Among patients with acute, low back pain presenting to an emergency department, neither the nonsteroidal anti-inflammatory drug (NSAID) naproxen combined with oxycodone/acetaminophen or the muscle relaxant cyclobenzaprine provided better pain relief or improvement in functional outcomes than naproxen combined with placebo, according to a study in the October 20 issue of JAMA.
Low back pain (LBP) is responsible for 2.4 percent of visits to U.S. emergency departments, resulting in more than 2.5 million visits annually. These patients are usually treated with NSAIDs, acetaminophen, opioids, or skeletal muscle relaxants, often in combination. Pain outcomes for these patients are generally poor.
Benjamin W. Friedman, M.D., M.S., of the Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y., and colleagues randomly assigned 323 patients who presented to an emergency department with nontraumatic, nonradicular LBP of 2 weeks’ duration or less to receive a 10-day course of naproxen + placebo (n = 107); naproxen + cyclobenzaprine (5 mg) (n = 108); or naproxen + oxycodone, 5 mg/acetaminophen, 325 mg (n = 108). Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP; naproxen, 500 mg, was to be taken twice a day. Patients also received a standardized 10-minute LBP educational session prior to discharge.
The researchers found that neither naproxen combined with oxycodone/acetaminophen nor naproxen combined with cyclobenzaprine provided better pain relief or better improvement in functional outcomes than naproxen combined with placebo. Measures of pain, functional impairment, and use of health care resources were not different between the study groups at 7 days or at 3 months after the emergency department visit.
Regardless of allocation, nearly two-thirds of patients demonstrated clinically significant improvement in LBP and function 1 week later. However, 40 percent of the cohort reported moderate or severe pain, half reported functionally impairing LBP, and nearly 60 percent were still using medication for their LBP 1 week later. By 3-month follow-up, nearly one-fourth of the cohort reported moderate or severe pain and use of medications for LBP. Three months after the emergency department visit, regardless of study group, opioid use for LBP was uncommon, with fewer than 3 percent of patients reporting use of an opioid within the previous 72 hours.
“These findings do not support the use of these additional medications in this setting,” the authors write.
1.Benjamin W. Friedman, Andrew A. Dym, Michelle Davitt, Lynne Holden, Clemencia Solorzano, David Esses, Polly E. Bijur, E. John Gallagher. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain. JAMA, 2015; 314 (15): 1572 DOI: 10.1001/jama.2015.13043
The American Physical Therapy Association (APTA) is urging patients with musculoskeletal pain to consider treatment by a physical therapist, in light of a new federal survey showing that more than one-third of American adults and nearly 12 percent of children use alternative medicine – with back and neck pain being the top reasons for treatment.
Results of the 2007 survey of more than 32,000 Americans were released December 11 by the National Institutes of Health’s National Center for Complementary and Alternative Medicine.
According to APTA, physical therapy offers an evidence-based, time-tested solution to these common conditions in comparison to alternative treatments.
For neck pain, for example, a recent study published in the medical journal Spine found that when patients received up to six treatments of manual physical therapy and exercise, they not only experienced pain relief, but were also less likely to seek additional medical care up to one year following treatment.
“This study, demonstrating the efficacy of physical therapy for a condition as widespread as neck pain, is particularly relevant in today’s challenging economic environment,” according to the study’s lead researcher and APTA spokesman Michael Walker, PT, DSc, OCS, CSCS, FAAOMPT. “The Kaiser Foundation, for instance, recently found that more than half of all Americans are not taking prescribed medication and postponing needed medical care in an effort to save money. It is important for consumers to know that there are effective, conservative solutions such as physical therapy available.”
Walker’s study compared the effectiveness of a three-week program of manual physical therapy and exercise to a minimal intervention treatment approach for patients with neck pain.
Study participants consisted of 94 patients with a primary complaint of neck pain, 58 (62%) of whom also had radiating arm pain. Patients randomized to the manual physical therapy and exercise group received joint and soft-tissue mobilizations and manipulations to restore motion and decrease pain, followed by a standard home exercise program of chin tucks, neck strengthening, and range-of-motion exercises. Patients in the minimal intervention group received treatment consistent with the current guidelines of advice, range-of-motion exercise, and any medication use prescribed by their general practitioner. Patients did not have to complete all six visits if their symptoms were fully resolved.
