BACK PAIN: painful muscle spasms and its treatment with muscle relaxants

This page has become the most popular on my site, and I understand that people come to it to get a specific answer to the question “how to treat back pain?” If you decide to go without a doctor, use the red flags to look for signs of dangerous pain.

You can take painkillers without examination only if you have taken this recommendation as carefully as possible and have not identified anything from the list of danger signs.

Despite the criticism of supporters of searching for the direct source of back pain (painful muscle nodules, sprained ligaments, joint damage), I remain a supporter of the absence of the need for detailed diagnostics in the absence of “red flags,” regardless of the anatomical structure involved, prognosis, treatment and prevention of pain in the back will not be different. Particular moments that lead to chronic pain and require special treatment (for example, long-acting steroid injections for pain associated with inflammatory joint damage) are extremely rare.

For my patients with acute back pain, I recommend treatment according to the following regimen:

(a) A heat compress on the area of ​​pain (a heating pad or a bag of sand/cereals at a temperature of 42-45˚ C, duration of use 1-1.5 hours) and/or Meloxicam 15 mg, 1 tablet in the morning. Due to the high risk of developing ulcerative complications, simultaneous administration of Omeprazole 20 mg, 1 capsule, 40 minutes before dinner is recommended; course of treatment – ​​4 weeks. (b) One of the local anesthetics: - “Analgesic ointment” 50.0 (pharmacies of the KIT Pharma chain) or - a compress with Dimexide on the area of ​​pain (every other day No. 5): mix equal parts of Dimexide (99.6 %); Lidocaine 2% and pure water (for the treatment of pain in the neck or back, 15-20 ml, pain in a small joint - 5 ml, large joint - 10-15 ml) - soak a napkin according to the size of the area of ​​pain (for the treatment of pain in the neck and back, joint pain - the size of a palm), apply to the area of ​​pain, cover with plastic wrap and a layer of cotton wool on top. After 10-15 minutes, assess the condition of the skin under the napkin. If there is redness, remove the compress; if the skin is in normal condition, keep it at 45-60′ (c) Recommendations for regimen and exercise for pain on the doctor’s website: https://bit.ly/neckopn (neck pain), https:// bit.ly/back-opn (back pain); educational material about back pain: https://bit.ly/back-treatment

In case of chronic pain, I add Gabapentin 300-1800 mg/day to the treatment regimen (there is no convincing evidence, personal observations indicate moderate effectiveness and high safety of the drug), a combination of duloxetine (60-120 mg/day) and tramadol 50-100 mg/day (at the beginning of treatment - regularly, subsequently - as an emergency drug; there is personal positive experience of using the combination in patients 80+ with chronic pain in the joints and spine, chronic back pain, there is personal experience - the drug significantly reduced muscle pain and made long-distance running more comfortable; the safety of duloxetine is worse than gabapentin, patients often report dizziness and pre-syncope).

Extremely rarely, when nothing else helps, I use Topiramate at a dose of 50-200 mg/day. There are isolated cases of successful use of the drug for the treatment of chronic back pain. The prescription of the drug is often accompanied by adverse events such as lethargy, dizziness, memory loss, and unsteadiness when walking.

Below is a review of the literature.

Analgesics and NSAIDs are effective in the treatment of acute back pain. According to the most common point of view, the prescription of centrally acting muscle relaxants increases the effectiveness of treatment, but is accompanied by a high risk of developing adverse events, primarily associated with the sedative effect of the drugs.

However, in a placebo-controlled study, Benjamin W., Andrew A., (2015) failed to demonstrate the effect of the addition of a centrally acting muscle relaxant (cyclobenzaprine) or a combination of paracetamol with an opioid analgesic (oxycodone) during treatment with naproxen.

There are a wider range of medications available for the treatment of chronic back pain, but clinical trial evidence for their benefit is less convincing.

Nonsteroidal anti-inflammatory drugs

Choice of drug

NSAIDs are effective in patients with low back pain, however, the improvement in the general condition of the patient associated with their use is insignificant. Paracetamol (acetaminophen) or NSAIDs are recommended as first-line drugs. The first, slightly inferior to NSAIDs in effectiveness, is cheaper and safer in most groups of patients (does not affect blood clotting or blood pressure regulation). For acute back pain in patients without an increased risk of adverse events, NSAIDs are prescribed for up to 4 weeks. No differences in the effectiveness of individual NSAID drugs have been shown in randomized clinical trials.

