Lower Back Pain

Question 1

What are some likely causes for back pain?

Answer 1

Osteoarthritis (bone spur impingement)

Muscle strain

Hip joint problem

Sciatica (severe nerve pain rather than muscle pain)

Osteoporosis (bone crumbling can impinge nerves)

Slipped Disk

Question 2

What is referred pain?

Answer 2

It is the sensation of pain in one region your body that is actually occurring in a different area completely?

Question 3

What are some causes of referred back pain?

Answer 3

Disorder of large bowel

Dysmenorrhea

Renal condition

Prostate

Urinary tract infection

Question 4

What are some patient factors that can worsen back pain?

Answer 4

Sedentary lifetstyle

Bursts of activity/improper lifting

Pregnancy

Poor posture

Bad Shoes

Excess weight

Question 5

How many people that report back pain experience it chronically?

Answer 5

Up to 10% of cases

This can be due to strain on spinal column muscles, abdominal muscles, and glutes

Question 6

Do most patients know what causes their back pain?

Answer 6

Most likely cannot recall a specific possible cause

MDs try to rule out red flags, it is harder to pin point a particular diagnosis though

Question 7

What is the value of X-rays in back pain?

Answer 7

In cases without trauma, and X-ray may find minor damage due to just living for decades (irrelevant/misleading findings).

X-rays are usually not done at the get go in diagnostics. X-rays are performed later in the diagnostic process

Question 8

Are NSAIDs useful in neuropathic pain (sciatic pain)?

Answer 8

No, refer to massage therapists and MD for better treatment option

Question 9

What is the difference between neuropathic and nociceptive pain?

Answer 9

Neuropathic pain may be felt as burning or tingling (hitting funny bone)

Nociceptive pain is usually due to an injury (most pain is nociceptive (bumping your toe)

Question 10

What is the first question pharmacists should ask a patient with back pain?

Answer 10

What have you tried? This can help us gauge what we can help with or what is going on with the patient

Question 11

Is back pain a large part of a pharmacist’s professional duties?

Answer 11

No, this is for physiotherapists and MDs

Question 12

What questions should pharmacists ask in patients with back pain?

Answer 12

How long has it been and how bad is the pain?

Is it just low in your back or higher (more severe) up too? Sore neck

Any chance this was due to a fall

IS the pain worse when lying down/sleeping?

Any numbness in bum area (if more than a few hours, seek medical attention)

Besides the pain, do you feel sick (fever, chills, weight loss)?

Question 13

What are some red flags for referral in back pain?

Answer 13

Pain located high in spine (could be whiplash, Osteoarthritis, osteoporosis)

Trauma (fall from height)

Fever, shills, unexplained weight loss

Pain worse when lying down/sleeping

Numbness in bum area

Young kids vs. Elderly (kids shouldn’t have back pain)

Leg pain>back pain (could be sciatic)

Increasing pain

Steroid usage

Question 14

What is good advise for when patients to see an MD if they have back pain without red flags?

Answer 14

See an MD after 5 days with no relief of general back pain

Question 15

Do most cases of back pain go away on their own?

Answer 15

WIthin 30 days: 2/3 of cases resolved

WIthin 3 months: 90% of cases resolved

Chronic: about 10% of patients will have pain long-term and it will not go away on its own

Question 16

Should pharmacists recommend exercise in back pain?

Answer 16

No, this is not our professional expertise. We need to refer to physiotherapists

There are some patients with back pain that will not benefit, or even be harmed by activity. These patients need to rest

Question 17

What does our typical patient look like?

Answer 17

They do not have red flags

They are under 40

Have a long history with back pain (chronic)

Question 18

Is acetaminophen useful in back pain?

Answer 18

No, even if it is marketed for back pain

Acetaminophen is not recommended for pain

Question 19

What should a pharmacist do if a patient is adamant on using acetaminophen?

Answer 19

Advise them to use it for acetaminophen for 2 weeks and examine whether their back pain is better

Question 20

What are some NSAIDs used in back pain?

Answer 20

ASA (up to 4g/day): has both analgesia and anti inflammatory

Ibuprofen (1200mg max OTC): analgesia, anti inflammatory not possible at OTC levels

Naproxen (440mg max OTC): analgesia, anti inflammatory is not possible at OTC levels

Question 21

Do increasing doses of NSAIDs mean better pain control?

Answer 21

No at a certain point, increased dose does not increase analgesic effect

Unlike morphine

Question 22

What patient profiles are we worried about when using NSAIDs?

Answer 22

Geriatrics
Cardiovascular
GI
Asthma
Renal

Question 23

What is the utility of skeletal muscle relaxants?

Answer 23

Not very anti-spasmodic (not really used due to negligible benefit)

Question 24

What is the common ingredient in the different Robax formulations?

Answer 24

Methocarbamol

Question 25

What is the best Robax formulation for back pain?

Answer 25

Robax-isal (methocarbamol and ASA)

ASA mainly doing the heavy lifting anyway, methocarbamol along for the ride

Question 26

What is the utility of heat or cold packs in back pain?

Answer 26

In acute cases, Cold is generally reccomended

If chronic, recommend heat (can be anti-spasmodic)

Question 27

What is the utility of topical external analgesics (RUB-A535)?

Answer 27

They are counterirritants (methyl salicylate and menthol)

These agents fool the brain by irritating the skin above the irritated muscle. The brain stops perceiving the muscle pain less strongly

Efficacy in back pain is not very definitive

Voltaren is an NSAID, not an external analgesic

Question 28

What is the efficacy of lidocaine in back pain?

Answer 28

Lidocaine does not get very deep into the skin.

It can be used with other external analgesics

Not a big player in LBP treatment

Question 29

Should Zostrix be used in back pain?

Answer 29

No, only use for post-herpetic pain because the side effects are simply too severe (NSAIDs are better suited)

Question 30

What is the efficacy of diclofenac?

Answer 30

It is a great NSAID product and it offers less side effects

Maybe DOC in patients over 75 due to low side effects and drug interactions

Used TID or QID (use an FTU)

Question 31

What are some herbals that are effective in back pain?

Answer 31

Turmeric is the only one with merit for this indication

Question 32

What is the indication for glucosamine?

Answer 32

It is an oral agent that is supposed to repair synovial joints (this is a herbal disease modification agent)

This mechanism is ineffective in back pain. Not an analgesic + there are no synovial tissues in the back

Question 33

Is arnica herbal useful in back pain?

Answer 33

Nope, its dog water

Question 34

What is the active ingredient in turmeric?

Answer 34

Curcumin, evidence supports use of 1g in arthritis

Question 35

Why should pharmacists avoid recommending back braces for back pain?

Answer 35

We need to refer to physiotherapists, they can better examine patient.

We could risk making their back pain worse via improper technique or sizing

Question 36

What is the efficacy of cyclobenzaprine?

Answer 36

It can be used for muscle spasm relief, works better than methocarbamol

Can cause drowsiness, dry mouth, and fatigue (decreased SNS)

Question 37

What is the efficacy of antidepressants in back pain?

Answer 37

Amitriptyline was the go to product for neuropathic pain, but newer evidence suggests it is not the best

Question 38

Are Dr. Ho’s pads effective in back pain?

Answer 38

They can stimulate the muscles and help with neck pain