7/27/2019 67226149

1/10

Diagnosis and Treatment of Low-Back PainBecause of Paraspinous Muscle Spasm:A Physician Roundtablepme_1253 119..127

Bill H. McCarberg, MD,* Gary E. Ruoff, MD,

Penny Tenzer-Iglesias, MD, and Arnold J. Weil,MD

*Kaiser Permanente, Escondido, California;

Westside Family Medical Center, Kalamazoo,

Michigan;

University of Miami, Highland Professional Bldg.,

Miami, Florida;

Non-Surgical Orthopaedics, PC, Atlanta, Georgia,

USA

Reprint requests to: Bill H. McCarberg, MD, KaiserPermanente, 732 North Broadway, Escondido, CA92025, USA. Tel: 760-839-7008; Fax: 760-839-7053;E-mail: Bill.H.Mccarberg@kp.org.

Disclosures: The authors make the followingdisclosures of financial relationships during the past 3years with companies whose products may be relatedto the topic of this article: Dr McCarberg has served

on the speakers bureaus for PriCara, Forest, Endo,and NeurogesX. Dr Ruoff has served on the advisoryboards and speakers bureaus for Takeda, Endo, andCephalon. Dr Tenzer-Iglesias has served on theadvisory boards for UCB and Forest. Dr Weil hasserved as a speaker for King, Cephalon, and Ferring.

Support: Support for the publication of thissupplement was provided by Cephalon, Inc.

Disclaimer: Information contained in this supplementrepresents the opinions of the authors and is notendorsed by, nor does it necessarily reflect the viewsof Cephalon, Inc.

In order to facilitate the review of this supplement toPain Medicine and to maintain the integrity of theeditorial peer review process, reviewers of thissupplement were chosen independently by theSupplement Editor. No compensation was paid tothese reviewers for their review.

Abstract

Background. Despite the availability of evidence-based guidelines to diagnose and treat acute

low-back pain, practical application is nonuniformand physician uncertainty regarding best practicesis widespread.

Objective. The objective of this study was to furtheroptimal treatment choices for screening, diagnos-ing, and treating acute low-back pain caused byparaspinous muscle spasm.

Methods. Four experts in pain medicine (threefamily physicians and one physiatrist) participated

in a roundtable conference call on October 18, 2010,to examine current common practices and guide-lines for diagnosing and treating acute low-backpain and to offer commentary and examples fromtheir clinical experience.

Results. Participants discussed the preferredchoices and timing of diagnostic and imagingtests, nonpharmacologic therapies, nonopioid andopioid medication use, biopsychosocial evaluation,complementary therapies, and other issues relatedto treatment of acute low-back pain. Principalclinical recommendations to emerge included thor-ough physical exam and medical history, early

patient mobilization, conservative use of imagingtests, early administration of muscle relaxants com-bined with nonsteroidal anti-inflammatory medica-tions to reduce pain and spasm, and a strongemphasis on patient education and physicianpatient communication.

Conclusions. Early, active management of acutelow-back symptoms during the initial onset maylead to better patient outcomes, reducing relatedpain and disability and, possibly, preventing pro-gression to chronicity.

Key Words. Acute; Low-back Pain; Muscle Relax-

ants; Muscle Spasm; Opioids; Paraspinous

Introduction

Most adults experience low-back pain sometime duringtheir lifetimes. Approximately one-quarter of U.S. adultshave had an episode of low-back pain lasting at least 1day within the past 3 months [1], and the lifetime preva-lence approaches 80% [2]. Low-back pain exacts largecosts to society. Only symptoms of upper-respiratoryillness rank higher as a reason for physician office visits [3],and direct health care expenditures and indirect economic

Pain Medicine 2011; 12: S119S127Wiley Periodicals, Inc.

S119

7/27/2019 67226149

2/10

losses because of back pain and related disability exceed$100 billion per annum [4].

Acute low-back pain (lasting

7/27/2019 67226149

3/10

50 might need to be seen more urgently, usually if theywere in an accident and sustained major injuries. We areseeing more injuries in the younger group than in the pastbecause of more competitive sports. Cheerleading andgymnastics, for example, can be very dynamic and theseyounger athletes may have major injuries. The 20- to50-year age group would more likely have disc patholo-gies. I see a lot of nonspecific back pain because ofmuscle spasm in this age group, too. I agree with Pennythat in the older age group, there are more osteoarthriticchanges, disc pathology, spinal stenosis, and osteoporo-sis, which may lead to fractures and serious pain.

