Page 224 Guide to Pain Management in Low-Resource Settings

212 Mathew O.B. Olaogun and Andreas Kopf

What medications are recommended or restore physical, psychological, and social function.
in nonspecifi c back pain? Management involves knowing the cause and course of

Unfortunately, many patients with nonspecifi c back the pain, educating patients in simple terms, and select-
pain are treated as in acute specifi c diseases causing ing appropriate “resource-oriented” physical and psy-
pain, with long-term prescriptions of nonsteroidal an- chological modalities and techniques. For success, it is
algesics, opioids, and centrally acting muscle relaxants, vital to achieve a “change motivation” in patients and to
although there is no evidence in the literature for use of educate them on what can be done as self-care.
these drugs for this indication, and a number of guide-
lines do not recommend them. Only a few medications Pearls of wisdom
are indicated. Tricyclic antidepressants in low to mod-
erate doses are useful to alleviate insomnia, enhance • Chronic nonspecifi c back pain is one of the most
endogenous pain suppression, reduce painful dysesthe- frequent patient complaints.
sia, and help the patient’s ability to cope. If a depressive • It is crucial to diff erentiate nonspecifi c back pain
disorder is diagnosed, higher doses would be needed. In from specifi c back pain because the therapeutic
some patients, the anxiolytic and sleep-quality-improv- techniques diff er considerably. Th is diff erentia-
ing calcium channel blockers gabapentin or pregabalin tion should be made at the earliest possible mo-
might be helpful. Other coanalgesics and narcotics may ment, because nonspecifi c back pain tends to
only be used if the pain is of malignant, chronic infl am- take on a life on its own within a couple of weeks
matory, or severe degenerative origin. or months, resulting in a diffi cult-to-treat disease.
• “Red fl ags” help to identify indications for specifi c
Are invasive therapeutic techniques and nonspecifi c pain.
indicated in nonspecifi c back pain? • In general, opioids, NSAIDs, and central muscle

In carefully selected patients, such as those with con- relaxants as well as invasive procedures are inef-
comitant sacroiliacal or facet joint aff ection, local in- fective in nonspecifi c back pain and even have
jections might facilitate recovery with physical therapy. the risk to further promote chronic pain develop-
Local injections into paravertebral soft tissues, specifi - ment. Instead, intensive counseling, patient edu-
cally into myofascial trigger points, are widely advocat- cation, physical activation, and behavioral inter-
ed. However, study results are rather disappointing. ventions have been proven to be eff ective.
• Psychiatric comorbidity is frequent and should
If conventional analgesics and invasive not be overlooked.
techniques are not recommended, what therapy • An important goal in advanced chronic back
is best for chronic nonspecifi c back pain?
pain patients is concentration of therapeutic ef-
Behavioral and cognitive behavioral multidisciplinary forts on functional improvement rather than
pain programs have proven eff ective for many patients, pain reduction.
but they need dedicated, well-trained personnel and
rather high fi nancial resources to be eff ective. Th erefore,
References
prevention of chronic nonspecifi c back pain is the key
to therapeutic success. Morbid obesity, smoking, gen- [1] Odebiyi DO, Akinpelu AO, Olaogun MOB. S Afr J Physiother
eral fi tness, and job satisfaction should be addressed in 2006;62:17–20.
[2] Olaogun MOB, Adedoyin RA, Ikem IC, Anifaloba OR. Physiother Th e-
all patients to avoid development of chronic nonspecifi c ory Pract 2004;20:135–42.
[3] Swagerty DL, Hellinger DO. Am Fam Physician 2001;64: 279–86.
back pain. Adequate and knowledgeable patient guid-
ance seems to be the most important prophylactic and
therapeutic instrument in nonspecifi c back pain. Th e Websites
goals of chronic pain management are to relieve dis-
http://www.rcep7.org/projects/handbook/back.pdf
comfort (partially) and (more importantly) to improve