Lumbar Sprains & Low Back Pain: Treatment Options

/ Thomas Cohn, MD

lumbar sprainLumbar sprains are often considered a generic term to explain low back pain that originates from the muscles or ligaments.  It is usually just in the low back and buttock area, and does not spread into the legs.  Lumbar strains and sprains are not serious injuries, they do not involve damage to lumbar discs, lumbar nerves, the vertebrae, or joints.  Pain is localized to the back and will resolve with conservative treatment.

What is a Lumbar Sprain?

Technically, sprains are tears of ligaments. In the lumbar area, these ligaments hold the bones in alignment with the help of muscles.  Strains occur to muscles when they are overstretched.  Most lumbar pain is related to injuries to the muscles, and thus are more correctly considered strains.

Mobility of the lumbar region is dependent on the action of both very large and very small muscles along the spine.  The lumbar spine can bend forward and back, rotate and twist.  Lifting and twisting can put excessive forces through the spine and muscles causing a strain. Pain usually appears after doing any of the following:

  • Performing too much lifting
  • Staying in a bent position
  • Performing repetitive lifting and twisting

Performing activities without the proper body mechanics, obesity, and poor conditioning are all contributing factors.

Treatment Options

Treatment of lumbar strains is typically conservative.  Ice initially for a day or two and then heat is often helpful.  Ice reduces initial swelling and pain, while heat facilitates muscle rest, blood flow, and healing.  Nonprescription medications including anti-inflammatories like ibuprofen and aspirin as well as analgesics like acetaminophen are helpful.  Rest should be limited to no more than two days.  Over 90% of these will resolve readily in less than a month.  Chiropractic therapy, massage, and physical therapy may all help improve function and diminish pain.

Full medical evaluation may be necessary if the pain continues longer than several weeks, or there are more serious problems like:

  • actual leg weakness,
  • numbness,
  • loss of control of the bowels or bladder,

Rarely will an injury to the spine, discs or nerves be present.  Even in cases of more severe back injuries, most of these also heal with conservative care.  Only in cases of neurologic compromise causing leg weakness or loss of control of the bowel or bladder would surgery be a definite consideration.

Low back pain is usually due to a muscle strain.  Learning proper body mechanics and maintaining good core strength helps prevent injury.  Almost everyone strains his or her back at some point.  Conservative care and time will heal almost everyone.

4 Pain Myths, Busted

/ Thomas Cohn, MD

pain mythsPain is a complex beast. Since it’s based on subjective factors, each person experiences pain differently than the next. If two people break their arms under exactly the same circumstances, their perception of pain will undoubtedly be different.

With this subjectivity comes a lot of misconceptions and myths about pain. These myths often lead to societal “rules” and mantras that, in reality, are not based in fact. Here are some common pain myths, and the truths behind them:

  1. No pain, no gain. This is a common mantra amongst athletes who believe that they must push their bodies to the point of pain in order to improve. This is incorrect. If your exercise routine is causing you pain beyond simple muscle soreness, it’s probably not a good thing. Listen to your body, and seek medical help if you hurt yourself during exercise.
  2. Going to the doctor won’t help. Some people who are in pain believe that their pain will never go away no matter what, and this sometimes prevents them from seeking medical assistance. The truth is a physician or pain management specialist can help you craft a plan for managing your pain and getting you on track to a better life.
  3. Pain meds are addictive and I shouldn’t take them. It’s true that pain medication can be addicting. However, that should not deter you from using meds to manage your pain. If used in a responsible manner, pain medication can be a great help in alleviating your pain.
  4. Every type of pain can be cured. This is not necessarily true. There are several forms of chronic pain (such as CRPS) that cannot be completely cured. Instead, the best course of action is to come up with a plan to manage the pain.

When it comes to pain, you can’t always trust what your mother says (unless she’s a pain doctor of course!). She may be wise beyond her years, but the way your body experiences pain is drastically different than anyone else. So don’t stick to these old mantras. If you’re in pain, or have a question about treatment options, reach out to a qualified medical professional who can analyze your unique situation and help relieve your pain.

