Acetaminophen

Acetaminophen is a commonly-prescribed medication for pain management because of its general effectiveness for acute pain and relatively low risk profile. Acetaminophen was previously recommended as a first-line agent for the management of back pain. ^{6 , 7} However, more recent data has changed that recommendation and found that there is no significant benefit from using acetaminophen for chronic low back pain. Evidence is not available to make recommendations about the use of acetaminophen for acute or radicular low back pain. ⁸ Despite the widespread use of acetaminophen for pain, there are risks associated with its use, especially in older adults. Heavy alcohol use, liver pathologies, and other medications metabolized by the liver should also be noted prior to recommending acetaminophen, and the potential risks and benefits should be discussed.

Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflmmatory drugs (NSAIDs) are another medication commonly used for pain management in the general population. Recent data continues to support the recommendation of NSAIDs as a first-line treatment for acute low back pain, with demonstrated pain relief, although the effect on function is inconsistent. The same is true for chronic low back pain, with NSAIDs being more effective than placebo for pain relief. ⁸ There are risks associated with NSAIDs, especially in the older adult populations. For example, other medications metabolized by the kidney can interact with NSAIDs, increasing the risk of kidney damage. Additionally, regular nonaspirin NSAID use is associated with a 4-fold increase risk of serious upper gastrointestinal tract disease. ⁹ The elevation in risk is dose-dependent and also rises with increasing age. Beers Criteria recommends avoiding chronic use unless other options are not effective. ⁵

Opiates

Opiates and other mu-receptor agonist drugs are commonly prescribed for pain. There has been a steady rise in the prescription rate of opiates, paralleled by a rise in opiate overdose-related deaths. ¹⁰ Opiates can be effective pain relievers under the right circumstances, but evidence does not support the use of opiate and opiate-like medications for acute back pain. ⁸ Stronger opioids such as morphine and hydromorphone have been shown to provide some-short term relief for chronic low back pain, but evidence does not support their continued use or show any positive effect on function. ⁸ There are many potential adverse effects associated with opioid use, which include nausea, vomiting, constipation, somnolence, dry mouth, dizziness, and addiction. These risks are elevated in older adults with a slower drug metabolism rate. Additionally, the use of long-acting opioids in patients with chronic noncancer pain has been shown to significantly increase all-cause mortality, including the risk of death from causes other than overdose. ¹¹

Skeletal Muscle Relaxants

The phrase “Skeletal Muscle Relaxants” is a very broad term for medications that can have significantly different mechanisms of action. Skeletal muscle relaxant is a bit of a misnomer. Evidence for the use of these medications is mixed for acute low back pain. Some of these medications include cyclobenzaprine, tizanidine, orphenadrine, and carisoprodol. Cyclobenzaprine and tizanidine fall under the tricylic antidepressant (TCA) umbrella. Orphenadrine is an anticholinergic medication. Carisoprodol is a centrally-acting medication metabolized to meprobamate, an addictive substance in the carbamate class. There is evidence to support an improvement in short-term pain relief with the general class of skeletal muscle relaxants, compared with placebo. However, there is insufficient data to make any conclusions regarding changes in function. Evidence does not suggest a benefit on pain nor function in chronic back pain. ^{12 , 13} Beers Criteria strongly recommends against the use of skeletal muscle relaxants in older adults because of the risk of anticholinergic effects, sedation, and increased risk of fractures. ⁵

Benzodiazepines

There is limited and inconsistent evidence regarding the use of benzodiazepines for acute, chronic, or radicular low back pain. ⁸ The American College of Physicians was unable to determine any magnitude of effect of benzodiazepines on pain or function based on the available research. Additionally, benzodiazepines were associated with an increased risk of central nervous system adverse effects including somnolence, fatigue, and lightheadedness. ⁸ While the Beers Criteria does not comment on the use of benzodiazepines in back pain, they note that the medication should generally be avoided, except in certain disorders such as seizures, generalized anxiety disorder, or ethanol withdrawal. ⁵

Antiseizure Medications

Anti-seizure medications such as gabapentin and pregabalin do not have strong evidence for acute, chronic, or radicular low back pain. ^{8 , 14} These medications are associated with a risk of adverse effects, including fatigue, dry mouth, difficulties with mental concentration, memory, or visual accommodation, and loss of balance. ¹⁴ Again, when combined with other medications that an older adult patient may be taking, these adverse effects may be exacerbated due to slowed drug metabolism.

