What is the Best Medication for Back Pain?

 

What is the Best Medication to Take for my Back Pain?

I am frequently asked by patients: ‘what drug should I take to ease my back pain?’ My normal response is to avoid taking them if possible, unless you are really finding it a struggle to sleep at night.

One of the most commonly available pain-killers is paracetamol, and, because most people already have some at home, it is often taken in an attempt to ease back pain.

One study reviewed all the published evidence in relation to using paracetamol to treat low back pain (1)

Based on the available evidence they concluded that: ‘paracetamol is ineffective in the treatment of low back pain and provides minimal short-term benefit for people with osteoarthritis.’

The UK National Institute for Health & Care Excellence (NICE) guidelines corroborated this and they no longer recommend paracetamol for back pain treatment.

 

Anti-inflammatories for Back Pain. Naas Physio & Chiropractic Clinic


What Anti-Inflammatory Drug Should I Take for My Back Pain?

The drugs that are most frequently used for treating back pain are the anti-inflammatory group of drugs. For decades, they formed the standard practice in treating back pain.

Because of the opioid crisis, the pharmaceutical industry are looking for alternative treatments for pain. One alternative is the use of non-steroidal anti-inflammatory drugs (NSAIDs). (5)

In the U.S. for example, around 60% of patients with osteoarthritis or chronic low back pain are prescribed NSAIDs.

In the UK, the National (NICE) guidelines recommend anti-inflammatories (NSAIDs) as the first choice for treating back pain & sciatica.

Anti-inflammatory drugs (NSAIDs) are commonly used for pain management. Common examples of include:

  • Ibuprofen
  • Diclofenac
  • Celecoxib

The logic behind the use of anti-inflammatories is that decreasing inflammation will lead to a decrease in pain and speed up recovery. A common misconception amongst patients is that their back pain is caused by local inflammation. In the vast majority of back pain that I treat there is  no evidence of inflammation in the site of back pain.

Even in cases where inflammation is present, the question is:

Is inflammation harmful?
Does blocking inflammation improve healing?
How much inflammation is too much?
How long should I take anti-inflammatories for, if at all?

 

Should I take anti-inflammatories if I have a fracture?

It has been recognised for a long time that taking NSAIDs decreases bone healing and increase the rates of non-union of bones. Because of this, they are generally avoided after orthopaedic surgery.

Previous research in animals also suggests that anti-inflammatory drugs (NSAIDs) may delay wound healing (4,6).

The anti-inflammatories block prostaglandins which have been shown to play an important role in bone repair, which includes differentiation of osteoblast and osteoclast precursor cells (6)

If they block wound and bone healing, is this an indication that they may have a similar impact when it comes to spinal pain?

What is the Evidence for Anti-Inflammatories in Helping Back Pain?

Mancado & colleagues reviewed the available data on anti-inflammatory drugs for treating spinal pain. They included 35 high quality studies (known as randomised controlled trials). (3)

From analysing all the available research, they concluded that anti-inflammatories (NSAIDs) are effective in treating spinal pain; however, they are no more effective than using a placebo

They reported that 6 participants needed to be treated with NSAIDs, for one additional participant to achieve clinically important pain reduction.

Can Blocking Inflammation Lead to Long-Term Back Pain?

A recent study attempted to answer some of these questions by testing for inflammatory markers in blood samples from 98 patients with recent onset low back pain (2)

At follow-up 3 months later, when testing blood samples for inflammation, they found that participants whose pain had gone at 3 months demonstrated more inflammation on initial testing. Inflammation was indicated by the presence of a higher number of immune cells known as neutrophils.
In the group with persistent pain, there was no increase in inflammatory cells measured on initial testing.

Neutrophils are a type of immune cell that helps to fight infection and dominate in the the early stages of injury.

Here, the researchers found that blocking neutrophils in mice prolonged the pain up to ten times the normal duration. In mice, treating the pain with steroid or nonsteroidal anti-inflammatory drugs (NSAID) like diclofenac led to prolonged pain, despite helping to decrease pain in the short term. The mice were less sensitive to touch in the initial phase.

If the scientists administered neutrophils, then this prolonging of pain was reversed, showing that these immune cells are vital for recovery from back pain.

So, the presumption that decreasing swelling aids recovery needs to be re-evaluated in light of these findings.

