Pain Medicine 2011; 12: S119S127 Wiley Periodicals, Inc.

Diagnosis and Treatment of Low-Back Pain Because of Paraspinous Muscle Spasm: A Physician Roundtable
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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, Kaiser Permanente, 732 North Broadway, Escondido, CA 92025, USA. Tel: 760-839-7008; Fax: 760-839-7053; E-mail: Bill.H.Mccarberg@kp.org. Disclosures: The authors make the following disclosures of nancial relationships during the past 3 years with companies whose products may be related to 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 advisory boards and speakers bureaus for Takeda, Endo, and Cephalon. Dr Tenzer-Iglesias has served on the advisory boards for UCB and Forest. Dr Weil has served as a speaker for King, Cephalon, and Ferring. Support: Support for the publication of this supplement was provided by Cephalon, Inc. Disclaimer: Information contained in this supplement represents the opinions of the authors and is not endorsed by, nor does it necessarily reect the views of Cephalon, Inc. In order to facilitate the review of this supplement to Pain Medicine and to maintain the integrity of the editorial peer review process, reviewers of this supplement were chosen independently by the Supplement Editor. No compensation was paid to these reviewers for their review.

low-back pain, practical application is nonuniform and physician uncertainty regarding best practices is widespread. Objective. The objective of this study was to further optimal treatment choices for screening, diagnosing, and treating acute low-back pain caused by paraspinous muscle spasm. Methods. Four experts in pain medicine (three family physicians and one physiatrist) participated in a roundtable conference call on October 18, 2010, to examine current common practices and guidelines for diagnosing and treating acute low-back pain and to offer commentary and examples from their clinical experience. Results. Participants discussed the preferred choices and timing of diagnostic and imaging tests, nonpharmacologic therapies, nonopioid and opioid medication use, biopsychosocial evaluation, complementary therapies, and other issues related to treatment of acute low-back pain. Principal clinical recommendations to emerge included thorough physical exam and medical history, early patient mobilization, conservative use of imaging tests, early administration of muscle relaxants combined with nonsteroidal anti-inammatory medications to reduce pain and spasm, and a strong emphasis on patient education and physician patient communication. Conclusions. Early, active management of acute low-back symptoms during the initial onset may lead to better patient outcomes, reducing related pain and disability and, possibly, preventing progression to chronicity. Key Words. Acute; Low-back Pain; Muscle Relaxants; Muscle Spasm; Opioids; Paraspinous

Introduction Most adults experience low-back pain sometime during their lifetimes. Approximately one-quarter of U.S. adults have had an episode of low-back pain lasting at least 1 day within the past 3 months [1], and the lifetime prevalence approaches 80% [2]. Low-back pain exacts large costs to society. Only symptoms of upper-respiratory illness rank higher as a reason for physician ofce visits [3], and direct health care expenditures and indirect economic S119

Abstract Background. Despite the availability of evidencebased guidelines to diagnose and treat acute