Antidepressant Medications

Antidepressants have been gaining in popularity for pain management, as increasing research is supporting their use. Antidepressants most commonly used for pain management include tricyclic antidepressant (TCA), serotonin and norepinephrine reuptake inhibitor (SNRI), and selective serotonin reuptake inhibitor (SSRI) classes of medications. Specific to low back pain, duloxetine has been found to be of some benefit for the treatment of chronic low back pain after a 12-week course of treatment. ^{8 , 15} Again, there are risks associated with duloxetine, including, but not limited to, nausea, dry mouth, fatigue, diarrhea, hyperhidrosis, dizziness, and constipation. ¹⁵ Caution should also be taken when prescribing any of the antidepressant medications if a patient is already on other centrally-acting medications. Beers Criteria recommends caution in older adults, as TCAs, SSRIs, and SNRIs may cause or exacerbate the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia. ⁵

Corticosteroids

Systemic corticosteroids are often prescribed with the goal of reducing inflammation and subsequently reducing low back pain. As an oral formulation, they are easier to administer than a local steroid injection, however, available research does not support the use of systemic corticosteroid for acute or chronic low back pain in the general adult population. ⁸ Additionally, Beers Criteria recommends against the use of corticosteroid in older adults who are at risk for delirium or in conjunction with NSAIDs because it can increase the risk of GI bleeding or peptic ulcer formation. ⁵

Motor Control Exercise

Motor control exercise (MCE) focuses on the activation and control of deep trunk muscles. Once this muscle control is established, the exercises focus on integrating functional tasks into muscle activation. MCE is unique from other forms of exercise because it is meant to target a direct cause of low back pain. ¹⁶ The theory behind MCE is that people with back pain tend to have a weak core that provides poor stabilization to the spine. This leads to the onset and perpetuation of nonspecific low back pain. ¹⁶ By targeting these stabilizing muscles, the patient can theoretically increase the support to the spine, and reduce the strain placed on it, leading to a reduction in pain.

MCEs require extensive training to ensure proper performance. Some methods used by physical therapists to ensure activation of the targeted muscles include palpation, ultrasound imaging, and pressure biofeedback. The goal is to teach patients how to isolate and contract specific muscles and muscle groups, build up strength and endurance, and eventually integrate the specific muscle contractions into functional tasks. MCEs differ from stabilization exercises because of this integration of functional tasks.

The utility and risks of MCE as it specifically pertains to older adults has not been extensively studied. The same risks that apply to most forms of exercise should be considered when recommending MCE. Providers should take into consideration the overall health of the patient before recommending more intensive physical activity. The evidence for MCE for the general adult population is mixed but suggests a clinically important effect when compared to minimal intervention for chronic low back pain, ¹⁶ and has been shown to be more effective than general exercise for addressing pain and function. ¹²

Trigger Points and Dry Needling

Trigger-point treatments, including dry needling, are interventions that can be performed by a variety of providers, including physical therapists. Trigger points, in this context, are referred to as myofascial points that are pain-generating palpable zones of tense musculature. Trigger points have identifiable morphologic changes in muscle tissue under microscopic visualization. ¹⁷ Dry needling refers to the use of a high gauge needle inserted into areas of trigger points identified by the practitioner. ¹⁷ While physicians will often perform trigger point injections with medications (local anesthetics and/or steroids), physical therapists are increasingly using dry needling of trigger points as a treatment for trigger point-associated back pain. Trigger points can also be treated by physical therapists using manual techniques. Recent data shows that manual trigger-point therapy using an inflatable ball improved function and alleviated pain in older adults with chronic low back pain. ¹⁸ The purpose of acting on these trigger points, through manipulation, dry needling, or other techniques, is to disrupt to pathologic muscle contractions, decrease tone, and reduce pain. ¹⁷

The evidence in support of dry needling for the treatment of chronic low back pain has been growing in recent years, as the popularity of this intervention increases. More studies are being conducted to evaluate the effectiveness of dry needling as an adjunct to other treatments, as well as in comparison to other commonly used interventions. A 2005 Cochrane Review of the literature suggests that dry needling is an effective adjunctive therapy for chronic low back pain. ^{19 , 20} There is further review evidence suggesting that dry needling has a statistically significant effect on pain intensity and functional disability in the immediate postintervention period, but no statistically significant difference at follow up. ²⁰ There is some controversy on whether dry needling is a form of acupuncture. Early training of physical therapists in dry needling was performed by acupuncturists, and there are some that consider this a type of acupuncture (Ahsi point acupuncture), though terminology varies in different regions of the world.

Dry needling does have its possible adverse effects that need to be considered in elderly patients. There are very few differences in risks when compared to the general population, but the provider should use caution with patients on anticoagulation due to increased risk of bleeding and hematoma formation. Other risks to be taken into consideration include infection, tissue damage, and injury to nearby structures.