Weil: I, too, see a lot of older people who are veryactive, and theyre still expecting to do a lot. I also seea lot of younger kids who are having acute musculosk-eletal injuries, mainly from school sports. While the epi-demiology of causes of back pain is important to keep inmind, from a clinical practice standpoint, I think it isimportant to evaluate each person independently so

nothing gets missed.

The Difficulty of Diagnosis

McCarberg: Let me ask another question that becomesvery difficult for us in primary care and that is the lack ofdiagnostic accuracy in assessing specific causes of painin the musculoskeletal conditions, especially in the low-back and neck. Is it discogenic? Is it a nerve? Is it aligament? Is it arthritic? Has it something to do with a facet

joint that may be arthritic or traumatic? First, how precisecan we be, and second, how important is it that we beprecise?

Weil: This is where the practice of medicine is more an artthan a science, because I have always thought thatespecially with back painyou can get a very good sense

of the pathophysiology from a really good history andphysical exam. There is almost always muscle spasm withacute back injuries, so you know you are always going tobe treating a muscular component, but a lot of times, justhow the person was injured and what you find on exami-nation can give you a good sense of whether you aredealing with something discogenic, whether there isinvolvement of nerve root irritation, or whether it may bemore of a facet type of pain.

How important is it to be precise? You could say it isvery important because you are going to tailor your treat-ment to the underlying problem. But, on the other hand,

after ruling out serious neurological risk, it is not quite soimportant in the acute phase, because you are prettymuch going to use a strong anti-inflammatory andmuscle relaxant, encourage early mobilization, and getthem into physical therapy. I think a lot of times, we gethung up on looking for pathology in an X-ray, and if thereare no acute findings, there is a tendency to dismissthe patient and say there is nothing wrong, and thepatients just have to live with it. The X-ray may rule outa fracture, but it is really not the primary diagnostic tool.

The history, physical exam, and laying hands on thepatient are going to give you a great indication of whatis going on and what needs to be done the majorityof the time.

Ruoff: I agree with a good physical examination, whichwould include reflexes, dorsiflexion, and plantar fle-xion of the ankle, and foot checking for paresthesiasof the legs and feet, and weakness in any of themusculature.

Tenzer-Iglesias: Do not just focus on the straight-legraise alone, because that is what I see our trainees doingat times. They may forget to assess the hips, knees, andother areas such as sacroiliac joints. Under the physicalexam, you are not just focusing on that one sign, youare focusing on the complete patient and range ofpossibilities.

When is Imaging Indicated?

Ruoff: All forms of imagingplain X-rays and evenmagnetic resonance imaging (MRI)can be misleading

The risk of low-back pain rises from 1% to 6% inchildren to between 18% and 50% in adolescents [8].Peak prevalence occurs in the United States betweenages 55 and 64 [8]. The onset of symptoms typicallyoccurs between the ages of 30 and 50, and back painis the most frequent cause of work-related disability inpeople under 45 [12].

A joint practice guideline from the American Collegeof Physicians (ACP) and the American Pain Society(APS) strongly recommends a thorough history and

physical examination to determine whether back painstems from a specific cause or whether patients fallinto the category of the 85% of acute suffererswhose back pain is of nonspecific origin [5]. Theexam should focus on the presence and extent ofneurological involvement and on risk factors for spe-cific underlying conditions. The exam should alsoinclude assessment of psychosocial factors that arepredictive of ongoing disabling pain and includedepression, passive coping strategies, job dissatis-faction, and high disability levels [5]. An investigationbased on 20 studies comprising 10,842 patients with

7/27/2019 67226149

4/10

as many patients with severe changes may be com-pletely asymptomatic, and others that have minorchanges may be very symptomatic. Imaging does notadd any value to the diagnosis unless the patient has apositive finding on a neurological exam. The majority ofback cases will be of nonspecific nature, mainly becauseof muscle spasm. The radiation of pain in those casesoccurs from the back to above the kneevery rarelybelow the knee unless a neurologic event is takingplace, such as injury, compression, or inflammation of anerve. In those latter cases, there may also bediminished reflexes in the knees or ankles, weaknessin dorsiflexion or plantar flexion of the feet andankles, and a sensory loss in some aspect of the lowerleg or foot.