Diabetic Neuropathy: Types, Causes, & Pain Management Options

/ Thomas Cohn, MD

diabetesDiabetes can cause multiple problems in the body.  High blood sugars can cause damage to nerves.  Diabetic neuropathy occurs in up to 70% of diabetics, and is painful in up to 30%. There are four common types of diabetic neuropathy: 

  1. Peripheral polyneuropathy
  2. Autonomic neuropathy
  3. Amyotrophy mimicking a radiculopathy
  4. Mononeuropathy

The small sensory pain fibers are the most commonly affected, causing pain in the feet and slowly progressing to the legs and often developing in the hands.  Loss of sensation in the legs can lead to open wounds, infections, amputations, and sometimes even death.

Causes of Diabetic Neuropathy

The causes of diabetic neuropathies are all thought to start with high blood sugars.  This is known to cause damage directly to the nerve, the insulation covering the nerves, and the blood vessels that provide nutrition.  There is also thought to be an auto-immune factor that diabetes provokes our immune system to fight the body itself like a foreign organism and cause damage.  Smoking and alcohol can also increase the likeliness of damage.  Lastly, diabetes makes the nerves more sensitive to damage, thus injury can cause significant increase in overall damage to nerves.

Peripheral Polyneuropathy

Peripheral polyneuropathy is the most common type of damage seen in diabetes.  It is noticed first affecting sensory nerves, but motor nerves can be equally damaged.  People often first notice numbness in the feet and toes, and changes in temperature.  Tingling, and burning is common, as well as pain and sensitivity even to the lightest of touches.   Motor changes include weakness in the feet and legs and difficulty with walking and balance.

Autonomic Neuropathy

Autonomic neuropathy is the next most common diabetic neuropathy.  The nerves that control the heart, bladder, stomach and intestines, sex organs, and eyes are from the autonomic nervous system.  Loss of control of the bladder may be from damage to these nerves.  In males, erectile dysfunction is a common issue.  Stomach problems include slow emptying, constipation, and sometimes diarrhea.  Heart problems include fluctuating blood pressures and heart rates.

Prevention & Treatment Options

Once diabetic neuropathies occur, they are often hard to manage and control, since the nerve damage is often permanent.  Good blood sugar control is the most important aspect in reducing the incidence and severity.  Painful neuropathies are best treated with neuropathic medications such as:

  • Gabapentin
  • Lyrica
  • Cymbalta

Narcotic/opioid medications are often only minimally helpful at best.  In the worst cases, implantable pain control devices such as spinal cord stimulation and intrathecal pain pumps are useful.  When pain is an ongoing problem, enlisting the help of an experience pain physician can be a lifesaver in symptom management.

Uncommon Pain Medications Used to Treat Pain

/ Thomas Cohn, MD

uncommon pain medicationMany medications are used in the treatment of pain. The most common pain medications include opioids, anti-inflammatories, simple analgesics, and others. Read our previous blog for more detailed information on these common pain medications.

For many patients, these common pain medications are not effective and specialized medications are often used. These uncommon medications include seizure medications, antidepressants, and a variety of others.  These drugs are often considered neuropathic medications and are used whenever abnormal nerve function is suspected in causing pain. Read on for more detailed information about these uncommon pain meds and how they’re used in the treatment of pain.

Antidepressant Medications

Antidepressant medications are used to control neuropathic pain. Two types of antidepressants are commonly used:

  • Tri-cyclic antidepressants (TCAs). Tricyclic antidepressants include amitriptyline, Nortriptyline, and desipramine, the later two are the best tolerated and used at very low dose.  The TCAs have many side affects including dry mouth, low blood pressure, sedation, and urinary problems.
  • Serotonin/noradrenaline reuptake inhibitors (SNRIs). The newer SNRIs include Cymbalta and Savella have very few side affects.  Cymbalta is very effective in a number of neuropathic pain situations including diabetes, radiculopathy and fibromyalgia, while Savella only is known to work in fibromyalgia.

Antidepressants such as Zoloft, Prozac, and Celexa along with Effexor have no affect on pain.  These medications decrease nerve transmission and nerve sensitivity.

Seizure Medications

Seizure medications were among the first neuropathic medications.  The originals were Dilantin and Depakote, but due to their significant side affects, these are now rarely used.  Tegretol is also used rarely for similar reasons, but has been found uniquely helpful with trigeminal neuralgia.

All seizure medications work by decreasing the ability of the nerves to be active and send signals.  They can be sedating and can cause mental clouding.  The newer ones include gabapentin (Neurontin) and Lyrica. For any pain nerve associated, these medications can be very effective, and if monitored and prescribed correctly have minimal side effects.