The most acceptable drugs are ibuprofen (200-400-600 mg up to 4 times a day), and naproxen (200-500 mg x 2 times a day), both drugs are well studied and are quite safe for short-term use. In our country, due to aggressive advertising, the prescription of selective COX-2 inhibitors - oxicams (meloxicam, lornoxicam), sulfonanilides (nimesulide) - is common. The presence of a large number of generics on the market makes these drugs accessible.

It is advisable to use drugs in minimal doses that produce a sufficient analgesic effect from the patient’s point of view. In the recommendation for taking the drug for each individual patient, indicate the permissible dosage range and maximum duration of use. To create realistic expectations, it is important to inform the patient that most often taking medications reduces pain, but does not eliminate pain completely. In most cases, in patients without concomitant affective disorders, the tolerance of back pain is satisfactory, the severity of the pain syndrome is moderate.

Security questions

Frequent use of NSAIDs and long courses of drug administration place great emphasis on patient safety. With short-term use, there are risks of damage to the gastrointestinal tract, adverse events from the cardiovascular system, blood system and allergic reactions:

Adverse events from the gastrointestinal tract

Damage to the gastrointestinal tract is the most common complication of taking NSAIDs. It has been shown that for every $1 spent on NSAID treatment, $0.66 to $1.25 is spent on treating gastrointestinal complications

Taking medications reduces the protective properties of the gastric mucosa. The mechanism of the ulcerogenic effect of NSAIDs is due to two independent mechanisms:

• local damage to the gastric mucosa;
• systemic depletion of cytoprotective prostaglandins. NSAIDs, as weak acids, are present in the acidic environment of gastric juice in the form of lipophilic neutral molecules. They slowly penetrate the epithelial cells of the stomach and accumulate in the neutral environment of the cytoplasm. The action of the drugs contributes to the disorganization of gastric surfactant, disrupts the composition of phospholipids, glycolipids and glycoproteins of epithelial cells, uncouples oxidative phosphorylation, causing energy deficiency in epithelial cells.

In the American College of Gastroenterology Lanza FL, Chan FK, Quigley EM, Practice Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009;104( 3):728.) the following risk assessment model is proposed:

Symptoms of pain with hernias

There are markers, or “special flags,” that suggest that pain is associated specifically with damage to the musculoskeletal system and is discogenic in nature. These are the following symptoms and signs:

• sharp and acute pain appears either at the time of severe physical activity or immediately after it;
• acute pain has the character of an electric current, it is sudden, shoots in the lower back, most often in the leg, right down to the ankle joint;
• pain leads to a sharp restriction of mobility in the lumbar spine, and the patient takes a specific anti-pain position. In this pose, the slightest movement is eliminated, and breathing becomes less deep;
• pain associated with damage to the intervertebral discs is of a so-called radicular nature. This means that the slightest shock to the lower back leads to a sharp increase in pain in the form of lumbago, which is called lumbago. This is laughing, coughing, sneezing, trying to change body position or pushing in the toilet due to great need;
• later a permanent, aching component is added, associated with the reaction of the deep muscles to the appearance of an inflammatory focus caused by a hernia.

All these symptoms clearly indicate that the cause of the pain was discogenic complications of osteochondrosis - protrusion or hernia in the lumbar spine, in which these defects occur most often. Why does pain occur? Why does it develop?

Low risk

No risk factors

NSAIDs differ in the severity of their ulcerogenic effects.

Indomethacin has the highest risk of gastrointestinal complications (relative risk {RR} 2.25), followed by naproxen (RR 1.83), diclofenac (RR 1.73), piroxicam (RR 1.66), ibuprofen (RR 1.43), and meloxicam (OR 1.24).

A dose-dependent effect of the drugs was noted (Richy F, Bruyere O, Ethgen O, 2004):

Low-dose ibuprofen (RR 1.6, 95% confidence interval 0.8-3.2)

High-dose ibuprofen (RR 4.2, 95% confidence interval 1.8–9.8)

Low-dose naproxen (RR 3.7, 95% confidence interval 1.7-7.7)

Naproxen at high doses (RR 6.0, 95% confidence interval 3.0-12.2)

Low-dose indomethacin (RR 3.0, 95% confidence interval 2.2-4.2)

High-dose indomethacin (RR 7.0, 95% confidence interval 4.4-11.2)

Not included in this review, ketorolac also has a pronounced gastrotoxic effect. In one study (García Rodríguez LA, Cattaruzzi C, 1998), it was shown that the risk of developing adverse events from the gastrointestinal tract with the drug is 5.5 times higher than that of other NSAIDs. Therefore, the duration of taking the drug is limited to 5 days.

