Recommendation: Require medical referral

• Age >50 years" is a red flag for possible cancer
• Older age (≥75 years old)" is listed as a red flag for possible fracture.

Recommendation: Require medical referral

Recommendation: Require medical referral

Recommendation: Require medical referral

If a patient has a history of recent trauma, the suggested evaluation should include lumbosacral plain radiography. If the results of the radiography are inconclusive, advanced imaging may be indicated.

LBP following recent trauma should not be assumed to be a simple musculoskeletal issue that can be self-treated. Instead, it necessitates medical evaluation to rule out serious conditions such as a fracture.

Recommendation: Require medical referral

May have steroid induced osteoporosis.

Recommendation: Require medical referral

Require physician intervention.

Recommendation: Non-pharmacological and pharmacological therapy

Non-pharmacological treatment

• Heat/ Cold therapy
• Heat Therapy:
  • • Increases blood flow to the area, which help to:
      • Relax muscle stiffness
      • Reduce muscle spasms
      • Improve tissue healing
      • May also decrease pain signals.
    • Methods: Heating pads, Hot water bottles, Warm baths or showers, Heat wraps
    • Cautions:
      • Avoid using heat on acute injuries in the first 48 hours, as it can increase inflammation.
      • Don't apply heat for too long (generally, 15-20 minutes at a time is sufficient).
      • Be careful to avoid burns.
• Cold Therapy
  • • Reduces blood flow, which can:
      • Decrease inflammation
      • Numb the area, providing pain relief
      • Reduce muscle spasms
    • When to use it:
      • Best for acute injuries (within the first 48 hours) to reduce inflammation.
      • Can also be used for flare-ups of chronic pain.
    • Methods: Ice packs, Cold packs, Ice massage
    • Cautions:
      • Never apply ice directly to the skin; always wrap it in a cloth.
      • Limit applications to 15-20 minutes at a time to prevent tissue damage.
      • People with certain conditions (e.g., circulatory problems) should consult a doctor before using cold therapy.
  • Which is Better?
    • It often depends on the nature of the pain:
    • Acute pain (especially with injury): Cold first, then heat after a couple of days.
    • Chronic pain or muscle stiffness: Heat is often preferred.
    • Many people find that alternating between heat and cold can be helpful.
• Self-Care Advice to Remain Active
  • Most acute LBP resolves on its own and that movement is safe and beneficial.
  • Continue with their usual daily activities as much as possible, even if it means modifying them temporarily.
  • Explicitly avoid prolonged bed rest, as it can weaken muscles and worsen pain.
    • Maintains muscle strength and function.
    • Prevents deconditioning.
    • Promotes faster recovery.
    • Reduces the risk of chronic pain.
• Cognitive Behavioral Therapy (CBT) and/or Mindfulness-Based Stress Reduction (MBSR)
• Clinician-Directed Exercise Program
  • Physical therapist tailored programs which include:
    • Aerobic exercise (e.g., walking, swimming)
    • Strengthening exercises (for core and back muscles)
    • Mobility exercises (to improve flexibility)
    • Motor control exercises (to improve coordination and stability)

Pharmacological treatment

• Network meta-analyses often suggest that there's no large difference in overall effectiveness between different NSAIDs like ibuprofen, naproxen, diclofenac, etc., tend to provide similar levels of pain relief.
• Choice should be based upon Individual patient response, Tolerability, Safety profile.
  • Coxibs generally have a lower GI risk than traditional NSAIDs.
  • Ibuprofen seems to pose a slightly lower GI risk when compared to other non selective NSAIDs.
  • preferred among NSAIDs for those patients having cardiovascular risks (use minimum dose for shortest duration)
  • Diclofenac have higher CV and GI risks
  • All NSAIDs have similar renal risk profile

• Take NSAIDs and salicylates with food or milk to decrease GI irritation.

• Recommend salicylates, acetaminophen, ibuprofen, naproxen or ketoprofen as appropriate (<=3 times/week)

  • Acetaminophen.
    • Dosing: 10-15 mg/kg every 4-6 hours, not to exceed 4000 mg/day.
    • Time to effect: 30-60 min to reduce 1-2F with maximum reduction with 2 hours
    • Caution:
      • Liver toxicity with high doses or in patients with liver disease.
        • Overdose symptoms (>4gm per day)- N/V, rashes (rare) and eventually hepatic failure (may appear only after 4-6 days)
        • A/E: Nausea, hepatotoxicity, rash (rare)
      • Safe in
        • Pregnancy (safe if used <8 days. Emerging evidence in ADHD in child when used >29 days)
        • breastfeeding: crosses breast milk but safe. A rare occurrence of maculopapular rash in infants but will subside with discontinuation
        • aspirin hypersensitive patients,
        • GI ulceration,
        • Patient on anticoagulants, methotrexates or thiazides,
        • pt with renal, cardiac impairment in
        • conjunction of diuretics or ACE inhibitors;
        • elderly and
        • babies over 3 months.
      • A/E monitoring:  If signs of liver toxicity occur (jaundice, right upper quadrant pain)- Refer
   