Weil: Actually, of the patients I see, I would say that over50% of the time, they do have pain down to the foot. Isee patients with acute back injuries that have sciaticsymptoms all the way down to the foot. But I do agree

that the X-rays can be misleading. X-rays and MRIsserve as diagnostic or confirmatory tools to corroborateyour physical exam and not the other way around. I donot jump to MRIs unless I need that for whatever isnext in the treatment process, whether it be epiduralinjections or facet injections or something of thatnature.

Tenzer-Iglesias: What we are saying is so important,and yet it seems to be the rule and not the exceptionthat MRIs are ordered and often very early. I did an inter-active question during a case-based lecture askingabout patient workup, and ordering an MRI is one of thepossible answers. It is the wrong answer per the guide-

lines, and yet a significant percentage of the audiencewill pick MRI as the answer. We need to listen to thepatients storythe mechanism of injury, especially in anacute episode, and focus on a thorough physical exami-nation as well as assess psychosocial factors to look forclues. If I order a test, I will ask what is the question thatthe test will answer for me that I am not able to answerfor myself right now? How will it change my treatmentplan? I try to instill this way of critical thinking in ourresidents and medical student trainees. At times it is verydifficult, because a lot of different forces promote goingstraight to lab tests and imaging studies instead ofrelying on a thorough clinical assessment as recom-mended by the guidelines.

Weil: Not to be real cocky, but I do not need an MRI totell me somebodys got an L4/5 disc protrusion com-pressing the L5 nerve root. In fact, when I started prac-ticing 18 years ago, if somebody did not improve with anadequate amount of conservative treatment, eventually Iwould do an epidural injection and not necessarily get anMRI. Now the patients insurance company is not goingto authorize epidurals unless you have an MRI, but inreality you do not need it because with a good historyand a good physical exam, most of the time, you can tellexactly where the pathology is and where the problemlies.

Red Flags: Do Not Miss a Diagnosis

McCarberg: Most of the guidelines mention looking outfor red flags, including fever, serious trauma, progressiveneurologic deficit, cancer, osteoporosis, chronic steroiduse, and others. If there are no red flags, the guidelinespretty much say you are going to treat everybody thesame. What do you think of that kind of approachruleout red flags and then treat everybody the same?

Ruoff: That is what I would do. Indeed, guidelines dosuggest that we rule out red flags first to quickly determinethat the patient will not sustain further injury through reli-ance on conservative therapy. For example, if the patienthas paresthesias around the rectal sphincter, has difficulty

with urination or defecation, cauda equina syndrome mustbe considered, so this would be considered a surgicalemergency. I would bring up referred pain in areas otherthan the back, such as kidneys, gallbladder, or from thebowel or female organs. An aortic aneurysm that is readyto rupture can also cause considerable back pain. Wecould talk about palpating the abdomen and feeling thepulses. Anytime you are dealing with an older patient withvery severe back pain, missing these diagnoses can becatastrophic for the patient.

Furthermore, if the patient had chills and fever and ten-derness along the joint area, it could lead us to diagnoseinfection or abscess of some joint. If the patient has a

history of cancer or immunosuppressive disorder, acancer diagnosis must be considered. Most of us wouldprobably get X-rays at that point. They may not be ashelpful as one might think, and for the most part many ofthe discs just quiet down with resolution of the secondaryneurological problem. Many times, even in the older agegroup, I do not even worry about what the X-rays may looklike because I know they will have spinal stenosis, osteoar-thritis, and disc disease. I know I am not going to be ableto change that pathology and I will continue to do con-servative therapy with medication and physical therapyand even a home exercise program and, hopefully, avoidsurgery. Most of them will get better.

Few patients with acute back pain need diagnostictesting, including X-rays, computed tomographyscans, and MRI, during the first few weeks subsequentto the onset of symptoms. The ACP/APS joint practiceguideline recommends diagnostic imaging only in

patients with severe or progressive neurological deficitsor when the physical exam and history give reason tosuspect a serious underlying condition [5]. Imagingstudies may also be performed on patients who arecandidates for invasive interventions because of per-sistent back and leg pain. Many causes of nerve rootirritation are not diagnosable via plain X-rays, andcommon findings of imaging studies, including bulgingdiscs, often correlate poorly to the actual experience ofback pain [12].

S122

McCarberg et al.

7/27/2019 67226149

5/10

Tenzer-Iglesias: Remember, in male smokers over age65, it is recommended that we get a screening ultra-sound at least once to look for an abdominal aorticaneurysm.

