Rational Treatment for Low Back Pain

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 Rational Treatment for Low Back Pain

Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar

Rational treatment involves practicing the golden principles of clinical medicine i.e. taking a detailed clinical history covering every aspect (the most important) and a thorough efficient clinical examination so that a correct diagnosis is clinched or the differential diagnosis is narrowed down to a few conditions so that rational treatment i.e. simple remedies or a minimum number of cost-effective drugs and investigations are employed. This is the crux of good scientific practice and quality of a good clinician.


Lt. Gen. (R) Mahmud Ahmad Akhtar

It was Al-Razi who stated that the best state of health is the medication free state. He remarked, “When you can cure by a regimen of simple remedies, avoiding having a recourse to a medicine and when you can effect cure by means of a simple medicine, avoid a complex one. This forms the basis of ‘life-style therapies’ including preventive medicine which should receive utmost importance. Methews said, “Cured yesterday of my disease, I died last night of my physician” and William Pens echoed the same feelings when he said, “remedy often times proves worse than the disease”. These are the two physicians of the 17th century who were vocal about the misuse and the adverse effects of drugs. Iatrogenic disease caused by misuse of drugs, procedures investigation etc. are important cause of morbidities and mortalities, Today modern drugs are more effective but are also more lethal if not used correctly and judiciously. In order to safe-guard the lives of patients a physician must be well-versed in the art and science of modern medicine.

Low back-pain is as common as common cold. It is defined simple when confined to low-back and does not radiate to lower limbs. It is arbitrarily labeled acute back pain when limited to one month duration and chronic up to three months duration.

Even in the developed country USA. It is mismanaged. The “American College of Physicians” in a recent updated guide-lines has high-lighted these aspects. On the basis of meta-analysis of multi-center studies, it has concluded that unnecessary strong medicines like narcotic pain killers are used, even making many patients drug dependents or addicts. The guidelines recommend using simple therapies like massages, physical exercise, bone manipulation, remaining active as far possible, if needed using simple medicines, Aspirin or Ibuprofen- Paracetamol is noted to be useless. It has advised against the use of muscle relaxants and intra-spinal steroid injections.

In their studies ‘Placebos’ were also found to be helpful, of course assurances and encouragements by a treating physician about its benign nature is very important.

The college panel has advised against the use of unnecessary investigation like x-ray and particularly MRI’s as normal age related abnormalities are wrongly related to backache. The college expert panel has commented that many professional bodies and the related industry are promoting unnecessary investigations and harmful treatments.

In Pakistan low back-pain is very common particularly in women due to their poor health, lacking proper nutrition and excessive burden of work – a single woman taking load of large families, males not sharing the work. It is also mismanaged on a large scale. There is strong tendency to use narcotic related pain-killers and using expensive muscle relaxants particularly combinations of paracetamol with muscle relaxants and narcotics.

Expensive NSAIDs are frequently used and unnecessarily PPIs are used even without any history of dyspepsia / acidity. Expensive NSAID’s, local application / preps are used. It is pertinent to point out that in the UK, Canada etc. in the National Health Services these ointments / creams are prepared in the hospital pharmacies at very low cost. If oral NSAIDs are being used, there is no need to use local NSAIDs application.

There is no need to prescribe PPIs / H2 antagonists, if there is no history of dyspepsia’s / acidity particularly when used in short courses and low dosage Pakistani markets are flooded with irrational combinations of paracetmol, in-effective muscle relaxants and narcotics.

Furthermore Gabapentin’s which have role for the treatment of neuropathic pains are aggressively advertised for use for simple backache. The “Drug Regulatory Authority” whose responsibility is to strictly control advertisements and save people from harm and irrational use of drugs allows rather collaborates with industry in the malpractice / corruption. Cortico-steroid intra-spinal injections are misused on a large scale charging patients exorbitantly thousands of rupees without revealing the name of medicine which costs only a few rupees.

Unnecessary X-ray and even MRIs are done. Patients are not given proper listening/consultation, not told about the benign nature of disorder, its good prognosis, early recovery and the use of simple physical therapies and hazards of using harmful drugs. There is a dire need of continued medical education of doctors by the professional bodies through print media particularly medical journals and medical news-papers like the ‘PULSE’ which every doctor should read. Public should be provided information through print and digital media. Drug Regulatory Authority should do its solemn duty to protect people’s lives by making sure that drugs are used rationally and pharmaceutical industry promotes medicines ethically. Like departments of cardiology, pulmonology, gastro-entomology etc. there should be clinical units / departments of clinical pharmacology, clinical therapeutics in the teaching hospitals / institutions to promote rational uses of medication. Irrational medicines should be de-registered. All medicines not registered by the ‘Drug Regulatory Authorities’ of the scientifically progressive countries like UK, European Union, USA, Nordic countries, Australia, Canada, New Zealand etc. should be removed from the Pakistani markets. Only World Health Organisation’s recommended “Essential Medicines” should be used.

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