What to Consider for Severe Back Pain

If you have severe back pain that lasts more than a few days, or if you have mild to moderate back pain that does not respond to self-treatment, it is important to visit your primary care physician.

Regardless of the cause of the pain, a doctor will probably recommend self-treatment techniques. In general, you should limit bed rest and pain medication—a strategy supported by current research.

In a study of more than 1,000 people, doctors were divided into three groups based on whether they were low, medium or high prescribers of pain medications and bed rest. People treated by physicians in the low-prescribing group improved more quickly than those in the other groups.

After one month, only 30 percent of these people had to make moderate to severe cutbacks in their daily activities, compared with 37 percent of people treated by doctors in the medium-frequency group and 46 percent in the high-frequency group. After a year, however, there were no differences among the three groups in pain levels or ability to function.

Many doctors feel that successful treatment of back pain with minimal bed rest and minimal medication is a result of the self-care practices they recommend. The above study supports this belief: People whose physicians were least likely to prescribe bed rest and pain-relief medications reported being more satisfied with their personal knowledge of how to treat back pain and just as satisfied with their medical care as those whose doctors prescribed drugs and rest.

Prescription NSAIDs

When over-the-counter medications do not relieve back pain, the doctor might need to prescribe a stronger nonsteroidal anti-inflammatory drug (NSAID), such as diflunisal or meclofenamate (available in generic form only). Although a newer type of NSAID known as COX-2 inhibitors has been shown to treat pain and inflammation as effectively as traditional NSAIDs, they have come under scrutiny for their adverse effects, including an increased risk of heart attack and stroke in people with or at risk for cardiovascular disease. As a result of these concerns, the Food and Drug Administration has strengthened the warnings on the labels of all NSAIDs. Currently, celecoxib (Celebrex) is the only COX-2 inhibitor that remains on the market in the United States.

Muscle relaxants

Studies have shown that muscle relaxants are an effective treatment for low back pain that lasts less than four weeks. Their usefulness for chronic low back pain, however, requires further study. Muscle relaxants appear to work by depressing the activity of the nerves in the spinal cord and brain. Commonly prescribed muscle relaxants are baclofen (Lioresal), carisoprodol (Soma), cyclobenzaprine (Flexeril) and methocarbamol (Robaxin). A few studies suggest that a combination of a muscle relaxant and an NSAID may be more beneficial than a muscle relaxant alone.

The use of muscle relaxants is controversial because they are potentially addictive. You should not take them for more than one or two weeks, and people with a history of substance abuse or other mental health conditions should use them with great caution. Possible side effects of muscle relaxants include dizziness, drowsiness, dry mouth, headache, stomachache and nausea or vomiting.

Epidural steroid injections

Epidural steroid injections may be used to treat low back pain and sciatica. The injections usually contain an anesthetic for pain relief and a corticosteroid, which helps to reduce inflammation around irritated nerves in the epidural space. Studies have shown that epidural steroid injections can relieve back pain. Unfortunately, that relief is often only temporary.

Opioids

Highly addictive painkillers such as opioids (morphine, codeine and meperidine) should also be used with a great deal of caution and only when all other treatments have failed. People who need opioids for more than a few days sometimes take controlled-release formulations of oxycodone (OxyContin) or morphine (MS Contin). Those long-acting drugs provide more consistent control of back pain than standard, short-acting narcotics.

Disease-modifying anti-rheumatic drugs

The medication etanercept (Enbrel), which is a disease-modifying anti-rheumatic drug (DMARD), is used to treat ankylosing spondylitis. The drug works by interfering with tumor necrosis factor, an immune system protein that contributes to inflammation. Enbrel and other DMARs may increase the risk of serious fungal, bacterial, and viral infections.

Exercise

If your back pain is mild, it is safe to get back to an aerobic exercise routine as soon as treatment eases your pain. After two weeks, exercises to strengthen the back and abdominal muscles can be started slowly. Building core strength in the back and abdomen is very beneficial in preventing recurrence.

Not Recommended or Unproven Treatments

Prolonged bed rest (more than four days) is not recommended as part of treatment. Although still used, transcutaneous electrical nerve stimulation (TENS)—the application of low-energy electrical current to “numb” the nerves—is declining in popularity.

Support belts and back machines have not been found to be of any benefit in the treatment of back pain.