Lidocaine Skin Patches

Lidocaine skin patches use a local anesthetic to decrease nerve sensitivity at the skin.  These patches work on a variety of painful conditions including shingles (post-herpetic neuropathy), and diabetic neuropathy.  They may be helpful in headaches, neck and low back pain.  Myofascial pain and fibromyalgia sometimes respond to lidocaine skin patches as well.

Clonidine & Tizanidine (Zanaflex)

Clonidine and tizanidine (Zanaflex) are alpha-2 adrenergic agonists, blocking certain sensory interneurons important in pain transmission.  Clonidine is normally a potent blood pressure medication, but sometimes is very effective in neuropathic pain and is sometimes even used in intrathecal pumps.   Tizanidine has properties that help with analgesia in neuropathic pain and helps with muscle spasms, and was originally developed for controlling muscle spasm in quadriplegia.

Capsaicin & Baclofen

Capsaicin is a crème derived from chili peppers used in neuropathic diabetic pain and post-herpetic neuralgia. It activates certain pain fibers on the skin.

Baclofen is an unusual medication affecting nerve receptors in the spinal cord and brainstem.  Originally, it has been for spasticity, often in paraplegia, quadriplegia, cerebral palsy, and multiple sclerosis.  It is used orally as pills and sometimes by intrathecal pump.  It can help also with neuropathic pain.

NMDA Receptor Antagonists

A final group of adjuvant pain medications are NMDA receptor antagonists.  These medications also block a set of sensory fibers and pain transmission.  Ketamine is the main drug in this category.  It can only be given by IV or intrathecal pump, and has been used in CRPS, and cancer.  It is similar to the drug LSD, and can cause hallucinations.

Common Non-Opioid Pain Medications

/ Thomas Cohn, MD

pain medsThe most common medications prescribed by primary care physicians for pain are analgesics.  They can be divided into to two main categories: opioids/narcotics and non-opioid type medications. We have discussed opioids at length in previous blogs. This article will cover common non-opioid pain medications.

Acetaminophen/Tylenol

Acetaminophen/Tylenol works for mild to moderate pain, such as headaches. It works by enhancing the body’s inhibitory pain pathways.  The maximum safe dose was considered to be 4000 mg, but data now available is questioning that level.

Breakdown products of acetaminophen can be toxic to the liver, especially when the liver has other compounds to metabolize.  Alcohol can greatly interfere with acetaminophen breakdown, and when toxic it can kill the liver, and has been found to be the most lethal nonprescription medication sold. In short, be careful when taking this medication with alcohol.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most prescribed pain medications.  Common examples include:

  • Ibuprofen
  • Naproxen
  • Aspirin
  • Diclofenac
  • Celebrex

These medications inhibit enzymes that are released from cells when they are injured and inhibit inflammation and secondarily peripheral pain receptors.  These drugs act on the “COX” enzymes.

  • COX 1 enzymes protect the gut, maintain kidney function, and cause platelets to form clots.
  • COX 2 enzymes are involved in inflammation.

Most NSAIDs are nonselective, impacting both COX 1 and2 enzymes, and therefore can cause stomach damage, bleeding and kidney problems.  NSAIDs are used for joint pain and pain after injury.

Corticosteroids

Corticosteroids are medications that include:

  • Prednisone
  • Hydrocortisone
  • Injectable steroids

These medications only work on inflammation.  They are very powerful, and can be used in a number of ways.  Topically they are used for rashes.  Orally and via injection they can bring down local or diffuse inflammation.  They have been injected in joints to bring down joint pain, and often are used by pain physicians as epidural injections to treat spinal pain causing radiculopathy.  Unfortunately, if not used with caution, they can have numerous side affects due to affecting hormone balance.

Muscle relaxers and anti-spasm medications

Muscle relaxers and anti-spasm medications are used to reduce muscle tightness.  Most of these drugs have no impact on pain, and may act by sedating a person.  These medications may help pain that is due to muscle tightness beyond what is necessary.  Some of them are very addictive, since they include Valium and similar anxiety medications. In chronic pain, most of these medications are ineffective.  Other muscle relaxers commonly used include Robaxin, Skelaxin, and Norflex.  These medications are sedating and some may be addicting, but generally have very little affect in overall pain.