Chronic Lower Back Pain Treatment

Use patient-friendly strategies to help guide treatment options

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Learning Scope #423
1 contact hour
Expires March 4, 2015

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide the latest information to nurses about chronic lower back pain treatment. After reading this article, you will be able to:

1. Describe the need to determine the cause of back pain before treatment is initiated.
2. Describe the various treatment options for chronic back pain in terms appropriate for patient education.
3. Discuss the latest evidence-based treatments for chronic back pain.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Back pain affects eight out of 10 people at some point during their lives, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). In addition, chronic back pain, defined as pain that lasts for more than three months, impacts up to 25 percent of the U.S. adult population. The most chronic back pain is in the lower back, which is caused by wear and tear.1

This article provides an overview and update on various treatments for chronic low back pain as well as resources for further study and a list of materials to share with patients.

A Symptom, Not a Diagnosis
James Smith, age 58, asked his neighbor Robert Gonzales, RN, to help him understand more about treatment options for chronic low back pain. He just returned from a consultation appointment with an orthopedic surgeon and was told he had intervertebral disc degeneration and may need surgery in the future. Mr. Smith told Robert he wasn't too keen on surgery and wanted more information about how he might prevent or at least postpone surgery. Robert agreed to help and told Mr. Smith he wanted to contact a colleague, Joyce Williams, RN, who had more experience treating patients with chronic back pain and he would come back to visit him early next week.

When Robert and Mr. Smith sat down for a discussion, Robert first shared that it is important to recognize that back pain is a symptom of a condition, not a diagnosis itself.1 He explained that appropriate treatment could not be suggested until the cause of the back pain was known.

Common causes of back pain include:

• mechanical problems such as intervertebral disc degeneration and ruptured or herniated discs
• injuries such as back sprains and fractured vertebrae
• certain conditions and diseases such as scoliosis, spondylolisthesis, some forms of arthritis and spinal stenosis, pregnancy, kidney stones, endometriosis and fibromyalgia
• infections and tumors of the back such as osteomyelitis, discitis and metastatic tumors
• emotional stress that causes tension in back muscles

Mr. Smith reminded Robert the orthopedic surgeon told him he had intervertebral disc degeneration. Robert shared with Mr. Smith that he had a good chance of caring for his back without the need for surgery. He pointed out a study where candidates for a lumbar discectomy (surgical removal of all or part of an intervertebral disc) because of herniated (slipped) discs choose not to have surgery fared similarly to those who had the surgery.2

Next, Robert explained to Mr. Smith that he could do a variety of things to ease his back pain but cautioned him these were not cures. He listed application of heat or cold, exercises, traction, lumbar supports (corsets and braces), and lifestyle modifications.1

Mr. Smith said he had some relief from the use of ice and knew it worked by reducing inflammation. He asked Robert what type of exercises might help him. Robert explained evidence showed specific back exercises that stretch and strengthen the muscles of the back, abdomen and buttocks provided enhanced structural support, reduced back stiffness and improved range of motion. He also related that aerobic exercises such as brisk walking, jogging and swimming help with weigh control and increase general circulation. Robert cautioned that not every exercise works for everyone.

For example, some individuals, especially those with disc disease, may be harmed by exercises that include twisting, vigorous forward flexion, heavy lifting or high-impact activities.1 Robert suggested Mr. Smith work with his primary care clinician and a physical therapist to determine which exercises would benefit him most.

Mr. Smith asked about the use of traction. Robert explained traction increases the space between the vertebrae, allowing a bulging disc to slip back into place, thus relieving pain. However, pain often recurs after traction is removed and no evidence shows traction provides any long-term benefits.3 Robert also shared that lumbar supports may be helpful for a short time after injury or surgery; however, there was insufficient evidence to suggest they help with chronic low back pain.4

Mr. Smith expressed a keen interest in learning how lifestyle modifications might help him avoid surgery. Robert told him of his conversation with Joyce, who shared that lifestyle modifications often are more effective than either physical therapy or medical treatments. Avoiding heavy lifting, pushing or pulling; regular general exercise; relaxation; and regular sleep have proven helpful in the relief of back pain. In addition, dropping bad habits, such as smoking and eating poorly, also can help.5

Robert explained getting enough rest does not mean staying in bed. NIAMS recommends individuals with back pain should not stay in bed for more than two days as this can make it worse.1 Robert continued by explaining getting enough rest means making sure you get adequate sleep and resting between periods of activity.