In Russia and abroad, the drug is available with a prescription.

Despite the possibility of early gastrotoxicity, in most cases it does not appear within several weeks of taking the drugs. The possibility of modifying risk factors depends on the conditions of medical care for the patient.

• Patients with a history of complicated or uncomplicated gastrointestinal ulcer disease are advised to undergo testing for H. pylori before prescribing NSAIDs or aspirin. If the result is positive, appropriate treatment is carried out (even in cases where it is assumed that the previous development of ulcers was associated with taking NSAIDs).
• It is necessary to use minimal doses of drugs, the course of treatment should be as short as possible.
• In patients with an average and high risk of complications from the gastrointestinal tract, the use of selective COX-2 inhibitors or NSAIDs in combination with antisecretory drugs: proton pump inhibitors (omeprazole 20 mg/day, esomeprazole 20 mg/day up to 6 weeks), H2 blockers is indicated -histamine receptors (ranitidine 150 mg/day once at night, famotidine 40 mg x 2 times a day). Both groups of drugs reduce the severity of dyspepsia in patients. Efficacy at recommended doses is similar.
• In patients with a high risk of complications from the gastrointestinal tract, selective COX-2 inhibitors may be prescribed in combination with antisecretory drugs
• Concomitant use of aspirin with COX-2 inhibitors completely eliminates the gastrointestinal safety benefits of the latter.
• Unexplained anemia, iron deficiency, severe dyspepsia, signs of gastrointestinal bleeding indicate a possible complication of taking NSAIDs. It is necessary to consider the possibility of performing esophagogastroduodenoscopy.

Carrying out treatment

The algorithm is as follows:

• before applying ointments, the skin should be washed and dried;
• ointments are applied in an even layer to the painful area;
• rub in with light pressure, using massaging movements, excess is removed with a napkin.

It is recommended to apply ointments at night; in the evening, the effect of medicinal components is more active. The use of therapy at night promotes restful sleep without pain.

Table 1 Recommendations for the prevention of complications associated with taking NSAIDs

Another drug that has a sufficient gastroprotective effect is the synthetic prostaglandin E1 - misoprostol, but its use is limited by its high cost.

The protective effect of the H2-histamine receptor antagonist, famotidine, has been proven only in combination with ibuprofen. A combination drug was created, which is currently not available in Russia. However, both of its components can be purchased and taken separately. They are affordable.

It is necessary to inform the patient that even despite intense back pain, his health is not in danger. The vast majority of patients have a favorable prognosis: within 3 months, more than 90% of patients do not seek medical help again.

Less significant are complications from the urinary and central nervous systems, hepatotoxic effects of drugs:

Adverse events from the urinary system

All NSAIDs can have nephrotoxic effects. When taking drugs of this group, the following types of complications may develop: Development of acute renal failure due to spasm of renal vessels. Other mechanisms of organ damage are also possible. NSAIDs cause a moderate increase in arterial hypertension, reduce the effectiveness of antihypertensive drugs, and can cause electrolyte disturbances (hyperkalemia, hyponatremia and edema). Taking NSAIDs is associated with an increased risk of kidney cancer.

Adverse events from the cardiovascular system

All NSAIDs, both selective and non-selective, increase the risk of developing cardiovascular complications: clinical manifestations of coronary heart disease, heart failure, increased blood pressure, and the development of atrial fibrillation. Naproxen has the lowest risk of developing complications from the cardiovascular system. (Daniel H Solomon, MD, 2015). NSAIDs interact with all classes of antihypertensive drugs except calcium antagonists, reducing their effectiveness. Their use may increase blood pressure in patients (White WB. 2007). Safety issues are more relevant for patients with a high risk of cardiovascular complications (old age, long-term hypertension, constant use of antihypertensive drugs, diabetes mellitus); in patients with a low risk, they do not limit the use of drugs in this group.

