ende says. Even then, you can hold off if you’re seeing improvement.

Imaging Tests: When to Consider, When to Skip

You may be tempted to run to your doctor and request an X-ray or MRI for back pain. But that’s rarely helpful.

“One of the biggest misconceptions about these screening tests is that we can easily ID the cause from them,” says Richard Deyo, M.D., M.P.H., a professor of evidence-based medicine at Oregon Health & Science University. “The reality is, older adults usually have something that shows up on an X-ray or MRI, like worn-out or bulging disks. But oftentimes that’s not the cause of the problem.”

Consider imaging if you’ve had pain for six weeks and it’s not getting better, Deyo says. In that case, a pinched nerve may be contributing to the problem.

You should also contact your doctor immediately for an imaging test if you have back pain along with unexplained weight loss, a fever higher than 102° F, loss of bowel or bladder control, loss of strength or numbness in one or both legs, or a history of cancer. These may be signs of nerve damage, infection, or a tumor.

Source: Consumer Reports