McCarberg et al. losses because of back pain and related disability exceed $100 billion per annum [4]. Acute low-back pain (lasting <4 weeks) [5] may begin with a sudden localized tissue injury or sprain within the structure of the spine [3] or may result from cumulative muscle fatigue and strain [6]. Most cases of acute lowback pain do not involve serious pathology with 85% of patients who present to primary care classied as having pain of nonspecic origin [3,5]. In the vast majority of cases of acute low-back pain, symptoms are selflimiting, although up to 73% of people have a recurring episode within a year [7]. Patients who have not recovered from an initial acute attack at 12 weeks often see improvement taper off or cease altogether [7]. Up to 10% of low-back pain sufferers seen in primary care will go on to develop chronic pain [8], underscoring the need to prevent the progression to chronicity through early treatment choices and care. To assist primary care providers, to whom most patients rst present with acute back symptoms, professional physician associations have made available a variety of treatment guidelines, including, in 2007, a collaboration between the American Pain Society and the American College of Physicians [5,9,10]. Evidence-based guidelines, however, are far from uniformly applied in clinical practice, and imaging tests and strong medications, such as opioids, are frequently introduced early, despite expert advice to postpone such measures in the majority of cases [11]. The variation in care decisions by treating physicians likely indicates continuing uncertainty regarding best practices as well as the complications posed by time pressures, patient expectations, prior history, and other realities of daily clinical practice. Thus, the search for consensus as to optimal treatment practices continues. To address these concerns, four experts in pain medicine (three family physicians and one physiatrist) participated in a roundtable conference call on October 18, 2010, to discuss current evidence and to contribute personal clinical experience and commentary regarding the treatment of acute low-back pain, primarily or secondarily because of muscle spasm, in a typical practice setting. Roundtable participants were as follows: Moderator: Bill H. McCarberg, MD, Kaiser Permanente, Escondido, CA Panelists: Gary E. Ruoff, MD, Westside Family Medical Center, Kalamazoo, MI; Penny Tenzer-Iglesias, MD, University of Miami, Miami, FL; and Arnold J. Weil, MD, Non-Surgical Orthopaedics, PC, Atlanta, GA Topics covered during the discussion included prevalence and pathogenesis, physical exam and medical history, preferred screening methods and their timing, pharmacologic and nonpharmacologic therapies, patient education, and physician communication skills. Participant comments (edited for brevity, clarity, stylistic consistency, and S120 logical ow) are combined with text boxes containing relevant supporting documentation from the scientic literature. The goal is to address the practical issues observed in clinical practice and to elucidate helpful methods of applying treatment guidelines to improve patient outcomes.

Patient Characteristics McCarberg: Let us start with a short discussion about how commonly you see acute musculoskeletal pain in practice. Do you think it is disruptive and disables people? Ruoff: Musculoskeletal pain is in the top three problems seen in my practice. Musculoskeletal pain disorders can be quite disabling, especially when they affect the neck, the low-back, or a weight-bearing joint. Patients will usually call the ofce when their quality of life is interrupted or if theres major disruption in their normal daily routine. I see these patients early and make room in my schedule. I think other pain syndromes such as shoulder, elbow, and other non-weight-bearing joints need to be seen on a less urgent basis. Tenzer-Iglesias: It is denitely one of my top ve diagnoses and it takes on different avors, so to speak, according to different age groups as well. An important point that you touched on pertained to weight-bearing joints, including the lower spine. The increased prevalence of obesity in the population right now is making this even more common. McCarberg: Penny, you are a geriatrician. In what age group are you seeing most acute musculoskeletal injuries? Am I correct that the incidence and prevalence are probably going to go up with time as our older population becomes more interested in physical activities? Tenzer-Iglesias: In my geriatric population, this is very common, and osteoarthritis is the most common complaint that brings people into the ofce. Our geriatric population is variable with regard to activity level. For example, I have an 84-year-old patient who works out for 2 hours a day, including jogging for an hour, and is in far better shape than many women half her age. In addition, I have people who are frail and those who have not always taken very good care of themselves. In these cases, I see a lot of knee, back, and joint pain. Then, I see younger people, some who may be inactive and then decide suddenly to have a signicant activity increase. As we get older, because of degenerative processes, back pain is going to be much more prevalent and is often due to arthritis and spinal stenosis. In younger patients in their 30s and 40s, I am seeing more pain because of disc injury and related disorders. Ruoff: The guidelines for back pain usually state that the patient who is younger than 20 years of age or older than