The Spasm-Pain-Spasm Cycle

McCarberg: I want to ask a question about the spasm-pain-spasm cycle. After injury the muscle goes intospasm, presumably to splint and protect the area of injury,so that whatever damage has occurred, theres less rangeof motion. This cycle of spasm-pain-spasm becomeschronic, leading to long-lasting pain. Do you think that is avaluable approach to looking at what happens in acutemusculoskeletal injury?

Weil: I do because, again, almost all acute musculosk-eletal pain has muscle spasm with it. If you have some-body come in with acute pain and you palpate them,you can oftentimes feel the muscle spasm. I do think it

is real, although I know controversy exists about theextent of muscle spasm that can be proven. There havebeen some studies that looked at concomitant use ofmuscle relaxants with nonsteroidals that showed anincreased rate of recovery. With the patients I see, thereis muscle spasm, and when you treat it, they get bettera lot quicker.

Tenzer-Iglesias: I agree. It is that vicious cycle, and tostay on top of it, you have to treat it aggressively early on.

There is this critical period between acute and subacutepain where you really have to get even more aggressive,because what we are trying to do is avoid a chronic painsyndrome.

McCarberg: Penny, do you think that trainees cominginto your residency program understand what the spasm-pain-spasm cycle is all about?

Tenzer-Iglesias: In general, not well enough. I do not findthat there is standardized training in this area. Residentscome to our program from all over the country, so it is notany one particular medical school. In addition they areusually young, and very few have experienced pain, sothey cannot often understand it fully. The ones that haveexperienced pain have somewhat of an idea, betterempathy, and understanding. We have to teach themabout pain and muscle spasm and their possible causes

and consequences.

McCarberg: I am going to ask a question to the groupand hope that Gary will be the one to answer this. I thinkit is particularly misunderstoodspasm splints the area.But how do spasms make pain worse?

Ruoff: From an initial injury the patient develops pain.Motor neurons are activated as a reflex to splint that areacausing muscle spasm. Muscle spasm clearly causespain, but the exact cause of pain is poorly understood.Regardless, this pain will cause more muscle spasm. Avicious cycle takes place. Palpable nodules may occur

chronically, under the skin, which are quite tender, similarto what patients develop in fibromyalgia and myofascialpain syndrome. Understanding this reflex pathway shouldmotivate us to treat the acute pain as quickly as possible.Hopefully, if this cycle is interrupted, a chronic problem willnot occur.

Abnormal Splinting and Return to Normal Activities

McCarberg: I want to make sure that we have stated asfirmly as we are able that the muscle goes into spasm.Spasm splints the area of injury, and the thought is thatwith prolonged splinting, there is also vascular stasis, lossof normal circulatory flow. The circulatory flow helps clearaway those metabolic products that can be toxic to themuscle environment as well. What you are trying to do inall treatment is get that muscle unit back to normal func-tion through early return to activity.

For 20 million years, the human body was working

without disability and social security and bed rest andtime away from work or compensated sick leave. Whatpeople did when they injured their muscles, which I amsure they injured more than we injure today, would be togo back and work right away, because they were notable to stay away from predators if they did not movethe muscle, and the body is designed to get moving veryearly. When you abnormally splint the area or you resttoo long, then you are going to have metabolic productbuildup, you are going to have prolonged spasm andthat is not good. Everything that we do to get peopleback to normal is trying to get their motion back tonormal as well.

Ruoff: It is so important to return the patient to normalactivity as quickly as possible. Deconditioning of the mus-culature appears very quickly, after about 48 hours, so youdo not want to encourage bed rest. You want them tomove around and have them walk as best they can, evenif they are in some pain. Encourage more activity everyday. Many times, the nonpharmacologic therapies, suchas walking, stretching, heat, and range-of-motion exer-cises, are best to regain and maintain function.

Tenzer-Iglesias: I will steal an expression from the sportsmedicine folks, which is motion is lotion. It helps, par-ticularly with certain joints, obviously the knee and severalweight-bearing joints. But any area, even the back can

benefit from this. It is helpful for patients to have assis-tance or support at homei.e., physical therapy, occupa-tional therapy, and various modalitiesand, if they arefortunate, to have insurance coverage for this. We haveworked with osteopathic physicians, and I know that weshould mention the use of manipulation as an effectivetreatment for musculoskeletal problems as well.

McCarberg: If you think about it from a patients view-point, it is counterintuitive to advise stretching, bending,moving, and walking when patients think that lying downis the thing to do. Movement is counterintuitive, becauseit hurts.