The McKenzie Method of MDT

The McKenzie Method of MDT is a classification-based assessment and treatment system for low back pain. The technique was developed by physical therapist Robin McKenzie in 1981 and classifies patients with low back pain based on how their pain responds during the initial evaluation. The primary categories of classification are derangement, dysfunction, and postural. The classification is made by the physical therapists watching and evaluating a patient’s pain response to various repetitive movements.

Centralization of pain and directional preference are key features in the McKenzie therapy. Centralization occurs when a patient’s back pain moves from radiating more peripherally to a more central location in the spine. This occurs when a practitioner guides the patient to find positions, or directional preferences, that lead to this type of change in their pain. Studies show strong evidence indicating that back pain which centralizes has much better clinical outcomes when compared with back pain the does not centralize. ^{21 , 22} Once the practitioner identifies positions that are beneficial to the centralization of their patient’s pain, they can instruct the patient on ways to incorporate those activities into their daily routine. This has been shown to reduce pain as well as lower incidences of pain recurrence. ^{23 , 24}

The effectiveness of MDT compared to other physical therapy techniques has been studied with mixed results. A 2006 meta-analysis found that MDT may be more effective than passive treatment for acute low back pain, although clinical significance was unclear. ²³ Further research found MDT to be more effective than other treatments—including NSAIDs, education, strengthening exercises, back massage, and spinal mobilization—in short-term pain and disability. ²⁴ Most available research agrees that there is limited evidence for improvement in pain in intermediate and long-term outcomes, or those with chronic back pain. ^{23 , 24}

Chronic Back Pain and Depression

An association between depression and chronic, disabling low back pain has been established in the adult population including in aging patients. In aging patients, this association becomes increasingly complex due to physical and psychological changes associated with the aging process. Research focused on the community-dwelling older adult population has found that the presence of depressive symptoms was a strong and independent risk factor for the occurrence of disabling back pain, with studies suggesting that depression worsens both the severity of and the disability caused by chronic low back pain. ^{25 , 26 , 27} Findings suggest this is a bidirectional relationship, as it is widely recognized that chronic pain conditions can increase the risk of depressive symptoms.

There are several theories behind the relationship of depression and chronic pain, especially chronic nonspecific back pain, in the older adult population. One is that depressed older adults may be less likely to spontaneously report depressive symptoms and may instead communicate emotional distress by focusing on somatic complaints and describe feeling helpless or debilitated due to back or joint pain. ²⁷ Another widely discussed theory is that pain-related disability in aging patients may be driven by pain “homeostenosis”. This is described as a diminished ability to effectively respond to the stress of persistent pain due to the comorbidities of the aging process, including cognitive and physical impairments, increased sensitivity to suprathreshold pain stimuli, medical and psychological comorbidities, altered pharmacokinetics and pharmacodynamics, and increased social isolation. ²⁶ Psychological similarities between patients with depression and patients with chronic low back pain have also been noted, including diminished mental flexibility and decreased self-efficacy with subsequent learned helplessness. ²⁷

Research looking at the neurochemical and neuromorphology of depression and chronic low back pain in the older adult population have also elucidated a relationship at this biological level. It has been proposed that neurochemical changes in serotonergic or noradrenergic function that occur as a consequence of depression have the potential to increase sensitivity to painful stimuli, rendering affected patients more susceptible to disabling chronic pain. ²⁵ Several areas of the brain which modulate mood also process pain, including the dorsolateral prefrontal cortex, anterior cingulate cortex, periaqueductal gray, insular cortex, and hypothalamus. Data has demonstrated that older adults with chronic low back pain have pain morphology differences from pain-free individuals, including decreased gray matter volume in the posterior parietal cortex and middle cingulate white matter volume of the left hemisphere. ²⁵

This shared biology and psychology support a unified approach to treatment, including screening older adult patients presenting with chronic low back pain for depression. The Patient Health Questionnaire-2 (PHQ– 2) is a commonly used and validated screening tool which is best utilized when the patient has no prior diagnosis of depression and no spontaneous report of depressive symptoms. Patients who screen positive with the PHQ-2 and those who already carry a diagnosis of depression or are spontaneously reporting depressive symptoms should be administered the Patient Health Questionnaire-9 (PHQ-9) or the 15-item Geriatric Depression Scale. Expert-based recommendations include following up the diagnosis of clinically significant depression with screening for comorbid psychiatric conditions, including anxiety, cognitive impairment, PTSD, and alcohol or other substance misuse. ²⁷ The intent of treating depression and chronic low back pain in older adults as linked conditions is to encourage a holistic approach to treatment and prescribing which may spare the overuse of opioids in this population.