Treatment of Paraspinous Muscle Spasm 50 might need to be seen more urgently, usually if they were in an accident and sustained major injuries. We are seeing more injuries in the younger group than in the past because of more competitive sports. Cheerleading and gymnastics, for example, can be very dynamic and these younger athletes may have major injuries. The 20- to 50-year age group would more likely have disc pathologies. I see a lot of nonspecic back pain because of muscle spasm in this age group, too. I agree with Penny that in the older age group, there are more osteoarthritic changes, disc pathology, spinal stenosis, and osteoporosis, which may lead to fractures and serious pain. Weil: I, too, see a lot of older people who are very active, and theyre still expecting to do a lot. I also see a lot of younger kids who are having acute musculoskeletal injuries, mainly from school sports. While the epidemiology of causes of back pain is important to keep in mind, from a clinical practice standpoint, I think it is important to evaluate each person independently so nothing gets missed. after ruling out serious neurological risk, it is not quite so important in the acute phase, because you are pretty much going to use a strong anti-inammatory and muscle relaxant, encourage early mobilization, and get them into physical therapy. I think a lot of times, we get hung up on looking for pathology in an X-ray, and if there are no acute ndings, there is a tendency to dismiss the patient and say there is nothing wrong, and the patients just have to live with it. The X-ray may rule out a fracture, but it is really not the primary diagnostic tool. The history, physical exam, and laying hands on the patient are going to give you a great indication of what is going on and what needs to be done the majority of the time. Ruoff: I agree with a good physical examination, which would include reexes, dorsiexion, and plantar exion of the ankle, and foot checking for paresthesias of the legs and feet, and weakness in any of the musculature. Tenzer-Iglesias: Do not just focus on the straight-leg raise alone, because that is what I see our trainees doing at times. They may forget to assess the hips, knees, and other areas such as sacroiliac joints. Under the physical exam, you are not just focusing on that one sign, you are focusing on the complete patient and range of possibilities.

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

The Difculty of Diagnosis McCarberg: Let me ask another question that becomes very difcult for us in primary care and that is the lack of diagnostic accuracy in assessing specic causes of pain in the musculoskeletal conditions, especially in the lowback and neck. Is it discogenic? Is it a nerve? Is it a ligament? Is it arthritic? Has it something to do with a facet joint that may be arthritic or traumatic? First, how precise can we be, and second, how important is it that we be precise? Weil: This is where the practice of medicine is more an art than a science, because I have always thought that especially with back painyou can get a very good sense of the pathophysiology from a really good history and physical exam. There is almost always muscle spasm with acute back injuries, so you know you are always going to be treating a muscular component, but a lot of times, just how the person was injured and what you nd on examination can give you a good sense of whether you are dealing with something discogenic, whether there is involvement of nerve root irritation, or whether it may be more of a facet type of pain. How important is it to be precise? You could say it is very important because you are going to tailor your treatment to the underlying problem. But, on the other hand,

A joint practice guideline from the American College of Physicians (ACP) and the American Pain Society (APS) strongly recommends a thorough history and physical examination to determine whether back pain stems from a specic cause or whether patients fall into the category of the 85% of acute sufferers whose back pain is of nonspecic origin [5]. The exam should focus on the presence and extent of neurological involvement and on risk factors for specic underlying conditions. The exam should also include assessment of psychosocial factors that are predictive of ongoing disabling pain and include depression, passive coping strategies, job dissatisfaction, and high disability levels [5]. An investigation based on 20 studies comprising 10,842 patients with <8 weeks of back pain found that powerful predictors of ongoing pain at 1 year are nonorganic signs, maladaptive pain-coping behaviors, high baseline functional impairment, psychiatric comorbidities, and poor general health [13]. It has been suggested that psychological distress mediates approximately 30% of the relationship between low-back pain and subsequent disability [14].

When is Imaging Indicated? Ruoff: All forms of imagingplain X-rays and even magnetic resonance imaging (MRI)can be misleading S121

