Question

build a case study focusing on a patient who presents with chronic low back pain in which you, as the practitioner,

first provide a non-pharmacological intervention and then follow up with a pharmacological intervention.

This case study should mimic a provider's note and be 500 words or less.

Answer 1

Pharmacology

For chronic low back pain, pharmacological management can be used on a continuous basis or as needed. However it’s important to advise patients to use it as a tool to stay active and to engage in treatment, rather than as a solution itself.

• Acetaminophen: The American Pain Society/American College of Physicians guidelines recommend that acetaminophen be used as a first-line option with any duration of low back pain. Acetaminophen is an antipyretic and analgesic medication without anti-inflammatory properties. Risk of hepatotoxicity is the main complication, therefore dosing instruction must be followed carefully.
• NSAIDS: Non-steroidal Anti-Inflammatory drugs are another medication recommended as a first-line medication for short-term use. They are pain relieving and anti-inflammatory medications that block the cyclo-oxygenase (COX)-2 enzyme.
• Opioids: Opioids are considered an option in patients with moderate or severe pain.
• Antidepressants: Tricyclic antidepressants (TCA) are commonly used to treat numerous chronic pain syndromes. However, there is conflicting evidence on whether there are significant changes in pain relief or disability with CLBP.
• Other medications: Skeletal muscle relaxants, benzodiazepines, and antiepileptic medications are not recommended because of the insufficient evidence towards their effectiveness for chronic low back pain.

Non-Pharmacological

Exercise therapy has been shown to have beneficial effects for the management of chronic low back pain. Utilization of trunk coordination, strengthening, and endurance exercises reduces low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments. Moderate- to high-intensity exercise will be considered for patients with CLBP without generalized pain. For patients with CLBP with generalized pain incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies will be considered.

• Core strengthening exercises: are used to restore the coordination and control of the trunk muscles to improve control of the lumbar spine and pelvis. These exercises aim to restore the strength and endurance of the trunk muscles to meet the demands of control.
• Motor control exercise: motor control exercise protocols have been shown to be an effective treatment of chronic low back pain. Common targeted muscles include transversus abdominis, multifidus, the diaphragm and pelvic floor muscles.The focus of motor control exercises is to improve neuromuscular control of trunk segments involved in movement of the spine.
• Sensory discrimination training: cortical reorganization presents a barrier to successful recovery; however the plasticity that underpins cortical reorganization also suggests that it might be responsive to targeted treatments, such as sensory discrimination training (SDT).
• Traction: Summary evidence concludes that mechanical lumbar traction is not effective for treating acute or chronic nonspecific low back pain (LBP) Few trials evaluated the effectiveness of treatments for radicular low back pain, but the available evidence showed traction and spinal manipulation were not effective or were associated with small effects^.
• Mckenzie Method: Has been shown to be as effective as other exercise therapy. Compared to motor control exercises there is no significant difference in pain and function scores. However patients reported greater improvement in sense of recovery in the short term compared to patients who received motor control exercises.
• Massage and modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions. Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain^.
• Pilates: there is inconclusive evidence that pilates is effective in reducing pain and disability in people with CLBP. More research is necessary.
• Yoga: may be an efficacious adjunctive treatment for CLBP. Strongest and most consistent evidence is there for the short-term benefits on functional disability. More research is necessary.