Question

LBP managementTreatment of LBP is specific to the underlying etiology. Many patients with LBP will require a multimodal treatment approach, including non-pharmacologic and pharmacologic options. Using more than one class of medications combined with a nonpharmacologic approach will typically help alleviate the pain.3 In certain situations, referrals to special-ists, such as pain management spe-cialists, may be necessary.Nonpharmacologic interventions.Providers should not refer patients for nonpharmacologic treatments unless a patient has experienced LBP for more than 3 weeks because many patients will spontaneously improve during that time.25 Physical therapy (PT), exercise, acupuncture, massage, spinal manipulation, and transcutane-ous electrical nerve stimulation are common nonpharmacologic interven-tions. Evidence is emerging about nonpharmacologic care as a way to provide adequate pain management and subsequently reduce the need for opioid medications.26,27 To prevent future LBP, patients should exercise as they are able, wear back braces when lifting heavy items, use ergonomic furniture at work if appropriate, and avoid putting excessive strain on their spine.26PT and exercise play an important role in treating patients with LBP. Bed rest is no longer recommended, as evidence shows that it generally delays improvement of LBP.2 Yoga, Tai Chi, and Pilates have been stud-ied and shown to improve outcomes when compared with no interven-tion.28,29 When performed appropri-ately, no adverse reactions are associ-ated with these exercises.PT is a great option for patients with subacute, chronic, or recurrent LBP. It may improve motor control, core strength, joint flexion and ex-tension, directional preference, and general physical fitness.30 Directional preference refers to a therapy that avoids painful movements in favor of movements that lessen pain related to LBP.31 Physical therapists evaluate patient responses and develop an indi-vidual therapy plan, ensuring that they perform the exercises correctly and maintain spinal alignment. Patients are instructed on exercises to do at home when discharged from the PT program.Acupuncture, a safe mode of treat-ment, may provide short-term pain relief for patients with LBP.27,32 How-ever, it has not been shown to improve function.12 Additional long-term stud-ies are required to support acupuncture as an effective treatment option.13,32Massage may provide short-term pain improvement in patients with acute, subacute, and chronic LBP, and some patients receiving massage for LBP have reported higher satis-faction.27,33 As with acupuncture, it has not been shown to improve func-tion, and some studies have shown that it may increase the intensity of pain in some patients.33,34Spinal manipulation is performed by chiropractic providers. It is a form of manual therapy that involves the movement of a joint near the end of the clinical range of motion.27 This technique may provide short-term pain reduction and improve func-tion.30 Spinal manipulation should be utilized only when combined with other treatment methods.26 Spinal manipulation also has the potential to worsen LBP.30Transcutaneous electrical nerve stimulation (TENS) can be used for LBP management. TENS involves the use of a small battery-operated device to provide continuous elec-trical impulses via surface elec-trodes, with the goal of providing symptomatic relief by modifying pain perception.30 Evidence of the effectiveness of TENS therapies is mixed, with some reports showing short-term improvement and some showing none.3Pharmacotherapy. Nonopioid analgesics, opioids, skeletal muscle relaxants, and adjuvant analgesics can be used for patients with LBP.3However, long-term studies regard-ing pharmacologic treatment for back pain are lacking.3The most common nonopioid an-algesics are NSAIDs and acetamino-phen. A Cochrane review from 2016 shows that acetaminophen did not improve LBP compared with pla-cebo.25,35 Risks for acetaminophen include hepatotoxicity.27 Caution is advised when administering acet-aminophen in patients with hepatic dysfunction or active hepatic dis-ease, alcohol use disorder, chronic malnutrition, severe hypovolemia, or severe kidney dysfunction. Not enough research has been conducted . to include acetaminophen as a first-line treatment.12For patients with no contraindi-cations or cardiovascular or gastro-intestinal (GI) risk factors, NSAIDs are a first-line treatment for symp-tom relief in acute LBP.2,13,27 They are used in short-term therapies (2 to 4 weeks). Educate patients about the risk of cardiovascular events, dyspepsia, GI bleeding, hepatotoxic-ity, hypertension, heart failure, renal toxicity, and exacerbation of asthma.3Given the risk of misuse and de-pendence, nonopioid analgesics are a better treatment option than opioid-based medications.3Opioids may be used in the short term for patients with acute LBP, but they should not be used to treat chronic LBP.3 To reduce the potential for misuse and dependence, the CDC does not rec-ommend the use of opioids for acute pain beyond 3 days.36,37 Given a lack of long-term documented efficacy, they are not a first-line treatment option for nonmalignant pain.Potential adverse reactions to opioids include sedation, respiratory depression, constipation, and nau-sea.27 Opioids are contraindicated for patients with a history of substance abuse, addiction, or misuse.Despite their questionable use in the treatment of LBP, opioid medica-tions continue to be prescribed. One study demonstrated that they were prescribed in 45% of patients present-ing with LBP.38Although they are generally used as adjunctive therapy to NSAIDs, skeletal muscle relaxants(SMRs) may also be utilized in patients with LBP to help with pain associated with muscle spasms.27 The most commonly pre-scribed SMRs include carisoprodol, tizanidine, and cyclobenzaprine. Com-mon adverse reactions to SMRs, such as dizziness and sedation, make the use of these medications risky, espe-cially in patients over age 65.2,3 Long-term studies for treatment of chronic LBP using SMRs are still needed.3Adjuvant analgesics such as anti-depressants and antiepileptic drugs (AEDs) are also used in the treat-ment of subacute and chronic LBP, but they are not used for acute LBP. Overall evidence suggests that anti-depressants are no more effective than placebos.3,26 However, duloxetine, a serotonin and norepinephrine reuptake inhibitor, is FDA-approved for chronic musculoskeletal pain and has demonstrated some positive outcomes in patients with chronic LBP.3,12 It is a good choice for pa-tients with chronic LBP and comor-bid depression.3,12AEDs such as gabapentin and topiramate are used for subacute and chronic LBP with radicular symptoms. Topiramate has been shown to help compared with placebo.3 These medi-cations are considered off-label for this indication. The most common ad-verse reactions associated with gaba-pentin are fatigue, dizziness, problems with concentration, dry mouth, and loss of coordination.39 The most com-mon adverse reactions associated with topiramate are somnolence, trouble with concentration, vision trouble, and anorexia.40ReferralsPrimary care providers can care for most patients with LBP. However, patients should be referred to an orthopedist or neurologist for treat-ment of serious disorders such as CES, which requires immediate hos-pitalization; disk herniation; spinal stenosis; spinal fractures; and spinal infections. Referral to a specialist is also indicated for patients with a suspected or confirmed aortic or thoracic aneurysm. Patients with ankylosing spondylitis should be referred to a rheumatologist to help manage the autoimmune component of the disease.Implications for nursingThe prevalence of patients with LBP is significant, and nurses must be