McCarberg et al. as many patients with severe changes may be completely asymptomatic, and others that have minor changes may be very symptomatic. Imaging does not add any value to the diagnosis unless the patient has a positive nding on a neurological exam. The majority of back cases will be of nonspecic nature, mainly because of muscle spasm. The radiation of pain in those cases occurs from the back to above the kneevery rarely below the knee unless a neurologic event is taking place, such as injury, compression, or inammation of a nerve. In those latter cases, there may also be diminished reexes in the knees or ankles, weakness in dorsiexion or plantar exion of the feet and ankles, and a sensory loss in some aspect of the lower leg or foot. Weil: Actually, of the patients I see, I would say that over 50% of the time, they do have pain down to the foot. I see patients with acute back injuries that have sciatic symptoms all the way down to the foot. But I do agree that the X-rays can be misleading. X-rays and MRIs serve as diagnostic or conrmatory tools to corroborate your physical exam and not the other way around. I do not jump to MRIs unless I need that for whatever is next in the treatment process, whether it be epidural injections or facet injections or something of that nature. Tenzer-Iglesias: What we are saying is so important, and yet it seems to be the rule and not the exception that MRIs are ordered and often very early. I did an interactive question during a case-based lecture asking about patient workup, and ordering an MRI is one of the possible answers. It is the wrong answer per the guidelines, and yet a signicant percentage of the audience will pick MRI as the answer. We need to listen to the patients storythe mechanism of injury, especially in an acute episode, and focus on a thorough physical examination as well as assess psychosocial factors to look for clues. If I order a test, I will ask what is the question that the test will answer for me that I am not able to answer for myself right now? How will it change my treatment plan? I try to instill this way of critical thinking in our residents and medical student trainees. At times it is very difcult, because a lot of different forces promote going straight to lab tests and imaging studies instead of relying on a thorough clinical assessment as recommended by the guidelines. Weil: Not to be real cocky, but I do not need an MRI to tell me somebodys got an L4/5 disc protrusion compressing the L5 nerve root. In fact, when I started practicing 18 years ago, if somebody did not improve with an adequate amount of conservative treatment, eventually I would do an epidural injection and not necessarily get an MRI. Now the patients insurance company is not going to authorize epidurals unless you have an MRI, but in reality you do not need it because with a good history and a good physical exam, most of the time, you can tell exactly where the pathology is and where the problem lies. S122 Few patients with acute back pain need diagnostic testing, including X-rays, computed tomography scans, and MRI, during the rst few weeks subsequent to the onset of symptoms. The ACP/APS joint practice guideline recommends diagnostic imaging only in patients with severe or progressive neurological decits or when the physical exam and history give reason to suspect a serious underlying condition [5]. Imaging studies may also be performed on patients who are candidates for invasive interventions because of persistent back and leg pain. Many causes of nerve root irritation are not diagnosable via plain X-rays, and common ndings of imaging studies, including bulging discs, often correlate poorly to the actual experience of back pain [12].

Red Flags: Do Not Miss a Diagnosis McCarberg: Most of the guidelines mention looking out for red ags, including fever, serious trauma, progressive neurologic decit, cancer, osteoporosis, chronic steroid use, and others. If there are no red ags, the guidelines pretty much say you are going to treat everybody the same. What do you think of that kind of approachrule out red ags and then treat everybody the same? Ruoff: That is what I would do. Indeed, guidelines do suggest that we rule out red ags rst to quickly determine that the patient will not sustain further injury through reliance on conservative therapy. For example, if the patient has paresthesias around the rectal sphincter, has difculty with urination or defecation, cauda equina syndrome must be considered, so this would be considered a surgical emergency. I would bring up referred pain in areas other than the back, such as kidneys, gallbladder, or from the bowel or female organs. An aortic aneurysm that is ready to rupture can also cause considerable back pain. We could talk about palpating the abdomen and feeling the pulses. Anytime you are dealing with an older patient with very severe back pain, missing these diagnoses can be catastrophic for the patient. Furthermore, if the patient had chills and fever and tenderness along the joint area, it could lead us to diagnose infection or abscess of some joint. If the patient has a history of cancer or immunosuppressive disorder, a cancer diagnosis must be considered. Most of us would probably get X-rays at that point. They may not be as helpful as one might think, and for the most part many of the discs just quiet down with resolution of the secondary neurological problem. Many times, even in the older age group, I do not even worry about what the X-rays may look like because I know they will have spinal stenosis, osteoarthritis, and disc disease. I know I am not going to be able to change that pathology and I will continue to do conservative therapy with medication and physical therapy and even a home exercise program and, hopefully, avoid surgery. Most of them will get better.

