Hey Austin - Just got done with your lecture to the Fort Irwin group. You discussed medications and its poor use for low back pain. I work as a PT - part of my time is spent in an orthopedic urgent care setting. As you would imagine, we get a lot of patients that present with acute onset of LBP. Many of these patients get the “typical” prescriptions of muscle relaxers and prednisone. Occasionally a prescriptions strength NSAID or gabapentin depending on their presentation. These are typically prescribed on a short term basis.
My question is if there any research on the efficacy of prednisone in subsets of cervical or lumbar radiculopathy.
For instance, some patients get prescribed prednisone for general lumbar sprain/strain where pain is only localized to lumbar spine. I don’t generally see the point of prednisone in this case. My bias (likely thick with confirmation bias) is that prednisone would be more effective in a patient that has signs of an aggr nerve root that may suggest inflammation around the nerve. I believe Adriaan Louw referred to this as the nerve resting in “spicy soup” in his Pain neuroscience course. So, in a hetrogenous population of those with low back pain, prednisone may show little/no effect but if the population is more homogenous then it may?
I am completely on board with the discussion of the multi-factorial nature of pain and recognize that the question above narrows it down to treating a “pain generator” but curious to hear your thoughts (also that of the rehab crew)
Thanks - By the way, I appreciate your lectures/talks and have used a lot of them clinically. Specifically, the Youtube videos Alan posted after he tweaked his back deadlifting has been useful to lifters that I have seen that instead of confronting the “injury” instead avoid those movements. Keep up the good work/content!
You are correct that there does not appear to be a benefit for acute non-specific LBP, with substantial risk of harms (as discussed here: https://bjsm.bmj.com/content/53/3/196 )
For acute radiculopathy, the evidence is mixed. For example:
According to the ACP’s clinical practice guideline,
…systemic steroids were not shown to provide benefit and should not be prescribed for patients with acute or subacute low back pain, even with radicular symptoms.
It is too bad the lumbar study did not have a non-pharm group. I would assume it the ODI and NPRS figure would look somewhat similar to Placebo vs prednisone reflecting the natural history of the pain episode.
Interesting that the Cervical radic study seemed to have better results with prednisone compared to placebo.
My current tact is to up-sell the potential benefits of prednisone for the patients that I see to maximize any placebo effect that I may offer. Louw descibred it as a “movement enhancing drug” - so I try to have them view it as means to a more active therapy approach. The up-sell may benefit them short term but hopefully doesn’t get them reliant on steroids for future episodes of back/neck pain.
One last question regarding pharmacology. Muscle relaxers are prescribed at my clinic but typically as an alternative for opioids to aid with sleeping. Thoughts on this practice? What is your general recommendation for those who are having difficulty sleeping?
Check out the Traeger study I linked above, where some of the data on the “muscle relaxers” are cited. I’m OK with them for short-term use in patients where the risks (e.g., of oversedation, medication interactions as we commonly see in the elderly, etc.) are low, particularly when compared with opioids (which I do not use in this situation).
I’m not a fan of the term “muscle relaxer” for several reasons, though. They primarily act centrally and are thus essentially tranquilizers, with no muscle-specific effects. But they are often paired with typical back pain narratives about “spasm” in a way that seems to make sense, even though that isn’t what’s happening.