As part of the study, they examined data of 500,000 people from the United Kingdom Biobank, a database of medical information. They found those taking anti-inflammatory drugs to treat their pain were much more likely to have pain two to ten years later.

They also found that taking painkillers, such as Tylenol were less likely to experience chronic pain compared to those who took anti-inflammatory medication.

Medication for Back Pain

Benefit & Risk From Taking Anti-Inflammatories

At present, there are no pain-killers that provide clinically important effects for spinal pain over placebo (3)

Even after all this is considered, ‘NSAIDs increased the risk of gastrointestinal reactions by 2.5 times’, contributing to 18,000 gastric bleeds each year in the UK, & contributing to over 2,000 deaths.

 

References:

  • Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015 Mar 31;350:h1225. doi: 10.1136/bmj.h1225. PMID: 25828856; PMCID: PMC4381278.
  • Parisien M, Lima LV, Dagostino C, El-Hachem N, Drury GL, Grant AV, Huising J, Verma V, Meloto CB, Silva JR, Dutra GGS, Markova T, Dang H, Tessier PA, Slade GD, Nackley AG, Ghasemlou N, Mogil JS, Allegri M, Diatchenko L. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Sci Transl Med. 2022 May 11;14(644):eabj9954. doi: 10.1126/scitranslmed.abj9954. Epub 2022 May 11. PMID: 35544595.
  • MachadoGC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the Rheumatic Diseases 2017;76:1269-1278.
  • Nagano A, Arioka M, Takahashi-Yanaga F, Matsuzaki E, Sasaguri T. Celecoxib inhibits osteoblast maturation by suppressing the expression of Wnt target genes. J Pharmacol Sci. 2017;133(1):18–24.
  • Zhao-Fleming, H., Hand, A., Zhang, K. et al.Effect of non-steroidal anti-inflammatory drugs on post-surgical complications against the backdrop of the opioid crisis. Burn Trauma 6, 25 (2018). https://doi.org/10.1186/s41038-018-0128-x
  • Jeffcoach DR, Sams VG, Lawson CM, Enderson BL, Smith ST, Kline H, et al. Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in long-bone fractures. J Traum Acute Care Surg. 2014;76(3):779–83.

Myth Busters: What’s the Best Way to Lift to Avoid Back Pain?

Is bending dangerous if you have back pain?

Lifting with back pain: The approach of lifting with the legs and avoiding bending from the back is “common knowledge” as a key method for protecting the back from injury. However, the question is: does research back this approach up?

How many times have you heard someone being advised to “keep the back straight” and “bend from the knees”. Is this actually effective or should it be largely ignored? Questioning such firmly entrenched beliefs is part of the scientific process.

 

Naas Physiotherapy & Chiropractor. Best way to lift to avoid back pain

What Happens in My Back When I Squat versus Bending while Lifting?

Spinal compression and the pressure present within the spinal discs does not appear significantly different whether squatting or bending from the spine when lifting. Research suggests that the forces were equal or slightly higher in squatting when compared to bending from the back when lifting. 

In fact, a recent review of the science actually found that flexing from the lower back improved lifting capacity and muscle coordination when compared to a straight spine lift. This research brings into question the traditional advice to lift with a flat or slight backward arch of the back (Mawston et al. 2021). 

 

Should I Squat or Bend My Back When Lifting?

 Saraceni N, Kent P, Ng L, Campbell A, Straker L, O’Sullivan P. To Flex or Not to Flex? Is There a Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2020;50(3):121-130. doi:10.2519/jospt.2020.9218

Here, the authors reviewed all the literature on spinal flexion when lifting.

They found that there was low-quality evidence that greater spinal flexion during lifting was not a risk factor for LBP onset or persistence.  

 

Does Ergonomic/Lifting Technique Training in the Workplace Prevent Back Pain? 

Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais S. Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J. 2010;10(6):554-566. doi:10.1016/j.spinee.2010.03.033

This research included 35 studies. They found moderate evidence of an association for specific types of lifting and LBP.

The authors reported that ‘based on these results, it is unlikely that occupational lifting is independently causative of LBP in the populations of workers studied.’

 

Luger T, Maher CG, Rieger MA, Steinhilber B. Work-break schedules for preventing musculoskeletal symptoms and disorders in healthy workers. Cochrane Database Syst Rev. 2019 Jul 23;7(7):CD012886. doi: 10.1002/14651858.CD012886.pub2. PMID: 31334564; PMCID: PMC6646952.