Treatment of Paraspinous Muscle Spasm Tenzer-Iglesias: Remember, in male smokers over age 65, it is recommended that we get a screening ultrasound at least once to look for an abdominal aortic aneurysm. The Spasm-Pain-Spasm Cycle McCarberg: I want to ask a question about the spasmpain-spasm cycle. After injury the muscle goes into spasm, presumably to splint and protect the area of injury, so that whatever damage has occurred, theres less range of motion. This cycle of spasm-pain-spasm becomes chronic, leading to long-lasting pain. Do you think that is a valuable approach to looking at what happens in acute musculoskeletal injury? Weil: I do because, again, almost all acute musculoskeletal pain has muscle spasm with it. If you have somebody 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 the extent of muscle spasm that can be proven. There have been some studies that looked at concomitant use of muscle relaxants with nonsteroidals that showed an increased rate of recovery. With the patients I see, there is muscle spasm, and when you treat it, they get better a lot quicker. Tenzer-Iglesias: I agree. It is that vicious cycle, and to stay on top of it, you have to treat it aggressively early on. There is this critical period between acute and subacute pain where you really have to get even more aggressive, because what we are trying to do is avoid a chronic pain syndrome. McCarberg: Penny, do you think that trainees coming into your residency program understand what the spasmpain-spasm cycle is all about? Tenzer-Iglesias: In general, not well enough. I do not nd that there is standardized training in this area. Residents come to our program from all over the country, so it is not any one particular medical school. In addition they are usually young, and very few have experienced pain, so they cannot often understand it fully. The ones that have experienced pain have somewhat of an idea, better empathy, and understanding. We have to teach them about pain and muscle spasm and their possible causes and consequences. McCarberg: I am going to ask a question to the group and hope that Gary will be the one to answer this. I think it 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 reex to splint that area causing muscle spasm. Muscle spasm clearly causes pain, but the exact cause of pain is poorly understood. Regardless, this pain will cause more muscle spasm. A vicious cycle takes place. Palpable nodules may occur chronically, under the skin, which are quite tender, similar to what patients develop in bromyalgia and myofascial pain syndrome. Understanding this reex pathway should motivate us to treat the acute pain as quickly as possible. Hopefully, if this cycle is interrupted, a chronic problem will not occur. Abnormal Splinting and Return to Normal Activities McCarberg: I want to make sure that we have stated as rmly as we are able that the muscle goes into spasm. Spasm splints the area of injury, and the thought is that with prolonged splinting, there is also vascular stasis, loss of normal circulatory ow. The circulatory ow helps clear away those metabolic products that can be toxic to the muscle environment as well. What you are trying to do in all treatment is get that muscle unit back to normal function through early return to activity. For 20 million years, the human body was working without disability and social security and bed rest and time away from work or compensated sick leave. What people did when they injured their muscles, which I am sure they injured more than we injure today, would be to go back and work right away, because they were not able to stay away from predators if they did not move the muscle, and the body is designed to get moving very early. When you abnormally splint the area or you rest too long, then you are going to have metabolic product buildup, you are going to have prolonged spasm and that is not good. Everything that we do to get people back to normal is trying to get their motion back to normal as well. Ruoff: It is so important to return the patient to normal activity as quickly as possible. Deconditioning of the musculature appears very quickly, after about 48 hours, so you do not want to encourage bed rest. You want them to move around and have them walk as best they can, even if they are in some pain. Encourage more activity every day. Many times, the nonpharmacologic therapies, such as walking, stretching, heat, and range-of-motion exercises, are best to regain and maintain function. Tenzer-Iglesias: I will steal an expression from the sports medicine folks, which is motion is lotion. It helps, particularly with certain joints, obviously the knee and several weight-bearing joints. But any area, even the back can benet from this. It is helpful for patients to have assistance or support at homei.e., physical therapy, occupational therapy, and various modalitiesand, if they are fortunate, to have insurance coverage for this. We have worked with osteopathic physicians, and I know that we should mention the use of manipulation as an effective treatment for musculoskeletal problems as well. McCarberg: If you think about it from a patients viewpoint, it is counterintuitive to advise stretching, bending, moving, and walking when patients think that lying down is the thing to do. Movement is counterintuitive, because it hurts. S123