Fear Avoidance Beliefs and Pain Catastrophizing

Both fear avoidance beliefs and pain catastrophizing have been associated with persistent pain and disability in both middle-aged and aging patients with back pain. The fear-avoidance model as it relates to chronic pain has been widely studied since its introduction in 1983 by Letham et al, who theorized that fear avoidance may contribute to the development of adverse pain behaviors and subsequent pain experiences, including chronic pain and increased disability. ²⁸ Research focused on the role of physical activity fear-avoidance beliefs in older American adults with low back pain have found these beliefs to be independently associated with self-reported disability and overall physical health. ²⁹ Additional research has demonstrated that physical activity fear-avoidance beliefs were significantly associated with both self-reported and observed measures of disability even after controlling for other potential contributors to disability. Notably, psychological factors, including fear-avoidance beliefs, may be more predictive of disability in older adults with chronic low back pain than the pathology of the pain itself and its associated impairments. These researchers found an intervention consisting of general conditioning and aerobic exercise to improve fear-avoidance beliefs beyond reduction in pain. ²⁸

Pain catastrophizing has also been found to be predictive of pain-related outcomes in both surgical and nonsurgical patients. Pain catastrophizing has been described as an exaggerated negative “mental set” associated with pain and has been linked to increased perceived pain intensity and disability, which has been theorized to explain the relationship between fear-avoidance beliefs and increased low back pain associated disability in aging patients. ²⁹ Research has found preoperative pain catastrophizing to be a unique predictor of postoperative pain intensity during activity and analgesic use after lumbar fusion surgery. ³⁰ Research looking at the effect of pain catastrophizing in patients undergoing lumbar stenosis surgery found that pain catastrophizing predicted back pain intensity, pain interference, and disability. These researchers propose employing interventions such as TCAs and cognitive behavioral therapy (CBT), which have been utilized to address increased levels of pain catastrophizing in other patient populations. ³¹

Cognitive Behavioral Therapy

CBT is a classification of therapy that is commonly utilized in the treatment of chronic pain. CBT aims to reduce the psychological distress and dysfunction associated with pain by teaching patients methods to challenge maladaptive thoughts and beliefs, decrease maladaptive behaviors, increase adaptive behaviors, and increase self-efficacy for pain management. ³² CBT can also include pain education and instruction in adjunctive techniques, such as progressive muscular relaxation. CBT has demonstrated clinical benefit for treatment of both depression and chronic low back pain and utilizes similar techniques for treatment of both conditions, including activity pacing, active coping and problem-solving skills, relaxation techniques, and involvement of spouses/caregivers. ²⁷

Cognitive Functional Therapy

Cognitive functional therapy (CFT) is a related behavioral approach to pain that encourages patients to both cognitively reconceptualize the pain experience and functionally normalize provocative movements and postures while discouraging pain behaviors. The aim of CFT is to address multiple dimensions of chronic pain, including fear-avoidance behaviors and catastrophizing. The intervention is behaviorally based and targets specific physical behaviors, such as pain behaviors, aggravating postures and activities, and muscle guarding while simultaneously addressing related psychosocial and/or cognitive behaviors. ³³

Research has shown CFT to have promise in reducing functional disability and reported pain amongst adult patients with nonspecific chronic low back pain. ³³ However, this has yet to be looked at specifically in the older-adult population.

Mindfulness Meditation and Mindfulness-Based Stress Reduction

Meditation is a mind and body practice that has been in use for over 5,000 years. Practices focus on the interactions between the brain, mind, body and behavior and aim to support practitioners’ learning to focus their attention as a way of gaining greater insight into themselves and their surroundings. There are many forms of meditation, each of which falls into one of two categories: mindfulness meditation and concentrative meditation. Mindfulness meditation focuses attention on breathing to develop increased awareness of the present, while concentrative meditation aims to increase overall concentration by focusing on a specific word or phrase. Most forms of meditation have four elements in common: a quiet location with minimal distraction, a specific comfortable posture, a focus of attention, and an open attitude. ³⁴

