Faisel Zaman, MD
Managing acute back or neck pain flare-ups are a challenge faced by the majority of the population at one point or another. Back pain is the most common physical condition for which patients visit their doctor. (United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Fourth Edition, forthcoming. Rosemont, IL. Available at http://www.boneandjointburden.org. Accessed on 11 November 2018.) How to handle these challenging situations are a dilemma faced by many.
Acute back pain is pain that has been present for four weeks or less.1 Pain flare ups can occur from aggressive activities and from seemingly minor incidents as well. Heavy lifting, motor vehicle collisions, playing with and caring for a child, sporting injuries, coughing or sneezing, household chores, and even taking the first step out of bed in the morning are all common inciting events patients have described. Because of the debilitating nature of the pain, I have had patients mention an inability to get out of bed, or off the floor for hours. Some have called ambulances to get them to the emergency room for urgent care.
Generally speaking there are two rooms people should stay out of when dealing with acute pain; the emergency room, and the operating room. Fortunately, true spine emergencies are rare, though must be considered in cases of significant trauma, recent spine surgery, or loss of nerve function. Because of this, some hospital centers have developed “walk in spine clinics” that are often managed by a “mid-level practitioner”, generally a nurse practitioner or physician assistant, sometimes with physical therapy involvement. This model has been developed with the intention of optimizing care and minimizing cost, while trying to keep people from going to the ER every time a debilitating flare up of acute pain were to occur.
How should one manage acute back or neck pain flare-ups then? First, understanding that the flare-up will usually subside is paramount. As my eighth grade English teacher told me, “All Things Pass”. This adage holds true with acute back pain as well. Most flare-ups will resolve on their own and many people will not seek any medical care.1, 2 In the primary care setting, clinicians provide reassurance, which can help with the pain related anxiety that is often associated. Pain and anxiety can perpetuate each other, and managing both is important, preferably without medications, whenever possible.
When treatment is necessary, it is helpful to classify possible treatments as medication-based or non-medication-based. A variety of non-medication-based treatments are available. For example, both heat and cold have been proposed as potential pain-relieving modalities. While cold helps control inflammation and decrease swelling, it can also cause increased muscle tightness and potentially subsequent spasms. While heat can help increase blood flow and decrease muscle tightness and spasms, it can also increase swelling and inflammation in certain cases. One guideline has documented a superficial heat-wrap to improve pain and disability when compared to a placebo.1 However, it can be reasonable to try both.
Decades ago, bed rest was advocated for back pain flare-ups. We now know that bed rest can cause significant deconditioning, very quickly, and especially in the elderly population. This can make remobilizing after the flare up has subsided very challenging, and impact the long term outcome. Furthermore, in the workers compensation literature, we know that the longer one stays out of work, the less likely they are to return successfully. In contrast to bed-rest, exercise has also been proposed as a treatment for back pain. Exercise has been shown to have a beneficial effect on chronic low back pain, and even more beneficial; exercise has been shown to help prevent back pain as well.1, 3 Of course, regarding exercise and activity, remember to use common sense and let pain be your guide. For example, if you consistently hurt your back doing dead-lifts in the gym, you may be best-served by finding another exercise to do.
What about a neck brace or lumbar support brace or support belt? Dynamically speaking, the joints of the spine are supported by the surrounding structures. These include muscles and ligaments. Keeping these muscles and ligaments in the best possible shape is paramount in assuring as complete and swift a recovery as possible. While support devices can and should theoretically provide some symptomatic relief, by decreasing the workload on these integral supporting structures, they do so at the expense of conditioning. Research has proven that integral core spinal muscles weaken, and shrink or atrophy, in response to support brace usage. The result is a dependency upon these devices, and subsequent persistent chronic pain syndromes can develop. If they are going to be used at all, they should be used intermittently, and judiciously for very short intervals. Despite being studied, data has not emerged to suggest that they may help with pain or function.1
When should you see a physical therapist or chiropractor? If symptoms fail to improve, seeing one of the above could help dramatically. Their access to various modalities as well as massage, manipulation and other techniques such as guidance on strengthening and stretching can be beneficial. In all cases, patients should be given a home exercise regimen, and that regimen needs to be maintained in order to optimize spinal musculoskeletal health. It is important to understand that physical therapists and chiropractors are not the same. Patients are encouraged to do their research to find out which may be best for them, and asking a medical doctor for a referral can be helpful as well, and in some cases, required. Although they have not been well-studied, other treatments available include inversion tables, cupping, magnet therapy, and acupuncture.
In addition to the non-medication treatments discussed above, there are also medication options which may be effective. What are the best medications to use during an acute pain flare up? There are a number of oral medications that can and should be considered if the symptoms are too difficult to manage despite implementation of the conservative strategies above. Regarding over the counter medications, often abbreviated as “OTC meds”, first line considerations include acetaminophen, and a group of medications called non-steroidal anti-inflammatory drugs, also known as “NSAID’s”. The most commonly used NSAID’s are ibuprofen and naproxen. Ibuprofen is also known by the trade names Advil and Motrin, and naproxen is also known by the trade name Aleve. Given their similar mechanisms of action and side effect profiles, only one NSAID should be used at a time. Acetaminophen can be used in conjunction with NSAID’s, if needed, and is often mixed with far more dangerous drugs called “opioids” in various prescription formulations. Opioids deserve special discussion, and have been at the root of America’s deadliest drug-epidemic, and should considered with only the greatest of caution. Acetaminophen alone has been shown to be a good pain reliever.
Generally speaking, pain is often associated with some degree of inflammation. Hence the benefit of anti-inflammatory medications. The strongest anti-inflammatory medications known to man are steroids, but the side effect profile of these strong medications makes it unwise to use them if other options exist, and consequently, they are available by prescription only. If adequate improvement has not been obtained and acute pain is persisting despite oral NSAID’s and other strategies above, various steroid formulations can be considered under the guidance of a physician, and can be administered by the injection route, in addition to the oral route.
When considering oral medications, looking at the big picture is important, as always. For example, other medical conditions matter, and a patient with diabetes and poor kidney function should not be offered NSAID medications such as ibuprofen or naproxen, given the impact of these medications on the kidneys. Caution needs to be exercised when considering steroids as well, given the temporary, but potentially significant impact on blood sugar in this patient population. Another example would be a recovering alcoholic patient with liver damage, or any patient with elevated liver enzymes. They should minimize usage of medications that are metabolized by the liver, such as acetaminophen, or opioids, which are known to be hepatotoxic, or potentially damaging to the liver. Still another example is an elderly patient at a high risk of falls on a muscle relaxer. Nearly all muscle relaxers are associated with some degree of sedation, which can dramatically increase the risk of falling and its associated potential complications, such as hip fracture.
Above all else, remember the words of my eighth grade teacher, Mr. Brogan, who said that “all things pass”. Hopefully this adage will help minimize anxiety, decrease health care expenses, and keep you and your family and friends out of the ER and the OR.
1. Qaseem A, Wilt TJ, McLean RM, Forciea M, for the Clinical Guidelines Committee of the American College of P. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the american college of physicians. Ann Intern Med. 2017.
2. Carey TS, Evans AT, Hadler NM, Lieberman G, Kalsbeek WD, Jackman AM, et al. Acute severe low back pain. A population-based study of prevalence and care-seeking. Spine (Phila Pa 1976). 1996;21(3):339-44.
3. Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(2):199-208.