This article serves as a natural follow-up to the article “What Causes Low Back Pain?” begin to answer what treatment options are available for low back pain. These options can be split into surgical and nonsurgical treatments. This article will begin to focus on the latter. Nonsurgical treatments can again be split into three categories: therapies, medications, and injections. We shall start by taking a look at the first two of these in more depth.
I use the term therapy to broadly describe anything that is not a medication or an injection. The mainstay of these options is traditional physical therapy but other treatments in this category include chiropractic care, therapeutic massage, acupuncture, dry needling, and any other non-invasive, non-medicinal treatments available from a healthcare provider or at home such heating/cooling therapies, bracing, TENS unit, therapeutic ultrasound, inversion/decompression, etc.
When we think about back pain or even most chronic pain syndromes, one of the main causes can be repeated suboptimal use of a body part that leads to chronic wear on that part as well as the parts that connect to it. As time goes on, this wear leads to degradation of the part and either subsequent pain on its own or increased risk of injury (injury which will lead of course to pain). As an example, sitting daily in front of a computer for years with poor posture through the spine will add stress to the musculature, ligaments, and tendons. Combine this poor posture with a lack of strength through the core muscles and we have a recipe for disaster. Physical therapy aims to fix suboptimal use as seen in this example by correcting postural problems and improving the strength of the muscles around the affected area. For most muscular issues, physical therapy represents the best chance at a long term solution. Additionally, it can help remove pain from the muscles from the overall pain state making it easier to determine the non-muscular pain source (e.g. joint, nerve). Finally, strengthening these muscles and improving posture will also help to slow down the wear and tear present in the joints, discs, etc. This strengthening and slowing of the wear and tear helps to impede the progress of issues related to these structures.
Non-medicinal muscle relaxation:
Many of the other “therapy” options aim to treat the symptoms of muscle pain. They can be helpful in making participation in physical therapy less painful and therefore more beneficial. Some of the first options tried by patients prior to seeing a spine specialist include massage and heat which both work to improve blood flow to the muscles and help release tension. Dry needling seeks to break up the tense muscle by inserting small needles into the muscle belly repeatedly. It is commonly done by physical therapists or other healthcare professionals. A TENS unit is an electrical device that connects to adhesive pads placed on either side of the painful muscle. The device then sends an electrical signal that travels between the pads which stimulates the muscle to contract and relax. The repeated contraction and release helps the muscle to relax. Additionally, similar to rubbing your elbow after hitting your “funny bone”, the sensation of feeling the muscle twitch and release will “muddy” the pain signals as they travel up the spinal cord to the brain such that the pain signals become less severe.
This or decompression therapy is a topic that comes up often. It entails a device that uses your own body weight via gravity or traction from the device to stretch the spine. It is low risk which stands as a positive for the treatment. Some patients with a bulging or herniated disc have found it to be helpful in combination with physical therapy. The evidence for the use of inversion/decompression is mixed, however, because they are so low risk, there is little reason not to try it if the opportunity arises (e.g. a friend’s device, a good return policy). Most chronic low back pain patients find that their pain can be helped while on the device but that their symptoms return abruptly after getting off of it.
There are multiple types of non-opioid medications including acetaminophen, NSAIDs, local anesthetics, steroids, muscle relaxers, anti-seizure medications, and antidepressants. We will look closer at each of these in turn.
This could be acetaminophen (Tylenol) and NSAIDs (non-steroidal anti-inflammatory drugs; e.g. ibuprofen, naproxen, meloxicam) are generally the first medications tried by a patient. There are prescription versions of NSAIDs which are easier to take because they are a larger dose that requires fewer daily pills. The total dose of acetaminophen should be strictly adhered to and even lowered in the case of those with liver or kidney disease but otherwise have relatively few cautions. NSAIDs should not be taken consistently over long periods of time due to their ability to cause stomach issues (ulcers), kidney issues, and they can increase the risk of a heart attack or stroke.
These include local anesthetics and analgesics (e.g. lidocaine, menthol) in the form of patches and creams that can help soothe minor aches and pains. They do a better job of helping pain that is closer to the skin surface. There are topical formulations of NSAIDs as well that can be useful for joint and muscle pains. Their main side effect is irritation to the skin from adhesives or other ingredients in the medications.
Steroids come in a variety of formulations but for this discussion we will look at short courses of oral steroids. The main goal is the reduction of the inflammation in and around joints, muscles, and/or nerves. The negative side effects include elevations in blood sugar levels, immune system depression, decreased bone density, weight gain, flushed skin, restlessness, and/or agitation. The elevation in blood sugar is unavoidable but generally only of concern for patients who are diabetic. If the flushing reaction with restlessness or agitation occurs it generally ceases within 24 hours. The other effects are usually only of concern when large doses of steroids are given over a long period of time which is why your physicians will limit the total amount of steroid you receive.
Muscle relaxers like cyclobenzaprine and tizanidine work in a myriad of ways to help relax the muscles. As previously discussed, other sources of pain can lead to tension and pain in the muscles as well. Therefore, these medications can be helpful even if the muscles themselves are not the main problem. Their main side effect is sleepiness or drowsiness. For this reason most patients prefer to take these medications at night. This will not affect everyone the same and will even vary between the different medications.
(e.g. gabapentin, pregabalin) are useful in the treatment of nerve pain and/or numbness and tingling. They may have some benefit for other sources of pain as well. They work to calm the irritated nerves so that they do not send as many pain and irritated signals. Given that they work on all nerves in the body, their main side effects include sleepiness or drowsiness. They can lead to weight gain as well. These medications must have their doses slowly increased and should not be stopped abruptly.
Medications like duloxetine and nortriptyline are useful both in the treatment of nerve pain as well as arthritic joint pain. They work by changing the level of a chemical in your body that affects how pain signals are sent and how strong these signals are. They also have a tendency to cause sleepiness and/or drowsiness and should not be stopped abruptly at higher doses. Most healthcare professionals are familiar with the use of anti-seizure medications in the treatment of nerve pain and irritation. There is however, still some confusion even among physicians and pharmacists about the use of certain antidepressants in the treatment of pain. This can lead to patient confusion when these medications are seen on prescription lists or picked up from the pharmacy and conflicting information is given. The use of these medications does not mean that your provider believes the pain is all in your head. Quite the opposite, they represent one of the best medications we have in our arsenal!
Based on this brief overview of therapies and medications, I hope it becomes clear that there are many different options available in the treatment of pain that do not involve surgery, injections, or opioid medications. In no way is the above list exhaustive either for the medications themselves or their side effects but hopefully serves as a good reference. Speak to your healthcare provider if you feel that you are experiencing a worrisome side effect related to a medication. Another article will examine the third pillar of non-surgical treatments: injections.