Mindfulness meditation aims to transform everyday activities, such as sitting and walking, into a meditation through nonjudgmental observation of physical sensations, thoughts, and feeling. Dr. Jon Kabat-Zinn has been credited with conceptualizing mindfulness meditation for a Western audience with his pioneering of the mindfulness-based stress reduction (MBSR) program at the University of Massachusetts Medical Center in 1979. ³⁵ MBSR, in particular, focuses on increasing a detached observation and acceptance of experiences, including uncomfortable emotions and physical sensations. ³⁶ Because it has been operationalized and standardized, MBSR has been studied in clinical trials for a variety of disorders and diseases, including chronic pain. Several neuroimaging studies have attempted to elucidate the mechanism of mindfulness meditation and have found increased cortical thickness in the prefrontal cortex and right anterior insula among long-term meditators compared with controls. The prefrontal cortex and occipito-temporal regions of the brain show a typical decline with age; however, studies have shown that long-term meditators aged 40–50 are more likely to maintain their cortical thickness. ²⁶

Research comparing a MBSR-based intervention to health education for community-dwelling adults aged 65 years or older with chronic low back pain demonstrated the MBSR intervention led to improved short-term function and improved long-term pain. This led researchers to conclude that the utility of the intervention could be increased by focusing on the durability of functional improvement. ³⁷ Other research focusing on adults ages 20–70 with nonspecific low back pain has shown MBSR to be as effective as CBT in improving both pain and functional limitations, noting that MBSR-based interventions may be more accessible in populations where patient access to skilled CBT may be limited. ³⁶

Acupuncture

Acupuncture is a 3,000-year-old technique of Traditional Chinese Medicine which utilizes the insertion of fine, sterile needles into the skin at specific anatomic sites, or acupuncture points, to release blockages in the flow of qi or energy. The theory is that the release of blocked qi encourages the balance of oppositional forces within the body, which improves function of the internal organs and promotes the body’s natural healing response. Other methods used to stimulate acupuncture points, or acupoints, include manual pressure, moxibustion or heat therapy, electrical stimulation, and the application of topical herbal liniments. ⁴⁰

While acupuncture is traditionally used for various health conditions, there is significant research supporting the efficacy of acupuncture for a variety of pain conditions, including low back pain. Acupuncture has been shown to be most beneficial for reducing pain and improving function in chronic low back pain when used as an adjunct to conventional treatments. There is conflicting evidence over the difference in effect between acupuncture and sham acupuncture (superficial needle insertion at nonacupoints). It is possible that superficial needle penetration could potentially mediate analgesic placebo effects and that nonpenetrating acupuncture is a more reliable control. ³⁸

Acupuncture is considered to be a relatively safe procedure with serious complications, such as pneumothorax, being rare. The most common complications include bleeding, hematoma or ecchymoma formation, and insertion site pain. ⁴¹ Caution should be exercised when recommending acupuncture to patients with clotting disorders or on long-term anticoagulation.

Chiropractic Care

Chiropractic care is based on the belief that health is directly affected by the relationship between the body’s structure (primarily that of the spine) and its function, as coordinated by the nervous system. Hands-on therapy is central to chiropractic care, with spinal manipulations, or adjustments, being a core mechanism of treatment. Additional approaches may include modalities such as heat and ice, electrical stimulation, ultrasound, rehabilitative exercise, and lifestyle counseling. ⁴²

Efficacy studies of middle-aged adults have established a therapeutic and restorative benefit of chiropractic care on functional abilities and relief of low back pain. Studies focused on the older adult population have also demonstrated chiropractic care to be beneficial with an observed protective effect of chiropractic care against declines in ADLs, IADLs, and declines in self-rated health. ⁴³ Spinal manipulation therapy combined with home exercise has also been shown to lead to greater intermediate-term pain reduction than home exercise alone. ⁴⁴

A primary concern regarding chiropractic care is the risk of injury or adverse events. Because spinal manipulation involves application of physical force, there is a potential risk of traumatic injury, especially with patients particularly vulnerable to injury and/or if the manipulation is deficient in technical skill or precision. Risks identified by systemic review include arterial dissection, myelopathy, fracture, disk extrusion or herniation, cauda equina syndrome, and formation of hematoma. ⁴⁵ While the rate of injury is considered to be low, ranging from 0.05 to 1.46 adverse events per 10,000,000 manipulations in a middle-aged population ⁴⁶ to 40 incidents per 100,000 subjects in a population aged 66–99 years, ⁴⁵ these injuries are associated with significant morbidity. When considering patients for chiropractic care, one should exercise extreme caution with regard to the provision of spinal manipulation in patients with long-term use of anticoagulation therapy or coagulation disorders, history of aortic aneurysm or dissection, or inflammatory spondylopathy. Occlusion or stenosis of precerebellar arteries are contraindications to cervical spine manipulation, given the increased risk for vertebrobasilar stroke. ⁴⁵