The evidence collected indicates that manual handling training is largely ineffective in reducing back pain and back injury.

Naas Physio Clinic: What's the Best Way to Lift to Avoid Back Pain?

Clemes SA, Haslam CO, Haslam RA. What constitutes effective manual handling training? A systematic review. Occup Med (Lond). 2010 Mar;60(2):101-7. doi: 10.1093/occmed/kqp127. Epub 2009 Sep 4. PMID: 19734238.

In this review that included 53 papers the authors found that ‘the evidence collected indicates that manual handling training is largely ineffective in reducing back pain and back injury.’ 

 

Sundstrup E, Seeberg KGV, Bengtsen E, Andersen LL. A Systematic Review of Workplace Interventions to Rehabilitate Musculoskeletal Disorders Among Employees with Physical Demanding Work. J Occup Rehabil. 2020 Dec;30(4):588-612. doi: 10.1007/s10926-020-09879-x. PMID: 32219688; PMCID: PMC7716934.

The evidence synthesis recommends that implementing strength training at the workplace can reduce injury among workers with physically demanding work.

Based on the scientific literature, participatory ergonomics and multifaceted workplace interventions seem to have no beneficial effect on reducing musculoskeletal disorders among this group of workers. 

 

Does Lifting Technique Training Help to Decrease Back Pain?

Unfortunately, education on lifting technique has not been shown to reduce the incidence of low back pain. Despite this, proper lifting technique is taught in workplaces across the globe, and also frequently, in clinics.

As mentioned, bending the back more when lifting has not been shown to be linked to back injury!

 

Do Ergonomic Work Supports Help for Shoulder & Arm Pain?

Van Eerd D, Munhall C, Irvin E, Rempel D, Brewer S, van der Beek AJ, Dennerlein JT, Tullar J, Skivington K, Pinion C, Amick B. Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence. Occup Environ Med. 2016 Jan;73(1):62-70. doi: 10.1136/oemed-2015-102992. Epub 2015 Nov 8. PMID: 26552695; PMCID: PMC4717459.


This literature review showed moderate evidence for amending mouse setup, use of forearm support, & stretching programmes in preventing shoulder & arm pain.

Interestingly, they did find that a resistance training programme had strong evidence in preventing upper limb disorders.

 

What About Work Breaks?

Luger T, Maher CG, Rieger MA, Steinhilber B. Work-break schedules for preventing musculoskeletal symptoms and disorders in healthy workers. Cochrane Database Syst Rev. 2019 Jul 23;7(7):CD012886. doi: 10.1002/14651858.CD012886.pub2. PMID: 31334564; PMCID: PMC6646952.

We found low-quality evidence that different work-break frequencies may have no effect on participant-reported musculoskeletal pain, discomfort and fatigue.

For productivity and work performance, evidence was of very low-quality that different work-break frequencies may have a positive effect. 

 

Do People with Back Pain Lift Differently to Those Without Back Pain?

Saraceni N, Campbell A, Kent P, Ng L, Straker L, O’Sullivan P. Exploring lumbar and lower limb kinematics and kinetics for evidence that lifting technique is associated with LBP. PLoS One. 2021 Jul 21;16(7):e0254241. doi: 10.1371/journal.pone.0254241. PMID: 34288926; PMCID: PMC8294511.

21 LBP and 20 noLBP participants completed a 100-lift task, where lumbar and lower limb kinematics and kinetics were measured during lifting, with a simultaneous report of LBP intensity every 10 lifts.

 

Workers with a history of LBP, lift with a style that is slower and more squat-like than workers without any history of LBP.

 

Common assumptions that LBP is associated with lumbar kinematics or kinetics such as greater lumbar flexion or greater forces were not observed in this study, raising questions about the current paradigm around ‘safe lifting’.

 

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Myth Busting: Is My Back Pain Caused by Bad Posture?

Myth Busting: Is Poor Posture the Cause of Back Pain?

 

Most people attending the clinic with back pain believe that poor posture has played a significant role in their back pain. Some clinicians spend a considerable amount of time analysing posture and attempting to link this to back pain. The question is: is this scientifically valid?