McCarberg et al. In a study of patients with <8 weeks of back pain, patients who did not fear to remain active and whose baseline impairment was low had a heightened likelihood of recovery at 1 year [13]. A systematic review of randomized, controlled trials comparing bed rest with advice to remain active for acute low-back pain found patients in the latter category improved faster on measures of pain, disability, and return to work [15]. Blood clots, depression, and decreased muscle tone are additional risks of prescribed bed rest. the particular area, which has been shown to be therapeutic. Applying acupressure usually helps break up the spasm. It is possible to decrease the spasm and the pain about 5060% just by that easy maneuver. Arnold also mentions the use of local anesthetics injected into a trigger point, which we see very commonly in the trapezius and rhomboid areas around the neck and the lumbosacral area around the lower spine. I will inject the trigger points with bupivacaine 0.25% about 2.5 cc to break up the spasm. Using acupressure usually eliminates the trigger point and relieves the spasm. It is possible to relax the muscle right at that particular point in time. I like to teach patients that basically they need to use heat for 15 minutes twice a day, range-of-motion exercises, and stretch. If they lack the ability to pay for physical therapy, then showing them some simple exercises in the ofce is of great benet. McCarberg: Trigger point injections, stretch, and spray. These things, I do not think tend to work very well unless they 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 not a passive therapy. There is activity on the patients part once they get the immediate pain relief.

Treatment Choices: Nonpharmacologic McCarberg: How do you use nonpharmacologic options with an acute musculoskeletal injury? Weil: I will do trigger point injections in the ofce as well as other 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 why a lot of patients like going for manipulations and adjustments, because somebody is actually doing something to them and touching them. One of the advantages of manipulations in the ofce can be more immediate, albeit temporary, relief. I also perform acupuncture. I have done that for about 13 years. That is another type of approach to really address pain and, in some instances, muscle spasm. Tenzer-Iglesias: I am a big believer in nonpharmacologic treatments, 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 the more they are actually vested in their recovery. Plus, I think it is very important to ask the patient what they think will work, because they hear about a lot of therapies out there that we do not have clear evidence on. One example is magnet therapy. But if their belief system is such that it will work, it is important to know and work with them. In some cases they may have even tried it. Good evidence supports physical therapy. Acupuncture is something I use with good results in the right patient. You do not want to send patients to a yoga class in a gym that has an inexperienced or untrained instructor who does not know how to adjust for the patients needs, age, illness, or restrictions. I am also a big believer in cognitive behavioral therapy and teaching patients about their painhow our minds and our bodies are so connected and that our thoughts do create our feelings. I am not saying you can bring a pain from a 10 to a 0you often cannot do that anywaybut you certainly can decrease pain and improve function. Some of the interdisciplinary programs, back schools especially for people that need to return to work, focus on educating people about proper mechanics and strengthening the back and can be very effective. Ruoff: In dealing with spasms, especially in the back, I isolate the area and spray it with ethyl chloride. This cools S124

Well-supported initial nonpharmacologic recommendations for the treatment of acute low-back pain include providing patients with literature containing evidence-based information and self-care measures, advice to remain active, and the application of supercial heat [5]. Spinal manipulations have demonstrated small-to-moderate benet in the treatment of acute back pain (<4 weeks duration) [10,16]. Evidence is generally unsupportive of trigger point or facet injections and acupuncture in the management of acute low-back pain [16].

Treatment Choices: Pharmacologic McCarberg: I want to summarize a study from Group Health Cooperative of Puget Sound, where they have a good database, and they looked at acute low-back and neck problems and surveyed to nd out the most common drug that was given, and an anti-inammatory was number one [17]. When a second drug was given, it was usually a muscle relaxant. The next most common was an opioid. Do you think that is a reasonable approach? How would you do it if you were going to pharmacologically treat an acute musculoskeletal injury? Weil: I think it is very reasonable, because I almost always give a combination of a nonsteroidal anti-inammatory drug (NSAID) with a muscle relaxant, and my patients do not really need the opiates, because the muscle relaxant is treating the muscle spasm and the anti-inammatory medication is treating inammation and also the pain. If you do not give them some type of medication, theres a good chance that they may be dissatised and go