1.

READ THIS ARTICHE AND GIVE 1.5 PAGES OF SYNOPSIS. THIS ARTICLE IS ABOUT HOW TO CARE FOR ADULTS WITH LOW BACK PAIN IN THE PRIMARY CARE SETTING

Answer 1

Low back pain is highly prevalent in adults due to varied reasons.Treatmnet is focused on two aspects like pharmacological intervention and non pharmacological intervention

The non pharmacological treatment includes the therapy like massage , acupuncture, physical therapist, exercise ,Tens.These treatment can be recommended by a provider only when the pain is less than three weeks.If it is more than three weeks it has to be combined with pharmacological and non pharmacological treatment to treat the pain.Among these physical therapy, exercise,massage has given a positive approach to relieve pain where as acupuncture has not great relief.The mind relaxation techniques like yoga ,tai chi ,Pilates also provides a great relief.The recommendation based now is do exercise,wear back braces and use ergonomic material to reduce the incident of back pain.Spinal manipulation is the last choice to relieve pain.TENS also provides a great relief.

The pharmacological treatment with medication is effective but has its own adverse reactions like. Acetaminophen is a very mild pain killer with less relief of LBW with hepatotoxicity.NSAID can relieve pain effectively but can cause severe adverse effects on cardiovascular, gastrointestinal system. SMR can give great relief but due to its side effects it cannot be used above 65 years. Gabapentin,Topiramate are off label medication.Anti depressants and anti epileptic are prescribed as an adjuvant therapy.The patient can be referred to the specialist to treat acute , subacute and chronic pain.