A 60-year-old woman comes to the office due to back pain. For the last 3 months, the patient has had dull, achy pain in the lumbar area radiating to the buttocks bilaterally. The pain is worse with lifting heavy boxes and is not relieved with acetaminophen or heating pads. She has had no fever, weight change, dysuria, incontinence, abdominal pain, or muscular weakness. The patient's medical history is notable for hypertension, for which she takes chlorthalidone, and osteoarthritis of the knees and hands. She does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 148/98 mm Hg and pulse is 84/min. BMI is 32 kg/m². Examination shows normal range of motion in the lumbar spine. Lower extremity strength, sensation, and reflexes are normal. Straight leg raise causes worsening of pain in the back but no radiation of pain.
Laboratory results are as follows:
MRI of the lumbar spine shows a mild L4-L5 disc bulge without neural impingement and moderate facet arthropathy at multiple levels.
Which of the following interventions is most likely to be beneficial for this patient?

Question

A 60-year-old woman comes to the office due to back pain. For the last 3 months, the patient has had dull, achy pain in the lumbar area radiating to the buttocks bilaterally. The pain is worse with lifting heavy boxes and is not relieved with acetaminophen or heating pads. She has had no fever, weight change, dysuria, incontinence, abdominal pain, or muscular weakness. The patient's medical history is notable for hypertension, for which she takes chlorthalidone, and osteoarthritis of the knees and hands. She does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 148/98 mm Hg and pulse is 84/min. BMI is 32 kg/m². Examination shows normal range of motion in the lumbar spine. Lower extremity strength, sensation, and reflexes are normal. Straight leg raise causes worsening of pain in the back but no radiation of pain.
Laboratory results are as follows:

MRI of the lumbar spine shows a mild L4-L5 disc bulge without neural impingement and moderate facet arthropathy at multiple levels.
Which of the following interventions is most likely to be beneficial for this patient?

Quizplus · Accepted Answer

This patient has uncomplicated back pain with no systemic symptoms or neurologic deficits. Back pain can be categorized as acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks). Acute back pain usually resolves spontaneously and may be managed conservatively (eg, heating pads, nonsteroidal anti-inflammatory drugs). However, chronic pain is less likely to improve without additional interventions. Also, imaging is not usually necessary in acute pain; it can be considered for patients with chronic pain, but frequently shows nonspecific findings (eg, degenerative changes, disc herniations) that do not correlate with symptoms, as in this patient. Management of chronic back pain should emphasize nonpharmacologic measures. A multidisciplinary rehabilitation program, including physical therapy (with recommendations for a home exercise program), occupational therapy, and cognitive-behavioral therapy, has been shown to improve pain and functional status better than a single-modality approach. For obese patients, an effective weight loss program can reduce or eliminate long-term pain. (Choice A) Nonsteroidal anti-inflammatory drugs (eg, naproxen) can be effective in chronic back pain, although long-term use can be problematic in those, such as this patient, with chronic kidney disease or hypertension. In addition, patients should not be advised to restrict activity but should maintain normal, moderate activity. (Choice B) Centrally acting muscle relaxants (eg, cyclobenzaprine, tizanidine) are effective for pain relief in patients with acute back pain. However, muscle relaxants are not advised for those with chronic pain, and the risks of carisoprodol (eg, abuse/withdrawal, driving impairment) outweigh the benefits for nearly all patients. (Choice D) A number of physical modalities for chronic back pain, such as transcutaneous electrical nerve stimulation, back braces, traction devices, and shortwave diathermy, have been promoted in the lay media. Evidence of benefit for these treatments is generally of low quality and shows inconsistent benefits. They are not currently recommended. (Choice E) Epidural glucocorticoids can be considered for patients with persistent pain due to lumbosacral radiculopathy if noninvasive management is ineffective. Glucocorticoid injections (eg, epidural, facet joints) are not effective for uncomplicated nonradicular chronic back pain (as in this patient). Educational objective: Management of chronic back pain should emphasize nonpharmacologic measures. A multidisciplinary rehabilitation program, including physical therapy, occupational therapy, and cognitive-behavioral therapy, has been shown to improve pain and functional status better than a single-modality approach. __________ References: Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25694111)

A 60-Year-Old Woman Comes to the Office Due to Back