Medications
Next, Robert and Mr. Smith talked about medications to help relieve chronic low back pain.1 Many people take over-the-counter analgesics, such as acetaminophen and aspirin, as well as nonsteroidal anti-inflammatory drugs (NSAIDs). Others need prescription medications, such as oxycodone with acetaminophen (Percocet) or hydrocodone with acetaminophen (Vicodin) for persistent severe pain or when pain flares up. Topical analgesics such as prescription lidocaine patches also are used.

Robert explained that although NSAIDs can be useful in treating back pain, they may cause stomach irritation which can lead to serious GI problems, including ulcers, bleeding and perforation of the stomach or intestine. Robert suggested he use topical NSAIDs (such as Pennsaid and Voltaren gel) and/or salicylates (such as Aspercreme, Bengay and Flexall) if he experienced GI distress.

Mr. Smith asked Robert about capsaicin cream for pain relief. Robert explained that over-the-counter creams have varying strengths and formulas and may not provide relief. He then told Mr. Smith about Qutenza, an 8% high-concentration capsaicin patch.6 It shows promise in providing pain relief and might be an option for him. Robert suggested Mr. Smith speak with his healthcare clinician about using Qutenza, as he would need a prescription to try it.

Physicians also prescribe other medications, such as muscle relaxants and certain antidepressants, for chronic back pain. Robert also advised Mr. Smith to work with his primary care clinician to make sure he has regular blood tests to check for any problems his medications may be causing to his kidneys or liver.

Mr. Smith then asked about injectable medication, saying a friend of his has had them. Robert described the three main types of injections used to treat back pain:1

• nerve root blocks of steroid or anesthetic medication used to relieve inflammation or compression of a nerve as it passes from the spinal column between the vertebrae
• injections of the facet joint (where the vertebrae connect to one another)
• trigger point injections or injection of an anesthetic or combination anesthetic and steroid into painful areas of the back

Robert talked with Mr. Smith about the use of botulinum toxin injections (Botox, Lantox, Myobloc and Neurobloc) for pain control. He shared that the FDA has not approved the use of botulinum toxin injections for low back pain, and because of this, the safety and effectiveness of these injections still are open to question. Even though some people may report relief from these injections, more research needs to be done to determine how effective it is in the larger population.7

The downside to injection therapy is it is often difficult to find and inject the correct nerve for a nerve block; the effectiveness of facet joint injections is not well-documented and it might be overused; some studies suggest trigger point injections provide no more relief than "dry needling" (inserting a needle without injecting medication).1 Robert also noted a Cochrane Collaboration group reviewed 18 randomized controlled trials of injection therapy for back pain and concluded no strong evidence exists for or against the use of injection therapy for individuals with subacute or chronic low back pain, and advised that more research be conducted.8

Robert wanted to make sure Mr. Smith had all the information about injection therapies, so he discussed a newer therapy called prolotherapy injections, or the use of repeatedly injecting ligaments with compounds such as dextrose and lidocaine to cause a controlled acute inflammation. The aim of this therapy is to make the ligaments stronger and thus better able to support the low back. Joyce had provided Robert with some information about prolotherapy that concluded usefulness for chronic low back pain is still unclear.9 Robert suggested Mr. Smith spend some time learning more about injection therapy before deciding whether he thought this might be helpful for him.