Sample exercises to relieve neck pain can be found on the APTA Web site, http://www.apta.org/consumer.
Results show that manual physical therapy and exercise was significantly more effective in reducing mechanical neck pain and disability and increasing patient-perceived improvements during short- and long-term follow-ups. These results are comparable with previous studies that found manual physical therapy and exercise provided greater treatment effectiveness (Hoving et al, 2002) and cost effectiveness (Kothals-de Bos et al, 2003) than general practitioner care.
1.Hoving et al. Manual Therapy, Physical Therapy, or Continued Care by the General Practitioner for Patients With Neck Pain. Ann Intern Med, 2002;136 DOI: (10):713-722
2.Bos et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial * Commentary: Bootstrapping simplifies appreciation of statistical inferences. BMJ, 2003; 326 (7395): 911 DOI: 10.1136/bmj.326.7395.911
Among adults with chronic low back pain, both mindfulness-based stress reduction and cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations when compared with usual care, according to a study appearing in the March 22/29 issue of JAMA.
Low back pain is a leading cause of disability in the United States. There is need for treatments with demonstrated effectiveness that are low risk and have potential for widespread availability. Mindfulness-based stress reduction (MBSR) focuses on increasing awareness and acceptance of moment-to-moment experiences including physical discomfort and difficult emotions. Only 1 large randomized clinical trial has evaluated MBSR for chronic low back pain, and that trial was limited to older adults.
Daniel C. Cherkin, Ph.D., of Group Health Research Institute, Seattle, and colleagues randomly assigned 342 adults age 20 to 70 years with chronic low back pain to receive MBSR (n = 116), cognitive behavioral therapy (CBT; n = 113), or usual care (n = 113). CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever other treatment, if any, the participants received. The average age of the participants was 49 years; the average duration of back pain was 7.3 years.
The researchers found that at 26 weeks, the percentage of participants with clinically meaningful improvement on a measure of functional limitations was higher for those who received MBSR (61 percent) and CBT (58 percent) than for usual care (44 percent). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 44 percent in the MBSR group and 45 percent in the CBT group, vs 27 percent in the usual care group. Findings for MBSR persisted with little change at 52 weeks for both primary outcomes.
“The effects were moderate in size, which has been typical of evidence-based treatments recommended for chronic low back pain. These benefits are remarkable given that only 51 percent of those randomized to receive MBSR and 57 percent of those randomized to receive CBT attended at least 6 of the 8 sessions,” the authors write.
“These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain.”
Editorial: Is It Time to Make Mind-Body Approaches Available for Chronic Low Back Pain?
“Although understanding the specificity of treatment effects, mechanisms of action, and role of mediators are important issues for researchers, they are merely academic for many clinicians and their patients. For patients with chronic painful conditions, options are needed to help them live with less pain and disability now,” write Madhav Goyal, M.D., M.P.H., and Jennifer A. Haythornthwaite, Ph.D., of Johns Hopkins University School of Medicine, Baltimore.
“The challenge is how to ensure that these mind-body interventions are available, given the existing evidence demonstrating they may work for some patients with chronic low back pain. Most physicians encounter numerous obstacles finding appropriate referrals for mind-body therapies that their patients can access and afford. High-quality studies such as the clinical trial by Cherkin et al create a compelling argument for ensuring that an evidence-based health care system should provide access to affordable mind-body therapies.”
1.Daniel C. Cherkin, Karen J. Sherman, Benjamin H. Balderson, Andrea J. Cook, Melissa L. Anderson, Rene J. Hawkes, Kelly E. Hansen, Judith A. Turner. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA, 2016; 315 (12): 1240 DOI: 10.1001/jama.2016.2323
2.Madhav Goyal, Jennifer A. Haythornthwaite. Is It Time to Make Mind-Body Approaches Available for Chronic Low Back Pain? JAMA, 2016; 315 (12): 1236 DOI: 10.1001/jama.2016.2437