Hassan, a 38-year-old marketing manager, is talking about his first bout with lower back pain. “It was so bad, I could hardly step off the sidewalk,” he said. “I tried everything. I did stretching and when that didn’t work I rested. I used Deep Heat on the afflicted area. I even thought I had cancer when I diagnosed my self on the internet,” he laughed. “In the end, I went to the pharmacy and the woman gave me muscle relaxants. They worked, but they played havoc with my stomach."
Hassan has since pinpointed the reason for his pain. “It was stress related. I would feel it coming back if I started to feel tense or anxious. It was like a wave lapping me on the beach, getting closer and closer. I would have to lie down and really relax for the sensation to go away.” More than 80% of the world’s population will experience some sort of lower back pain at least one time in their life. It is the second most frequent disability after the common cold, afflicting people between the ages of 18 and 30, and the most prevalent ailment to affect adults under the age of 45. Of the $27 billion spent on musculoskeletal trauma worldwide, $16 billion is spent on the treatment of lower back pain, over half of which is spent on surgery. “There are a lot of economic ramifications resulting from lower back pain, like absence from work and financial compensation for those immobilized from the affliction,” said Dr. A.F. Masri, attending physician of arthritis and rheumatology at the AUH and the former president of the Lebanese Rheumatology Society. There are no statistics in Lebanon for just how many days are lost from back related illnesses but it is estimated that in the United States last year, the total cost of back pain from back disorders in the workplace, was between $50 billion to $100 billion. This figure includes the cost of medical care, absence from work, social costs, personal loss and disability payments. So, what exactly is lower back pain?
“Lower back pain can best be described as a feeling of discomfort in the lower part of the spinal column – which is basically the area from the waist to the buttocks,” said Masri. Masri explained that there are three forms of back pain: acute, chronic and sub-acute. Acute pain generally comes on suddenly, lasting – as in the case of Hassan – up to four to six weeks, and the degree of pain ranges from mild to severe. A high percentage of acute pain sufferers take days off work to recover.
Chronic back pain lasts beyond three months but the level of pain experienced is not necessarily high. Chronic pain has higher economic repercussions, however, because this is where financial compensation due to immobility comes in the picture – i.e. the sufferer is laid off because he/she is no longer able to continue working. Sub-acute pain is in between acute and chronic and lasts about six to 12 weeks. According to Masri, treatment for lower back pain depends on the type of injury, of which there are four main categories. The first, mechanical injuries, usually consist of sprained muscles as a result of lifting heavy objects. “Such injuries heal with time, and can be eased with massage therapy, medication or physical therapy,” said Masri. Osteoarthritis is another type of mechanical back injury and it is the most common cause of lower back pain in the elderly, as it comes with age. Treatment is usually medication, physical therapy and massage. Falling under the same category are fracture injuries – which are usually caused by falls and treatment is bed rest – and herniated discs – which usually heal with time and proper care, including rest, physical therapy, muscle relaxants and avoiding any heavy lifting. The second form of back injury is inflammatory, which is usually a result of chronic arthritis that affects the joints of the back. “This usually affects young people between the ages of 18 and 30-years-old,” explained Masri. Treatment for such ailments is usually anti-inflammatory analgesia drugs, like Panadol, Advil and Volteran.
Next come infections, which affect the spine and cause extreme pain in the back region. “The most common spinal infection in Lebanon is BRUCELLOSIS, and to a lesser extent, TUBERCULOSIS,” said Masri. “Signs of infection are fever, chills and weight loss, and treatment is antibiotics.”
However, Masri was quick to point out that perhaps the most severe form of back ailments is cancer, which results in a high degree of pain if affecting the spinal area. Treatment is chemotherapy or radiotherapy. “No matter what form of back pain a patient is suffering from,” said Masri, “surgery is usually a last resort,” adding that although not generally a necessary treatment, back surgery is common. For the most part, lower back pain eases with time, however, Masri advises that if the pain continues longer that one to two weeks, a consultation with a physician is necessary. “About 90% of the time, a diagnosis can be made based on the history of a patient combined with a physical exam,” said Masri, adding that x-rays are usually not needed. “Most of the time, x-rays are unnecessary and just a waste of money.”
To avoid the most common lower back pains, Masri advises to always maintain proper posture – keeping shoulders back, and when sitting, making sure both feet are on the floor and knees form a right angle – exercise regularly, avoid putting stress on your back with heavy lifting, and lose weight if you are more than 10% overweight. “It’s important to remember that lower back pain affects all people, all races, all ages, is very common, and, a diagnosis is relatively simple to determine.”
Those, like Hassan, who were plagued by discomfort such as nausea and stomach pain, when they took anti-inflammatory drugs, can look forward to milder treatments. Enter rofecoxib, a newly developed painkiller and anti-inflammatory drug, which, in recent tests, has proved to be as efficient as traditional treatment techniques and much safer. It has also been formally endorsed by the US Food and Drug Administration (FDA).
“[There is] a growing international concern about the safety of traditional pain treatment techniques, which are based on prescribing Non-Steroid Anti-Inflammatory Drugs (NSAID),” said Dr. Tore Kvien, speaking at the 6th Pan-Arab Congress of Rheumatism and Rehabilitation, held in Beirut in September. “Those traditional medications have proven to be dangerous to the human gastrointestinal (GI) system, and the international medical community has been looking for new alternatives for over a decade.”
The symposium discussed the results of two most recent studies, which showed that rofecoxib provided fast and powerful relief from the pain of osteoarthritis (OA), rheumatoid arthritis (RA), and chronic low-back pain (CLBP). The studies, which were conducted on 1,925 patients, also proved that the new medication was more effective than traditional anti-inflammatory drugs.
Other studies revealed that rofecoxib provided superior pain relief in dental and regular surgery. Those studies showed that pre-operative use of rofecoxib is not associated with increased risk of procedure-related bleeding. Finally, treatment with rofecoxib was safe in treating both upper and lower gastro-intestinal disorders. “The emergence of certain drugs, such as rofecoxib, gave prolonged and safe duration of pain relief and analgesic effect from a single dose. The importance of these qualities in acute pain relief has only recently been appreciated and quantified,” Kvien noted.