Complementary & Alternative Treatments
Next, Robert shared with Mr. Smith some of the recent data about the effectiveness of using complementary and alternative treatments. Joyce had provided information that spinal manipulation, a procedure in which professionals use their hands to mobilize, adjust, massage or stimulate the spine or surrounding tissues, can be effective for people with uncomplicated pain, especially when used with other therapies. Robert cautioned Mr. Smith that spinal manipulation is sometimes contraindicated in people who have osteoporosis, spinal cord compression or rheumatoid arthritis, or are taking blood-thinning medications such as warfarin (Coumadin) or heparin.10

Robert also said studies of transcutaneous electrical nerve stimulation (TENS) show that not only do these devices discharge mild electrical impulses to nerves that modify the perception of pain, they also might elevate the levels of endorphins in the spinal fluid.1 Mr. Smith had not heard of a TENS unit before, so Robert explained it was a small battery-operated unit that when connected to the skin by electrodes delivers electric current that stimulates nerves for therapeutic purposes, such as pain relief.

Robert and Mr. Smith then discussed the use of massage and acupuncture as treatments for chronic low back pain. Robert explained various types of massage, including strong pressure on deep tissues in the back to relieve tightness of the fascia (Rolfing), have successfully treated chronic back pain. In a review of 13 randomized trials assessing various types of massage therapy for low back pain, researchers found massage to be most effective if combined with exercise, especially stretching exercises, along with education. Massage benefitted individuals more than joint mobilization, relaxation, physical therapy, self-care education or acupuncture. Deep tissue work and acupressure or pressure point massage techniques provide more relief than Swedish massage. Some people reported being sore after a massage session.11

Robert related that acupuncture, or the insertion of thin needles at precise locations in the back, may foster the production of the body's natural pain relievers, such as endorphins, serotonin and acetylcholine. Acupressure, or the use of pressure instead of needles, also is used to treat back pain. However, more research needs to be done to show its usefulness.12 Acupuncture as well as dry needling are slightly more effective for pain relief when added to other conventional therapies.1

Back Surgery
Robert told Mr. Smith all back surgery is done to relieve pressure on the spinal cord or nerves or to stabilize the back. The Mayo Clinic advises back surgery is needed in only a small percentage of cases. Those contemplating back surgery should seek a second opinion from a qualified spine specialist. Spine surgeons hold differing opinions about when to operate, what type of surgery to perform and whether surgery is even warranted.13

Robert listed the surgical options in case they may be needed in the long term. He explained back surgery usually is needed if spinal nerves are compressed, causing severe back pain or numbness along the back of the leg; bulging or ruptured (herniated) discs cause persistent pain; or the spinal column becomes unstable. Robert explained the most common surgeries for herniated discs include:1,13

• Laminectomy: Surgeons remove the bone that makes up the back portion of the spinal canal (lamina), thereby enlarging the spinal canal and relieving pressure on the nerve.
• Discectomy: Surgeons remove all or part of the strong but flexible structures (discs) that cushion and separate the small bones of the spine (vertebras). This usually requires a full or partial removal of the lamina. Microdiscectomy is like the traditional discectomy, but the incision is much smaller and a magnifying microscope or lens is used to locate the disc through the incision. The smaller incision may reduce pain and the disruption of tissues, and it reduces the size of the surgical scar.
• Laser surgery: Surgeons insert a needle in the disc that delivers a few bursts of laser energy to vaporize the tissue in the disc. This reduces its size and relieves pressure on the nerves. More research is needed as the results vary widely.

Robert then explained other surgeries might be needed by those with low back pain:1,13
• Spinal fusion: Surgeons remove all or part of a damaged disc and join the vertebra above and below it with small rods, wires or brackets, stabilizing the back.
• Vertebroplasty: Surgeons inject bone cement into compressed vertebrae to stabilize fractures and relieve pain.
• Kyphoplasty: Surgeons insert balloon-like device into compressed vertebrae to attempt to expand them before bone cement is injected.
• Artificial disc implantation: Surgeons place artificial discs between two adjacent vertebrae.

Research on additional treatments includes intradiscal electrothermal therapy (IDET). This less invasive surgery, which is done as an outpatient procedure, involves threading a wire through a small incision in the back and into a disc. An electrical current is then passed through the wire to heat the disc and strengthen the collagen fibers that hold the disc together. After the procedure, the wire is removed and patients can return home. Patients report pain is relieved within a few days and may last for up to six months. The long-term side effects of IDET are not known at this time.1,14

After their discussion, Mr. Smith thanked Robert for his help and said he felt much better prepared to take care of his back. Robert suggested they meet up again in about two weeks to review what they had talked about and to check on Mr. Smith and if he had any questions.