Adverse events from the blood system

Neutropenia is a rare complication of taking NSAIDs and develops in less than 1% of patients; no risk factors for the development of this condition or association with taking individual drugs from this group have been established. The antiplatelet effect is associated with inhibition of COX-1, which leads to a decrease in the production of thromboxane A2. It is necessary to avoid taking NSAIDs in patients with thrombocytopenia (less than 50 x 109/l). Before surgery, drugs should be discontinued within 3-5 half-life periods. For most NSAIDs, the antiplatelet effect disappears 3 days after discontinuation. The antiplatelet effect of ibuprofen is eliminated 24 hours after discontinuation of the drug. Highly selective COX-2 inhibitors have little effect on platelet hemostasis. Concomitant use of NSAIDs and aspirin may reduce the antiplatelet effect of the latter. Interaction with warfarin leads to a significant increase in INR when taken simultaneously. More frequent monitoring of the indicator is required.

Allergic and pseudoallergic reactions

Pseudoallergic reactions associated with inhibition of COX-1 can be caused by taking aspirin and all (“crossover”) NSAIDs that inhibit COX-1: Piroxicam, Indomethacin, Ibuprofen, Naproxen, Ketoprofen, Diclofenac, Ketoralac, and less commonly, drugs with weakly expressed properties of COX inhibitors -1 — paracetamol; and even less often when using drugs that selectively inhibit COX-2, nimesulide, coxibs, oxicams; a dose-dependent effect was noted for these drugs. Allergic reactions to NSAIDs develop in the form of angioedema, urticaria or anaphylaxis. Cross-reactions to drugs with similar chemical structures are possible. If pseudo-allergic and allergic reactions to any of the NSAIDs develop, it is necessary to avoid taking all drugs in this group; as an alternative, use paracetamol in a single dose of no more than 650 mg.

Adverse effects from the respiratory system

When taking aspirin and other non-selective COX-1 blockers, it is possible to develop bronchospasm, decompensation of bronchial asthma and other obstructive bronchial lesions of inflammatory origin.

Adverse events from the hepato-biliary system

Cases of liver failure when taking NSAIDs are quite rare (3.7 per 100,000 patients taking drugs of this group). Transient slight increases in the activity of liver enzymes (less than 3 upper limits of normal) are not prognostic signs of the development of acute liver failure associated with the action of NSAIDs. Ibuprofen is the safest NSAID and has not shown severe liver damage in large studies. Along with paracetamol and aspirin, the drug is one of the best-selling over-the-counter drugs in the world. Newer NSAIDs, selective COX-2 inhibitors, oxycams and coxibs have a relatively low risk of toxicity. In rare cases, piroxicam can cause severe liver damage.

The drug Nimesulide was withdrawn from sale in a number of countries (Japan, Finland, Turkey, Israel, India, Sri Lanka, and later Ireland), and was never put on sale in the USA and Great Britain, due to a pronounced hepatotoxic effect in a series of clinical observations , however, various epidemiological studies do not confirm this information.

The European Medicines Agency (EMA) recommends only short-term use of the drug (15 days), at a dose not exceeding 200 mg/day (100 mg x 2 times a day) in adults. Taking into account all the data obtained, the Agency believes that the potential benefits of the drug, subject to restrictions, outweigh the potential risks.

The economic feasibility of monitoring liver enzyme activity in patients taking NSAIDs has not been established.

In case of an increase in activity by more than 3 times compared to the upper limit of normal, a decrease in the concentration of serum albumin, or an increase in INR, it is necessary to assume the hepatotoxic effect of NSAIDs.

Adverse skin effects

The risk of developing toxic epidermal necrolysis and Stevens-Johnson syndrome (malignant exudative erythema) when taking NSAIDs is 1 in 100,000. The highest risk is when taking piroxicam, the lowest is when taking diclofenac and ibuprofen.

Adverse effects from the nervous system

Elderly patients taking NSAIDs, especially indomethacin, may experience worsening cognitive impairment and the development of psychosis. Taking ibuprofen and naproxen is associated with the development of aseptic meningitis. In a small proportion of patients, taking NSAIDs is accompanied by the development of tinnitus. The complication is reversible after discontinuation of the drugs.

How to relieve back pain?