  • Does the patient have NSAID contraindication like GI ulcers, renal diseases? If no use NSAID (Ibuprofen/Naproxen) otherwise use acetaminophen or NSAID with PPI.
    • Dosing:
      • Ibuprofen: 5-10 mg/kg every 4 to 6 hours as needed, not to exceed 1200 mg/day (OTC)
        • It takes 30-60 min to reduce 1-2F with maximum reduction with 2 hours
      • Naproxen: 220 mg every 8-12 hours as needed, not to exceed 660 mg/day (OTC).
        • preferred among NSAIDs for those patients having cardiovascular risks (use minimum dose for shortest duration)
    • Onset: Naproxen/ibuprofen: 30 minutes
    • CI: naproxen: <12 years age; salicylates: <18 years; ketoprofen: < 16 years
    • Special consideration
      • COX-2 selective preferred for patients having GI issues
      • Pregnancy: avoid (esp third semested) due to risk of bleeding potential, pregnancy prolongation and teratogenic effect.
      • Breastfeeding: Naproxen avoid in lactating mothers. Ibuprofen is considered safe.
      • Elderly: Cautiously use in elderly above 65 years (short term use is likely less problematic)
      • Children: Ibuprofen can be used for patients above 6 months age; Naproxen can be used for children above 12 years
    • Caution:
      • Causes GI irritation, bleeding risk, renal effects. Avoid in patients with a history of Asthma with nasal polyps, chronic/recurrent GI ulcers, gout, coagulation disorders or anticoagulant therapy, high blood pressure, CHF, kidney disease, or aspirin allergy.
    • A/E monitoring:
      • GI: Heartburn, nausea, abdominal pain, black stools (melena), vomiting blood.
        • Action: Take with food.
        • Referral: If signs of GI bleeding occur.
      • Renal: Decreased urine output, swelling in legs/ankles.
        • Referral: In patients with pre-existing renal disease.
  • Patient may report a better response to one NSAIDs than to another for unknown reason. if one NSAIDs fail to provide relief, another may be tried.

• Drug interaction
  • Acetaminophen
    • With alcohol
      • Potential effect: Increased hepatotoxicity risk
        • Management and preventive measure: avoid concurrent use, minimize alcohol intake when acetaminophen use
    • With warfarin
      • Potential effect: Increase bleeding risk (elevate INR)
        • Management and preventive measure: limit acetaminophen to occasional use; monitor INR for several weeks when acetaminophen 2-4 gm is added or discontinued in patients on warfarin. Acetaminophen < 2gm may not alter INR
  • Aspirin
    • With NSAIDS including COX-2 inhibitors
      • Potential effect: increased risk of GI bleeding and ulcers
        • Management and preventive measure: avoid
  • Ibuprofen
    • With Aspirin (CV prophylaxis)
      • Potential effect: decreased antiplatelet effect of aspirin
        • Management and preventive measure: take aspirin 30 minutes before or 8 hours after ibuprofen. Use acetaminophen or other analgesic instead
  • NSAIDs
    • With Bisphosphonates
      • Potential effect: increased GI ulceration
        • Management and preventive measure: use with caution and monitor
    • With Digoxin
      • Potential effect: decreased digoxin renal clearance
        • Management and preventive measure: monitor digoxin, adjust dose
    • With agents with antiplatelet properties (SSRIs, NSAIDs, P2Y12 inhibitors)
      • Potential effect: increased bleeding risk
        • Management and preventive measure: monitor therapy
    • With antihypertensive agents (e.g., beta blockers, ACEIs, vasodilators, diuretics)
      • Potential effect: antihypertensive effect inhibited; possible hyperkalemia with potassium-sparing diuretics and ACEIs
        • Management and preventive measure: monitor BP, cardiac function and potassium level
    • With Anticoagulants
      • Potential effect: increased bleeding risk (esp. GI)
        • Management and preventive measure: avoid
    • With Alcohol
      • Potential effect: increased bleeding risk
        • Management and preventive measure: avoid concurrent use, minimize alcohol intake when NSAIDs use
    • With Methotrexate
      • Potential effect: decreased methotrexate clearance
        • Management and preventive measure: avoid NSAIDs with high-dose methotrexate therapy, monitor levels
    • With Sulfonylureas
      • Potential effect: increased hypoglycemia risk
        • Management and preventive measure: avoid concurrent use, if possible monitor blood glucose level when changing dose
    • With Caffeine
      • Potential effect: have additive effect
        • Management and preventive measure: monitor for side effect such as nausea, headache, insomnia