S123

Treatment of Paraspinous Muscle Spasm

7/27/2019 67226149

6/10

Treatment Choices: Nonpharmacologic

McCarberg: How do you use nonpharmacologic optionswith an acute musculoskeletal injury?

Weil: I will do trigger point injections in the office as well asother types of injections. It is really kind of a combination

of the pharmacologic approach with physical therapy.Patients like the laying on of hands, and I think that is whya lot of patients like going for manipulations and adjust-ments, because somebody is actually doing something tothem and touching them. One of the advantages ofmanipulations in the office can be more immediate, albeittemporary, relief. I also perform acupuncture. I have donethat for about 13 years. That is another type of approachto really address pain and, in some instances, musclespasm.

Tenzer-Iglesias: I am a big believer in nonpharmacologictreatments, because I believe they empower the patient.

The more you involve themthe more they feel in

controlI think the more likely they will recover and themore they are actually vested in their recovery.

Plus, I think it is very important to ask the patient what theythink will work, because they hear about a lot of therapiesout there that we do not have clear evidence on. Oneexample is magnet therapy. But if their belief system issuch that it will work, it is important to know and work withthem. In some cases they may have even tried it. Goodevidence supports physical therapy. Acupuncture issomething I use with good results in the right patient. Youdo not want to send patients to a yoga class in a gym thathas an inexperienced or untrained instructor who does notknow how to adjust for the patients needs, age, illness, or

restrictions. I am also a big believer in cognitive behavioraltherapy and teaching patients about their painhow ourminds and our bodies are so connected and that ourthoughts do create our feelings. I am not saying you canbring a pain from a 10 to a 0you often cannot do thatanywaybut you certainly can decrease pain andimprove function. Some of the interdisciplinary programs,back schools especially for people that need to return towork, focus on educating people about proper mechanicsand strengthening the back and can be very effective.

Ruoff: In dealing with spasms, especially in the back, Iisolate the area and spray it with ethyl chloride. This cools

the particular area, which has been shown to be therapeu-tic. Applying acupressure usually helps break up thespasm. It is possible to decrease the spasm and the painabout 5060% just by that easy maneuver. Arnold alsomentions the use of local anesthetics injected into a triggerpoint, which we see very commonly in the trapezius andrhomboid areas around the neck and the lumbosacral areaaround the lower spine. I will inject the trigger points withbupivacaine 0.25% about 2.5 cc to break up the spasm.Using acupressure usually eliminates the trigger point andrelieves the spasm. It is possible to relax the muscle right atthat particular point in time. I like to teach patients thatbasically they need to use heat for 15 minutes twice a day,range-of-motion exercises, and stretch. If they lack theability to pay for physical therapy, then showing them somesimple exercises in the office is of great benefit.

McCarberg: Trigger point injections, stretch, and spray.These things, I do not think tend to work very well unlessthey are combined with active motion. So you do not just

give them an injection and send them home to get in bed.They have to start stretching these areas as well. It is nota passive therapy. There is activity on the patients partonce they get the immediate pain relief.

Treatment Choices: Pharmacologic

McCarberg: I want to summarize a study from GroupHealth Cooperative of Puget Sound, where they have agood database, and they looked at acute low-back andneck problems and surveyed to find out the mostcommon drug that was given, and an anti-inflammatorywas number one [17]. When a second drug was given, it

was usually a muscle relaxant. The next most commonwas an opioid. Do you think that is a reasonableapproach? How would you do it if you were going topharmacologically treat an acute musculoskeletal injury?

Weil: I think it is very reasonable, because I almost alwaysgive a combination of a nonsteroidal anti-inflammatorydrug (NSAID) with a muscle relaxant, and my patients donot really need the opiates, because the muscle relaxant istreating the muscle spasm and the anti-inflammatorymedication is treating inflammation and also the pain. Ifyou do not give them some type of medication, theresa good chance that they may be dissatisfied and go

In a study of patients with

7/27/2019 67226149

7/10

somewhere else and another physician or provider couldmuck up the situation if they do not really have the sameknowledge of how to treat the spasm and pain.

McCarberg:The best evidence we have is for nonsteroidalanti-inflammatories in an acute back injury. Muscle relax-ants were a pretty good pharmacologic option as well. Anyother kind of comments on what medication would berecommended other than the three that I mentionedso far?

Ruoff: Very often I see residents and seasoned physi-cians, especially emergency-room physicians, initiallytreating the acute pain and spasm with opioids, such ashydrocodone and oxycodone or other combinations.

