Abstract
Background: Back pain affects about 40% of people at some point in their lives. Medications are recommended for the duration that they are helpful. The symptoms of low back pain usually improve within a few weeks from the time they start. Our study was undertaken to study the effect of analgesics in the management of pain, as well as overall and complete recovery of patient and the return to normal life.
Methods: Our study is a randomised controlled trial involving 40 people with severe acute lower back ache, who were divided into 2 groups of 20 each and were observed over 6 weeks for pain relief and return to normal activities.
Results: The duration of moderate or severe pain was on an average 4.1 days in analgesic group and 6.3 days in placebo group. But the time to total relief from pain (even mild) was almost the same in both groups (2w6d and 2w3d). The time to return to normal activities was also almost the same.
Conclusions: Though pain killers may be useful in the management of moderate to severe pain, their role in mild pain is less obvious and their usefulness in returning the patient to normal routine is also not obvious.
Introduction
Back pain is one of the most frequent reasons for hospital visits and is the second most common reason for leaves from work. [1, 2]
It affects about 40% of people at some point in their lives. [3]. The first experience of acute low back pain is typically between the ages of 20 and 40. [4] In the USA, back ache costs about $25 billion annually. [5]
Low back ache is said to be acute, if its duration is less than 6 weeks. Most of the acute LBA are due to mechanical problems such as muscle or joint strain. The treatment of acute low back pain is conservative involving the use of steroids, simple pain medications, bed rest of no more than 3 days, avoidance of strenuous activity, avoidance of flexion of back and the continuation of as much normal activity as the pain allows.
Medications are recommended for the duration that they are helpful. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40-90% of people completely better by six weeks. [6]
Materials and Methods
We usually receive around 5-10 patients with acute severe low back ache in our casualty ward daily. Out of these, patients in whom this was the first episode, there were no neurological deficits, there were no comorbidities or red flag signs, those who consented to experimental study and who lived within 10 km range of our hospital were selected for the study. 40 such patients were selected.
Patients were divided into 2 groups by toss of coin; first group was discharged on analgesics, and bed rest. And the second group was discharged on bed rest and placebo (serratiopeptidase) [7].
Patients were questioned daily for first 7 days and then every 3 days for the next 5 weeks about amount of pain (mild, moderate, severe) and return to ambulation (nil, to bathroom, to the garden, home activities, normal (not including strenuous/heavy activities)) and sick leave or return to work. The patients were examined daily for first 4 days and then weekly for the next 5 weeks and Straight leg raising (SLR) was recorded.
The patients were to be followed till 6 weeks or till SLR returned to 70o or more and patient returned to normal ambulation and work and was pain free; whatever came early.
Ethical Issues
We are giving a placebo to the patient, and might subject the patients in placebo group to more discomfort. The nature of the study was explained in local language to all the patients. It was explained that there is a 50/50 chance that we might give them a placebo and they might experience pain for more time. It was also explained that the pain will go away in any case in a few days, and that most likely there will be no permanent damage or benefit with the intake or without the intake of either drug. Consent was taken in form of a signed document from the patients.
Results
The patients were followed for no more than 6 weeks and following results were found.
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Conclusion
Although analgesics are useful in the acute management of painful conditions and our research shows that they reduce the time spent with moderate/severe pain, their efficacy in total relief from pain (even mild) is less evident.
The time to return to bathroom or light activities was almost the same for both the groups. But the time to return to routine activities was slightly less in placebo group, and so were the sick leaves taken.
Straight leg raising test returned to normal values at approximately the same time in both the groups.
Hence we conclude that, though pain killers may be useful in the management of moderate to severe pain, their role in mild pain is less obvious and their usefulness in returning the patient to normal routine is also not obvious.
Therefore, in lower back pain especially mild pain, painkillers must be prescribed with caution taking into account the possible gastric and renal side effects especially in elderly, and the side effects of unnecessary injections. And the potential of abuse of not only opioids but of NSAIDS as well in populations that are too prone to OTC drugs, too casual towards drug intake and less tolerant to even mild pain, like our population.
References
1. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291-300.
2. Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health 1991;12:141-56.
3. Hoy D, Bain C, Williams G et al. (June 2012), "A systematic review of the global prevalence of low back pain". Arthritis Rheum. 64 (6): 2028–37.
4. Casazza, BA (15 February 2012). "Diagnosis and treatment of acute low back pain". American family physician 85 (4): 343–50.
5. Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am 1991;22:263-71
6. Menezes Costa Lda, C; Maher, CG; Hancock, MJ; McAuley, JH; Herbert, RD; Costa, LO (7 August 2012). "The prognosis of acute and persistent low-back pain: a meta-analysis.". CMAJ: Canadian Medical Association journal 184 (11): E613–24.
7. "Serratiopeptidase: Finding the Evidence". Bandolier online edition. Retrieved 2008-03-20.
Source(s) of Funding
Self-financed
Competing Interests
None
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