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How back pain management is changing


Patients with lower back pain shouldn’t expect to receive prescription medication from their family doctor as international treatment guidelines respond to the opioid crisis.

A University of Sydney review of the management of lower back pain (LBP) – the leading cause of disability worldwide – has found patients are more likely to be recommended yoga and exercise as treatment options.

“Until now, the recommended approach to help LBP in general practice was to prescribe simple pain medicines such as paracetamol or anti-inflammatories,” said lead author Dr Adrian Traeger, researcher from the Musculoskeletal Health Group at the University’s School of Public Health.

But the review shows there’s been a “substantial change in thinking”.

“If you have an uncomplicated case of recent-onset LBP, your doctor may now simply provide advice on how to remain active and non-drug methods for pain relief such as heat and massage, and arrange to see you in two weeks to make sure the pain has settled,” said Dr Traeger.

“Everyone is aware of the opioid crisis, that’s a global problem, so they are really trying to find a different approach to management that would not start with these prescription drugs.”

The guidelines for the UK’s National Institute for Health and Care Excellence – released at the end of last year – and the American College of Physicians also discourage other invasive treatments such as injections and surgery.

There are currently no official National Health and Medical Research Council guidelines for the front line management of lower back pain management in Australia.

However Dr Evan Ackermann from the Royal Australian College of General Practitioners (RACGP) says a non-pharmalogical approach to LBP has already started to filter through here.

“That’s where its be going for the last few years because most of the causes of lower back pain are mechanical, treatment is about movement and getting people mobile,” he told AAP.

Dr Ackermann says only about five per cent of lower back pain presentations will be serious and for most patients strong painkillers are not the answer.

He says what patients should expect from their doctors is a full examination and evaluation to determine the underlying cause for the back pain.

“That’s the critical thing,” said Dr Ackermann.

You can access the University of Sydney review here, and the latest lower back pain management guidelines here and here.

Spotlight on rheumatology

Gout is in the news this week, with a new study from the BMJ demonstrating that eating well can downgrade your risk of developing this inflammatory condition.

The so-called DASH diet, designed to reduce blood pressure, is also good for lowering uric acid levels, US and Canadian study involving 44,000 people has found. The diet is rich in fruit, vegetables, nuts and whole grains, and low in salt, sugary drinks, red and processed meats.

Gout is also the subject of an ongoing battle in the rheumatology community, reports Health Professional Radio. New guidelines from the American College of Physicians advise doctors against urate-lowering therapy in most patients, in stark contrast to both EULAR and ACR recommendations. It’s angered many gout specialists who have set up two new professional bodies to advocate use of urate-lowering drugs.

New fibromyalgia guidelines have also come under fire. The EULAR recommendations, write two Maltese rheumatologists, underplay the importance of severe anxiety and depression in the debilitating condition.

Meanwhile, biosimilars are making news at the Digestive Disease Week held in Chicago this month. The question of whether they are interchangeable with biologics has been troubling many Australian rheumatologists since the recent PBS listing of the etanercept biosimilar Brenzys for a number of rheumatology conditions.

Three new studies (here, here and here) suggest Inflectra, an infliximab biosimilar that was PBS-listed last year, can be switched with its originator Remicade without any effect on safety or efficacy.

And in other biologics news, abatacept has been found in a phase 3 study to be effective in psoriatic arthritis. In the study of over 400 patients, around 40% of those randomised to the biologic showed improvement compared with 22% in the placebo group.

How common is hand arthritis? A large study from the US crunches the numbers: it finds that one in two women will develop the condition at some stage in their life, while only one in four men will do so.

Hand arthritis affects Caucasians more than African-Americans and is more prevalent among obese people.

But people with any kind of arthritis should go easy on some kinds of painkillers, Canadian researchers say. The BMJ study involving 450,000 people found that taking any dose of an NSAID even for only a week significantly increases the risk of myocardial infarction.

And finally, a US study has found that squeaky knees are a better predictor of osteoarthritis than knee pain.

The study looked at 3500 people at high risk of developing OA and found that 75% had radiographic evidence of the disease despite the absence of pain.

Among those not experiencing pain, crepitus was more common in those who developed OA within a year.


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