Analgesics will help the pain but may not be very useful toreduce the spasms. Often times, patients will be dis-charged from the emergency room or another facility with

just pain medication and asked to see me in about aweek. I am concerned that the golden time to prescribe amuscle relaxant is in the first 4872 hours in conjunction

with a nonopioid pain reliever such as a NSAID becausemost of the injuries that occur also incite inflammation. So,a better choice would be a combination of a musclerelaxant with a nonsteroidal anti-inflammatory agent for23 weeks if necessary.

The muscle relaxants for the most part have to be takenexactly as directed. It is important to create the appropriatedrug level to reduce the spasm. The drug level tends to fallif the medication is not taken on time. Most of the musclerelaxants are given three to four times per day. It is really upto the patient to take the medication on time. If the medi-cation is taken hours later, the patient could lose thetherapeutic effect. Nonsteroidal anti-inflammatories have a

two-pronged approach. They are simple analgesics inlower doses, and in higher doses, they are both analgesicand anti-inflammatory. It is important to prescribe the non-steroidal anti-inflammatories initially in the higher doses andgraduate down as the patient becomes more comfortable.

I have no problem at all if physicians would like to add inan opioid after a muscle relaxant, and nonsteroidal anti-inflammatory are on board, if pain is intolerable. You canuse these opioids for rescue analgesia only and not as asole medical entity when initially dealing with musclespasm and inflammation, both of which are not handledwell by opioids because the opioids are not going to treatthe underlying process.

Tenzer-Iglesias: Residents come in with biases from thepeople that they have worked with, their teachers, andpossibly prior experiences with patients. Clearly there isopioid usage for back pain, which often brings up strongfeelings one way or the other. I use nonsteroidals for acutepain, for which there is absolutely great evidence;however, I am a huge believer in getting patients off ofnonsteroidals when there is chronic pain, because long-term usage of NSAIDs can have many adverse effectswith little evidence for any efficacy in neuropathic orchronic back pain. There is often a lack of understandingof appropriate use of the medications in acute as well as

chronic painwhich medications to use as well asdosage, duration, and combination treatments.

Ruoff: Well it is not recommended, but I think thereis a place for methylprednisolone or some other steroidanti-inflammatory medicine, in difficult-to-control cases,because I have seen that help dramatically at times, whenthe patient may have been treated with all the appropriatemedications and still has pain.

Tenzer-Iglesias: I agree with you clinically, on an indi-vidual basis we may see some efficacy, but if we look atthe guidelines, based on multiple studies, and if we look atlarge populations with low-back pain, there is actually agood level of evidence that there is no benefit for systemicsteroids. I tend to not use them now based on the guide-lines. Even though perhaps some people may feel better,I do wonder what the mechanism of pain relief is.

Weil: I can tell you from my experience that if somebody

comes in with acute pain, and they have a markedlypositive straight-leg-raise test, and they present with a lotof radicular symptoms, you give them a tapering scheduleof methylprednisolone and a muscle relaxant, they aregoing to come back in a week and, most of the time, theywill be significantly better. Then I will put them on a non-steroidal anti-inflammatory, continue the muscle relaxant,and put them in physical therapy. The times they comeback and they are not better, almost 99% of the time theyhave got a big disc herniation and that is why. In the rightpresentation, if they have got symptoms and a prettymarked positive leg-raise test, I think oral steroids is anexcellent form of treatment.

McCarberg: I have a question for you then regardingsteroid injections. What is the rationale for an intramuscu-lar injection of steroid vs. depositing the steroid in theepidural space?

Weil: Well, an intramuscular shot of 80 mg of methylpred-nisolone would have about a 24-hour effect, and thattends to just go away because it is absorbed, and there isreally no prolonged effect. If they have a disc that isherniated, there also tends to be a lot of inflammationaround that disc. Theoretically, you can use a steroid rightwhere the disc is herniated, right where the inflammationis. It is not the end of the story with the injection. It is stillvery important to get them into a spine-strengthening

program afterwards to strengthen all those muscles thathelp stabilize and support the spine. If you do not, they aregoing to be right back where they started.

Tenzer-Iglesias: One of the things I am hearing fromArnold is that you are not just using one treatment modal-ity. You are utilizing multiple approaches, and so we maynot know when we use combinations which one is havingthe effects, or if several are working together for an addi-tive impact. I am one of those people who try to teachabout reliable databases and evidence-based medicine,because we have to acknowledge well-done studies withlarge populations.