Pain in the back is a fairly common symptom. The reason may lie in a variety of disorders of the body. Discomfort manifests itself in an acute form, which limits a person’s movement and does not allow him to move normally or perform even simple tasks. The problem is eliminated with the help of modern drugs. Painkillers or anti-inflammatory drugs come to the rescue. They are selected taking into account the following factors:

• Patient's weight and age.
• Existing diagnosis.
• The severity of disease progression.
• The cause of the pain syndrome.
• Stage of development of the pathology.
• Presence of contraindications or allergic reactions.
• What medications are the patient already taking?

In order to prevent exacerbation of radiculitis, you should not take painkillers, as this will not be beneficial, but will also cause damage to internal organs, their dysfunction, and will cause addiction. Therefore, the next time you use it, it simply will not work or will provoke a number of side effects.

Summary

1. NSAIDs are a relatively safe group of drugs,
2. Most of the adverse events develop only with long-term use of the drugs.
3. The most acceptable drugs are ibuprofen (200-400-600 mg up to 4 times a day), and naproxen (200-500 mg x 2 times a day), both drugs are well studied and are quite safe if prescribed in short courses (2-4 weeks) .
4. Due to the similar effectiveness of all available agents, the choice in each individual case is determined by the safety profile of the drug and its cost.
5. When prescribed, an assessment of the risk of developing complications from the gastrointestinal tract and cardiovascular complications in each patient is indicated. The frequency of the former is increased to a greater extent by the use of non-selective NSAIDs, the latter - by NSAIDs and selective COX-2 inhibitors.
6. Due to the fact that NSAIDs have an antiplatelet effect, and their use is accompanied by a risk of developing thrombocytopenia, a complete blood count is indicated before starting treatment.
7. Monitoring the activity of liver enzymes during treatment with NSAIDs is not required for each patient. Liver tests may be performed when there is initial liver injury or when acute injury is reasonably suspected.
8. In patients with contraindications to the use of NSAIDs (a combination of a high risk of cardiovascular complications and adverse events from the gastrointestinal tract), it is advisable to use Paracetamol in a dose of 200-400 mg up to 2 times a day, for a course of up to 4 weeks. Another alternative to NSAIDs is the drug flupirtine (Katadolon). Both paracetamol and catadolone, when taken for a long time, especially in elderly patients, can have a hepatotoxic effect, including causing severe liver damage. On February 9, 2021, the Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) recommended that the marketing authorization of flupirtine be withdrawn because, despite precautions, the drug has been associated in isolated cases with serious liver damage.

Table 2 Recommendations for choosing medications for back pain

Indications for use of ointments

Ointments for back and lower back pain are used as individual therapy when feeling discomfort, expressed in varying degrees of pain.

Problems appear during the period of exacerbation of chronic pathological disorders when weather conditions change and the body becomes hypothermic. Moderate pain is characterized by minor muscle inflammation and pinched nerve endings.

When choosing an ointment for an individual prescription to a patient, the doctor must take into account the circumstances that caused the discomfort:

• homeopathic medicines with anti-inflammatory effects are prescribed to treat the inflammatory process;
• drugs that have a warming effect are prescribed for the treatment of osteochondrosis and spondyloarthrosis;
• ointments with the effect of local irritation - used to treat pathological changes with moderate pain.

To prescribe a specific drug, it is important to make the correct diagnosis.

Centrally acting muscle relaxants

According to systematic reviews, combined treatment with NSAIDs and centrally acting muscle relaxants is more effective than NSAID monotherapy. The use of muscle relaxants is accompanied by an increase in the frequency of adverse events, primarily general lethargy and drowsiness. The most studied drug is tizanidine. The drug is used in doses of 2-4 mg x 2 times a day. The most common adverse events are sedation and hypotension.

Benzodiazepine tranquilizers have a similar effect. Drugs in this group can be used in a hospital setting to enhance the effect of NSAIDs.

Causes of dorsalgia

If sharp or dull aching pain occurs in the back, many people associate its appearance with muscle spasm during exacerbation of osteochondrosis, pinched nerve, lumbago or relapse of intervertebral hernia. And in most cases they turn out to be right. But often the prerequisite for the development of dorsalgia is inflammatory processes occurring in the internal organs. Pain radiates to the back with pathologies affecting the gastrointestinal tract, kidneys, uterus and its appendages, prostate gland, bladder. It is especially dangerous to treat the back when dorsalgia occurs due to the passage of a calculus (stone) with sharp edges from the kidneys, gall or bladder.