Treatment of Paraspinous Muscle Spasm somewhere else and another physician or provider could muck up the situation if they do not really have the same knowledge of how to treat the spasm and pain. McCarberg: The best evidence we have is for nonsteroidal anti-inammatories in an acute back injury. Muscle relaxants were a pretty good pharmacologic option as well. Any other kind of comments on what medication would be recommended other than the three that I mentioned so far? Ruoff: Very often I see residents and seasoned physicians, especially emergency-room physicians, initially treating the acute pain and spasm with opioids, such as hydrocodone and oxycodone or other combinations. Analgesics will help the pain but may not be very useful to reduce the spasms. Often times, patients will be discharged from the emergency room or another facility with just pain medication and asked to see me in about a week. I am concerned that the golden time to prescribe a muscle relaxant is in the rst 4872 hours in conjunction with a nonopioid pain reliever such as a NSAID because most of the injuries that occur also incite inammation. So, a better choice would be a combination of a muscle relaxant with a nonsteroidal anti-inammatory agent for 23 weeks if necessary. The muscle relaxants for the most part have to be taken exactly as directed. It is important to create the appropriate drug level to reduce the spasm. The drug level tends to fall if the medication is not taken on time. Most of the muscle relaxants are given three to four times per day. It is really up to the patient to take the medication on time. If the medication is taken hours later, the patient could lose the therapeutic effect. Nonsteroidal anti-inammatories have a two-pronged approach. They are simple analgesics in lower doses, and in higher doses, they are both analgesic and anti-inammatory. It is important to prescribe the nonsteroidal anti-inammatories initially in the higher doses and graduate down as the patient becomes more comfortable. I have no problem at all if physicians would like to add in an opioid after a muscle relaxant, and nonsteroidal antiinammatory are on board, if pain is intolerable. You can use these opioids for rescue analgesia only and not as a sole medical entity when initially dealing with muscle spasm and inammation, both of which are not handled well by opioids because the opioids are not going to treat the underlying process. Tenzer-Iglesias: Residents come in with biases from the people that they have worked with, their teachers, and possibly prior experiences with patients. Clearly there is opioid usage for back pain, which often brings up strong feelings one way or the other. I use nonsteroidals for acute pain, for which there is absolutely great evidence; however, I am a huge believer in getting patients off of nonsteroidals when there is chronic pain, because longterm usage of NSAIDs can have many adverse effects with little evidence for any efcacy in neuropathic or chronic back pain. There is often a lack of understanding of appropriate use of the medications in acute as well as chronic painwhich medications to use as well as dosage, duration, and combination treatments. Ruoff: Well it is not recommended, but I think there is a place for methylprednisolone or some other steroid anti-inammatory medicine, in difcult-to-control cases, because I have seen that help dramatically at times, when the patient may have been treated with all the appropriate medications and still has pain. Tenzer-Iglesias: I agree with you clinically, on an individual basis we may see some efcacy, but if we look at the guidelines, based on multiple studies, and if we look at large populations with low-back pain, there is actually a good level of evidence that there is no benet for systemic steroids. I tend to not use them now based on the guidelines. 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 markedly positive straight-leg-raise test, and they present with a lot of radicular symptoms, you give them a tapering schedule of methylprednisolone and a muscle relaxant, they are going to come back in a week and, most of the time, they will be signicantly better. Then I will put them on a nonsteroidal anti-inammatory, continue the muscle relaxant, and put them in physical therapy. The times they come back and they are not better, almost 99% of the time they have got a big disc herniation and that is why. In the right presentation, if they have got symptoms and a pretty marked positive leg-raise test, I think oral steroids is an excellent form of treatment. McCarberg: I have a question for you then regarding steroid injections. What is the rationale for an intramuscular injection of steroid vs. depositing the steroid in the epidural space? Weil: Well, an intramuscular shot of 80 mg of methylprednisolone would have about a 24-hour effect, and that tends to just go away because it is absorbed, and there is really no prolonged effect. If they have a disc that is herniated, there also tends to be a lot of inammation around that disc. Theoretically, you can use a steroid right where the disc is herniated, right where the inammation is. It is not the end of the story with the injection. It is still very important to get them into a spine-strengthening program afterwards to strengthen all those muscles that help stabilize and support the spine. If you do not, they are going to be right back where they started. Tenzer-Iglesias: One of the things I am hearing from Arnold is that you are not just using one treatment modality. You are utilizing multiple approaches, and so we may not know when we use combinations which one is having the effects, or if several are working together for an additive impact. I am one of those people who try to teach about reliable databases and evidence-based medicine, because we have to acknowledge well-done studies with large populations. S125