 

Two key questions in addressing the link between back pain & posture are:

 

  • Does the Evidence Show a Link Between Poor Posture & Pain?
  • Is there a Difference in Posture Between Those with Back Pain and Those Without?

Is My Back Pain Caused by Bad Posture? Naas Physio & Chiropractor Clinic

Laird RA, Gilbert J, Kent P, Keating JL. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:229. Published 2014 Jul 10. doi:10.1186/1471-2474-15-229

In summarising 8 available studies, the authors found that, on average, people with low back pain had no difference in low back posture compared to those without low back pain.

 

Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech. 2020;102:109312. doi:10.1016/j.jbiomech.2019.08.006

These authors reviewed all the available research and found that ‘despite the availability of many reviews, there is no consensus regarding the link between physical activity exposure & LBP.’

 

What Causes Back Pain in Cyclists?

Streisfeld GM, Bartoszek C, Creran E, Inge B, McShane MD, Johnston T. Relationship Between Body Positioning, Muscle Activity, and Spinal Kinematics in Cyclists With and Without Low Back Pain: A Systematic Review. Sports Health. 2017;9(1):75-79. doi:10.1177/1941738116676260

Low back pain is reported by more than half of cyclists. The causes of back pain in this group is not clearly understood.

Eight studies were included in this review.

Core muscle activation imbalances, back extensor endurance deficits, and increased lumbar flexion while cycling were found to be present in cyclists with low back pain.

 

Is Bad Posture a Cause of Neck Pain?

Karen V Richards, D Clin Physio, M Manip Ther, Darren J Beales, PhD, M Manip Ther, Anne L Smith, PhD, M Biostatistics, Peter B O’Sullivan, PhD, Grad Dip Manip Ther, Leon M Straker, PhD B App Sc (Physio), Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study, Physical Therapy, Volume 101, Issue 3, March 2021, pzab007, https://doi.org/10.1093/ptj/pzab007

In this study with 686 participants, the authors found that sitting neck posture at 17 was not a risk factor for persistent neck pain at 22 years of age in males, whereas in females, more relaxed postures (slumped and Intermediate postures) were protective of neck pain compared with upright posture.

The authors concluded that ‘the practice of generic public health messages to sit up straight to prevent neck pain needs rethinking.’

Is My Nack Pain Caused by Bad Posture: Naas Physio and Chiropractor

Does Sitting for Long Periods with Poor Posture Cause Neck Pain?

Ariëns GA, Bongers PM, Douwes M, et al. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occup Environ Med. 2001;58(3):200-207. doi:10.1136/oem.58.3.200

This prospective cohort study was performed with a follow up of 3 years among 1334 workers from 34 companies.

Work related physical load was assessed via video recordings of neck flexion, neck rotation, and sitting posture. Neck pain was assessed by a questionnaire.

A significant positive relation was found between the percentage of the working time in a sitting position and neck pain, implying an increased risk of neck pain for workers who were sitting for more than 95% of the working time.’

A trend for a positive relation between neck flexion and neck pain was found, suggesting an increased risk of neck pain for people working with the neck at a minimum of 20° of flexion for more than 70% of the working time. No clear relation was found between neck rotation and neck pain.
‘Sitting at work for more than 95% of the working time seems to be a risk factor for neck pain and there is a trend for a positive relation between neck flexion and neck pain. No clear relation was found between neck rotation and neck pain.’

 

What About Taking Regular Breaks from Work?

Waongenngarm P, Areerak K, Janwantanakul P. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Appl Ergon. 2018;68:230-239. doi:10.1016/j.apergo.2017.12.003

The authors in this study evaluated the effectiveness of breaks on low back pain, discomfort, and work productivity in office workers. They referred to all publications released from 1980 to December 2016.

The length of both working time and break times were highly variable between studies and therefore difficult to compare.

‘…..active breaks with postural change may be effective in reducing pain in workers with acute low back pain and to prevent discomfort in healthy subjects.’

The evidence also suggested that the use of breaks had no detrimental effect on work productivity.

 

Should I Use a Sit-To-Stand Desk to Help My Back Pain?

Agarwal S, Steinmaus C, Harris-Adamson C. Sit-stand workstations and impact on low back discomfort: a systematic review and meta-analysis. Ergonomics. 2018;61(4):538-552. doi:10.1080/00140139.2017.1402960

Twelve articles were identified in this study and eight that presented results in means (SD) were included.

