A 35-year-old man comes to the office for follow-up of low back pain. He has aching pain in the left lumbar paraspinal area that is worse at the end of the day and relieved overnight with rest. The pain began 3 months ago with no precipitating trauma. The patient was initially treated with intermittent doses of acetaminophen and naproxen but continues to have moderate residual pain. There is no associated fever, weight loss, radicular pain, lower extremity weakness, or urinary symptoms. Medical history is unremarkable. The patient is employed as a factory line worker, requiring him to lift 5-7 kg (11-15 lb) several times daily. Vital signs are normal. On physical examination, the patient appears comfortable. Cervical and thoracic spine range of motion is normal, but flexion and extension of the lumbar spine elicit pain. Straight-leg raising test is normal. There is mild tenderness in the left lumbar paraspinal tissues but no midline tenderness. Upper and lower extremity strength and deep tendon reflexes are normal. Which of the following is the best recommendation for management of this patient's pain?

Question

A 35-year-old man comes to the office for follow-up of low back pain.  He has aching pain in the left lumbar paraspinal area that is worse at the end of the day and relieved overnight with rest.  The pain began 3 months ago with no precipitating trauma.  The patient was initially treated with intermittent doses of acetaminophen and naproxen but continues to have moderate residual pain.  There is no associated fever, weight loss, radicular pain, lower extremity weakness, or urinary symptoms.  Medical history is unremarkable.  The patient is employed as a factory line worker, requiring him to lift 5-7 kg (11-15 lb) several times daily.  Vital signs are normal.  On physical examination, the patient appears comfortable.  Cervical and thoracic spine range of motion is normal, but flexion and extension of the lumbar spine elicit pain.  Straight-leg raising test is normal.  There is mild tenderness in the left lumbar paraspinal tissues but no midline tenderness.  Upper and lower extremity strength and deep tendon reflexes are normal.  Which of the following is the best recommendation for management of this patient's pain?

Quizplus · Accepted Answer

11ec25c8_d506_2789_bc81_c9801aecb16e_MD0003_00 This patient has uncomplicated low back pain (LBP). Following initial onset of acute (<4 weeks) LBP, patients should be advised to maintain moderate activity and use short courses of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) as needed; most patients experience complete resolution of symptoms. However, those with subacute (4-12 weeks) or chronic (>12 weeks) LBP, such as this patient, are more likely to have recurrent or persistent pain and therefore warrant additional intervention. In patients with chronic LBP, exercise is beneficial in reducing pain and improving function. Patients often start with a supervised exercise program (eg, physical therapy) that emphasizes stretching and strengthening of the back muscles. Aerobic exercise may also be helpful. Subsequently, patients can transition to a home exercise program, which should be continued indefinitely. Short courses of acetaminophen or NSAIDs can be used intermittently. Some patients also may benefit from duloxetine or tricyclic antidepressants, but opioids are not advised for routine use. (Choice A) Prolonged activity restriction in patients with uncomplicated LBP is associated with increased long-term pain and stiffness. Patients should be counseled to maintain normal activity. (Choice B) Epidural glucocorticoid injections can be considered for patients with lumbosacral radiculopathy who have not responded to initial treatment. They are not helpful for nonradicular LBP. (Choice D) Lumbar support braces are commonly recommended in the lay media for chronic LBP. However, such braces may discourage activity, and there is limited evidence of reduced pain, improved function, or lower recurrence rates. The long-term benefit, if any, is likely much less than that from an appropriate exercise program. (Choice E) Nonbenzodiazepine muscle relaxants (eg, cyclobenzaprine) can be used as an adjunct therapy for LBP. However, benzodiazepines are not indicated for this purpose because they have minimal evidence of benefit, carry significant abuse potential, and can cause severe respiratory depression in patients on concurrent opioid therapy. Educational objective: Management of chronic back pain should include an exercise program emphasizing stretching and strengthening of the back muscles. Acetaminophen or nonsteroidal anti-inflammatory drugs can be used intermittently. Some patients may benefit from duloxetine or tricyclic antidepressants, but opioids and benzodiazepines are not advised. References: Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/25681408) Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. (http://www.ncbi.nlm.nih.gov/pubmed/29971708)

A 35-Year-Old Man Comes to the Office for Follow-Up of Low