Low Back Pain Flashcards
How common is back pain?
Very common
What is back pain likely due to?
Osteoarthritis
Muscle Strain
Hip Joint Problem
Sciatica
Osteoporosis
Slipped Disk
realm of MD, physio and chiropractor
Describe what an osteoarthritic spine?
- Bone Spurs
- Narrowed disks
- Knee/hand joints likely have OA to
What is responsible for lower leg numbness?
- Sciatica nerve firing at the wrong time
- Numbness from the lower back down the whole leg
- NSAID’s are not good for neuropathic pain
Signs of Osteoporosis
- Shortened height
- Stooped or hunched over
- Have developed back pain
With increased age, what is common?
Compression fractures are common with age
See abrupt onset of back pain, but many can be asymptomatic
Conditions for referred pain in the back area?
disorder of large bowel
dysmenorrhea
renal condition
prostate
urinary tract infection
What is the etiology/common causes of back pain?
Sedentary Lifestyle
Bursts of activity/improper lifting
Pregnancy
Poor Posture
Bad Shoes
Excess Weight
Is the cause of back pain usually identified?
NO
- most likely cannot recall a specific possible cause
Chronic low back pain may be due to what muscles….
Spinal Column muscles
Abdominal Muscles
Glutes
What are two major causes of back pain?
Inactivity and heavy lifting
Is there a psychological aspect of back pain?
Pain Amplifier - If think will not get better, make things worse
Is the cause usually idetnfied?
No –> MD’s rule out red flags
Are X-rays useful for back pain?
No
X-rays find stuff. In the analysis of this stuff, as backs get older, you will find things (kinicks and bruises but the vats majority is not the reason for the pain)
What is the risk of X-rays? When should they be used?
Substantial risk of uncovering irrelevant misleading findings
If Red Flags are absent, delay radiology until 6th week of conservative (inc drug) management
What are the sx of lower back pain?
tightness in lower back / muscle spasm (bodys way of protecting from injury)
difficulty bending, moving, sitting
Questions to ask:
How long has it been?
When worse? Better?
Shooting?
Dull?
Constant?
Back pain vs leg pain?
Any numbness?
- Not helpful to us. Do not get the chance to reproduce
In chronic cases, the pain origin is more likely….
Neuorpathic –> NSAID will not work
Nociceptive –> NSAID may work
What is neuropathic pain?
Damage to or dysfunction of the nerves
- Burning or tingling
- Ruptured intravertebral disk
What is nociceptive pain?
Injury to body tissues
- Most pain is nociceptive
- Aching, sharp, or throbbing
Sciatica is what type of pain? Are NSAIDs useful?
Sciatica = neuropathic
NSAIDs and opitaes are not that great of agents
What is one question that is very important to ask about back pain?
What have you tried so far?
Are most cases a serious medical problem?
NO
What is a pharmacists role in back pain?
Safe med use
- Recommend phsyio and massage
Red Flags. When to refer?
Pain located high in spine (beyond a sore neck) - 2 days
Trauma (esp. fall from height) - ASAP
fever, chills, unexplained weight loss - ASAP
Pain worse when laying down/sleeping - 2 days
Numbness in bum area - ASAP
Bladder/Bowel Dysfunction - ASAP
Young Kids/Elderly - Make appt (chronic), 2 days for acute
Leg > back Pain - Make appt
Increasing pain - 2-7 days
Oral steroid usage - ASAP
No TIGERS FIND LIONS, NOTHING BEATS ALPHA LIONS IN OHIO
One red flag has a what % chance of being something serious?
10%
What should a patient try to fix first?
How to Sleep/Stand
Balance of back/abdom muscles (spine moves in direction of stronger muscles)
How does the spine move?
The spine moves in direction of the stronger muscles
When do cases of back pain get better?
Most get better on their own –. Most resolved by 3 months
How much rest should a person have post-injury?
Rest - Old thinking
Return to Normal Activities - Current thinking (may seem counter-intuitive to most pt’s)
Exercise –> Not our domain
What is a typical patient of back pain?