They concluded that sit-stand workstations, by leading to changes in posture may reduce low back pain among workers.
 

 

De Carvalho D, Greene R, Swab M, Godwin M. Does objectively measured prolonged standing for desk work result in lower ratings of perceived low back pain than sitting? A systematic review and meta-analysis. Work. 2020;67(2):431-440. doi:10.3233/WOR-203292

Prolonged sitting has been shown to induce transient low back pain (LBP). Height adjustable office desks now present the opportunity to replace sitting with standing in the workplace. Since standing has also been associated with LBP, this may not be an advisable alternative.

The results of three studies were pooled using an inverse variance random-effects meta-analysis.

‘Objectively measured prolonged standing postures during desk work did not induce significantly less perceived LBP compared to seated postures.’

The authors concluded that ‘It appears that replacing seated desk work postures with standing for prolonged periods of time would not be recommended.’

My summary:
So, the evidence seems to be mixed when it comes to sitting or standing in terms of back pain. Prolonged sitting; however, has several negative influences in terms of health. For example, prolonged sitting is associated with negative metabolic changes which can predispose to weight gain, diabetes and cardiovascular disease.

It appears that ‘active breaks’, where you are moving or performing exercise may be optimal for decreasing back pain incidence and improving overall health

 

 

Do Repeated Awkward Postures Cause Back Pain?

Khan MI, Bath B, Boden C, Adebayo O, Trask C. The association between awkward working posture and low back disorders in farmers: a systematic review. J Agromedicine. 2019;24(1):74-89. doi:10.1080/1059924X.2018.1538918

Although studies of the general population have shown an association between low back disorders and awkward working posture, farmers have unique work context and exposures that may modify this relationship.

Nine studies were included in this review. All studies used self-report; there were no field-based studies including direct measurement of awkward posture.

Despite the diversity, the weight of evidence supported a relationship between awkward posture and low back disorders.

My summary:
This particular study, using self-reports of poor posture, would be deemed very poor quality.
The authors concluded there may be a link between extremes of posture, as might occur in farming or heavy labour, but it is hard to be definitive from this study.

 

Roffey DM, Wai EK, Bishop P, Kwon BK, Dagenais S. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine J. 2010;10(1):89-99. doi:10.1016/j.spinee.2009.09.003

A systematic review was performed to identify a potential link between awkward occupational postures and LBP. Eight high-quality studies reported on awkward occupational postures and LBP.

The authors found ‘no association between awkward occupational postures and LBP, with only two studies demonstrating significant associations compared with six studies reported mainly nonsignificant associations.’

‘It is therefore unlikely that awkward occupational postures are independently causative of LBP in the populations of workers studied.’

 

Coenen P, Gouttebarge V, van der Burght AS, et al. The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis. Occup Environ Med. 2014;71(12):871-877. doi:10.1136/oemed-2014-102346

Lifting at work is considered an important risk factor for low back pain (LBP). However, contradictory findings have been reported, partly because frequency, duration and intensity (ie, the weight of the load) of lifting have not been systematically considered.

The aims of this study were: to assess the effect of lifting during work (quantified in duration, frequency or intensity) on the incidence of LBP and to quantify the impact of these relationships on the occurrence of LBP in occupational populations exposed to lifting.

Eight studies were included.

‘..we estimated that lifting loads over 25 kg and lifting at a frequency of over 25 lifts/day will increase the annual incidence of LBP by 4.32% and 3.50%, respectively, compared to the incidence of not being exposed to lifting.’ Intensity and frequency of lifting significantly predict the occurrence of LBP.

 

 

My Summary of the Research:

  • There is no clear link between poor posture and neck & back pain
  • Prolonged sitting seems to be linked with back pain as opposed to the posture of sitting
  • Taking regular active breaks may help decrease back pain
  • The evidence for standing desks in terms of back pain is in its infancy but is unclear at present
  • Awkward postures being assumed regularly during work does not show a clear link with back pain.
  • Heavy manual labour, in most cases, has been shown to be associated with an increase in back pain

 

It might be a case that, for some people, posture is a significant cause of their pain, but because there are several factors that can cause pain, it might need to be present alongside other characteristics. When dealing with studies involving larger groups, this may not show up as statistically significant.

In other words: always keep an open mind!!

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