S125

Treatment of Paraspinous Muscle Spasm

7/27/2019 67226149

8/10

McCarberg: Yeah, that is why I brought up my partabout the guidelines do not support systemic steroids. Ido not want to deprecate clinical experience. Clinicalexperience is not always generalizable, but when youhave people doing it over and over again and seeinggood results, you have to take into account clinicalexperience. A cl inical study is done in a popu-lation that does not necessarily represent patientswe see.

PhysicianPatient Communication:

A Credible Explanation

McCarberg: I want to point out another thing that I thinkis very important and that is the patient education piece.Patients come in with a preconceived idea: Oh I need an

X-ray; I need an MRI. Or they come in and say, I knowIve got cancer. By just telling them what you think theyhavegiving them some literaturethe education alonereally makes a big difference. Dissipating anxiety is key.

There was actually a study that looked at chiropractors vs.primary care doctors vs. orthopedic surgery providerswith acute back pain patients [22]. The outcomes werethe same for all groups, the cost was the least amongprimary care providers, but the satisfaction was the bestwith chiropractic care. What the patients identified thatwas different was that the chiropractor gave the mostcredible explanation for their problem. That is interesting,because I dont think we do that very well in primary care.

Were trying to get to a diagnosis, were busy, were tryingto take care of multiple problems at each visit, and wedont teach as well as we could. Patients really want tohave something credibly explained to them, and thatexplanation and education has a therapeutic value.

Tenzer-Iglesias: We do not know what their fear is, justas you said. Perhaps they think they have cancer orsomething else going on, and until we find out what theirconcern is we cannot optimally treat the patient.

Clinical Pearls

Tenzer-Iglesias: The diagnosis is in a thorough historyand physical. Pharmacologic and nonpharmacologicapproaches should be integratednever one without theother. Evaluate for biopsychosocial risk factors. Depres-sion, anxiety, and related issues are going to be veryimportant in planning treatment.

Weil: Listen to the patients, they will tell you where thepathology is. The diagnostic tests are just an extension ofthe physical exam. I dont think you should ever focus onone of anythingone diagnostic test, one part of theexam.

McCarberg: Everything we do is an attempt for early

mobilization. Indeed, it is a proactive approach, getting thepatient up and moving, even when the pain may get a littleworse.

Ruoff: Communication and education to dispel anxiety ishighly therapeutic.

Acknowledgment

Medical writer Beth Dove, of Dove Medical Communica-tions in Salt Lake City, Utah, assisted in the preparation ofthis manuscript.

First-line medications for acute back pain are acetami-nophen (APAP) and NSAIDs [5]. NSAIDs are usuallymore effective for pain relief, but their gastrointestinaland renovascular risks must be considered. If a patienthas an unsatisfactory safety profile for the use ofNSAIDs or if pain control is unrealized or unlikely,opioids (usually short acting) can be considered but are

not recommended as first-line therapy because ofabuse, addiction, and diversion risks [5]. The use ofopioids for >90 days has been associated withemergency-department visits and adverse eventsinvolving drugs and alcohol, particularly in patientswith headache, back pain, and prior substance-usedisorders [18].

Skeletal muscle relaxants (e.g., baclofen, dantrolene,cyclobenzaprine, orphenadrine, and tizanidine)provide moderate analgesic benefit for acute low-back pain [9], particularly in combination with NSAIDsor APAP; such combination therapy has been foundto provide superior pain relief to monotherapy [19,20].Muscle relaxants usually are not recommended asfirst-line therapy because of risk of central nervoussystem adverse effects, principally sedation [5].However, the fact that good evidence shows moder-ate improvement with skeletal muscle relaxants foracute pain, but the evidence is less robust for thetreatment of chronic pain [5] suggests a possiblewindow of opportunity for optimal therapeutic effect.It is worth considering, too, whether muscle relax-ants, dispensed short term for acute pain, may havea better safety profile than opioids. Medicationslabeled as muscle relaxants differ from one anotherpharmacologically, and none has been clearly provenmore efficacious than another [20]. However, certainmuscle relaxants should be avoided for low-back

pain, namely carisoprodol because of abuse liability,and dantrolene because of its black box warning forpotentially fatal hepatotoxicity [20]. Tizanidine andchlorzoxazone are associated with less serious,usually reversible hepatoxicity.

Systemic corticosteroids are not recommended fornonspecific low-back pain [5] and have failed to dem-onstrate efficacy for acute non-radicular low-back painor sciatica [9,20]. Regardless, physician survey resultsshow that use of oral steroids is common in primarycare [21].