McCarberg et al. McCarberg: Yeah, that is why I brought up my part about the guidelines do not support systemic steroids. I do not want to deprecate clinical experience. Clinical experience is not always generalizable, but when you have people doing it over and over again and seeing good results, you have to take into account clinical experience. A clinical study is done in a population that does not necessarily represent patients we see. PhysicianPatient Communication: A Credible Explanation McCarberg: I want to point out another thing that I think is 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 know Ive got cancer. By just telling them what you think they havegiving them some literaturethe education alone really makes a big difference. Dissipating anxiety is key. There was actually a study that looked at chiropractors vs. primary care doctors vs. orthopedic surgery providers with acute back pain patients [22]. The outcomes were the same for all groups, the cost was the least among primary care providers, but the satisfaction was the best with chiropractic care. What the patients identied that was different was that the chiropractor gave the most credible 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 trying to take care of multiple problems at each visit, and we dont teach as well as we could. Patients really want to have something credibly explained to them, and that explanation and education has a therapeutic value. Tenzer-Iglesias: We do not know what their fear is, just as you said. Perhaps they think they have cancer or something else going on, and until we nd out what their concern is we cannot optimally treat the patient.

First-line medications for acute back pain are acetaminophen (APAP) and NSAIDs [5]. NSAIDs are usually more effective for pain relief, but their gastrointestinal and renovascular risks must be considered. If a patient has an unsatisfactory safety prole for the use of NSAIDs or if pain control is unrealized or unlikely, opioids (usually short acting) can be considered but are not recommended as rst-line therapy because of abuse, addiction, and diversion risks [5]. The use of opioids for >90 days has been associated with emergency-department visits and adverse events involving drugs and alcohol, particularly in patients with headache, back pain, and prior substance-use disorders [18]. Skeletal muscle relaxants (e.g., baclofen, dantrolene, cyclobenzaprine, orphenadrine, and tizanidine) provide moderate analgesic benet for acute lowback pain [9], particularly in combination with NSAIDs or APAP; such combination therapy has been found to provide superior pain relief to monotherapy [19,20]. Muscle relaxants usually are not recommended as rst-line therapy because of risk of central nervous system adverse effects, principally sedation [5]. However, the fact that good evidence shows moderate improvement with skeletal muscle relaxants for acute pain, but the evidence is less robust for the treatment of chronic pain [5] suggests a possible window of opportunity for optimal therapeutic effect. It is worth considering, too, whether muscle relaxants, dispensed short term for acute pain, may have a better safety prole than opioids. Medications labeled as muscle relaxants differ from one another pharmacologically, and none has been clearly proven more efcacious than another [20]. However, certain muscle relaxants should be avoided for low-back pain, namely carisoprodol because of abuse liability, and dantrolene because of its black box warning for potentially fatal hepatotoxicity [20]. Tizanidine and chlorzoxazone are associated with less serious, usually reversible hepatoxicity. Systemic corticosteroids are not recommended for nonspecic low-back pain [5] and have failed to demonstrate efcacy for acute non-radicular low-back pain or sciatica [9,20]. Regardless, physician survey results show that use of oral steroids is common in primary care [21].

Clinical Pearls Tenzer-Iglesias: The diagnosis is in a thorough history and physical. Pharmacologic and nonpharmacologic approaches should be integratednever one without the other. Evaluate for biopsychosocial risk factors. Depression, anxiety, and related issues are going to be very important in planning treatment. Weil: Listen to the patients, they will tell you where the pathology is. The diagnostic tests are just an extension of the physical exam. I dont think you should ever focus on one of anythingone diagnostic test, one part of the exam. McCarberg: Everything we do is an attempt for early mobilization. Indeed, it is a proactive approach, getting the patient up and moving, even when the pain may get a little worse. Ruoff: Communication and education to dispel anxiety is highly therapeutic.

Acknowledgment Medical writer Beth Dove, of Dove Medical Communications in Salt Lake City, Utah, assisted in the preparation of this manuscript.

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