Not have any red flags
Will be >40
Long history of back pain
Acet Back Pain
Analgesia, but not anti-inflamm
Not efficacious for back pain
ASA for Back Pain
Not common, but a very good agent
- ASA brings it at OTC doses, the other guys do not
Analgesia and anti-inflammatory
Ibu for Back Pain
- Analgesia
- Questionable for anti-inflammatory at OTC doses
Naproxen for Back Pain
- Analgesia
- Questionable for anti-inflamm at OTC doses
To achieve anti-inflammatory actions of NSAID’s, one needs
HIGHER DOSES –> RX territory
What is often used in patients?
Stronger prescribed NSAID’s are often used in many patients
What are skeletal muscle relaxants?
Sedation –> Not well known
- Sedation in brain; not in muscles
- Do not appear to be anti-spasmodic
What are s/e of muscle relaxents?
CNS s/e (sedation, dry mouth, constipation)
Are muscle relaxents useful?
NOT EFFECTIVE
Example of Muscle Relaxent and Product
Methocarbomol - Robax
What are some muscle relaxents? Do we care which ones?
Methocarbamol
Chlorzoxazone
Orphenadrine
Methocarbamol
Do not care which one. All bad.
As a pharmacist, we should recommend (oral stuff)
Plain analgesic (main)
Muscle relaxent (No)
Combo (if pt wants, need analgesic in there)
Does the muscle aches and body pain label have different ingredients?
No –> if pt says works for them, good enough
What is another thing we should recommend as pharamacists?
Heat and cold
When should cold be used?
First 48 hours
In the first 48 hours ______ should used
Cold
If chronic or recurring episode of low back pain ______ is recommended. What is its benefit?
Heat
Heat can be anti-spasmodic
Cold should be used for…..
Acute Injury
Heat should be used for…..
Chronic Injury
How many times a day should heat be used?
2-3 times a day for however long you can
- Every 2-3 hours
What is the MOA of topical external analgesics?
Counter-irritation
Massage/blood flow
Psychological (odour)
Is voltaren a topical external analgesic?
NO
Where are external topical analgesics more effective at?
More effective on larger muscles and sore muscles rather than back pain
What are the two agents in external topical analgesics?
Methyl Salicylate
Menthol
How does menthol work?
First 1/2 –> menthol hits cool receptors (not actually lowering temp)
After 1/2 hour –> Becomes warmth
What is the % of menthol for what purpose?
<1% - anti-itch
> 1% - Counter irritant
What is an important counselling tip to tell a patient with topical external analagesics?
Don’t use a heating pad at same time with any of these products!
Is lidocaine used for back pain?
No –> Numbing agent
Does not get deep into the skin
What is used for neuropathic pain? Is it useful?
Capsaicin
- Gnerally for post-herpetic neuralgia (post-shingles)
- Needs continous use to decrease substance P
- Irritating when applied
DOC for Back Pain
Topical Diclofenac
1% - TID or QID
Extra Strength - BID
May be drug of choice in patients > 75 yo if not younger
What is the algorithm for back pain?
Topical Diclofenac
Standard (Oral)
Rub A535
Topical diclofenac has more proof for….
More proof for OA knee and hand than back area
Topical Diclofenac vs. NSAID’s
Less side effects than oral NSAIDs. Little systemic absorption
Topical Diclofenac Amount to Use
1 FTU
What is the only herbal that may be useful for back pain?
Tumeric
is glucosamine useful for back pain?
NO
- A disease modifying agent –> Only works on synovial joints
- No synovial joints in the back
Is tumeric the actual agent or not?
Curcumin –> Active ingredient
Turmeric –> Delivery device
What is the amount of curcumin used for releif of pain in arthritis?
1-2 g
Are back braces useful for back pain?
In 2-3 weeks, gait may be changed that can cause wrong relaxation of the wrong muscles
If walking around, should be unsinched –> will not affect the gait if unsinched
Are opiods good for back pain?
NO
What is cyclobenzaprine?
- Blocks nerve impusles
- MD realm not us
- Relief of muscle spasms
Cyclobenzaprine Length of Usage
Short periods (up to two or three weeks)
What are some s/e of cyclobenzaprine?
Drowsiness, dry mouth, fatigue
Antidepressants use in Low Back Pain
Amitryptyline –> Neuropathic Pain
- SNRI’s and TCA’s
