Low Back Pain

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Chronic (lasting > three months) low back pain is a common health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) like Advil, Aleve, etc. are often used to help relieve the pain, as is a sub-class of NSAIDs called COX-2 inhibitors (Mobic, Celebrex). NSAIDs and COX-2 inhibitors are among the most prescribed medications. Most clinical practice guidelines recommend short-term use of these medications for pain relief in patients with low back pain, however their effectiveness remains unclear. Recently a summary review of studies performed to evaluate NSAIDS and relief of back pain was published.

The review looked at 13 studies performed between 1981 and 2013. These studies compared pain relief from NSAIDs and COX-2 inhibitors vs. placebo, paracetamol (Tylenol), pregabilin (Lyrica), tramadol, and home-based exercise. The studies measured primary outcomes in pain intensity, overall improvement, back pain-specific functional status, and adverse events. The studies found by and large low-quality but positive evidence that NSAIDs did provide some relief of low back pain and did mildly improve the functioning ability of those with low back pain. Four studies measured improvement in disability. Again low-quality evidence was found that NSAIDs were associated with greater benefit than placebo for the outcome of disability. Six studies looked at adverse events and found that NSAIDs were not associated with higher rates of adverse event vs. placebo, however these studies were short and may have underestimated the rates of adverse events. One study looked at home-based exercise and found that disability improved but pain did not.

Because of the risk of adverse events like gastrointestinal bleeding and kidney dysfunction, the European Guidelines of the Management of Chronic Low Back Pain recommends using NSAIDs for no longer than three months, while the American College of Physicians and the American Pain Society guidelines on chronic low back pain recommend the shortest duration possible. Low back pain that does not extend below the buttocks, also known as mechanical back pain or lumbago, usually resolves by itself over time. How traditional medicine treats low back pain and especially more complicated back problems like sciatica and lumbar radiculopathy is becoming more, rather than less, problematic. Traditional treatments like microdiscectomy and lumbar fusion are increasingly being found to have limited benefit over the long term. Disc arthroplasty, where the problematic disc is removed and an artificial disc is inserted, once thought to be a bright ray of hope for pain relief has not lived up to its high hopes so far. Epidural steroid injections, while often prescribed and performed, usually give limited short-term pain relief, if they even work at all. Insertion of a spine stimulator may offer some help, but problems like infection of the inserted device are not uncommon. Narcotic medications for relief of back pain are never recommended, at least initially, due to their side effects and the high risk of addiction, abuse, and diversion.

So for the time being the use of NSAIDs and COX-2 inhibitors is still recommended, at least in the short term, with home exercise and/or physical therapy, and more research is needed to find ways to help those afflicted with chronic low back pain.

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