Robert recognized many patients are unsure about treatment options and that by talking with a healthcare provider, they can understand their condition and treatment choices better. It also helps patients become a more willing and capable partner with their primary care provider in working toward optimal health.

References
1. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Back Pain Handout on health: back pain. http://www.niams.nih.gov/health_info/back_pain/default.asp

2. Weinstein JN, et al. Surgical vs. nonoperative treatment for lumbar disc herniation. JAMA. 2006;296(20):2451-2459.

3. Clarke JA, et al. Traction for low-back pain. http://summaries.cochrane.org/CD003010/traction-for-low-back-pain

4. van Duijvenbode I, et al. Lumbar supports for the prevention and treatment of low-back pain. http://summaries.cochrane.org/CD001823/lumbar-supports-for-the-prevention-and-treatment-of-low-back-pain

5. Henschke N, et al. Behavioral treatment for chronic low-back pain. http://summaries.cochrane.org/CD002014/behavioural-treatment-for-chronic-low-back-pain

6. Anand P, Bley, K. (2011). Topical capsaicin for pain management: therapeutic potential and mechanisms of action of the new high-concentration capsaicin 8% patch. Br J Anaesth. 2011;107(4):490-502.

7. Waseem Z, et al. Botulinum toxin injections as a treatment for low-back pain and sciatica. http://summaries.cochrane.org/CD008257/botulinum-toxin-injections-as-a-treatment-for-low-back-pain-and-sciatica

8. Staal JB, et al. Injection therapy for subacute and chronic low-back pain. http://summaries.cochrane.org/CD001824/injection-therapy-for-subacute-and-chronic-low-back-pain

9. Dagenais S, et al. Prolotherapy injections for chronic low-back pain. http://summaries.cochrane.org/CD004059/prolotherapy-injections-for-chronic-low-back-pain

10. Rubinstein SM, et al. Spinal manipulative therapy for chronic low-back pain. http://summaries.cochrane.org/CD008112/spinal-manipulative-therapy-for-chronic-low-back-pain

11. Furlan AD, et al. Massage for low-back pain. http://summaries.cochrane.org/CD001929/massage-for-low-back-pain

12. Furlan AD. Acupuncture and dry-needling for low back pain. http://summaries.cochrane.org/CD001351/acupuncture-and-dry-needling-for-low-back-pain

13. Mayo Clinic. Back surgery: when is it a good idea? http://www.mayoclinic.com/health/back-surgery/HQ00305

14. American Academy of Physical Medicine and Rehabilitation. Intradiscal electrothermal therapy (IDET). http://www.aapmr.org/patients/conditions/msk/spine/Pages/IDET.aspx

Nurse Resources
1. MedlinePlus: http://www.nlm.nih.gov/medlineplus/backpain.html#cat1

2. North American Spine Society: http://www.knowyourback.org

3. American Academy of Physical Medicine and Rehabilitation: http://www.aapmr.org

4. American Academy of Orthopaedic Surgeons: http://orthoinfo.aaos.org/topic.cfm?topic=A00560

5. Mayo Clinic: http://www.mayoclinic.com

6. National Institute of Arthritis and Musculoskeletal and Skin Diseases: http://www.niams.nih.gov

Patient Resources
1. MedlinePlus. Back exercises and back pain - how to prevent: http://www.nlm.nih.gov/medlineplus/tutorials

2. American Academy of Orthopaedic Surgeons. Preparing for low back surgery: http://orthoinfo.aaos.org/topic.cfm?topic=A00597

3. National Institute of Arthritis and Musculoskeletal and Skin Diseases: http://www.niams.nih.gov

Joan M. Lorenz is a clinical specialist in psychiatric mental health nursing for adults. Throughout her career, she has held a variety of clinical positions, including patient safety manager, nurse manager, staff development educator and patient education coordinator. She currently provides consultation and workshops on a number of issues designed to empower work teams to make changes needed to put more joy in their work environments.




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