S126

McCarberg et al.

7/27/2019 67226149

9/10

References

1 Deyo RA, Mirza SK, Martin BI. Back pain prevalenceand visit rates: Estimates from U.S. national surveys,2002. Spine (Phila Pa 1976) 2006;31(23):27247.

2 Carey TS, Garrett JM, Jackman AM. Beyond the goodprognosis. Examination of an inception cohort ofpatients with chronic low back pain. Spine (Phila Pa1976) 2000;25(1):11520.

3 Deyo RA, Weinstein JN. Low back pain. N Engl J Med2001;344(5):36370. Review.

4 Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimatesand patterns of direct health care expenditures amongindividuals with back pain in the United States. Spine2004;29(1):7986.

5 Chou R, Qaseem A, Snow V, et al. Diagnosis andtreatment of low back pain: A joint clinical practiceguideline from the American College of Physiciansand the American Pain Society. Ann Intern Med2007;147(7):47891.

6 Pransky G, Buchbinder R, Hayden J. Contemporarylow back pain researchand implications for practice.Best Pract Res Clin Rheumatol 2010;24(2):2918.

7 Pengel LHM, Herbert RD, Maher CG, Refshauge KM.Acute low back pain: Systematic review of its progno-sis. BMJ 2003;327(7410):3237.

8 Kent PM, Keating JL. The epidemiology of low backpain in primary care. Chiropr Osteopat 2005;13:13.

9 Chou R, Huffman LH, American Pain Society, Ameri-can College of Physicians. Medications for acute andchronic low back pain: A review of the evidence for an

American Pain Society/American College of Physi-cians clinical practice guideline. Ann Intern Med2007;147(7):50514.

10 Chou R, Huffman LH, American Pain Society, Ameri-can College of Physicians. Nonpharmacologic thera-pies for acute and chronic low back pain: A review ofthe evidence for an American Pain Society/AmericanCollege of Physicians clinical practice guideline. AnnIntern Med 2007;147(7):492504.

11 Ivanova JI, Birnbaum HG, Schiller M, et al. Real-worldpractice patterns, health-care utilization, and costs in

patients with low back pain: The long road toguideline-concordant care. Spine J 2011;11(7):62232.

12 United States Bone and Joint Decade. USBJDcondition kit on low back pain. Rosemont, IL;

2007. Available at: http://www.usbjd.org/research/research_op.cfm?dirID=260 (accessed June 212011).

13 Chou R, Shekelle P. Will this patient develop persis-tent disabling low back pain? JAMA 2010;303(13):1295302.

14 Hall AM, Kamper SJ, Maher CG, et al. Symptoms ofdepression and stress mediate the effect of pain ondisability. Pain 2011;152(5):104451.

15 Waddell G, Feder G, Lewis M. Systematic reviews ofbed rest and advice to stay active for acute low back

pain. Br J Gen Pract 1997;47(423):64752.16 Shen FH, Samartzis D, Andersson GB. Nonsurgical

management of acute and chronic low back pain.J Am Acad Orthop Surg 2006;14(8):47787.

17 Cherkin DC, Wheeler KJ, Barlow W, Deyo RA. Medi-cation use for low back pain in primary care. Spine(Phila Pa 1976) 1998;23(5):60714.

18 Braden JB, Russo J, Fan MY, et al. Emergencydepartment visits among recipients of chronicopioid therapy. Arch Intern Med 2010;170(16):142532.

19 Beebe FA, Barkin RL, Barkin SA. clinical and pharma-cologic review of skeletal muscle relaxants for muscu-loskeletal conditions. Am J Ther 2005;12(2):15171.

20 Chou R. Pharmacological management of low backpain. Drugs 2010;70(4):387402.

21 Di Iorio D, Henley E, Doughty A. A survey of primarycare physician practice patterns and adherence toacute low back problem guidelines. Arch Fam Med2000;9(10):101521.

22 Carey TS, Garrett J, Jackman A, et al. The outcomesand costs of care for acute low back pain amongpatients seen by primary care practitioners, chiroprac-tors, and orthopedic surgeons. The North CarolinaBack Pain Project. N Engl J Med 1995;333(14):9137.

S127

Treatment of Paraspinous Muscle Spasm

7/27/2019 67226149

10/10

Copyright of Pain Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to

multiple sites or posted to a listserv without the copyright holder's express written permission. However, users

may print, download, or email articles for individual use.