Pharmacia 68(1): 117–120 DOI 10.3897/pharmacia.68.e50297 Review Article Therapeutic guidelines in chronic low back pain Daniela Taneva1, Angelina Kirkova2, Pеtar Atanasov3 1 Medical University – Plovdiv, Department of Nursing, Faculty of Public Health, 15A Vasil Aprilov Blvd., Plovdiv 4002, Bulgaria 2 Medical University – Plovdiv, Department of Medical Informatics, Biostatistics and E-learning, Faculty of Public Health, 15A Vasil Aprilov Blvd., Plovdiv 4002, Bulgaria 3 Clinic of Internal Diseases, UMHATEM “N. I. Pirogov”, Sofia, Bulgaria Corresponding author: Angelina Kirkova ([email protected]) Received 20 January 2020 ♦ Accepted 27 January 2020 ♦ Published 8 January 2021 Citation: Taneva D, Kirkova A, Atanasov P (2021) Therapeutic guidelines in chronic low back pain. Pharmacia 68(1): 117–120. https://doi.org/10.3897/pharmacia.68.e50297 Abstract Chronic low back pain is a heterogeneous group of disorders with recurrent low back pain over 3 months. The high incidence of lumbago is an important phenomenon in our industrial society. Patients with chronic low back pain often receive multidisciplinary treatment. The bio approach, the psycho-approach, and the social approach optimally reduce the risk of chronicity by providing rehabilitation for patients with persistent pain after the initial acute phase. Damage to the structures of the spinal cord and the occur- rence of low back pain as a result of evolutionary, social and medical causes disrupt the rhythm of life and cause less or greater dis- ability. Recovery of patients with low back pain is not limited only to influencing the pain syndrome but requires the implementation of programs to eliminate the complaints that this pathology generates in personal, family and socio-professional terms. This paper aims to familiarize the audience with the medication used, and the programs for active recovery in patients suffering from chronic low back pain. Keywords chronic low back pain, therapy Introduction Epidemiology of low back pain Chronic low back pain is a heterogeneous group of disor- The study of the risk factors clarifies the rules of be- ders with recurrent low back pain over 3 months. They are havior to be followed and helps to cope with this growing associated with the disease of the century (Becheva 2014). pathology (Zhelev et al. 2001). The risks of chronicity are Chronic low back patients often receive multidisciplinary less studied than the chronic effects of this disease over treatment. The bio approach, the psycho-approach, and a long time (Bernard 2012). Risk factors are divided into the social approach optimally reduce the risk of chroni- three big groups: personal factors, biomechanical psycho- city by providing rehabilitation for patients with persis- social factors (Popov et al. 2008) and occupational factors tent pain after the initial acute phase (Becheva et al. 2011). (Expertise collective 2000). Multidisciplinary treatment programs are often labor-in- Recovery of patients with low back pain is not limited tensive and require good collaboration between patients, only to influencing the pain syndrome but requires the the rehabilitation team and the corresponding work en- implementation of programs to eliminate the complaints vironment (Goranova 2009). that this pathology generates in personal, family and Copyright Taneva D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 118 Taneva D et al.: Guidelines chronic low back pain socio-professional terms (Vakrilova Becheva and Traiko- can be summarized as a transition from passive to active va 2012). treatment. There is consensus in the literature regarding the need for active exercise to treat low back pain without spec- ifying which exercises are more effective (Todorova et al. Medication treatment of chronic 2015; Becheva 2016). Becheva recommends a kinesithera- low back pain py program to restore the functionality of the spine based on improved neuromuscular protection. It is achieved by The first step is related to the anesthesia and the inter- avoiding risky situations and training in articulate ergo- ruption of the inflammatory processes. When choosing nomics, as well as by lumbo-pelvis stabilization and avoid- non-steroidal anti-inflammatory drugs, the possible side ing extreme positions. Programs with excellent results em- effects as nausea, stomach pain, vomiting should be spe- phasize the stabilization of the corpse and the maintenance cified. There are products with an improved safety profile. of the neutral position of the spine (Panjabi et al. 2001). It is Non-steroidal anti-inflammatory agents such as Paraceta- important to recommend physical exercises that restore and mol, Ibuprofen, Dexketoprofen, Diclofenac – in the form maintain the normal activity of the lumbar spine (Beche- of tablets, capsules, sachets, gels, and creams are recom- va 2012). Most authors combine exercises to improve joint mended (Mancheva 2004). amplitude with exercises for muscle elasticity (Blain 2016). The combination of non-steroidal anti-inflammatory Some forced exercises, especially flexion exercises, can drugs with group B vitamins is more effective than using lead to negative results. The extreme increase of spine mo- non-steroidal anti-inflammatory drugs as a monotherapy. bility in some cases is associated with the recurrence of Corticosteroids have anti-inflammatory and anti-edema low back pain (De Gasquet 2016). Good lumbar mobility effects. They are used for disc herniation with nerve root can prevent relapse in patients with low back pain. Some- compression or joint inflammation. Muscle rigidity fur- times it is only necessary to carry out light daily activities ther exacerbates the pain syndrome, so it is advisable to to prevent pain (Becheva 2015b). take muscle relaxants such as Tolperisone, and parenteral In patients with low back pain, there is a loss of mobil- administration of Alcuronium chloride (Aloferrin), Pan- ity in the hip joints, which results in a decrease in muscle curonium bromide (Pavulon), Pipecuronium bromide elasticity in the ischiocrural group and m. iliopsoas (Mul- (Arduan) in a hospital setting (Kostov et al. 2010). Inject- chanova 2003), therefore, exercises are recommended able treatment involves a local injection of anesthetics, for actively stretching the statically contracted muscles corticosteroids, and drugs into the soft tissues, joints and (Vakrilova Becheva and Traikova 2013). More work is other areas around the spine. The aim is to block nerve being done on the mobility of the hip joints. Achieving conduction, that is, to deal with pain. The injections may the optimum volume of movement in these joints is of the be in the form of an epidural block or administered lo- utmost importance because it minimizes the load on the cally in the adjoining muscles. In chronic pain, the com- spine, thus protecting it while performing various activi- bination of a steroid and an anesthetic locally is better ties (Vakrilova Becheva and Belcheva 2010). than the administration of an anesthetic alone and has a Compared to healthy subjects, patients with chronic longer-lasting effect. The use of antidepressants and anti- low back pain have decreased lumbar extensor strength as convulsant drugs has a good effect on chronic low back well as a very low endurance. Endurance values can serve pain, reducing the pain and the severity of possible de- as predictors of low back pain as opposed to force dur- pressive symptoms (Kostadinov 2000). ing maximal volitional contraction (Pollock et al. 2004). For this reason, exercises to strengthen the spinal cord extensors should emphasize the restoration of muscular Programs for active treatment of endurance (Becheva and Viteva 2015) rather than muscle chronic low back pain strength (at high workload and low repetitions). Based on results of studies on changes in intradis- Damage to the structures of the spinal cord and the occur- cal pressure, Axler, McGill, and Nachemson state that it rence of low back pain as a result of evolutionary, social is necessary to exercise the abdominal muscles from the and medical causes disrupt the rhythm of life and cause position of occipital lying with peeled blades because this less or greater disability (Becheva and Gencheva 2011). In position does not significantly increase the intradiscal order not to deteriorate these patients’ quality of life, it is pressure (Axler et al. 2001; McGill et al. 2000; Nachemson necessary to establish programs for the overall response et al. 2001). Vakrilova Becheva, Viteva and Traikova study to complaints and objective functional deficits (Herisson the effect of a kinesitherapy program on weak and rapidly 2000). Exercises to improve the mobility of the hip joints fatiguing body flexors. The authors find improvement in (Becheva 2013) stabilization exercises, as well as those for muscle strength as a result of a one-year follow-up of pa- strength and endurance of the structures of the spine (Be- tients (Vakrilova Becheva et al. 2016). cheva 2015a) must be applied to achieve a good recovery of Morphological changes – mm. multifidi atrophy are the aspects of motor and perceptual function of the spine. found in patients with chronic low back pain. This type Recommendations for the treatment of low back pain of atrophy can persist for a long time after the symptoms are undergoing major changes